Aim: This study aimed to evaluate the efficacy and safety of endoscopic resection with one port placement (EROPP) and endoscopic full-thickness resection (EFTR) for gastric gastrointestinal mesenchymal tumor (GIMT).

Methods: This retrospective study included 38 patients with gastric GISTs originating from the muscularis propria who underwent EROPP and EFTR between 2019 and 2023. EROPP was performed as follows. One camera port was inserted in the umbilicus before initiating the endoscopic procedure to maintain intra-abdominal pressure, which was monitored and adjusted via this port.

Results: The median operative time, the En block resection rate and the R0 resection rate of EROPP and EFTR were 50/48 min, 100/100%, 81/100% respectively. In the EROPP group, only one patient had Clavien-Dindo grade IIIa postoperative delayed perforation. This patient recovered after endoscopic treatment including the polyglycolic acid shielding and the OTSC.

Conclusion: EROPP is excellent not only in terms of safety but also in the introduction of EFTR procedures.

Objective: Recently, the number of people infected with Helicobacter pylori has decreased. Our purpose was to clarify the transition and current situation of gastric cancer detected during endoscopic screening.

Methods: A total of 159,995 persons underwent endoscopic examination in our health management center from 2008 to 2022. We divided the period into group A from 2008 to 2012, group B from 2013 to 2017, and group C from 2018 to 2022, and compared the clinicopathological characteristics of gastric cancer.

Results: The gastric cancer detection rate was 0.23% in group A, 0.18% in group B, and 0.13% in group C. Regarding H. pylori infection status, the proportion of current infected patients decreased, and the proportion of uninfected patients increased. In H. pylori-uninfected cancers, the proportion of signet-ring cell carcinoma decreased, and the proportion of foveolar type adenocarcinoma increased.

Conclusions: The detection rate of gastric cancer has gradually decreased. There was a relative increase in the proportion of H. pylori-negative gastric cancer, especially H. pylori-uninfected gastric cancer.

At our acute phase hospital, emergency endoscopy cases and patients requiring endoscopy procedures performed by the bed side in the intensive care unit are on an increasing trend.

We herein report two patients with using a novel disposable endoscope that became available in Japan in March 2023 which we introduced previously.

In both patients, hemostatic clamps were applied and hemostasis was ultimately achieved by local injection of cyanoacrylate. At the time of using cyanoacrylate, there was a high possibility of endoscopy damage, and it was thought that the use of an endoscope was useful.

Learning endoscopic submucosal dissection (ESD) techniques requires acquiring the skills of experts through repeated practice. However, the time commitment for training is a significant issue that needs to be addressed, especially when trying to balance academic activities and family life. In this study, two trainees and one doctor from the United States utilized the G-master model for practical training in ESD. The completion rate within 30 minutes, without assistance, was 40% (2/5), whereas all the cases with traction assistance (5/5) were completed by trainees only. The use of traction had a positive effect, reducing resection time and improving operability. Notably, an ESD-inexperienced physician successfully performed clinical ESD immediately after the training with G-master. By incorporating a traction aid for G-master, trainees can learn the technique in a shorter period of time, allowing them to allocate more time to other tasks. This practical training approach is also applicable to foreign physicians, enhancing the ability of our Japanese staff to communicate and teach in English. Overall, this study demonstrates the effectiveness of using the G-master model with traction assistance for efficient ESD training, which can help improve training efficiency and maintain a better work-life balance.

Background: We introduced Underwater colonoscopy (UC) to eliminate the discomfort during lower gastrointestinal endoscopy. Between June 2018 and December 2023, we performed UC on 2553 cases and underwater polypectomy including endoscopic mucosal resection (EMR), hot and cold polypectomy on 2371 cases. We often experienced the difficulty of a secure field of vision due to the bleedings causing to several procedures during UC. Therefore, we applied Viscoclear™ in the examination of colonoscopy.

Materials and Methods: We performed UC in 1217 cases from January 2022 to December 2023, and used Viscoclear™ for 76 cases (6.2%) with the difficulty of secure field of vision due to bleedings during the procedure. They consisted of a biopsy from advanced colonic cancers in 2 cases, EMR in 2 and cold polypectomy in 72, respectively.

