It is well known that there have been gaps in the pathological diagnosis and definition of endoscopic findings between Japan and the US. Specifically the difference in the pathological definition of intraepithelial neoplasm is well known. In Japan, gastrointestinal epithelial neoplasm tends to be diagnosed and removed focally, while in the US, it tends to be recognized as a premalignant field defect and is treated in the field. These differences may be due to differences in surveying technique where targeted biopsy tends to be performed in Japan while random biopsy tends to be performed in the US. In Japan, endoscopic submucosal dissection (ESD) has been performed to treat esophageal squamous cell carcinoma, gastric cancer associated with H. pylori infection, and colorectal lesions. On the other hand, in the US, ESD is performed to treat Barrettʼs adenocarcinoma, gastric cancer without H. pylori infection, and hereditary colorectal neoplasm. Other differences include sedation techniques, performing advanced procedures on an inpatient verses outpatient basis and overall health care delivery. As globalization progresses, we should continue to share endoscopic knowledge and resection techniques across the world.

The evidences, problems and future of endoscopic gastric cancer screening in Japan are discussed. Endoscopic gastric cancer screening has reduced gastric cancer deaths to 23-71% of the number of gastric cancer deaths prior to the introduction of endoscopic gastric cancer screening. The effect of endoscopic gastric cancer screening in reducing gastric cancer deaths is greater than that of upper gastrointestinal X-ray screening with barium sulphate (UGIS). The feasibility of endoscopic gastric cancer screening depends on the capacity of endoscopic examination, budget for screening and access to facilities where individuals undergo endoscopic examination. If endoscopic gastric cancer screening is not feasible, secondary endoscopic examination after UGIS in which the background gastric mucosa is evaluated for chronic gastritis, is more efficient than primary endoscopic screening. Merits and demerits of endoscopic screening should be considered before introducing endoscopic gastric cancer screening because endoscopic examination is associated with severe adverse events. The Japan Ministry of Health, Labour and Welfare aims at a gastric cancer screening rate of 40% or greater. However, the prevalence of Helicobacter pylori infection is decreasing, and the adjusted number of gastric cancer deaths has been decreasing in Japan. Therefore, a simple policy that encourages an increase in the screening rate is not always efficient irrespective of increasing the budget and workload of medical staffs. A primary endoscopic screening system may be needed to stratify subjects with gastric cancer risks such as H. pylori infection and atrophy. Not only risk stratification but also endoscopic screening by special technologists or nurses who are assisted by artificial intelligence (AI) may decrease the workloads of endoscopists. It is expected that intervention with such gastric cancer screenings may reduce gastric cancer deaths more efficiently than the natural decrease in gastric cancer deaths in the future.

An 83-year-old woman was transported by ambulance to our hospital due to bloody stools. Upper and lower gastrointestinal endoscopic examinations did not reveal an obvious source of bleeding.

By capsule endoscopy, a press-through package (PTP) was found lodged in the small intestine, and a linear ulcer was found nearby. Oral double balloon endoscopy revealed an ulcer at the site of lodging of the PTP, and stenosis was observed on the anal side. The PTP was stuck in the wall of the small intestine and it was difficult to remove it endoscopically. Laparoscopic-assisted partial intestinal resection was performed, and two pieces of PTP sheet, each with an area of about 15 mm², were picked out from the resected specimen. Capsule endoscopy may be useful for diagnosis of accidental ingestion of PTP.

A 74-year-old man was admitted for epigastralgia. He was diagnosed with acute cholangitis and was scheduled for endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage. The major duodenal papilla with a periampullary diverticulum (PAD) was located on the right inferior rim of the diverticular orifice, and the initial ERCP was unsuccessful. The papilla faced outside of the diverticulum only when the biopsy forceps pinched and pulled the mucosa towards the anal side. Using a traction device (S-O clip^TM), the papilla could be everted from the diverticular pouch to an appropriate position and selective bile duct cannulation was successfully performed.

This procedure was feasible without using a wide-channel duodenal endoscope. The S-O clip can be a beneficial adjunct to the ERCP procedure in patients with a PAD.

We report the case of a 59-year-old man. After multidisciplinary treatment was initiated for severe acute alcoholic pancreatitis, a giant walled-off necrosis developed. Percutaneous and transgastric drainage were ineffective. Thus, a lumen-apposing metal stent was used to improve the patientʼs condition in addition to performing transgastric drainage and endoscopic necrosectomy. The lumen-apposing metal stent has recently become available, and we report our initial experience of using it.

