The LASEREO system was developed as a novel endoscopic system with a light source consisting of two kinds of lasers with wavelengths of 410 and 450 nm. The combination of two lasers and fluorescent light enables three kinds of image-enhanced endoscopy as follows: blue laser imaging (BLI), BLI-bright that allows a brighter view with narrow-band light observation, and linked color imaging (LCI). We report that magnifying BLI can be used to diagnose early gastric cancer (EGC) more accurately than white-light imaging (WLI) according to the vessel-plus-surface classification system and the diagnostic effectiveness of magnifying blue laser imaging (M-BLI) is similar to that of magnifying narrow-band imaging (M-NBI). In addition, we report that BLI-bright improves the real-time EGC detection rate compared with WLI. LCI enables visualization of red lesions that appear redder and whitish lesions that appear whiter. LCI visualizes gastric intestinal metaplasia as lavender color and diffuse redness as crimson color. Therefore, LCI enables evaluation of the risk of gastric cancer easily and objectively. Moreover, LCI is expected to improve EGC detection by identifying EGC more clearly.
Malignant gastric outlet obstruction (GOO) can develop by tumor invasion to the upper gastrointestinal tract, resulting in cachexia, deterioration of quality of life and poor prognosis. Endoscopic gastroduodenal stent placement is a minimally invasive therapy that is an alternative to surgical gastrojejunostomy and it has been widely used in clinical practice after approval reimbursement by Japanese health insurance in 2010. However, there are still no established criteria for treatment choice of surgical bypass or endoscopic self-expandable metallic stent (SEMS) placement according to the patientʼs condition. Moreover, debates on the ideal SEMS are required because both covered and uncovered SEMSs have inherent advantages and drawbacks. Recently, a novel treatment modality for GOO, endoscopic ultrasound-guided gastrojejunostomy using lumen-apposing metal stent, has been introduced and clinical application is awaited.
Objective: We examined the proportion of patients of each gender preferring a colonoscopist of a specific gender in order to identify the need for female colonoscopists. Method: We distributed a questionnaire to 1,157 patients (677 men and 480 women) who were scheduled to undergo colonoscopy before and after the colonoscopic examination. Results: Before the colonoscopy, female colonoscopists were requested by 25.8% of women and 0.9% of men (P＜0.01). Further, subgroup analysis of the female patients showed that 47.3% of patients ＜50 years and 39.7% with no previous colonoscopy history preferred female colonoscopists, compared with 20.7% of patients ≧50 years and 20.6% with prior colonoscopy history (both P＜0.01). After undergoing colonoscopy with a female colonoscopist, 52.6% of the female patients preferred female colonoscopists for future examinations, compared with 11.7% of female patients who did so after undergoing colonoscopy with a male colonoscopist (P＜0.01). Conclusion: Female patients, especially younger patients and those with no previous colonoscopic history, are more likely to request female colonoscopists.
The case was a 46-year-old female. Screening upper gastrointestinal endoscopy revealed discolored mucosa localized to the lower esophagus. An intraepithelial neoplasia was suspected, and she was referred to our hospital for close examination. Since the previous doctor detected eosinophilic infiltration by biopsy, we considered the possibility of eosinophilic esophagitis and started administration of esomeprazole. Eight weeks later, endoscopy showed that multiple discolored lesions in the mucosa and longitudinal grooves had spread over the area from the upper esophagus to the lower esophagus, resulting in the diagnosis of eosinophilic esophagitis. In recent years, the concept of localized eosinophilic esophagitis in the lower esophagus has been proposed and the possibility that eosinophilic esophagitis is an early form of esophageal eosinophilic inflammation has been pointed out. The endoscopic findings at the time of the screening endoscopic examination suggested localized lower esophageal eosinophilic inflammation. In this case, we were able to observe the natural course of diffusely spreading esophageal eosinophilic inflammation in the lower esophagus.
A case of symptomatic gastric aberrant pancreas with recurrent inflammation treated by laparoscopy and endoscopy cooperative surgery (LECS) is herein reported. A 31-year-old woman was referred to our hospital with the chief complaint of repeated occurrence and disappearance of upper abdominal pain. Upper gastrointestinal endoscopy showed a submucosal tumor of 25 mm in diameter at the greater curvature of the upper gastric body. Aspiration cytodiagnosis was performed, the results of which led to a suspicion of gastric aberrant pancreas. Next, we conducted LECS for the symptomatic tumor. On histological examination, the tumor was composed of pancreatic tissue from the submucosa to the muscularis propria, and it was diagnosed as gastric aberrant pancreas. She was discharged six days after the surgery with an uneventful clinical course and has been symptom-free thereafter. LECS can be a feasible treatment for symptomatic gastric aberrant pancreas, because the procedure enabled us to maintain minimal invasiveness with limited removal of the stomach wall.
A 72-year-old man presented with a complaint of epigastralgia that was not improved by an antacid. He was referred to our department for further examination, where abdominal computed tomography and endoscopic ultrasonography resulted in a diagnosis of peritoneal dissemination of pancreatic cancer. We planned to start chemotherapy, but he was admitted to our hospital with nausea and vomiting. Gastroendoscopy revealed a malignant gastroduodenal obstruction. We then deployed a partially covered duodenal metallic stent on the obstruction. However, the stent migrated to the esophagus a few days later, and could not be removed due to mucosal hyperplasia at the partially covered site. This adverse event is rare. We review the literature to consider indications and problems with covered stents.
