送気量の適切な調整は内視鏡診療において重要な手技であるが，送気量の調整は経験と感覚に頼ることが多く，修練医は空気量の調整に悩むことが多い．感覚的な送気量の調整を数値で表現できれば，修練医が適切な送気量を理解できる．今回我々は工業用の圧センサーと流量センサーを内視鏡に接続し，測定した腸管内圧と送気流量を，モニター上で確認しながら，大腸内視鏡検査を行った．送気により腸管が拡張すると，大腸内圧も上昇し，ほぼ無送気による挿入では腸管は拡張せず内圧も大気圧から上昇しなかった．今回，大腸内視鏡挿入から抜去まで腸管内圧と送気流量を計測できた．今後はさらにデータを集積することで臨床への効果を検証したい．

【背景】近年，無送気で消化管内を低圧環境下にし，水やゲルで満たした状態で内視鏡処置を行うWater Pressure Method（WPM）やGel Immersion Endoscopy（GIE）などが視野確保や内視鏡操作性向上および患者負担軽減に寄与する方法として注目されている．

【症例】69歳女性．上十二指腸角内側壁の30 mm，0-IIaに対しESDを施行した．病変は屈曲部に存在し内視鏡操作性不良だったがWPMに切り替えたことで操作性が顕著に向上した．治療中，視野確保困難な出血に見舞われたがGIE併用により瞬時に止血ができた．切除後の粘膜欠損部の縫縮も送気下から浸水下に切り替えることで腸管が虚脱し完全縫縮することができた．

【結論】十二指腸ESDにおいて，WPMやGIEの併用により困難克服することができた．

The purpose of this study was to investigate the efficacy and safety of palliative stent placement for colorectal stenosis due to peritoneal dissemination. We retrospectively reviewed twelve cases of stent treatment for colorectal stenosis due to peritoneal dissemination between January 2013 and December 2021. The bowel obstruction score (CROSS) was used as a measure of treatment effect. The technical success was 100%, the clinical success was 83%, and mean CROSS improved significantly from 0.75 to 3.5 points after treatment. There were no adverse events associated with stent placement, but long-term complications included stent occlusion in two patients. Stenting for colorectal stenosis due to peritoneal dissemination is considered safe and useful treatment for patients with a limited prognosis.

Background: We developed a new endoscopic resection method that combines endoscopic mucosal resection (EMR) with an over-the-scope clip (OTSC), termed EMR-O. In this study, we aimed to evaluate the short-term outcomes of EMR-O for colorectal tumors. Method: In total, 9 consecutive patients who underwent EMR-O from September 2017 and October 2022 were retrospectively enrolled. Patients' characteristics and treatment outcomes were evaluated. Result: The En bloc and R0 resection rates were 100% and 89%. The median resected specimen size was 16 (10-27) mm, with a median resected tumor size was 8 (5-17) mm. The median procedure time was 10 (7-15) min. There were no intraoperative or delayed perforation and postoperative bleeding. Discussion: Although EMR-O has limitations in target lesion size, it has the advantages of a short procedure time and the prevention of perforation.

An 80-year-old man underwent esophagogastroendoscopy, which revealed a white flat-elevated lesion (5 mm) with a reddish depression in the center and was diagnosed with superficial esophageal cancer. The lesion resembled a submucosal tumor, and deep submucosal invasive cancer was suspected. We performed endoscopic submucosal dissection, and histopathological evaluation of the resected specimen showed intramucosal basaloid carcinoma. BSC usually shows poor prognosis; however, curative resection was achieved owing to early detection in our patient. Retrospective review of previous endoscopic findings showed the lesion in images obtained six months prior to presentation; however, the changes in the lesion were scarce. This case report highlights changes in the initial findings of Basaloid carcinoma over time, which will benefit clinicians in routine practice.

