The incidence of Barrett’s esophageal adenocarcinoma (EAC) has been increasing throughout the world, especially in Western countries. The characteristic endoscopic findings of superficial EAC are either elevation or depression, and color change. However, it is difficult to make a differential diagnosis of EAC from intestinal metastasis, inflammation and erosion by white light imaging (WLI). Therefore, random biopsies are recommended for the surveillance of EAC in Western countries.

According to the published data of the authors, almost half of EAC cases had 0-Ⅱb spreading, and making the diagnosis of 0-Ⅱb spreading by WLI is difficult. Observation of the surface and vascular pattern by magnifying endoscopy with narrow-band imaging (NBIME) is useful for the diagnosis of lateral extension. Ninety-four percent of cases of 0-Ⅱb spreading were diagnosed correctly by NBIME.

However, it is more difficult to make the diagnosis of superficial EAC in patients with long segment (LS) Barrett’s esophagus (BE) than in patients with short segment BE. Therefore, the surveillance in LSBE patients should be performed by experienced endoscopists. A surveillance system that does not use random biopsy should be established using NBIME.

[Objective] Our objective was to assess the efficacy and safety of polyethylene glycol electrolyte solution with ascorbic acid (PEG-Asc) for achieving good bowel preparation prior to lower gastrointestinal endoscopy in children. [Methods] The night before endoscopy, oral solutions of PEG-Asc 20 mL/kg and sodium picosulfate 0.5 mL/kg were administered. The following morning, 25% glycerin enema solution 4 mL/kg and PEG-Asc oral solution 10 mL/kg were administered. In each patient, the extent of bowel cleansing was rated on a scale of 1 to 5, with 5 indicating a clean bowel. [Results] In 19 children (age range, 6-18 years) who took all the prescribed doses, although fecal residue was observed in all the segments, the amounts were small enough to allow performance of endoscopy. However, the extent of bowel cleansing after administration of PEG-Asc was significantly lower in children aged 11 years or younger [4.9±0.082 (n=10) vs. 4.5±0.28 (n=9), mean±SD, p＜0.015]. Furthermore, serum total protein, total bilirubin, creatinine, and calcium levels varied widely both before and after oral administration of PEG-Asc, but all remained within the normal range after administration. [Conclusion] Pretreatment with PEG-Asc appeared to be effective for achieving adequate bowel preparation and was safe for use in children.

A 73-year-old female with a medical history of total gastrectomy and Roux-en-Y reconstruction was admitted to our hospital for epigastric pain. Contrast-enhanced abdominal computed tomographic (CT) scan showed a markedly dilated afferent loop with suspected anastomotic obstruction, leading to the diagnosis of afferent loop syndrome. Anastomosis stricture was so severe that we could not initially identify the anastomosis site by esophagogastroduodenoscopy, but we finally found the pinhole-like anastomosis site with leakage of yellowish-white liquid by the aid of an endoscopic distal attachment. Endoscopic balloon dilation was performed for the pinhole-like anastomosis stricture, and after that a large amount of intestinal juice flowed out through the dilated hole. Her symptoms improved together with resolution of the dilated afferent loop. Endoscopic balloon dilation is an effective treatment for afferent loop syndrome, and CT scan and attentive endoscopic examination are useful to identify the anastomosis site in such cases.

Esophageal leakage after esophagectomy results in prolonged inability of oral intake and prolonged hospital stay. In this report, a covered stent was placed in the esophagus for management of the fistula whose formation had been induced by esophageal leakage. This led to good clinical results of acceleration of the time to oral intake and healing of the fistula compared with patients who did not undergo covered stent placement for esophageal leakage after esophagectomy. The length of hospital stay was also shortened. The effectiveness of covered stent placement for esophageal leakage after esophagectomy is reported in two cases.

