Since there are few pediatric gastroenterologists in Japan, adult gastroenterologists may be consulted for pediatric gastrointestinal (GI) endoscopy in pediatric patients. This report provides an overview of the role of endoscopy in pediatric patients, which includes esophagogastroduodenoscopy (EGD), colonoscopy (CS), small bowel capsule endoscopy, and balloon-assisted enteroscopy in children. First, the indication of GI endoscopy in children and the equipment suitable for use in infants and toddlers are discussed. A key difference between pediatric and adult diagnostic procedures is that routine tissue sampling is performed in children from at least the duodenum, stomach, and esophagus during EGD and from the rectum, colon, and terminal ileum during CS with ileoscopy. Endoscopists must consider safety during bowel cleansing for CS in pediatric patients and should take into account the patientʼs willingness. Almost all GI procedures in children are performed under sedation or general anesthesia to ensure the patientsʼ safety, comfort, and cooperation. There are a number of physiologic differences between pediatric and adult patients that can alter the risks of complications during sedation, and special precautions are required before, during, and after sedation. Preparation for endoscopy in pediatric patients requires attention to physiologic issues as well as the emotional anxiety and psychosocial well-being of both the patients and their primary caregivers.

In Japan, aging of the population is advancing. A problem therein is that while the average life expectancy is increasing each year, the healthy life expectancy is not changing. As a countermeasure to address this, medical departments overall are undertaking efforts aimed at extending healthy life expectancy, such as to address locomotive syndrome in patients with frailty and sarcopenia. Pharmacotherapy, nutritional therapy, and exercise therapy are three main factors that all improve outcomes, and it is important to coordinate these three factors. Nutritional intervention is a core factor in improving outcomes. Steady nutritional supply requires appropriate digestion and absorption functions in the digestive tract, as well as maintained appetite. However, the incidence rates of organic disease and functional disease caused by aging of the gastrointestinal tract increase with age. As a result, aging of the gastrointestinal tract can lead to changes in the human microbiota, malnutrition, and frailty, which are causes for concern. In other words, it is possible that aging of the gastrointestinal tract itself can cause loss of healthy life expectancy, and we believe that extension of healthy life expectancy is based on improvement and prevention of gastrointestinal disease. In the future, we hope to fully examine this in the field of gastroenterology including endoscopic medicine.

The patient was a 49-year-old. She had been diagnosed with Peutz-Jeghers syndrome during childhood. We diagnosed mucinous adenocarcinoma of the small intestine by several modalities including video capsule endoscopy and resected it surgically. Pathological examination showed that most of the tumor was composed of mucinous adenocarcinoma which was seen as a submucosal tumor on endoscopy. By video capsule endoscopy, we could see a papillary structure on part of the surface of the tumor and it was composed of papillary adenocarcinoma pathologically. Video capsule endoscopy may be useful for distinguishing histological types if the surface pattern of the tumor can be seen.

Colorectal pyogenic granuloma is a relatively rare disease. Here, we report a case of cecal pyogenic granuloma that required differentiation from neuroendocrine tumor (NET). A 72-year-old man was referred to our hospital because of fecal occult blood. Colorectal endoscopy revealed a polyp-like lesion on the ileocecal valve. Enhanced computed tomography and magnetic resonance imaging showed rich blood flow in the tumor, but somatostatin receptor scintigraphy showed absent accumulation of the isotope; therefore, it was not possible to make a definitive diagnosis. Laparoscopic-assisted ileocecal resection was performed as a diagnostic surgery. The postoperative pathologic diagnosis was pyogenic granuloma of the cecum.

Pyogenic granuloma of the large intestine that requires differentiation from NETs is rare. Our case indicates the importance of differentiating this disease when a blood-rich tumor is found in the large intestine.