60s male who had undergone multiple balloon dilatations for esophageal stricture after two endoscopic submucosal dissection procedures suffered perforation of the esophagus during the fourth dilatation. The prognosis was considered good, and the patient was hospitalized and treated conservatively with drainage tubes placed in the esophagus and stomach. On the 6th day, blood tests and CT scan showed improvement, so the drainage tube was removed and the patient resumed drinking on the 8th day. On the 12th day, esophagography confirmed that there was no problem, and enteral nutrition was started, and the patient was discharged on the 14th day. Esophageal perforation caused by balloon dilation can avoid surgical treatment by choosing conservative treatment if the prognosis is judged to be favorable.

A hemodialytic male in his 60s presented with intermittent chest pain and coffee-ground emesis. Esophagogastroduodenoscopy showed a well-circumscribed area with indistinct vascular pattern in the middle esophagus, followed by blackish ulcerative mucosa at the distal esophagus, ending abruptly at the squamocolumnar junction, which findings were compatible with AEML. With fasting and proton-pump inhibitors, his symptoms rapidly resolved. He did not appear at the follow-up appointment one month after hospital discharge. Five months after hospital discharge, he suffered cardiac arrest and died. AEML is an acute erosive esophagitis whose endoscopic appearance resembles that of severe reflux esophagitis (sRE). Our case-control study showed higher mortality from AEML than from sRE. The endoscopic finding of "well-circumscribed esophageal mucosa with indistinct vascular pattern" could be an endoscopic feature of AEML, and may be useful for distinguishing AEML from sRE.

A 30-year-old male arrived at our hospital with fever, bloody stools (5-6 times/day), abdominal pain, and chest tightness which had lasted for 20 days. He was admitted to our hospital on the same day as his blood test revealed high inflammation and CT showed thickening of the intestinal wall. Colonoscopy revealed Matts classification grade 3 ulcerative colitis (UC) of the whole colon. Esophagogastroduodenoscopy (EGD) revealed punched-out ulcers in the mid intrathoracic esophagus, but pathological examination revealed only nonspecific inflammatory cell infiltration, with no granuloma or cellular atypia, and immunostaining was negative for CMV, HSV-1, and HSV-2. Mesalazine 4800 mg was started for UC, and subjective symptoms improved. UC was relieved by repeat colonoscopies, and the esophageal ulcers were relieved by EGD. The esophageal ulcers improved with UC only with 5-ASA preparations, suggesting a relationship with UC.

A 74-year-old woman undergoing hormone therapy for breast cancer at our hospital visited our department because of dysphagia and difficulty with oral intake. Examination revealed stenosis of the cervical esophagus and accumulation of food residues on the oral side of the stenosis. No lesion was found outside the esophageal wall but upper gastrointestinal endoscopy revealed a circumferential constriction of the esophagus with a smooth mucosal surface 20 cm from the incisors, and biopsy confirmed esophageal metastasis of the breast cancer. Tumors not exposed to the esophageal lumen can sometimes be missed even with multiple biopsies and may thus be difficult to diagnose. In such cases, use of boring biopsy and endoscopic ultrasound-fine needle aspiration can be useful for diagnosis.

In general, perforation of the esophagus is a rare event during endoscopic submucosal dissection (ESD). However, perforation of the esophagus can lead to mediastinitis, which can have a serious outcome. We experienced a perforation due to a partial muscle layer defect during esophageal ESD. We interrupted the ESD and promptly performed appropriate treatment, which may have avoided a serious complication. A muscular layer defect was identified in the subsequent surgical specimen. Since it is difficult to predict a muscular defect before treatment by ESD begins, it is important to make appropriate decisions when a perforation is encountered during esophageal ESD.

A Japanese man in his 60s had undergone Billroth-II reconstruction for duodenal ulcer at 18 years of age. Five years ago, a gentle elevation at the anastomosis became prominent. This corresponded to the area of ectopic gastric glands, but no malignant findings were observed. Endoscopic examination performed 14 months ago revealed an irregular small depression over the above-mentioned elevation, and biopsy examination revealed poorly differentiated adenocarcinoma. Total resection of the residual stomach was performed. Pathological examination showed that gastric-type intramucosal carcinoma originated directly above the submucosal ectopic gastric glands and invaded the area of submucosal ectopic gastric glands.

