Personalized therapy for Helicobacter pylori eradication comprises optimal antimicrobial agents selected not only according to susceptibility testing but also individual patient characteristics, such as drug hypersensitivity and interactions with co-administered drugs. The eradication rate of the first-line treatment has been reportedly improved by personalized therapy using antibacterial agents selected based on bacterial susceptibility testing. In third-line therapy, a sitafloxacin-containing regimen is often used. For patients allergic to penicillin, a combination of metronidazole and clarithromycin or sitafloxacin is often prescribed. However, clarithromycin and metronidazole require caution in terms of their interaction with other concomitant drugs. Moreover, first- and second-line regimens for H. pylori eradication are inflexible in Japan’s health insurance guidelines. They should be modified to accommodate individual cases.

The prevalence of Crohnʼs disease (CD) has been increasing in Japan. If clinicians suspect a case of CD based on clinical symptoms and inflammatory findings on biochemical examination, the final diagnosis is confirmed by various morphological and histopathological findings. Although the process of diagnosis has not changed significantly, it has varied owing to the development of new diagnostic tools such as capsule endoscopy and balloon-assisted small bowel endoscopy. The common treatment options mainly include nutritional therapy and drug therapy. However, in recent years, the number of drug therapy options has increased with the addition of biologics and molecular targeted drugs. Shared decision making with patients is necessary to select effective and satisfactory treatment options. In addition, the current treatment of CD requires tight monitoring or “Treat to Target.”

A 66-year-old woman underwent upper gastrointestinal endoscopy, which revealed a whitish flat ridge (approximately 2 cm) with elongated villous protrusions covering the surface of the thoracic esophagus, together with small bumps, indicative of verrucous carcinoma (VC). Lugol chromoendoscopy showed lightly stained villous protrusions and dark staining of the base. Biopsy examination showed a slightly atypical cell type, and we could not exclude cancer, including VC; therefore, we performed ESD. Histopathological evaluation of the resected specimen confirmed diagnosis of a papilloma. Narrow-band imaging revealed villous protrusions with fine blood vessels without irregularity, similar to those observed in anemone-type papilloma. The aforementioned findings may be indicative of papilloma.

A 24-year-old woman with acute lymphoblastic leukemia underwent bone marrow transplantation after myeloablative conditioning with chemotherapy and total body irradiation. After transplantation, she developed graft-versus-host disease, which was treated with immunosuppressive therapy. Eighteen years later, she developed appetite loss and was referred to our hospital. Esophagogastroduodenoscopy screening revealed early esophageal squamous cell carcinoma in the upper thoracic esophagus, which was successfully treated with endoscopic submucosal dissection. Thereafter, she has been free from recurrence for 2 years. The patient had no common risk factors for esophageal cancer, such as male sex, drinking, or smoking. Thus, bone marrow transplantation was considered the main cause of esophageal cancer. Esophageal cancer is one of the most common solid tumors that develop after bone marrow transplantation. Furthermore, total body irradiation and chronic graft-versus-host disease are known risk factors for the development of esophageal cancer. For early detection of secondary esophageal cancer, endoscopic screening should be performed after bone marrow transplantation.

A 28-year-old woman presented to our department with a chief complaint of epigastric pain. Upper gastrointestinal endoscopy revealed multiple flat discolored areas in the posterior wall of the lesser curvature of the gastric angle, lesser curvature of the gastric antrum, and greater curvature of the lower body of the stomach. Pathological evaluation of the tissue biopsy sample suggested signet ring cell carcinoma. No evidence of Helicobacter pylori infection was observed in the background gastric mucosa. Based on the patientʼs age at the time of diagnosis and presence of multiple lesions, a probable diagnosis of hereditary diffuse gastric cancer was established; this was likely to be an isolated incident as the patient had no family history of this disorder. Accordingly, laparoscopic total gastrectomy was performed. Postsurgical pathological examination revealed 22 synchronous multiple intramucosal lesions, all of which had signet ring cell morphology. Genetic testing revealed a mutation in the gene encoding E-cadherin (CDH1), which led to the definitive diagnosis of hereditary diffuse gastric cancer. If a flat discolored area is found in the stomach of a young person not infected by H. pylori, it is important not to overlook multiple lesions and consider the possibility of hereditary diffuse gastric cancer.

