Malignant hilar biliary obstruction is caused by various diseases. The location and degree of biliary obstruction are different in each case. Endoscopic biliary drainage using stents is the first-line therapy for unresectable biliary obstruction. Uncovered self-expandable metallic stent (SEMS) is widely used because of longer stent patency. Plastic stent and covered SEMS with 6mm diameter have also been recently used. However, there has been no evidence with regard to drainage area (unilateral or bilateral) or deployment for bilateral drainage (side-by-side or stent-in-stent). Plastic stent is commonly used in re-intervention for recurrent biliary obstruction, but SEMS might be another option on the basis of longer stent patency.

A 78-year-old man was referred to our hospital with a posterior mediastinal lesion measuring 35 mm in diameter. We performed endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy of the mediastinal lesion using a 22-gauge needle. The patient was discharged the next day. Seven days later, the patient contacted the hospital with chief concerns including fever, chest pain, and dysphasia. Chest computed tomography showed widening of the mediastinum with an abscess and air. Urgent debridement surgery was performed and the patient was discharged 28 days postoperatively. This case report describes a patient who developed life-threatening mediastinitis after EUS-FNA of a mediastinal lesion.

The patient was a 63-year-old man. He was examined by a local doctor for dyspnea, where he was administered oral steroids and started on inhalation therapy for a diagnosis of bronchial asthma. However, his symptoms worsened and he was brought to our hospital. On admission, he was diagnosed with atrial fibrillation and acute heart failure. Upon administration of anticoagulants to prevent embolism in this patient with atrial fibrillation, the patient developed bloody stool. Colonoscopy revealed multiple diverticula in the hepatic flexure, along with ulcers and white coating localized to that area. Diverticular colitis was initially suspected, but vegetative amoebas were found in a tissue biopsy of the ulcers and he was diagnosed with amebic colitis. The ulcers healed with administration of metronidazole. We report this case in which amebic colitis developed in a man with asymptomatic Entamoeba histolytica infection from the use of steroids and anticoagulants, with the lesions localized in the area with multiple colon diverticula.

A 10-year-old boy who had sudden onset of abdominal pain and vomiting, was diagnosed with severe acute pancreatitis and referred to our hospital. Intensive care successfully suppressed inflammation in the acute phase, and infection of walled-off necrosis that arose two months after onset was cured by cystojejunostomy. However, the patient had a relapse of acute pancreatitis which might have been caused by stricture of the main pancreatic duct and developed chronic pancreatitis (CP). Although inserting stents through the main pancreatic duct and performing minor papilla sphincterotomy as pancreatic duct drainage were temporarily effective, pancreatitis relapsed. Eventually, he underwent the Frey procedure nine months after the first onset. Five years after the surgery, relapse of pancreatitis and pancreatic functional impairment have not been seen. It is important to determine the appropriate timing of surgical intervention considering the limits of endoscopic procedures for pediatric CP cases, in which the long-term prognosis including pancreatic function should be focused on.

Observation of the pancreatobiliary system using a curved linear array echoendoscope is based on observation from three areas: the stomach, first portion of the duodenum and second portion of the duodenum. First, the blood vessels in each area (i.e., the abdominal aorta or portal vein in the stomach, the portal vein in the first portion of the duodenum, and the abdominal aorta in the second portion of the duodenum) which are the starting points of observation, are depicted in each region. Next, while observing the surrounding organs and blood vessels such as the spleen, kidney, splenic vein, superior mesenteric vein, portal vein, and portal confluence which serve as landmarks, the pancreatobiliary system is scanned according to the basic observation protocol. Understanding and acquiring the standard visualization method using the curved linear array echoendoscope are extremely important for fully exploiting the high performance of endoscopic ultrasound-fine needle aspiration.

Use of a clip and thread is a simple and effective traction technique for endoscopic submucosal dissection (ESD) of lesions in the upper gastrointestinal tract. We can achieve good visualization of the submucosal layer during ESD by using a clip and thread. However, the conventional “clip-and-thread” technique required withdrawal of the endoscope for mounting the system; therefore, it was not fully applied for colorectal ESD. Our newly developed method - traction-assisted colorectal ESD using a clip and thread (TAC-ESD) - does not require withdrawal and reinsertion of the endoscope. Thus, we can easily apply this technique for colorectal ESD. TAC-ESD does not require special devices, and good traction can be achieved even in colorectal ESD. The strategy of TAC-ESD is simple, and it can be performed all over the world. TAC-ESD is useful for not only difficult cases but also standard cases in colorectal ESD. We can overcome the difficulties in colorectal ESD by performing TAC-ESD.

Background and Aim: This study evaluated the utility of endoscopic ultrasonography (EUS) combined with contrast-enhanced harmonic EUS (CH-EUS) for surveillance of the remnant pancreas after surgery for intraductal papillary mucinous neoplasm (IPMN).

Methods: This was a single-center, retrospective, descriptive study. A total of 134 consecutive patients who underwent surgical resection for IPMN between April 2009 and March 2015 were evaluated. Rates of recurrence and development of IPMN-concomitant pancreatic ductal adenocarcinoma (PDAC) during follow up were assessed. Clinical findings of patients with recurrence or development of PDAC were also evaluated.

Results: Of 134 resected IPMN 56 (41.8%) and 78 (58.2%) were classified as benign and malignant, respectively. Patients were followed up for a median of 29 months, 33 (24.6%) by both contrast-enhanced computed tomography (CE-CT) and EUS, and 101 (75.4%) by computed tomography (CT) alone. Thirteen patients (9.7%) showed tumor recurrence, five with intra-pancreatic recurrence and eight with extra-pancreatic metastases. An enhancing mural nodule within the dilated main pancreatic duct was successfully detected by EUS in one patient, but not by CE-CT. Two patients developed IPMN-concomitant PDAC during follow up. EUS combined with CH-EUS successfully detected small IPMN-concomitant PDAC in two patients, whereas these lesions were not detected by CT. CH-EUS was useful for better visualization of the margins of IPMN-concomitant PDAC in one of these two patients.

Conclusion: Endoscopic ultrasonography combined with CH-EUS may improve follow up of patients with resected IPMN.