Submucosal ectopic gastric glands may be a risk factor for gastric cancer. Careful endoscopic observation is necessary in such patients.

The patient was a man in his 70s. During hospitalization for glycemic control for diabetes mellitus, an upper gastrointestinal endoscopy was performed. Endoscopic ultrasound revealed infiltration into the proper muscle layer, and laparoscopic pyloric gastrectomy was performed. Gastrointestinal stromal tumor was observed incidentally in the vicinity of gastric cancer in the resected specimen. Gastric cancer and GIST complications are extremely rare, and we report them with a review of the literature.

The case was 60 year-old female. She visited the clinic for examining a submucosal tumor of the greater curvature of the middle body of the stomach. Blood examinations showed mild anemia, and serum amyloid A was within normal range. Endoscopic ultrasonography showed that the lesion had a uniform hypoechoic interior and localized in the third layer. A small amount of amyloid deposits was found in the biopsy specimen histologically. No significant changes in lesion size were observed one year later, and biopsy showed no amyloid deposits. Endoscopic submucosal dissection (ESD) was performed for diagnosis and treatment. Histopathological examination showed amyloid deposits throughout the resected lesion. In addition, immunostaining was positive for AA amyloid protein, therefore, the diagnosis of the SMT was AA amyloidosis. The patient had no amyloid deposits in other organs and was diagnosed with gastric-limited AA amyloidosis. Here, we reported a rare case of gastric limited amyloidosis diagnosed by ESD.

The Case was a 80-year-old male. Three years before his first visit, we detected atrophic gastritis and an H. pylori infection during an endoscopy. Both the primary and secondary eradication attempts were unsuccessful.

One year before his first visit, a hyperplastic polyp was detected in a follow-up endoscopy and he started on an oral PPI administration for reflux esophagitis. He was referred to our hospital because the polyp was enlarged to 30 mm.

Eight months after the first visit and after a successful third eradication, the polyp was enlarged to 60 mm. ESD was performed due to suspicion of a malignant tumor complication. The size of the resected lesion was 80 mm × 38 mm. Histopathological findings showed a hyperplastic polyp and no malignant findings were noted.

We report here a case of rapid growing giant gastric hyperplastic polyp, which implies an association between polyp enlargement and hypergastrinemia caused by long-term use of PPI.

Gastrointestinal bleeding and esophageal varices are adverse events that can occur following the introduction of molecular-targeted drugs for hepatocellular carcinoma. We report a case of ruptured gastric varices after the introduction of a molecular-targeted drug. The patient underwent repeated hepatic artery chemoembolization for hepatocellular carcinoma. Sorafenib was introduced for lung metastasis, followed by the progression of anemia. An upper gastrointestinal endoscopy confirmed the diagnosis of ruptured gastric varices, and endoscopic variceal sclerotherapy was performed. In this case, stable gastric varices ruptured after the introduction of sorafenib, suggesting that sorafenib was likely involved in the variceal rupture. Careful follow-up or pre-introduction sclerotherapy and IVR may be necessary when administering molecular-targeted drugs to patients with gastric varices.

We present an 84-year-old female patient with a colostomy for pelvic recurrence of esophagogastric junction cancer (T3 N2 M0, StageIIIA). Four months postoperatively, she complained of cessation of colostomy output and abdominal pain. The colostomy was stenosed owing to the progression of peritoneal metastases. We placed a self-expanding metallic stent (SEMS) via the colostomy site. Her abdominal distention improved once she passed stool. She started to eat from the next day and was discharged from the hospital 11 days later. Stenting for malignant stenosis of a colostomy may effectively improve the quality of life at the end of life in patients with peritoneal dissemination.

The patient was a 77-year-old woman who was admitted to our hospital because of heart burn and upper abdominal pain.

Endoscopy showed the rapsberry-like protruded lesion at the greater curvature of the lower body.

Narrow band imaging with magnified endoscopy showed the tumor was a papillary surface structures of varying sizes, a dilated intervening part with irregular microvascurality and a thinned white zone.