Case 1 is a 74-year-old male who had undergone total gastrectomy and Roux-en-Y reconstruction for gastric cancer one year and three months previously. He presented with repeated reflux symptoms and aspiration pneumonia infections. Upper endoscopic examination showed the accumulation of a large volume of bile juice in the esophagus and severe reflux esophagitis. Treatments with a pancreatic enzyme inhibitor and peristaltic stimulant were ineffective, but he improved and could be discharged after the addition of Rikkunshito, a traditional Japanese medicine. Case 2 is a 75-year-old male who had undergone distal gastrectomy and B-I reconstruction for gastric cancer. He presented with vomiting, hiccups, appetite loss and body weight loss, and visited our department five years after the surgery. We also diagnosed this patient as having severe reflux esophagitis and his symptoms were improved by administration of Rikkunshito. As to the effects of Rikkunshito, absorption of bile has been reported in addition to improvement of gastrointestinal motility and appetite promotion. Rikkunshito may be suitable for the treatment of postoperative reflux esophagitis and should contribute to improvement of various symptoms.

An 80-year-old man with unresectable lower bile duct cancer was followed up after placement of an indwelling biliary plastic stent. The patient had developed severe anemia even though he was being treated with repeated blood transfusions for chronic anemia. Endoscopy revealed invasion of bile duct cancer to the papilla of Vater and hemorrhage from the surface of the bile duct cancer. Radiation therapy was able to control the anemia and reduce the number of blood transfusions. Palliative radiotherapy may improve the quality of life by anemia control in patients with hemorrhagic lower bile duct cancer.

Barrett’s esophagus (BE) is a metaplastic condition that occurs secondary to gastroesophageal reflux disease. BE is also a precursor to esophageal adenocarcinoma, which, although still rare in Japan, is one of the most rapidly increasing cancers in Western countries. However, the prevalence of gastroesophageal reflux disease has increased significantly over the past few decades in Japan, possibly leading to an incremental increase in BE and the associated inherent risk of adenocarcinoma.

Given the poor prognosis of late-stage Barrett’s adenocarcinoma, it is important to detect early neoplasias in patients with BE. However, endoscopic identification of early neoplasms is still not sufficiently reliable or subjective, making targeted biopsy by conventional endoscopy extremely difficult. During the last decade, newly-developed imaging technologies such as acetic acid enhancement and narrow band imaging combined with magnification endoscopy have enabled identification of early neoplasias. This article focuses on how to accurately detect and diagnose early neoplasias by conventional and advanced imaging technologies.

Underwater endoscopic mucosal resection (UEMR) is a new hot snare polypectomy technique with electrocautery to remove gastrointestinal polyps without submucosal injection while filling the gastrointestinal lumen with water. Suctioning of luminal air and filling with water make the mucosa and submucosa “float” away from the muscularis propria. This makes snare capture easier. We describe herein the UEMR technique for colorectal polyps.

Background and Aim : The significance of examination time of esophagogastroduodenoscopy (EGD) for asymptomatic examinees is yet to be established. We aimed to clarify whether endoscopists who allot more examination time can detect higher numbers of neoplastic lesions among asymptomatic examinees.

Methods : We reviewed a database of consecutive examinees who underwent EGD in our hospital from April 2010 to September 2015. Staff endoscopists were classified into fast, moderate, and slow groups based on the mean examination time of EGD without a biopsy. Neoplastic lesion detection rate among these groups was compared using multiple logistic regression.

Results : Of the 55 786 consecutive examinees who underwent EGD, 15 763 asymptomatic examinees who were screened by staff doctors were analyzed. Mean examination time of 13 661 EGD without biopsy was 6.2 min (range, 2-18 min). When cut-off times of 5 and 7 min were used, four endoscopists were classified into the fast (mean duration, 4.4±1.0 min), 12 into the moderate (6.1±1.4 min), and four into the slow (7.8±1.9 min) groups. Neoplastic lesion detection rates in the fast, moderate, and slow groups were 0.57% (13/2288), 0.97% (99/10,180), and 0.94% (31/3295), respectively. Compared with that in the fast group, odds ratios for the neoplastic lesion detection rate in the moderate and slow groups were 1.90 (95% confidence interval [CI], 1.06-3.40) and 1.89 (95% CI, 0.98-3.64), respectively.

Conclusion : Endoscopists who do not allot adequate examination time may overlook neoplastic lesions in the upper gastrointestinal tract.