【背景】胃gastrointestinal mesenchymal tumor（GIMT）に対する標準治療は腹腔鏡下手術であるが，より低侵襲な内視鏡治療は普及していない．【目的】胃GIMTに対する内視鏡切除術の現状と課題を明らかにする．【方法】2014年から2024年までに当院において胃GIMTに対して内視鏡治療または腹腔鏡下治療が施行された102例を対象とした．内視鏡治療群（ER群）50例と腹腔鏡下治療群（LR群）52例を比較検討した．【結果】手術時間はER群/LR群：51/124.5分（p ＜0.01）とER群で有意に短く，R0切除率は有意差を認めなかった．ER群では30 mm以下の管内発育型腫瘍を適応としており，腫瘍径はER群/LR群：24/30 mm（p ＜0.01）とER群で小さく，管外発育病変はER群/LR群：4（8%）/15（29%）（p ＜0.01）とER群で少なかった．Clavien-Dindo Grade3aの偶発症を両群に1例ずつ認めた．ER群の偶発症は幽門前部小弯の遅発性穿孔であり，穿孔部へのPGA充填とOTSC縫縮により外科的治療を要さず保存的加療で改善した．【結論】経口回収可能な腔内発育型胃GIMTに対する内視鏡を用いた局所切除は腹腔鏡下手術と同等の安全性と確実性を有しつつ術時間を短縮できる可能性がある．

【背景】超音波内視鏡検査は太径の内視鏡を使用するため，鎮静薬の使用は必須であるが，鎮痛薬を使用すべきか否かについては十分検討されていない．【目的】外来超音波内視鏡検査における鎮痛薬の必要性を明らかにすることを目的とした．【方法】ミダゾラムのみを使用した患者をミタゾラム単独群，ミダゾラムとペンタゾシンを使用した患者をペンタゾシン併用群とした．評価項目は，アンケート調査による患者満足度，リカバリールーム滞在時間とした．【結果】アンケート調査では鎮静薬の効き具合に関する質問に対して満足と回答した患者は，ミダゾラム単独群95.8%，ペンタゾシン併用群87.8%とミダゾラム単独群が多い傾向にあった（P=0.066）．リカバリールームを60分で退室許可となった患者は，ミダゾラム単独群22.2%，ペンタゾシン併用群9.7%とミダゾラム単独群が有意に多かった（P=0.013）．【結論】外来超音波内視鏡検査にはペンタゾシンを用いない方がよいかもしれない．

当院において患者・看護師・医師を対象に，モビプレップ^Ⓡとの比較に関して67症例を対象にアンケート調査を行った．患者からは，飲みやすかった（62％），時間がかからなかった（76％），次回以降使用してもよい（93％），飲み方がわかりやすかった（100％），看護師からは，時間がかからなかった（91％），高圧浣腸が必要なかった（99%），説明しやすかった（99％），医師からは，治療に支障はなかった（99％），と高評価だった．サルプレップ^Ⓡの添付文書には重度の腎機能障害のある患者には服用禁忌と記載があり，拾い上げ方法さえ確立すれば，高い腸管洗浄力と利便性の良さから，活用が期待できると思われた．

アルコール性肝硬変で当院へ通院している80歳台の男性が，大量の血便を主訴に来院した．緊急上部消化管内視鏡検査では，Lg-f，F2の胃静脈瘤からの出血を認め，Cyanoacrylate注入による止血を準備していたところ，同部位から再出血し視野の確保が困難となった．このため，Sengstaken-Blakemore（S-B）チューブを挿入しバルーンによる圧迫止血を試みたが，食道内で胃バルーンを膨らませてしまい，食道に約10 cmにわたる裂創が形成された．再度，透視下でS-Bチューブを挿入しながら，胃静脈瘤出血点を圧迫しながら食道の裂傷をクリップで縫縮した．3日後に胃静脈瘤に対し内視鏡的硬化療法を施行した．4週間後，経過観察の内視鏡で裂創の閉鎖を確認し，食事を開始した．その後は胃静脈瘤の出血再発はなく，全身状態良好のため退院した．