Pathological examination of the biopsy a specimen revealed a mild atypical ductal structure and a mild irregular arrangement of nuclei.

Endoscopic submucosal dissection was done, and histopathologically, tumor was a well differentiated tubular adenocarcinoma.

Immunohistochemical staining showed that the neoplasm was positive for MUC5AC and negative for MUC2, MUC6, CD10, indicating that it was a foveolar-type gastric adenocarcinoma.

The patient had no history of Helicobacter pylori eradication therapy and without Helicobacter pylori infection.

A woman in her 80s underwent routine esophagogastroduodenoscopy (EGD). In X-9 year, a whitish mucosal lesion with dilated vessels was found on the posterior wall of the cardia. Biopsy examination showed that it was not malignant. In X year, biopsy examination of this lesion revealed gastric adenocarcinoma of the fundic gland type, and endoscopic submucosal dissection was performed. Upon reviewing previous endoscopic images obtained from the patient, the lesion was identified in an EGD image obtained in X-15 year. In X-11 year, the patient underwent H. pylori eradication therapy, but generally there was no significant change in endoscopic findings. We report a case of gastric adenocarcinoma of fundic gland type that was followed over a long period.

An 80-year-old man with a chief complaint of anemia underwent upper gastrointestinal endoscopy, and a 25-mm, white-toned, and elevated lesion was found on the posterior wall of the lower gastric body. Histopathological analysis revealed that the lesion was a mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) comprising adenocarcinoma and neuroendocrine tumor. This patient had an intramucosal carcinoma with a G1-equivalent neuroendocrine neoplasm (NEN) component, and no apparent recurrence 6 months after endoscopic submucosal dissection (ESD) resection. MiNEN is a relatively new concept, which was modified in the 2019 World Health Organization (WHO) classification, and there is currently a lack of an established treatment and evidence for this disease. Reports of endoscopic resection of early gastric MiNEN are rare. We here report a case of successful endoscopic resection in a patient with MiNEN, together with a literature review.

A 70-year-old man who visited our hospital with low platelet count and positive serum H. pylori antibodies, a condition which had persisted for 10 years. Based on blood test results at the first visit, the patient was diagnosed with immune thrombocytopenia (ITP). Upper gastrointestinal endoscopy performed before H. pylori eradication revealed 0-IIc in the posterior wall of the upper greater curvature of the gastric body. Since endoscopic treatment for greater curvature of the gastric body would not be able to control bleeding, H. pylori eradication was first performed in anticipation of an increase in platelet count. One month after eradication treatment, platelet count rose to 128,000/μL, indicating endoscopic submucosal dissection (ESD). As expected, major bleeding occurred during the treatment, but en bloc excision of the lesion was possible without complications. No bleeding occurred after ESD. Histopathological diagnosis was 0-IIc, 30×27 mm, tub1, pT1b (SM1 130 μm), ly0, v0, pUL (-), pHM0, pVM0. We report a case of early gastric cancer associated with ITP in which ESD was safely performed after H. pylori eradication.

A 73-year-old man with melena was transferred to our emergency room. His hemodynamic status was stable and he had abdominal pain without peritoneal signs. He was anemic (hemoglobin, 5.3 mg/dL). Contrast-enhanced abdominal computed tomography showed focal discontinuity of the mucosal hyperenhancement in the stomach and the possibility of intra-abdominal free air. After consultation with the surgeon, conservative treatment without endoscopy was administered. On the 10th day, the patient suddenly went into cardiac arrest due to hemorrhagic shock. After resuscitation, intra-aortic balloon occlusion (IABO) was performed and emergency endoscopy revealed active spurting from a gastric ulcer. Inflating the IABO balloon not only controlled his blood pressure but also improved endoscopic visibility, and hemostasis was achieved. After the balloon was deflated, his blood pressure remained unstable, although active bleeding was not found by endoscopy. Transcatheter arterial embolization of a branch of the left gastric artery was performed, and his hemodynamic status became stable.

Inflating the balloon cephalad to the celiac artery reduced hemorrhage. IABO is effective for improving not only hemodynamics but also endoscopic visibility in patients with gastrointestinal bleeding.