Results: We could get good fields of vision during colonoscopy in all of 76 cases. There were no adverse events and complications during the procedure.

Conclusion: The use of Viscoclear™ brought to a safe treatment with a fixation of bleedings and a good field of vision for the case which it is difficult to secure visual field against a bleeding during the procedure of UC.

An 80-year-old man presented to our hospital with anorexia. An esophagogastroduodenoscopy revealed a type 1 tumor occupying the esophagus and a diagnosis of esophageal carcinosarcoma was made. A palliative irradiation was planned, but as tumor invasion into the thoracic aorta was suspected on enhanced computed tomography, a thoracic endovascular aortic repair (TEVAR) was performed to prevent aorto-esophageal fistula (AEF). AEF has been reported to occur in 14.6% of patients during and after chemoradiotherapy for esophageal cancer invading the aorta and is fatal. This case suggests that prophylactic TEVAR and radiotherapy may improve the quality of life of patients with esophageal carcinosarcoma invading the aorta.

We report a case in which EUS-FNA was performed and pathological diagnosis was obtained for a lung mass that was difficult to diagnose by endobronchial ultrasonography using a guide sheath (EBUS-GS). A patient in his 50s with chronic pancreatitis was diagnosed with a nodule detected in the left pulmonary apex on computed tomography (CT). Three years later, the patient was referred to our hospital for EBUS-GS because the nodule showed an increasing trend on CT, but no pathological diagnosis was obtained. EUS-FNA was performed because the pulmonary mass was suspected to have invaded the mediastinum; it was possible to puncture the pulmonary mass without involving the lung parenchyma. The EUS finding from the cervical esophagus revealed a 20 mm-sized hypoechoic mass with irregular margins, which was punctured twice using a 22-gauge biopsy needle. A pathological diagnosis of lung adenocarcinoma was obtained. There was no adverse event related to EUS-FNA. Surgical resection was performed later. In conclusion, pathological diagnosis of primary lung cancer by EUS-FNA can be safely performed only in cases of mediastinal invasion adjacent to the esophagus.

A 90-year-old man with aortic stenosis was admitted to our hospital for anticoagulation and rate control of new atrial fibrillation. He started to administrate edoxaban. He was consulted to our department for a thorough examination because of continued anorexia. An esophagogastroduodenoscopy revealed esophagitis with easily exfoliated white lichen deposits in the lower esophagus. The histopathological assessment of the lesion showed consistent findings of exfoliative esophagitis, suggesting drug-induced esophagitis. After edoxaban was switched to rivaroxaban as anticoagulant, anorexia improved without any other symptoms.

A 70-year-old man underwent endoscopic submucosal dissection (ESD) for superficial esophageal cancer. Steroids were injected three times, including as an outpatient, to prevent stricture. On postoperative day 15, the patient presented to the outpatient clinic with chest pain and fever. Given the suspicion of mediastinitis, the patient was promptly admitted. Conservative treatment with antimicrobial agents was initiated, but the inflammatory response did not improve. On the eighth day of hospitalization, an ENBD tube was inserted into the post-ESD ulcer fistula using an upper gastrointestinal endoscope, and nasal mediastinal drainage was performed. The next day, the inflammatory response improved. The patient was discharged on day 31. We experienced a case in which mediastinitis was relieved by conservative treatment with endoscopic nasal mediastinal drainage.

A 66-year-old woman presented to Otorhinolaryngology with a sore throat after swallowing a fish bone and no improvement of symptoms. A CT scan of the neck showed foreign body with calcification within the esophageal, while upper gastrointestinal endoscopy did not reveal any foreign body. After admission, CT scans revealed a foreign body but no perforation or abscess. Upper gastrointestinal endoscopy was performed after edema had reduced, and the sharp fish bone was removed. Upper gastrointestinal endoscopy performed two months later showed no scarring. In this case, the fish bone was embedded in the esophageal submucosa, endoscopic treatment by boring biopsy was selected, and the foreign body was removed using an elective procedure.