【背景】大腸の巨大な0-Is病変は筋層牽引や粘膜下層の線維化を伴うことが多く，途中中断や術中穿孔に伴う緊急手術にいたることも珍しくない．内視鏡治療を安全に完遂するためには手技的な工夫が必要である．

【症例】46歳女性．横行結腸の40 mm大の0-Is病変に対して粘膜下層剥離術（ESD）を施行した．筋層牽引所見を認めたため，ダブルトンネル法で筋層牽引部位を露出し，SureClip^Ⓡを用いて筋層にクリッピングしながらその病変側を切開（Clip and cut technique）することで，合併症なく安全に一括切除に成功した．

【結論】Clip and cut techniqueを用いることで筋層牽引を伴う巨大な大腸0-Is病変を内視鏡的に安全に一括切除できる可能性がある．

Some early esophageal carcinomas are not visible on white light observation (WLI) or narrow-band imaging (NBI) and identified by iodine staining. Of the 39 cases and 55 lesions of early esophageal carcinomas discovered at our hospital between January 2021 and January 2024, only two lesions (3.6%) were not visible by WLI/NBI and identified by iodine staining. The two lesions that could only be recognized by iodine spraying were small against the esophageal background of iodine-free grade C in a man with a history of drinking and smoking who had been treated for head and neck and esophageal cancers. Early esophageal carcinoma is often recognized by WLI/NBI, but there are lesions that cannot be recognized without iodine spraying; therefore, the anterior wall in the tangential direction should be observed. If there is a history of treatment for head and neck and esophageal cancers or iodine-stained grade C in previous examinations, active iodine application should be considered.

The patient was a 64-year-old man who visited his local doctor with the chief complaint of upper abdominal pain. Upper gastrointestinal endoscopy revealed elevated lesions in the middle thoracic esophagus and gastric cardia, and the patient was referred to our hospital. A biopsy was performed at our hospital, and immunostaining tests were positive for CD56, Synaptophysin, and Chromogranin, leading to a diagnosis of small cell carcinoma. The tumor was also strongly positive for TTF-1, confirming it originated from lung cancer. In this case, we diagnosed esophagogastric metastasis from a pulmonary primary tumor by immunostaining. Here, we report this case along with a literature review.

A 78-year-old man underwent esophagogastroendoscopy, which revealed a 10 mm 0-IIa+IIc lesion on the posterior wall of the gastric angulus. A biopsy revealed a poorly differentiated adenocarcinoma, but a tendency towards neuroendocrine differentiation was suspected. Endoscopic submucosal dissection (ESD) was performed. The final pathological diagnosis was "4 mm, neuroendocrine carcinoma (NEC), pT1b2, pUL0, Ly0, V0, pHM0, pVM0," and the classification of endoscopic cure was eCuraC-2. Subsequently, a distal gastrectomy was performed with the surgical team. The surgical specimens showed no cancer.

As NEC is highly malignant and often found at an advanced stage, the NEC for which ESD was chosen is rare.

A man in his 80s was scheduled to undergo percutaneous endoscopic gastrostomy (PEG) because he was at high risk for aspiration due to Parkinson's disease. PEG was performed using the modified introducer technique with the EndoVive Seldinger PEG kit 24 Fr 3.5 cm (Boston Scientific Japan, Tokyo, Japan). The device through which the PEG tube would be connected was implanted on the anterior wall of the middle gastric body by endoscopy. Enteral nutrition and drug infusion were started the following day. Eleven days after implantation of the device, the patient experienced abdominal pain and hematemesis, and went into shock (day 0). Abdominal computed tomography revealed emphysematous gastritis, and intravenous administration of norepinephrine and antibiotics was started. His overall condition improved, and he was discharged on day 42. Although the occurrence of gastric emphysema after PEG is rare, conservative management can ensure recovery in such patients.

A male in his 70s had undergone pyloric gastrectomy for gastric cancer more than 20 years ago. Endoscopy was performed for postoperative follow-up of the gastric cancer, and a 25 mm IIc lesion was found on the suture line of the residual gastric lesser curvature. Biopsy showed a well-differentiated adenocarcinoma (tub1). Endoscopic submucosal dissection (ESD) was performed under general anesthesia. The dissection proceeded to the layer where we could recognize the staple was removed. The lesion was resected en bloc. The pathological findings were 25×24 mm, tub1, SM1 (350 μm), ly0, v0, HM0, VM0.