A 66-year-old man visited our hospital and was diagnosed with Lemierre's syndrome. The patient also developed sepsis and was treated with antibiotics. NSAIDs and PPI were prescribed for the pain. On day 9 of hospitalization, the patient developed melena and presented with hemorrhagic shock. Emergency upper gastrointestinal endoscopy revealed multiple bleeding postbulbar duodenal ulcers and hemostasis was performed by clipping methods, hypertonic saline epinephrine local injection, and soft coagulation. Subsequently, he developed several more duodenal ulcers and on day 29 of hospitalization, the patient again developed melena and hypotension. Emergency upper gastrointestinal endoscopy revealed multiple bleeding postbulbar duodenal ulcers and since it was difficult to identify the bleeding point, hemostasis was performed by clipping methods using gel immersion endoscopy (GIE). The endoscopy on the 43rd day showed that the ulcer was improving, and the patient was discharged on the 58th day. GIE was useful in the hemostatic treatment of refractory bleeding postbulbar posterior duodenal ulcer.

An 18-year-old Japanese woman with no medical history visited a nearby hospital for vomiting. She was diagnosed with superior mesenteric artery syndrome and had a nasojejunal tube placed. Although she was started on tube feeding, the vomiting recurred, and jejunal obstruction was suspected on a small bowel series. She was transferred to our hospital for treatment. We performed a computed tomography examination that revealed a mass lesion in the jejunum. Single-balloon enteroscopy was performed that showed a neoplastic lesion with ulcer, which was diagnosed as diffuse large B-cell lymphoma (DLBCL) based on biopsies. The lesion was considered primary, and a partial resection of the small intestine was performed. Histopathological examination confirmed the diagnosis of DLBCL and no metastases in the resected lymph nodes. The possibility of a tumor should be considered even at a young age, and aggressive examination will be helpful for early detection.

A 68-year-old man was admitted to our hospital due to abdominal pain and nausea. Abdominal computed tomography showed the 30 mm gallstone obstructed the transverse part of the duodenum. Therefore, gallstone ileus with a cholecystoduodenal fistula was diagnosed. During treatment, the 32 mm stone in the gallbladder moved to the transverse part of the duodenum. We tried to crush and remove the stones using mechanical lithotripsy, however the procedure was unsuccessful. Therefore, a laparoscopic surgery was performed, and approximately two 45 mm gallstones were removed from the ileum. Considering the size and number of stuck gallstones, this case is difficult to remove the gallstones with endoscopic treatment. Here, we describe the treatment of the gallstone ileus with a cholecystoduodenal fistula, with a review of the literature.

We report two cases of Dieulafoy's lesions treated by double-balloon endoscopy (DBE). The first case involved an 80-year-old woman with repeated hematochezia. Capsule endoscopy revealed blood accumulation in the ileum. An ileal Dieulafoy's lesion was identified by transanal DBE. Endoscopic clipping was successfully performed for the visible vessel. The second case involved an 85-year-old woman with repeated melena. Capsule endoscopy revealed blood accumulation in the jejunum. Per-oral DBE identified pulsating bleeding. Hemostasis using hemoclips and endoloop was performed for a Dieulafoy's lesion with a visible vessel. Melena recurred after 2 months, and per-oral DBE was repeated, which revealed a visible vessel at the same site. The vessel was successfully treated by endoscopic clipping. If small bowel bleeding is suspected, capsule endoscopy should be used to identify the bleeding site, and DBE should be repeated until hemostasis is confirmed.

Mucosal prolapse syndrome (MPS) is a benign inflammatory disease that causes symptoms such as blood-stained stools and anemia. It is caused by the excessive mechanical stimulus of straining in patients with chronic constipation. The basic treatment of MPS is to normalize the defecation, but surgical therapy is effective for treatment of resistant cases. A 30-year-old man presented with blood-stained stools and anemia due to MPS and had been treated conservatively for three years. However, the blood-stained stools have been bothering him. Colonoscopy revealed two lesions in the rectum and we performed endoscopic submucosal dissection (ESD) of the two lesions. He has had no symptoms for three years after ESD. This case shows that ESD can be effective for symptomatic MPS.

