Helicobacter pylori (H. pylori) -negative gastric cancers are divided into H. pylori-uninfected and H. pylori-eradicated types. H. pylori-uninfected cancers are undifferentiated adenocarcinoma and gastric-type differentiated adenocarcinoma (fundic gland type and foveolar epithelial type). Most undifferentiated adenocarcinomas are signet-ring cell, and an endoscopic feature is discolored Type 0-Ⅱc or 0-Ⅱb lesion. Fundic gland-type gastric cancer has a submucosal tumor-like appearance originating from the fundic gland area. Foveolar epithelial-type gastric cancers consist of two types: white flat elevation and raspberry-like protrusion. Most H. pylori-eradicated cancers are well-differentiated Type 0-Ⅱc lesions in patients with severe corpus atrophy. Diagnosis of H. pylori-eradicated cancer is sometimes difficult, as the cancer lesions are often covered with non-neoplastic epithelium. It is important to inform patients that the risk of gastric cancer remains over the long term after H. pylori eradication and to offer them endoscopic surveillance, especially patients with corpus atrophy.
A 41-year-old woman presented with a positive fecal occult blood test. Colonoscopy showed a 20mm, elastic, hard lesion at the appendiceal orifice. Abdominal computed tomography revealed a protruding lesion in the intestine. Laparoscopic ileocecal resection was performed. Histological examination showed endometrial glands in the muscularis propria, consistent with appendiceal endometriosis. We report a patient with appendiceal endometriosis with intussusception.
A 75-year-old woman was admitted to our hospital because of obstructive jaundice and was diagnosed with perihilar cholangiocarcinoma by endoscopic retrograde cholangiopancreatography (ERCP). After the procedure, severe acute pancreatitis associated with walled-off pancreatic/peripancreatic necrosis (WON) occurred. Although we performed endoscopic ultrasound and percutaneous drainage, it was difficult to control the infection. Additionally, a fistula between the WON and sigmoid colon was found. Therefore, we planned to perform endoscopic closure of the fistula using an over-the-scope clip (OTSC) system as a minimally invasive therapy. We succeeded in closing the pancreatico-colonic fistula, and the WON disappeared. A pancreatico-colonic fistula caused by acute pancreatitis, is a rare but difficult complication to resolve. We found that fistula closure using the OTSC system could be an effective treatment, especially for patients in generally poor condition.
We report a case of anaplastic pancreatic cancer showing osteoclast-like giant cells, which was preoperatively diagnosed using endoscopic ultrasound (EUS)- fine needle aspiration (FNA). A 68-year-old woman underwent contrast-enhanced computed tomography (CT) for evaluation of recurrent acute pancreatitis. CT revealed a hypovascular tumor involving the head of the pancreas. EUS revealed a hypoechoic mass (12×11mm) in the head of the pancreas, and EUS-FNA performed for further evaluation revealed dysplastic cells suspicious for malignancy in addition to osteoclastic giant cells. Therefore, the patient was diagnosed with anaplastic pancreatic cancer with osteoclast-like giant cells. She underwent pancreatoduodenectomy, and the resected tumor (13×12mm in size) is the smallest pancreatic tumor recorded in the Japanese literature. The tumor was classified as TS1 according to the Japanese classification system of pancreatic cancers. The patient received postoperative S-1 adjuvant chemotherapy for six months, and she continues to do well without recurrence, 4 years and 9 months postoperatively.
Case 1 was a 61-year-old woman who underwent endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of suspected pancreaticobiliary maljunction. Case 2 was a 77-year-old man who underwent ERCP for examination of left intrahepatic bile duct dilation. Both patients had undergone preventive pancreatic stent placement for post-ERCP pancreatitis. In Case 1, the stent migrated while placing the pancreatic stent. In Case 2, the stent spontaneously migrated after stent placement. Both stents were retrieved by the small-diameter biopsy forceps that dwelled in the pusher catheter of the pre-loaded biliary stent. There are many cases in which it is difficult to retrieve a migrated pancreatic stent because of poor operability of the device in the main pancreatic duct. We report two cases in which the migrated pancreatic stent was effectively retrieved by a small-diameter biopsy forceps that dwelled in the pusher catheter.
Esophageal achalasia is a benign disease that causes insufficiency of the lower esophageal sphincter and impaired peristalsis of the esophageal body. However, patients with esophageal achalasia have a high degree of distress due to the difficulty in eating, and it is a disease that needs to be treated. Previously, balloon dilatation and Heller myotomy had been used to treat esophageal achalasia. In addition, per-oral endoscopic myotomy (POEM) has been developed. POEM is a minimally invasive treatment using an oral endoscope, and it is able to provide a long-term effect. At present, only a limited number of facilities in Japan are able to perform the POEM procedure. However, the interest in and recognition of esophageal achalasia itself are increasing with the spread of POEM. In this paper, we describe tips and troubleshooting when performing POEM.
Objectives: Accurate diagnosis of invasion depth is important for reliable treatment of esophageal squamous cell carcinoma (ESCC), but it is limited to the muscularis mucosae to slight submucosal invasion (MM/SM1). The diagnostic accuracy of invasion depth is unsatisfactory and remains to be improved. We aimed to investigate the association between the color of the superficial ESCC and invasion depth using linked color imaging (LCI) under light-emitting diode (LED) light sources.
Methods: Lesions diagnosed as superficial ESCC were observed using white light imaging and then by LCI. The color values were calculated using Commission Internationale de lʼEclariage - L＊a＊b＊ color space, and the color difference was calculated according to invasion depth. The vascular diameters and vascular angles of the intrapapillary capillary loops were pathologically analyzed. Their correlation with mucosal color was also investigated by LCI.
Results: In all, 52 lesions from 48 patients were analyzed. On the basis of invasion depth, the color difference between the normal mucosa and the lesion was larger in the MM/SM1 or deeper group than in the epithelium and the lamina propria mucosa (EP/LPM) group using LCI (P=0.025). The vascular diameter was positively correlated with the b＊ color value (correlation coefficient=0.302, P=0.033).
Conclusion: Observation using LCI under LED light sources may improve the endoscopic diagnosis of the invasion depth of superficial ESCC. Further research is needed to validate its usefulness. (UMIN000024615)