Gastric cancer often occurs in the residual stomach after gastric cancer surgery. ESD is often difficult because the residual stomach is prone to bleeding, and endoscopic manipulation is so poor. In addition, ESD is more difficult with lesions on the suture line because of staples. It should be performed by an expert endoscopist.

An 83-year-old woman was taken to our hospital due to postprandial abdominal pain and nausea. Computed tomographic (CT) scan showed gastric dilatation and volvulus of the stomach, and insertion of a gastric tube revealed copious drainage. On day 3, blood tests showed markedly elevated inflammatory response and creatine kinase, and a contrast CT scan suggested ischemia due to volvulus of the stomach. Fluoroscopic endoscopy was performed, and a lower gastrointestinal scope could be passed through the pyloric ring and successfully released the volvulus. On day 10, fluoroscopic endoscopy was performed again, and the ischemic changes improved, but the volvulus had recurred. Endoscopic repair was judged to be inadequate, and laparotomy with gastric fusion and diaphragmatic hernia repair was performed on day 14. Volvulus of the stomach may cause blood flow disturbance, and early endoscopic repair may be useful for avoiding gastrectomy.

This is a case of a 72-year-old man with Mallory-Wise syndrome who was aware of stomach discomfort after clipping. When upper gastrointestinal endoscopy was performed at a local doctor, it was discovered that the clip remained, and he was referred to our hospital.

Upper gastrointestinal endoscopy revealed five clips remaining on the posterior wall of the cardia, so one clip near the esophagus was removed, and then all clips were removed. After all the clips were removed, the gastric discomfort disappeared, and the patient's condition progressed well with no recurrence of symptoms.

A search of past literature found no reports of cases of gastric discomfort occurring after clip closure at the gastroesophageal junction; however, if gastric discomfort occurs after clip closure, removal of the clip should be considered.

An 80-year-old man with a history of Helicobacter pylori eradication therapy underwent esophagogastroduodenoscopy, and a flat elevated lesion measuring 5 mm with discoloration and vascular dilation was noted on the gastric fornix. Endoscopic biopsy revealed adenocarcinoma of the fundic gland-type (GA-FG), and endoscopic submucosal dissection (ESD) was performed. The pathological diagnosis was GA-FG with superficial submucosal layer invasion. In addition, a 1-mm GA-FG was incidentally detected on the oral side of the resected specimen. This small lesion was hard to visualize even retrospectively. Considering the development pattern of GA-FG, originating in the fundic gland area and covered by nonneoplastic epithelium, there may be undetectable lesions hidden around the visibly detectable GA-FG. Therefore, it is essential to meticulously observe the area around the lesion before treatment and perform regular endoscopic follow-up after treatment.

The patient was a 67-year-old man with a history of cerebral infarction and clopidogrel use. Upper gastrointestinal endoscopy was performed to investigate the cause of his anemia imaging revealed multiple gastric hyperplastic polyps that were easily hemorrhagic. We diagnosed gastric hyperplastic polyps as the cause of anemia and planned to perform EMR. Endoscopy revealed a large amount of blood clots in the stomach and a 10 mm polyp with eruptive bleeding was found and resected by EMR. Bleeding from hyperplastic gastric polyps is often minimal, and severe bleeding, as in this case, is rare. In this case, clopidogrel therapy likely contributed to the increased bleeding susceptibility.

A case is an 87-year-old woman post percutaneous endoscopic gastrostomy (PEG). PEG was performed 10 years ago. Gastrostomy tubes had been exchanged every six months, but peristomal leakage and dermatitis around a gastrostomy tube appeared, and she was admitted to our department. Percutaneous Endoscopic Gastrojejunostomy (PEG-J) was performed and leakage decreased, but dermatitis didn't improved. In cooperation with a certified Wound, Ostomy and Continence nurse, we started using cosmetic puff as decompression of a fixation plate, which is superior in hygiene and cost, and dermatitis improved significantly. Not only managing leakage, cosmetic puff also enabled decompression to the skin. Endoscopists should collaborate with multiple professions not only for gastrostomy construction but for various gastrostomy-related problems.