A woman in her 70s was diagnosed with a 4 cm-diameter colonic lipoma following a hematochezia. Because it is generally reported that colonic lipomas larger than 4 cm in diameter cause intestinal accumulation about 70% of the time, prophylactic resection is desirable. Although surgery is often performed when the colonic lipoma is larger than 4 cm in diameter, we carried out endoscopic treatment to remove the tumor in consideration of the patient's wishes. Endoscopic Submucosal Dissection (ESD) was originally planned, but ESD was deemed too risky and switched to ischemic treatment. The SB knife Jr2^®, one of the scissor-type knives, is very safe and effective for endoscopic treatment of movable colonic lipomas. Ischemic treatment with a snare is also effective in treating lipomas.

A 76 year old female came to the outpatient clinic with a chief complaint of a string-like appearing substance in her stool. A fecalysis was done at our institution which showed the presence of eggs of Diphyllobothrium nihonkaiense. During hospitalization, a nasal endoscope was inserted into the descending duodenum followed by injection of 400 ml of gastrografin into the intestinal tract through the biopsy port; all were done under fluoroscopy. Expulsion of the worms was confirmed thirty minutes after gastrogafin injection. To date, this is the first reporting of Diphyllobothrium nihonkaiense treatment using nasal endoscopic gastrografin injection along with supplemental information from previous literatures.

We report the case of a man in his thirties with chronic hepatitis C who was treated with a direct-acting antiviral (DAA); Glecaprevir / Pibrentasvir combination tablet. After five weeks, he had diarrhea three to four times per day, and after seven weeks, he had 10 episodes of bloody and watery diarrhea per day with a fever of 38°C. Colonoscopy revealed erythema, loss of normal vascular pattern, erosions, friability, bleeding, purulent exudate and ulcerations without skip areas. Histopathologic findings revealed marked increase of inflammatory cell infiltration, Goblet cell depletion, mucosal distortion, cryptitis and crypt abscess. The diagnosis was ulcerative colitis. Although he had been treated with oral 5-aminosalicylic acid drugs, symptoms deteriorated; therefore, steroid therapy was started in hospital. The steroid therapy was effective; thereafter, outpatient treatment was continued. After six months, colonoscopy revealed inflammatory improvement. He had been treated with oral 5-aminosalicylic acid drugs and maintained state of remission. Furthermore, DAA therapy led to a sustained virological response.

We report a case of a woman in her sixties whose fecal immunochemical testing results were positive during a physical examination. She had been previously diagnosed with chronic gastritis and taking Rikkunshi-Tou. Colonoscopy revealed multiple cystic nodular lesions, with mucosal hyperemia and erosions in the ascending colon. Prior to nodular lesion removal, we attempted to lift the lesion from the submucosal layer by saline injection until saline spouted from top of the lesion. Next, we snared and partially dissected the lesion. Histopathological finding revealed inflammatory cell infiltration and increased capillary vessels. Furthermore, we dissected the cystic nodular lesion and a hollowed-out cystic wall was visible. Histopathological finding revealed inflammatory cell infiltration but the presence of a cystic wall could not be confirmed. Abdominal CT revealed multiple grape-like gas clusters in the ascending colon. The patient is being followed up regularly.

With the widespread use of immune checkpoint inhibitors (ICIs) to treat cancer, immune-related adverse events (irAEs) have become a topic of research. Gastrointestinal disorders, such as diarrhea and colitis, are frequently occurring irAEs, particularly grade 3-5 irAEs. Here, we report two cases of ICI-associated colitis with contrasting outcomes. Colonoscopy findings of colitis due to ICI are erythema, luminal bleeding, erosions, and ulcerations, which are nonspecific findings. Biopsy is necessary for a definitive diagnosis. Both cases showed CD8+ lymphocyte infiltration, leading to the definitive diagnosis. Early diagnosis and intervention for ICI-associated colitis improve the prognosis, and colonoscopy and mucosal biopsy should be performed promptly when ICI-associated colitis is suspected.