A 79-year-old woman was referred to our hospital on suspicion of esophageal cancer following an upper gastrointestinal endoscopy that revealed a protruding lesion in the middle esophagus. Upon reexamination at our hospital, a well-defined borderline protruding lesion with pale black deposits was observed starting from 24 cm from the incisors, surrounded by a black flat lesion. Additionally, black punctate lesions of varying sizes and shades were seen spreading within the lesion, strongly indicative of primary malignant melanoma of the esophagus (PMME). Histopathological examination confirmed tumor cell proliferation and melanin pigment deposition, primarily in the stratum basale. Immunostaining yielded positive results for S-100 protein and Melan-A, conclusively diagnosing PMME.

A CT scan revealed a 40-mm-sized lymph node enlargement in the gastroesophageal region. However, no distant metastasis was evident. Treatment was started with a combination of Nivolumab and Ipilimumab.

A male aged in his 30s was referred to our hospital for examination and treatment after an upper gastrointestinal endoscopy revealed extramural compression. Ultrasonography revealed a mass lesion approximately 40 mm in maximum diameter, with a cyst inside the posterior wall of the fornix. The interior was mosaic-like, and part of it was suspected to be continuous with the fourth layer. Following biopsy, a preoperative diagnosis of suspected gastric plexiform angiomyxoid myofibroblastic tumor was made. A laparoscopic partial gastrectomy was performed for both the pathological diagnosis and treatment. A malignant glomus tumor diagnosis was subsequently made based on the results of various immunohistochemical stains. Since then, no tumor recurrence has been observed during follow-ups. Malignant glomus tumors are exceedingly rare; however, they can be locally aggressive and have the potential to metastasize. Further reports and analyses are needed to better understand this disease.

The patient is a man in his 50s. Preoperative esophagogastroduodenoscopic examination prior to surgery for left renal cancer revealed a gastric varix that had developed due to liver cirrhosis caused by nonalcoholic steatohepatitis. Endoscopic injection sclerotherapy (EIS) was performed to prevent potential perioperative bleeding from the gastric varix. The sclerosant, 5% ethanolamine oleate containing vascular contrast agent, was directly injected into the varix under X-ray monitoring. Endoscopy performed one month after EIS and contrast-enhanced computed tomography three months after EIS showed that the gastric varices had shrunk. EIS is an effective treatment to control and prevent bleeding from gastric varices.

Gastric submucosal tumors (SMTs) are occasionally observed on gastrointestinal endoscopy. Ectopic pancreas is a rare but important entity. In this case report, we describe the case of a 21-year-old female patient who presented with frequent vomiting after meals and was found to have a giant gastric SMT causing gastric outlet obstruction. Upper gastrointestinal endoscopy, radiography, plain computed tomography (plain CT), contrast-enhanced computed tomography (CE-CT), abdominal ultrasound and abdominal magnetic resonance imaging (MRI) showed a cystic lesion in the gastric antrum. The lesion was completely removed through tumor resection via laparotomy on the serosal side, without damaging the gastric mucosa and without any leakage of fluids from the lesion. Pathological examination revealed that the lesion was ectopic pancreas, Heinrich type II with no malignancy. The fluid in the cystic tumor had high levels of carcinoembryonic antigen (CEA) and Carbohydrate Antigen 19-9 (CA19-9). Immunostainings of CEA and CA19-9 were positive.

A 70-year-old woman visited our hospital with a chief complaint of loss of appetite.

Esophagogastroduodenoscopy revealed edematous and erythematous mucosa in the antrum, the pyloric ring was stenotic and difficult to pass.

Advanced gastric cancer was suspected, however, two boring biopsies reveald no evidence of malignancy.

Endoscopic ultrasound-fine needle aspiration showed proliferative infiltration of atypical cells in the mucosal layer.

Immunohistochemical staining was indicated poorly differentiated adenocarcinoma of epithelial origin, leading to the diagnosis of advanced gastric cancer.

We report a case of advanced gastric cancer in which endoscopic ultrasound-fine needle aspiration was useful in confirming the diagnosis.