ERCP-related adverse events are observed more frequently compared with other endoscopic procedures. Among others, lateral wall perforation of the duodenum is often serious and can even be fatal. A 78-year-old female was diagnosed with choledocholithiasis. We planned ERCP procedure for stone retrieval, but it was quite difficult to insert the scope into the duodenum. After several attempts, a duodenal lateral wall was injured with a tip of the duodenoscope while advancing the endoscope. Fat tissue was confirmed beyond the perforation site, suggesting that ERCP-related perforation occurred. Then, endoscopic closure with over-the-scope clip (OTSC) was attempted to close the duodenal wall defect. The procedure was successfully performed. Subsequent duodenography did not show leakage of contrast agent outside the duodenal wall. No fluid collection or gas was observed on any of the CT following endoscopic closure and his clinical course was uneventful. We herein report a case underwent successful endoscopic closure with OTSC, helped avoid surgery.

A 67-year-old man originally suffering from Trisomy 8-positive myelodysplastic syndrome (MDS) and intestinal Bechet's disease (BD) was treated with PSL for symptom control. Symptoms such as hematochezia and abdominal pain did not improve despite increasing the dose of PSL. CT showed wall thickening of the small intestine in the pelvis. Double-balloon endoscopy (DBE) revealed multiple ulcers in the lower ileum with marginal swelling. The patient was started on adalimumab for Trisomy 8-positive MDS gastrointestinal lesions, and although his abdominal pain improved, he died due to massive hematochezia. The number of cases of Trisomy 8-positive MDS gastrointestinal lesions is small, and there are no established methods to differentiate it from inflammatory bowel disease or to treat it. The prognosis of this disease is poor, and more cases need to be accumulated in the future.

A 71-year-old woman diagnosed with pancreatic head cancer in 20XX−7 underwent pylorus-preserving pancreaticoduodenectomy. In 20XX−1, CT revealed recurrence in the remnant pancreas, but she declined treatment. In 20XX, she was admitted due to difficulty moving and hematochezia. On day 3, upper endoscopy revealed ruptured small intestinal varices near the anastomosis site. CT showed developed varices in the small intestine, and endoscopic injection sclerotherapy (EIS) with N-butyl-2-cyanoacrylate was performed. Follow-up CT on day 4 showed a treatment effect on the varices and their feeding/draining vessels. Endoscopy on day 9 confirmed variceal disappearance. No rebleeding occurred thereafter. EIS is effective in treating ruptured small intestinal varices.

A 56-year-old, male patient presented with abdominal pain and watery diarrhea. Computed tomography demonstrated thickening of the terminal ileal wall. A colonoscopy was attempted but the terminal ileum was too narrow to admit colonoscope. So, a sliding tube of small bowel balloon endoscopy was placed for nasal endoscope insertion. The nasal endoscope was passed through the stenotic area, where multiple ulcers were observed. The biopsy found no malignancy. Based on these findings, Crohn's disease was suspected, and treatment with mesalamine and prednisone was begun. In this case, the ulcers ware monitored for relapses during treatment by using nasal endoscope. This method is safe and useful for evaluating stenotic areas that are difficult to pass through with a colonoscope.

The patency capsule, used to assess intestinal patency, naturally disintegrates, reducing the risk of intestinal obstruction. However, rare cases of non-dissolvable coating film retention have been reported. We present a case of a 40-year-old female with Crohn's disease, where the non-dissolvable coating of a patency capsule was retained in the ileum. The patient, with a history of recurrent bowel obstruction, experienced persistent anorexia. Initial imaging showed multiple strictures in the ileum. Despite endoscopic balloon dilation, the symptoms persisted. Upon repeat double-balloon enteroscopy, a retained coating was identified and removed, leading to rapid symptom improvement. This case highlights the clinical significance of carefully evaluating intestinal strictures before using a patency capsule. Notably, Crohn's disease patients may have a higher risk of coating retention. Sharing such experiences can enhance the safety and efficacy of patency capsule deployment.