The provision of pediatric gastrointestinal endoscopy by a pediatric gastroenterologist is ideal because of their knowledge about disease and sedation specific to children. In Japan, there are limited opportunities for pediatric gastroenterologists to learn endoscopy, and the volume of endoscopic procedures necessary to improve and maintain the quality of endoscopic techniques is insufficient when treating pediatric patients only. At our hospital, pediatric gastroenterologists undergo weekly endoscopic training with adult patients in the gastroenterology department in parallel with pediatric practice. During this training, pediatric gastroenterologists experience more than 300 endoscopies annually, and sufficient endoscopic proficiency levels are achieved. We report this as a model of endoscopic training for pediatric gastroenterologists. In Japan, cooperation with gastroenterologists who treat adult patients is necessary to establish this pediatric gastrointestinal endoscopic training system.

Superficial non-ampullary duodenal epithelial tumors (SNADETs) were previously reported to be rare. However, the detection rate of SNADETs has been increasing because of recent endoscopic advances. Endoscopic resection is the standard treatment for duodenal intramucosal neoplasms due to the low risk of lymph node metastasis. Endoscopic submucosal dissection (ESD) is associated with a higher complete resection rate and a lower recurrence rate for SNADETs of more than 20 mm in size than endoscopic mucosal resection (EMR). However, duodenal ESD is associated with a high incidence of adverse events (perioperative perforation, delayed bleeding, and delayed perforation) because it is technically difficult due to the anatomical features of the duodenum. Therefore, ESD for SNADETs remains controversial.

In this paper, we reveal tips on performing a safe and reliable ESD procedure using a scissor-type knife including methods of prophylactic closing of post-ESD ulcers.

Colorectal endoscopic submucosal dissection (ESD) was approved for coverage by the national health insurance in April 2012, and this procedure is now widely performed at many institutions. Colorectal ESD is suitable for the treatment of large intramucosal colorectal cancers. However, colorectal ESD is technically more demanding than gastric ESD, and is associated with a higher incidence of procedural complications. The present article describes technical tips and trouble-shooting in colorectal ESD. We consider that the basic techniques are very important for the safe performance of ESD.

Nara Prefecture introduced endoscopic screening for gastric cancer. Since there is a disparity in medical resources for endoscopic screening between rural and urban areas, the Health Department of Nara Prefecture provided information on all medical facilities that can perform endoscopic screening in Nara Prefecture to the municipalities. We conducted a survey of municipalities in Nara Prefecture to evaluate the current status of endoscopic screening. In 2017, 23 out of the 39 municipalities had introduced endoscopic screening, and 8 municipalities introduced endoscopic screening in 2018. Therefore, approximately 80% of the municipalities in Nara Prefecture have conducted endoscopic screening. The survey of municipalities revealed that the “double check” system in which examiners submit all images and other doctors check the submitted images to avoid overlooking lesions, interferes with the introduction of endoscopic screening. Moreover, the largest barrier to introduction of endoscopic screening was insufficient medical resources. Approximately 20% of the medical facilities provided endoscopic screening for multiple municipalities in 2018. Since it is expected that the number of endoscopic screening examinees will increase in the near future, expansion of medical resources and elimination of regional disparities are necessary.

Objectives: Colonic spasm can interfere with colonoscopy, but antispasmodic agents can cause complications. This study aimed to assess the inhibitory effect of topical lidocaine compared with a placebo control.

Methods: In five tertiary-care hospitals in Japan, 128 patients requiring endoscopic resection of a colorectal lesion were enrolled and randomly and double-blindly allocated to colonoscopy with topical administration of 2% lidocaine solution 20mL (LID, n=64) or normal saline 20mL (control, n=64). During colonoscopy, the assigned solution was applied with a spray catheter near the lesion and the area was observed for three minutes. Primary endpoint was the inhibitory effect at three time-points (1, 2 and 3 minutes after dispersion), using a three-point scale (excellent, fair, poor). Secondary endpoints were rebound spasm and adverse events. All endpoints were scored in real time. Serum lidocaine levels were measured in 32 patients (LID 16, control 16).

Results: There were no significant differences between groups in patient demographics. At all time-points, the proportion of patients with “excellent” scores was greater in LID group than control group, with significant differences observed at 2 minutes (p=0.02) and 3 minutes (p=0.02). In LID group, the rate of “excellent” scores increased by 12.5% at 2 minutes and was maintained at 3 minutes. Rebound spasm did not occur in LID group, compared with 15.6% of control group (p=0.001). There were no adverse events in LID group. All serum lidocaine levels were below detectable levels.

Conclusions: Topical lidocaine is an effective and safe method for suppressing colorectal spasm during colonoscopy (UMIN000024733).