We report a case of a male patient in his 70s with Borrmann type 4 gastric cancer, accompanied by obstructive jaundice and duodenal invasion. He was referred to our institution due to unexplained liver dysfunction and dilation of the common bile duct. Upon undergoing upper gastrointestinal endoscopy, duodenal stenosis was identified. A biopsy from a lesion located in the greater curvature of the gastric vestibule revealed poorly differentiated adenocarcinoma, specifically signet-ring cell carcinoma (Group 5). Due to suspected peritoneal dissemination from advanced gastric cancer, which led to bile duct stricture, ureteral invasion, and bladder involvement, percutaneous transhepatic biliary drainage and chemotherapy were initiated to alleviate the obstructive jaundice. Four months post-treatment initiation, the duodenal stenosis showed improvement, resulting in internal drainage. However, liver dysfunction attributed to immune-related adverse events (irAE) necessitated the discontinuation of chemotherapy 9 months after treatment. Ultimately, disease progression led to patient demise.

Situs inversus totalis (SIT) is a rare congenital anomaly characterised by mirror-image transposition of the abdominal and thoracic organs. We performed a percutaneous endoscopic gastrostomy (PEG) in a 49-year-old male patient with SIT and amyotrophic lateral sclerosis. To avoid injury to the left-sided liver, we made the puncture from the right side and positioned the surgeon accordingly. Both the finger sign and illuminated sign were clearly identified. Subsequently, the gastrostomy tube was placed on the anterior wall of the stomach. No complications were observed during or after the procedure. We believe that PEG insertion in patients with SIT can be performed safely by confirming specular positioning with endoscopic and radiographic images.

60-year-old man with a past history of Helicobacter pylori eradication underwent upper gastrointestinal endoscopy, and a 25 mm protruding lesion with multiple black spots was found on the posterior wall of the anglar region. We performed endoscopic submucosal dissection (ESD). The histopathological diagnosis of the ESD specimen was gastric adenocarcinoma of fundic-gland mucosa type (GA-FGM), pT1a. It has been previously reported that some gastric adenocarcinoma of fundic-gland type may be accompanied by black spots localized within the lesion. Black spots may be a characteristic feature of gastric adenocarcinoma of fundic-gland mucosa type, and focusing on such pigmentation localized within fundic-gland mucosa may enable early detection of the tumor.

An 85-year-old man underwent esophagogastroduodenoscopy (EGD), revealing a 50-mm erythematous, depressed lesion with partial elevation in the gastric cardia on the lesser curvature. Endoscopic biopsy confirmed a diagnosis of adenocarcinoma, and subsequently, endoscopic submucosal dissection (ESD) was performed. During dissection, a centrally located, 6-mm spherical-white structure within the submucosal layer was identified, which was easily separable from the muscularis propria layer by injection. Pathological examination revealed early gastric cancer with submucosal invasion and concomitant leiomyoma within the submucosal layer, with negative resection margins. Gastric submucosal tumors, due to their deeper location beyond the muscularis mucosae, often present a diagnostic challenge during EGD, necessitating techniques such as endoscopic ultrasound. ESD demonstrates promising outcomes for managing gastric submucosal tumors originating within the muscularis mucosae and submucosal layers. Our findings suggest that ESD is beneficial even for preoperatively undetected gastric submucosal tumors encountered during mucosal dissection. Intraoperative injection assessment facilitates decision-making regarding incidentally discovered lesions.

Primary peritoneal cancer is difficult to detect until progress to cancerous peritonitis, so there have been few reports diagnosed by EUS-FNA. A 80-years-old woman was diagnosed with rheumatoid arthritis and started treatment with methotrexate (MTX) and steroids. In screening CT, intra-abdominal multiple lymph node swelling was detected, but which was diagnosed as methotrexate-associated lymphoproliferative disorders and MTX was discontinued. She visited our department complaining of intermittent abdominal pain. Although CT showed slightly reduced lymph node swelling, increased mesenteric fatty tissue density. LDH and sIL-2R were slightly increased, so endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was performed on suspicion of malignant lymphoma. However, the specimen showed no evidence of malignant lymphoma, suggested serous adenocarcinoma of Müllerian duct origin. The patient had elevated CA-125 without a primary tumor in any gynecological organ, so diagnosed with primary peritoneal carcinoma.

Pancreaticoduodenectomy (PD) is the standard treatment for duodenal cancers suspected of submucosal invasion. Pathological diagnosis from duodenal biopsy samples has some limitations. We present the case of a man in his 70s with bile duct dilation and a suspected parapapillary duodenal cancer. Given the uncertainty of the biopsy, endoscopic submucosal dissection (ESD) was performed as a minimally invasive diagnostic alternative to PD. Histological diagnosis revealed an adenomyoma with high-grade adenoma, underscoring the efficacy of ESD in accurately diagnosing periampullary lesions. For patients with periampullary lesions, this case suggests that ESD could serve as a less invasive approach, potentially avoiding overtreatment, such as radical surgery.