We report a case that use of the cholangioscopy retrieval devices allowed successful migrated biliary stent in several failed extraction attempts with standard techniques.

Patient is 73-year-old man who had undergone cholangiography for obstructive cholangitis and developed biliary 7 Fr 9 cm plastic stent. However, subsequent cholangiography showed that the stent had migrated to bile duct. The stent couldn't be retrieved by basket and extraction balloon. Later, the stent retrieval by SpyBiteMax with Cholangioscopy (SpyGlassDS) was difficult. Finally, use of the cholangioscopy retrieval device (9 mm SpySnare) allowed successful stent removal.

The outcomes of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for suspected postoperative recurrence of biliopancreatic malignant tumors from 2018 to 2021 were investigated, including eight cases. The median age was 68 years (range: 45-85), including five males and three females (five with pancreatic cancer, one with pancreatic neuroendocrine tumor, one with distal bile duct cancer, and one with intraductal papillary mucinous carcinoma). Target lesions included five remnant pancreas, one soft tissue around the celiac artery, one liver, and one mediastinal lymph node. The median lesion diameter was 15 mm, and the needle gauge was 22 G in six cases and 25 G in two cases. Pathological diagnosis was possible in all cases, with no adverse events. EUS-FNA is a powerful modality to diagnose the recurrence of biliopancreatic malignancies.

The patient was a 55-year-old woman who developed acute cholangitis due to a severe hepaticojejunostomy anastomotic stricture after undergoing pancreatoduodenectomy for pancreatic cancer. At the previous hospital, percutaneous transhepatic biliary drainage was performed to relieve cholangitis. The patient was referred to our hospital for an EUS-guided choledochojejunostomy (EUS-CJS). Using a forward-viewing echoendoscope, the common bile duct was visualized at the scarred anastomosis site and punctured with a 19-gauge needle. A double-lumen catheter was used to successfully insert guidewires into the hepatic ducts on both sides. After dilation of the anastomosis using a dilation balloon catheter, a fully covered self-expanding 10-mm diameter metallic stent and 7 Fr plastic stent were placed for the anastomotic stricture. No adverse events occurred during the procedure, the stent placement, or in the next 6 months. The stent was successfully removed, creating a firm fistula. The patient reported no fever or abdominal pain and had normal biochemical blood test results during the 7-month follow-up after stent removal. In conclusion, EUS-CJS using a forward-viewing echoendoscope may be a useful salvage procedure in cases with refractory anastomotic stricture.

The patient was a 55-year-old man who developed acute cholangitis with intrahepatic bile duct stones due to hepaticojejunostomy anastomotic stricture after subtotal stomach-preserving pancreatoduodenectomy. As an initial treatment, single balloon enteroscopy-assisted ERCP (SBE-ERCP) was performed, but the anastomosis site could not be identified. Thus, temporary EUS-guided hepaticogastrostomy was performed for biliary drainage with a 7 Fr plastic stent. After improvement of cholangitis, re-SBE-ERCP was performed, and the catheter was successfully inserted into the bile duct targeting the previously implanted plastic stent by applying the EUS-rendezvous technique (EUS-RV), and a 7 Fr plastic stent was placed through the anastomosis to the anterior and posterior of the right intrahepatic branches. In addition, a covered self-expandable metallic stent was placed in the left hepatic duct. Approximately 3 months after placement of the stent, the intrahepatic bile duct stones initially observed had disappeared, and upon stent removal, a firm fistula was created. The patient had no recurrence until 10 months after stent removal. In conclusion, EUS-RV may be a useful salvage procedure in cases where the anastomosis site cannot be identified.

A 84-year-old woman was referred to our hospital to find out the cause of weight loss. A computed tomography showed multiple enlarged lymph nodes, the mass near by the lesser curvature of the stomach and the mass of right hepatic robe. We couldn't identify the primary cancer. The mass near by the gastric lesser curvature was suspected to be an enlarged metastatic lymph node, and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for pathological diagnosis. Based on clinicopathological and immunohistochemical features of the tumor, it was diagnosed with high-grade serous carcinoma, and estimated ovarian origin. In women, we should consider the possibility of the gynecological tumors as a differentiation of cancer of unknown primary origin. EUS-FNA is useful for making histological diagnosis.