A 51-year-old woman underwent screening total colonoscopy (TCS), which revealed a flat elevated cecal lesion (20mm) with an unclear margin and a whitish area (15mm) in the central part of the lesion. Magnifying endoscopy revealed microbubbles within the mucous membrane in the whitish area. Histopathological evaluation of biopsy specimens showed uniformly small vacuoles within the superficial lamina propria and cells that were immunonegative for S-100, D2-40, Factor Ⅷ, CD34, CD31, and CD68. Therefore, the lesion was diagnosed as colonic pseudolipomatosis. Follow-up TCS performed 4 months later showed that the lesion had spontaneously disappeared. Considering the optical mechanisms of reflection and scattering, which produce a whitish color, the endoscopic appearance in the present case is attributable to microbubbles. Magnifying endoscopy documented confirmation of microbubbles in the mucous membrane is important for diagnosis of colonic pseudolipomatosis.

Traction device-assisted ESD (TA-ESD) was developed to facilitate laborious ESD. Various traction devices have been developed to facilitate TA-ESD as the acceptability of the procedure has been increasing However, each device presents its own set of specific technical challenges. Therefore, their indications and techniques vary substantially. In February 2021, a novel multi-loop traction device (MLTD, Boston Scientific Japan, Tokyo) was released in the Japanese market. The device was developed by an academia-industry consortium established in 2014 at the department of endoscopy, the Jikei University School of Medicine to provide solutions for existing challenges in the field of gastrointestinal endoscopy. The device is designed as a triple-ring chain of light-weight resin measuring 19 mm in length. Because of its ideal size and lightness, the device can be delivered to a surgical field through an accessary channel using a regular endoscope and any type of endoclip. An endoscopist can create optimal strength of traction force on tissues toward any direction by attaching one end of the traction device on the edge of the surgically freed mucosal overlay and the other edge on the opposite site of the GI wall. In addition, the direction and force of traction can be changed intuitively by fixing the free second ring of the device on other locations on the GI wall. Finally, the light-weight device can be easily retrieved using biopsy forceps when the excised specimen is removed at the end of a procedure. In this article, we have reviewed previously published literature to discuss the advantages of the traction device-assisted technique. In addition, we have discussed the technological and procedural details of ESD using an MLTD.

Conventional white-light imaging is a fundamental modality for colonoscopy, while magnification endoscopy visualizes the superficial glandular microstructure that contributes to the qualitative diagnosis of colorectal polyps. Therefore, the Japanese medical guidelines recommend the combined use of both modalities for the diagnosis of colorectal polyps. Recently, narrow-band imaging with magnification endoscopy (NBIME) has been widely used owing to its clinical feasibility. Magnification chromoendoscopy using crystal violet (CV-MCE) visualizes the shape of a crypt opening (pit pattern) more clearly than NBIME. However, as CV-MCE is time consuming and potentially carcinogenic, it is likely to only be used for cases in which the diagnosis difficult using white-light imaging and NBIME. In addition to CV-MCE, NBIME with acetic-acid enhancement (A-NBIME) visualizes the pit pattern and is safer and quicker than CV-MCE. Furthermore, the pit pattern is gradually visualized using NBIME, which makes it easier to compare the endoscopic images captured by both modalities. Therefore, A-NBIME is a useful diagnostic modality in the clinical and academic field.

Background and Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is used for the histopathological diagnosis of any type of gastrointestinal disease. Few adverse events are experienced with this procedure; however, the actual rate of adverse events remains unclear. This study aimed to clarify the current status of cases that experienced adverse events related to the EUS-FNA procedure used for histopathologic diagnoses.

Methods: A retrospective analysis of cases with EUS-FNA-related adverse events in Japanese tertiary centers was conducted by assessing the following clinical data: basic case information, FNA technique, type of procedural adverse events, and prognosis.

Results: Of the 13,566 EUS-FNA cases overall, the total number of cases in which adverse events related to EUS-FNA occurred was 234. The incidence of EUS-FNA-related adverse events was ～1.7％. Bleeding and pancreatitis cases accounted for ～49.1％ and 26.5％ of all adverse events, respectively. Bleeding was the most common adverse event with only seven cases requiring blood transfusion. In cases with neuroendocrine tumors, pancreatitis was the most frequent adverse event. Needle tract seeding because of EUS-FNA was observed during the follow-up period in only ～0.1％ of cases with pancreatic cancer. There was no mortality because of adverse events caused by EUS-FNA.

Conclusions: This study revealed that the adverse events-related EUS-FNA for histopathologic diagnoses were not severe conditions, and had low incidence.