A 23-year-old man was presented to the emergency room with bloody stools. His vital signs were stable on admission, but a blood test showed anemia (hemoglobin 10.9 g/dL). Contrast-enhanced computed tomography showed no obvious extravasation, and the source of bleeding was unclear. Esophagogastroduodenoscopy and colonoscopy were performed, but the source of bleeding could not be identified. Capsule endoscopy was performed on the day 4 of illness, and bloody stools recurred. Bleeding was observed in the small intestine on the monitor, suggesting it was the site of bleeding. Enteroscopy was performed immediately, which revealed bleeding from Dieulafoy's lesion. Hemostasis was performed with an endoscopic clip. Thereafter, no recurrence of hematochezia was observed, and the patient was discharged on day 11. Dieulafoy's lesion of the small intestine is very rare, and there are few reports of cases in which hemostasis was achieved endoscopically. Here we describe this case of small intestinal Dieulafoy's lesion in which hemostasis was achieved by enteroscopy performed immediately after confirmation of active bleeding and identification of the bleeding site on the capsule endoscope monitor.

A 65-year-old malewith squamous cell carcinoma of the lungs developed hematemesis one month after starting treatment using atezolizumab as a 6^th-line therapy. Upper gastrointestinal endoscopy revealed mucosal erythema and erosions within the descending and horizontal legs of the duodenum. Similarly, capsule endoscopy showed mucosal erythema and erosions from the jejunum to the ileum. Moreover, histopathology demonstrated moderate neutrophilic infiltrate in the intrinsic layer of the duodenal mucosa,with regenerative changes in the epithelium. After treatment with steroids, colonoscopy showed no evidence of inflammation, including in the terminal ileum, and the patient's symptoms and endoscopic findings improved markedly.

This is a significant case in which ICIs could be reinstituted after the small intestine inflammation had improved. We report this case with respect to a review of the relevant literature.

A 71-year-old woman was admitted to hospital with abdominal distension. Abdominal contrast-enhanced CT revealed ileum obstruction due to intussusception caused by submucosal tumor. A nasal-ileal tube was positioned first, but the intussusception was not treated.

We performed a single-balloon small bowel endoscopy to examine the cause of the intussusception. A submucosal tumor (SMT) was found in the ileum, 60 cm from the Bauhin valve. After confirming that there was no ischemia in the mucosa around the SMT on the endoscope, contrast medium was injected under pressure. The fluoroscopic image showed that SMT gradually moved toward the oral side of small intestine. Finally, the obstruction due to intussusception was released and the contrast medium flowed toward the oral side of the SMT. We report a case of small intestinal piles repaired by a single-balloon small bowel endoscopy.

Although surgery is traditionally the first choice for the treatment of afferent loop syndrome, there has been an increase in endoscopic treatment in recent years. Here, we report the case of a 68-year-old patient who had undergone pancreaticoduodenectomy and subsequently visited the doctor for abdominal distension. Computed tomography revealed intestinal and bile duct dilatation, and the patient was referred to our hospital. The patient was diagnosed with afferent loop syndrome and acute cholangitis. A short single-balloon endoscope was inserted into the choledocojejunostomy site. A metal stent was successfully deployed for intestinal stricture. After treatment, the afferent loop syndrome and cholangitis improved. Using short single-balloon endoscope, we were able to safely perform this treatment without adverse events.

A 62-year-old female underwent resection of malignant melanoma in the right lumbar region and sentinel lymph node biopsy of the right inguinal lymph node, resulting in a diagnosis of stage IIID (pT4bN3cM0). The patient received postoperative chemoradiotherapy but developed iron deficiency anemia and intermittent abdominal pain during the treatment. An abdominal CT scan revealed soft tissue shadows within the lumen of the jejunum, along with partial intestinal intussusception and dilatation of the proximal side. The enlargement of surrounding mesenteric lymph nodes was also noted. An antegrade double-balloon enteroscopy identified elevated lesions with black epithelium and ulceration in the proximal jejunum, which were prone to bleeding. Pathological examination revealed a dense proliferation of round atypical cells in the mucosal layer, with brown pigment observed in the spores of some atypical cells. Based on these findings, the patient was diagnosed with jejunal metastases of malignant melanoma.