A 46-year-old man visited our hospital with a chief complaint of abdominal pain at the right lower quadrant. Colonoscopy revealed a relatively well circumscribed, elevated, reddish lesion with ulcers in the terminal ileum, and ultrasonography detected multiple enlarged lymph nodes at the ileocecal region. Pathological examination of biopsy materials obtained from the ileal lesion led to the diagnosis of extranodal marginal-zone lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma, although IRTA1 was negative. The serum level of soluble IL-2 receptor was elevated. Because the patient was positive for urinary anti-H. pylori antibody, H. pylori eradication therapy was started. Follow-up endoscopy performed five months later showed scarring of the terminal ileal ulcers, and biopsy specimens no longer showed evidence of lymphoproliferation. In addition, the enlarged ileocecal lymph nodes disappeared on ultrasonography.
Primary ileal MALT lymphoma is relatively rare in Japan when its frequency is compared with that of MALT lymphoma of the stomach or large intestine. It is thus considered important to record the present case, in which the lymphoma completely regressed following H. pylori eradication therapy, to enlarge the list of such cases.
Adenomas develop only rarely in the ileum, and Ⅱa＋Ⅱc-like ileal adenomas are extremely rare. Therefore, there is no standardized diagnostic and therapeutic method for Ⅱa＋Ⅱc-like ileal adenomas. A 65-year-old man with an unremarkable family history was referred to our hospital to identify the cause of fecal occult blood. Colonoscopy revealed a Ⅱa＋Ⅱc-like tumor of 23 mm in diameter, located in the terminal ileum 10 cm proximal to the ileocecal valve. The diagnosis was further confirmed using narrow-band imaging with magnifying endoscopy (NBI-ME), which revealed a type 2A colorectal lesion according to the classification of the Japan NBI Expert Team (JNET) and which had histopathological findings of adenoma or low-grade mucosal cancer. Pathological examination of a biopsy specimen taken from the depressed part of the lesion revealed tubular adenoma with high-grade atypia. En bloc resection was achieved by endoscopic mucosal resection (EMR) without any adverse events, and complete resection was proven histopathologically. Surveillance endoscopy was performed one year after EMR, and there were no findings of recurrence. For suspected Ⅱa＋Ⅱc-like tumors in the ileum, NBI-ME and EMR should be considered.
The patient was a 90-year-old man who underwent hemostasis by clipping for active diverticular bleeding in the sigmoid colon performed by a previous doctor. After the procedure, the patient had two bleeding episodes that were difficult to manage, and he was transferred to our hospital. During lower digestive tract endoscopy, the responsible diverticulum was visualized, and the attached clip was observed close to the diverticulum. The clip was removed using an end-gripping forceps to clearly visualize the point of bleeding. A small blood vessel was exposed and cauterized by soft coagulation with a slight touch with the tip of the hemostatic forceps (Coagulasper, Olympus, Tokyo), and the diverticular area was clipped with the reefing method to prevent delayed perforation. To the best of our knowledge, no cases of successful endoscopic hemostasis of diverticular bleeding using hemostatic forceps where hemostasis had been unsuccessful by clipping have been reported. Here, we report such a case with a literature review.
Gastric endoscopic submucosal dissection (ESD) has been performed over a longer period of time than ESD for lesions located in other regions of the gastrointestinal tract, and gastric ESD has become the standard treatment for early gastric cancer. However, only experienced endoscopists can complete gastric ESD for technically difficult lesions located in the greater curvature of the gastric body and fornix of the stomach. Furthermore, gastric ESD is associated with bleeding; therefore, it is very important to learn how to successfully control bleeding during ESD. When gastric ESD is performed for lesions located in the gastric body, we apply the near-side approach method that combines the strategy of ESD using a needle-type knife and the strategy of ESD using an IT knife. The traction method using the clip-with-line technique is known to be very effective for shortening the procedure time of gastric ESD, particularly for lesions in the greater curvature. These strategies and tips lead to the success of gastric ESD even for technically difficult lesions.
Endoscopic retrograde cholangiopancreatography (ERCP) is now widely used as the first-choice procedure for performing biliary drainage to treat malignant biliary duct stricture. However, for cases in which performing this procedure would be difficult, endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are also available as effective alternatives. This article provides an overview based on our experience of the EUS-BD technique and describes our approach to selection between general EUS-BD and PTBD in cases where ERCP would be difficult. Endoscopic drainage and PTBD each have limitations with respect to biliary drainage. For this reason, both the endoscopist and the interventional radiology specialist need to have a clear objective of optimal drainage, and it is therefore critical to promote establishment of a strategic partnership between these individuals.
Background and Aim: The incidence of post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) can be decreased by closing mucosal defects. However, large mucosal defects after colorectal ESD cannot be closed endoscopically. We established line-assisted complete clip closure (LACC), a novel technique for large mucosal defects after colorectal ESD. We evaluated the prophylactic efficacy of LACC for preventing PECS.
Methods: Sixty-one consecutive patients on whom LACC after colorectal ESD was attempted from January 2016 to August 2016 were analyzed. After exclusion of patients with incomplete LACC and adverse events during ESD, 57 patients comprised the LACC group. In contrast, 495 patients who did not undergo closure of a mucosal defect comprised the control group. Propensity score matching was used to adjust for patientsʼ backgrounds. Treatment outcomes were evaluated between the groups.
Results: Median resected specimen size in the LACC-attempted group was 35 mm (range, 20-72 mm), and LACC success rate was 95% (58/61). Median procedure time of LACC was 14 min. In the LACC group, incidence of PECS was only 2%, and no delayed bleeding or perforation occurred. Propensity score matching created 51 matched pairs. Adjusted comparisons between the LACC and control groups showed a lower incidence of PECS (0% vs 12%, respectively; P = 0.03) and shorter hospitalization (5 vs 6 days, respectively; P ＜ 0.001) in the LACC group.
Conclusion: This study suggests that LACC can effectively reduce the incidence of PECS, although further large-scale studies are warranted.