A man in his 70s presented to a previous hospital with general malaise, night sweats, and anorexia. Blood tests revealed liver dysfunction, increased inflammatory response, and elevated serum Interleukin-2 receptor levels, raising the suspicion of malignant lymphoma. Computed tomography revealed hepatosplenomegaly, but no swollen lymph nodes suitable for biopsy were detected. The patient was referred to our department for a biopsy of the enlarged liver and spleen. Endoscopic ultrasound-guided fine-needle biopsy was performed on the enlarged liver and spleen, and the pathological results revealed diffuse large B-cell lymphoma. Subsequently, the patient was transferred to the Department of Hematology and chemotherapy was started.

A 68-year-old man presented with a history of Billroth II gastrectomy for duodenal ulcer. A follow-up CT scan for alcoholic chronic pancreatitis revealed a pancreatic stone in the main pancreatic duct (MPD) of the pancreatic head and upstream ductal dilation. Therefore, endoscopic treatment in combination with extracorporeal shock wave lithotripsy (ESWL) was selected. The reconstructed intestine was expected to be difficult to approach by the transpapillary procedure. Hence, endoscopic ultrasonography-guided antegrade treatment (EUS-AG) was implemented. First, an endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) was performed, and a plastic stent was placed in the MPD and the stomach. ESWL was performed after the formation of gastro-pancreatic duct fistula. ESWL was administered to fragment the stone. The stones were then removed using EUS-AG. No procedure-related adverse events were observed. Using EUS-AG for treating pancreatic stone diseases that are difficult to approach by the transpapillary procedure may be a useful alternative.

A 79-year-old man had undergone an extended cholecystectomy (pStage I) for gallbladder cancer three years previously. Contrast-enhanced computed tomography showed a 25-mm hypovascularized hepatic mass in the left lateral lobe. Because we would not have been able to obtain adequate samples from the lesion using ultrasound-guided biopsy, we performed ultrasound-guided fine needle aspiration (EUS-FNA). The patient was diagnosed with liver metastasis secondary to gallbladder cancer. Our findings suggest that EUS-FNA may be useful for the histological diagnosis of left hepatic lobe lesions that are difficult to puncture percutaneously.

A 29-year-old man with a history of alcohol-induced severe acute pancreatitis presented to our hospital with epigastric pain. Laboratory studies showed elevated C-reactive protein levels and pancreatic enzyme levels. Abdominal contrast-enhanced computed tomography findings showed walled-off necrosis (WON) with extravasation from a branch of the left gastric artery; therefore, we performed transcatheter arterial embolization. Ten days later, epigastric pain recurred with fever, and laboratory studies showed further increase in peripheral white blood cell count and C-reactive protein levels. The WON was considered infected, and a lumen-apposing metal stent (LAMS) was inserted transgastrically. Subsequently, the WON area reduced, and the patient recovered. The treatment with LAMS was effective in draining the infected WON. It is important to seek appropriate treatment based on the details of the WON and the patient's progress.

A 59-year-old man with no medical history presented at our hospital with persistent orbital pain since the previous day. Blood tests revealed elevated hepatobiliary and pancreatic enzymes. Computed tomography (CT) showed no bile duct stones, only elevated peripancreatic lipid concentrations. Magnetic resonance cholangiopancreatography (MRCP) revealed a 3.5 mm defect in the lower bile duct and the patient was diagnosed as having acute cholangitis and gallstone pancreatitis. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed to confirm the bile duct stones, and implant a 7 Fr × 7 cm plastic stent. The patient was discharged on post-operative day 12. Two months later, the patient underwent stone removal; the retrieved stones were found to be mainly composed of cholesterol. When acute cholangitis or gallstone pancreatitis is suspected and urgent ERCP is necessary, it is important to perform MRCP if the stones cannot be confirmed using CT.