A 27-year-old woman with ulcerative colitis (UC) underwent a colonoscopy for worsening symptoms. There was an elevated lesion in the sigmoid colon. A biopsy was performed on the lesion, resulting in atypical cells. She was referred to our hospital on suspicion of ulcerative colitis-associated neoplasia (UCAN). We performed a colonoscopy for further study. The lesion had no malignant findings, and we diagnosed the lesion as an inflammatory polyp. However, we performed underwater endoscopic mucosal resection (UEMR) as a total biopsy because the previous biopsy result was atypical cells. The pathological result of the lesion showed no malignancy, and the polyp was not UCAN. UEMR was effective for the polyp that has the mucosa with inflammation and fibrosis such as UC.

A woman in her 80s had not defecated for several days and was rushed to our hospital. A CT scan showed a fecal mass lodged in the colon, and the diagnosis was a fecal ileus. The CT images did not indicate any strangulation or necrosis of the colon, so we attempted an urgent colonoscopy to eliminate the fecal mass. The colonoscopy was not completed because the abdominal pain became more intense. The patient did not defecate for another 4 four days, so we again performed a colonoscopy and removed the fecal mass with an endoscopic snare. There was an ulcer, and partial obstruction of blood flow from the sigmoid region to the rectum. In cases of obstructive colitis caused by feces, necrosis or strangulation of the intestinal tract may require emergency surgery, but in this case, fecal ileus was successfully treated endoscopically, taking into account the patient's background.

We report the case of a man in his 60s with a history of hypertension and having soft stools for 3 months. Colonoscopic examination revealed a type 5 rectal tumor. Histopathological examination partially revealed signet-ring cell carcinoma (SRCC) and tubular adenocarcinoma. He underwent intensity-modulated radiotherapy with capecitabine. Thereafter, robot-assisted rectal amputation was performed. His Helicobacter pylori infection had been eradicated; thereafter, he underwent esophagogastrododenoscopy annually. One year and 8 months postoperatively, esophagogastroduodenoscopy revealed multiple verrucous-like elevated lesions in the stomach. Histopathological examination confirmed SRCC. Immunohistochemical analysis showed CK7 negative and CK20 positive. We diagnosed metastatic gastric cancer derived from rectal cancer. FOLFIRI (leucovorin, fluorouracil, and irinotecan) plus ramucirumab therapy was administered; unfortunately he died of peritonitis carcinomatosa after 7 months of gastric metastasis.

A case of an 81-year-old male. With a complaint of bloating sensation, a contrast-enhanced CT scan of the abdomen revealed a mass-like lesion in the ileocecal region and elevated fatty tissue density in the surrounding area, and then the patient was admitted to our hospital for close examination. A colonoscopy showed stenosis with inflammatory mucosa in the ascending colon, and endoscopic passage was impossible. The biopsy pathology results of the same lesion showed inflammatory cell infiltration into the colonic mucosa and numerous eggs, and a diagnosis of schistosomiasis japonica was made. Although schistosomiasis japonica has been declared eradicated in Japan, it is possible that in this case, the insect eggs infected in his childhood were activated due to infectious enteritis or age-related immunodeficiency, causing the very rare acute endoscopic findings.

A 50-year-old man complained of hematochezia. An abdominal contrast-enhanced computed tomography (CT) of the patient showed an extravasation-like finding in the sigmoid colon, which was judged to be sigmoid diverticular bleeding. However, colonoscopy revealed a pedunculated polyp with a diameter of 20 mm in the area CT revealed extravasation. The blood vessels inside the stem of the pedunculated polyp were judged to be observed as extravasation, and the contrast-enhanced CT revealed the presence of large blood vessels within the pedunculated polyp, allowing safe treatment.