An 82-year-old man was diagnosed as having persistent sigmoid volvulus, which was treated by repeated endoscopic reduction at the referring hospital. However, achieving complete reduction was somewhat difficult. The patient was referred to our hospital, where we could only perform gas reduction endoscopically, which alleviated his symptoms. Five days after the treatment, the patient developed abdominal distension and lower abdominal pain. Abdominal computed tomography showed edema-like wall thickening in the recto-sigmoid area and a high-density space-occupying lesion similar to a hematoma. Emergent surgery was performed due to the intestinal hematoma and the possibility of necrosis. The operative findings revealed recto-sigmoid mesenteric hemorrhage with an approximately 1,000-g hematoma but without bowel necrosis that was treated with Hartmann’s procedure. Histopathological examination of the resected specimen revealed extensive hemorrhage in the mesentery, but neither vascular occlusion nor thromboembolism was observed. We describe details of endoscopic findings and the clinical course of a rare case of recto-sigmoid mesenteric hemorrhage with late-onset hematoma after endoscopic reduction of sigmoid volvulus.

In colonic diverticular bleeding cases, the detection rate of the responsible lesion by colonoscopy remains unsatisfactory even with the supportive information of extravasation depicted by contrast-enhanced computed tomography (CECT). This is because colonoscopy does not provide as precise positional information as computed tomography (CT). The “step clipping” method could overcome this limitation by making artificial signposts that can be commonly recognized on both CT and colonoscopy. Colonoscopy with positional navigation through this method could boost the detectability of the responsible lesion and shorten the endoscopic searching time for the culprit lesion.

An accurate diagnosis of the extent of progression of hilar cholangiocarcinoma should be required in cases where radical hepatectomy will be performed. However, since the endoscopic examination was invasive and traumatic, it would be necessary to discuss the extent of excision of the liver corresponding to the extent of tumor progression using radiographic examination in advance. There are many endoscopic examinations such as endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreatography (ERCP) and related procedures including cholangioscopy, and we have to accurately diagnose the extent of tumor progression by integrating the results of various examinations. EUS is useful for diagnosing the extent of tumor spread in the extrahepatic bile ducts, and evaluation by cholangiography is indispensable to assess the Bismuth classification. Furthermore, information on tumor progression could be enhanced by adding intraductal ultrasonography (IDUS) and mapping biopsy, and cholangioscopic images could directly make a difference in the macroscopic diagnosis of the extent of tumor spread in bile duct epithelia.

Objectives: The time to recurrent biliary obstruction (TRBO) of unresectable distal malignant biliary obstruction is generally thought to be longer when a self-expandable metal stent (SEMS) with a thicker inner diameter is used for drainage, but the dependence on the inner diameter using a fully covered SEMS (FCSEMS) is uncertain. The objective of this multicenter prospective study was to compare TRBO and adverse events, such as cholecystitis and pancreatitis, in treatment of patients with unresectable malignant biliary obstruction using 8- and 10- mm diameter FCSEMS.

Methods: Eighteen tertiary-care centers participated in the study. Patients were allocated to the 8- and 10-mm diameter groups. TRBO, non-inferiority of the 8-mm FCSEMS, overall survival time, frequency and type of adverse events, and nonrecurrent biliary obstruction (RBO) rate at the time of death were compared between the two groups.

Results: Median TRBO did not differ significantly between the 8-mm (n=102) and 10-mm (n=100) groups (275 vs 293 days, P=0.971). The hazard ratio of the 8- to 10-mm groups was 0.90 (80% confidence interval, 0.77-1.04; upper limit lower than the acceptable hazard ratio [1.33] of the null hypothesis). Based on these findings, the 8-mm diameter stent was determined to be non-inferior to the 10-mm diameter stent. Survival time, incidence of adverse events and non-RBO rate at the time of death did not differ significantly between the two groups.

Conclusions: Time to RBO with an 8-mm diameter FCSEMS was non-inferior to that with a 10-mm diameter FCSEMS. This finding is important for development of future SEMS.