A 66-year-old man was diagnosed with T-cell large granular lymphocytic leukemia two years before he visited our hospital and had been receiving cyclophosphamide. Six months earlier, he had abdominal discomfort, diarrhea, and pancytopenia. He was referred to our hospital because PET-CT showed abnormal accumulations in the large intestine. Colonoscopy revealed irregular ulcers and stenosis in the rectum and sigmoid colon, and it was diagnosed as monomorphic epitheliotropic intestinal T-cell lymphoma in pathological examination. MEITL is an extremely rare primary malignant tumor of the gastrointestinal tract and the standard treatment regimens are not established. In our case, he was treated with CHOP and SMILE (dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide) and it was effective for the colonic stenosis and ulcer.

A 70s-year-old man presented with complained of right hypochondriacal pain. We diagnosed with a 3 cm abscess in hepatic caudate lobe (S1) and attempted percutaneous puncture for the abscess. However, due to difficulty in recognizing the lesion, we performed EUS-guided aspiration. EUS showed clear recognition of the abscess lesion and we could aspirate without adverse events.

Generally, puncture aspiration or continuous drainage are effective for liver abscesses, in addition to antibacterial treatment. Percutaneous drainage is a standard treatment with safety and high efficacy, but as in the present case, it is often difficult depending on the location of the abscess and the intervening organs in the puncture route. EUS-guided aspiration/continuous drainage has been reported to be effective and safe for abscesses that are difficult to puncture percutaneously, especially those in the hepatic S1. We thinks it would be a useful option in such situations.

We report two cases of an incarcerated confluence stone who were admitted in our hospital. At first, we diagonosed that they had cholangitis with a common bile duct (CBD) stone by CT scan and MRI. Then, we performed endoscopic retrograde cholangiography (ERC) to remove the CBD stone. But, we couldn't remove the CBD stone because it was an incarcerated in the part of communication of three ducts. We failed to remove the incarcerated confluence stone by using standard basket or balloon extraction, endoscopic mechanical lithotripsy (EML).

So, we decide to use the Spyglass DS-guided EHL. Fainally, we were able to visualize the confluence stone and break it into pieces. Spyglass DS System can be considered useful and effective for removal of confluence stones.

A woman in her 70s with a history of intraductal papillary mucinous neoplasm developed pancreatic head cancer. We attempted endoscopic retrograde cholangiopancreatography to replace an already implanted biliary plastic stent with a metal stent, but were unsuccessful because of duodenal invasion and stenosis caused by pancreatic head cancer. We removed the existing biliary stent and performed endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). Seven days after EUS-HGS, the patient developed hematoemesis. Abdominal CT showed hematoma in the stomach and biliary tract; hence, biliary hemorrhage was suspected. We performed abdominal angiography and discovered a pseudoaneurysm coincident with the stent insertion site, and performed coil embolization. There are very few reports of pseudoaneurysm formation and biliary hemorrhage after EUS-HGS. When gastrointestinal bleeding occurs after EUS-HGS, pseudoaneurysm should be assumed and prompt diagnosis and hemostasis should be considered.

A 76-year-old woman with hypertension and hyperlipidemia had been diagnosed with a 30 mm cyst in the pancreatic head at another clinic three years previously. She was referred to our hospital a year ago on suspicion of acute pancreatitis due to the cyst's enlargement and abdominal pain. Imaging examination revealed a bifocal cystic lesion in the pancreatic head measuring 46.8 mm and 13.8 mm with no wall mural nodules or ductal communication. EUS did not show any honeycomb-like components in the lesion; therefore, a diagnosis of SCN (serous cystneoplasm) could not be confirmed. The pancreatitis improved and careful follow-up was continued, but the patient had another attack of acute pancreatitis, and pancreatoduodenectomy was performed. The pathological diagnosis was macrocystic type serous cystadenoma. We report this interesting and valuable case as it reflects the importance of diagnostic imaging when considering cystic lesions.

A 77-year-old man with weight gain, whole body edema, and ptosis was referred to our hospital. Laboratory data shows hypokalemia, cortisol/adrenocorticotropic hormone (ACTH) elevation. Abdominal imaging revealed a mass at the pancreatic tail and multiple liver metastases. Since he was suffering from Cushing's symptoms, he received block and replace treatment after hospitalization to reduce cortisol level rapidly. EUS-FNA diagnosed ACTH-producing pancreatic NET G3. The patient's symptoms improved immediately following hormone therapy, and he was treated with combined sunitinib and lanreotide; however, the disease progression was extremely severe that he died because of the primary tumor.

The patient was a man in his 80s. A 23 mm ischemic mass in the pancreatic body and a necrotic accumulation in the tail of the pancreas were diagnosed as obstructive pancreatitis due to pancreatic cancer, and he was treated for pancreatitis. However, there was no improvement, and endoscopic ultrasonography showed dilatation of the main pancreatic duct caudal to the tumor and sludge echoes with high luminance, leading to a diagnosis of acute obstructive suppurative pancreatitis. An endoscopic pancreatic duct stent was placed, but stent obstruction occurred in the short term, which improved with pancreatic duct stent exchange. Our findings indicate that pancreatic duct drainage methods for acute obstructive suppurative pancreatitis should be considered on a case-by-case basis, as there is a risk of stent occlusion.

An 80-year-old man was diagnosed with groove pancreatic cancer based on duodenal findings of a routine esophagogastroduodenoscopy (EGD). The EGD showed slight narrowing of the duodenum at the superior duodenal angle suggestive of invasion of other organs by the carcinoma. Endoscopic ultrasonography (EUS) showed a 21 × 10 mm hypoechoic tumor with indistinct boundaries in the groove region. A histopathologic diagnosis of adenocarcinoma was made by EUS-guided fine-needle aspiration, and a subtotal stomach-preserving pancreaticoduodenectomy was performed. A pathological examination revealed that the tumor had invaded from the outer wall to the duodenal muscularis layer. This could have been recognized during EGD as slight narrowing of the superior duodenal angle. Since EGD may enable the detection of asymptomatic pancreatic cancer, careful endoscopic manipulation is required during duodenal examinations.

Endoscopic pancreatic stenting (EPS) is commonly performed for pancreatic duct stenosis. We report a case where the pancreatic duct was difficult to intubate but texture and color enhancement imaging (TXI) identified a parapapillary duct, enabling successful stent placement.

Case: A 49 year old man. CT showed diffuse pancreatic calcifications and caudal dilatation of the main pancreatic duct. The patient had repeated episodes of abdominal pain due to chronic pancreatitis; therefore, endoscopic treatment was selected. ERP was attempted three times but intubation of the pancreatic duct was difficult. His symptoms did not improve and parapapillary ERP was chosen. There was difficulty identifying the parapapillary duct, due to duodenal erosion, but TXI enabled identification of the parapancreatic duct, which was successfully intubated and a stent implanted. The patient was discharged with no post-operative complications.

Conclusion: Despite diffuse pancreatic calcifications, TXI identified the parapapillary duct, enabling EPS.

A 62-year-old man with a history of alcohol abuse had liver dysfunction, pointed out a pancreatic mass by ultrasound examination. Contrast-enhanced dynamic CT showed a 10-mm mass in the pancreatic body with faint contrast effect in the arterial phase and contrast effect in the equilibrium phase. Tumor marker, especially DUPAN-2 increased by 1000 U/ml. EUS showed a 12 mm hypoechoic mass and a stenotic pancreatic duct within the mass that could be a duct-penetrating sign. ERCP showed excretion of pale bloody pancreatic juice from the duodenal papillary region. Aspiration cytology was performed from the site of the main pancreatic duct stenosis in the pancreatic body, but no atypical cells were found.

The imaging results did not rule out pancreatic cancer, and distal pancreatectomy was performed. The pathological diagnosis showed an inflammatory pancreatic mass with fibrosis.

A woman in her 50s visited another hospital because of a left lower abdominal mass. CT showed masses in the pancreatic tail and lower left abdomen, and she was referred to our hospital. Contrast-enhanced CT showed masses in the pancreatic tail, left lower abdomen, and right lower abdomen, and heterogeneous contrast enhancement was observed in all masses. Percutaneous biopsy of the pelvic mass and EUS-FNA of the pancreatic mass were performed. As a result, she was diagnosed as Ewing sarcoma originate from the iliopsoas muscle with pancreatic metastasis. This was a rare case, as there has been no other report in which pancreatic metastasis of extraosseous Ewing sarcoma was diagnosed using EUS-FNA.