The endoscopic colonic stenting in the ileum end is difficult. The rotatable flexible tip cannula (Swing tip cannula; Olympus Medical Systems, Tokyo, Japan) has an articulation at its tip which allows the tip to be flexed from 85 degrees to 20 degrees. Colonic stenting in the ileum end was possible under the swing tip cannula.

Diagnostic and therapeutic procedures under ultrasound endoscopy (EUS), which began with EUS-FNA, have expanded its realms. Recently, endoscopic ultrasound-guided cyst drainage (EUS-CD) are increasing its applications to various infected cavities that originated from causes other than pancreatitis. We experienced a case of EUS-CD to abscess that was not caused by pancreatitis. The improvement was seen with EUS-CD, and open surgery was avoided.

We report a case of the endoscopic covered colonic stenting for the obstruction of the uncovered colonic stent.

A CT scan after bladder cancer treatment in a male in his 80s showed a large tumor in the ascending colon. Colonoscopy revealed a 50-mm 0-I tumor. Endoscopic mucosal resection was difficult because of the short stalk and the huge size of the apex. We therefore performed endoscopic submucosal dissection (ESD) using a bipolar device. By clipping the stalk and dissecting just above it, we could resect the lesion en bloc without complications. The pathology findings were 50×48 mm, tub1 (carcinoma in adenoma), pT1a (M), ly0, v0, HM0, VM0.

Large type 0-I tumors are at higher risk of perforation by monopolar devices used for ESD, especially if the apex is in contact with the contralateral mucosa and current flow runs from the apex to the contralateral mucosa. A bipolar device was useful in ESD of a large type 0-I tumor in the ascending colon.

An 84-year-old woman was admitted to hospital with abdominal pain. The CT findings revealed ascending colonic peritonitis due to perforation by a foreign body. After consultation with the surgeon, it was decided to perform lower gastrointestinal endoscopic extraction of the foreign bodies without preparation. The endoscope revealed that a toothpick had penetrated the ascending colon. The tip of the toothpick was grasped with a grasping forceps, and then the tip was placed in the hood and removed transanally. The patient was then discharged after conservative treatment without major complications.

Minimally invasive endoscopic extraction may be an option for colorectal penetration due to a foreign body in the digestive tract.

Aeromonas hydrophila is a rod-shaped, gram-negative bacterium typically found in aquatic environments, including in drinking water, wastewater, sewage, and food. Herein, we describe two cases of A. hydrophila colitis. The patient in Case 1 was a woman in her eighties who had been diagnosed with hypertension, type 2 diabetes, and dyslipidemia. An annual colonic endoscopy revealed erosion, redness, and ulceration in the cecum and ascending colon. A. hydrophila was detected in endoscopic stool sample culture. The infection route was unclear. The patient in Case 2 was a woman in her seventies who had been diagnosed with hypertension and dyslipidemia and presented to our hospital with lower abdominal pain and lower gastrointestinal bleeding. Emergency colonic endoscopy revealed erosion, redness, and ulceration in the cecum and type 2 colon cancer of the ascending colon. A. hydrophila was detected in endoscopic stool sample culture. The infection route was unclear.

A 57-year-old male patient underwent pylorus-preserving pancreaticoduodenectomy for a pancreatic neuroendocrine tumor. Hepatic dysfunction and intrahepatic bile duct dilatation were indicated. A diagnosis of hepaticojejunostomy anastomotic stricture was made, and SBE-ERCP was thus performed but the anastomosis site could not be identified. The following day, EUS-HGS was performed, and a 7 Fr plastic stent (PS) was placed with the tip slightly beyond the anastomosis. Two months later, SBE-ERCP was performed again, and the bile duct was successfully intubated using the PS that was placed by EUS-HGS as a marker, and a FCSEMS was placed in the right intrahepatic bile duct for the anastomotic stricture. The PS and FCSEMS were removed 6 months after the surgery. The patient is under follow-up with no evidence of recurrence. Bile duct drainage using the EUS-guided rendezvous technique is a useful salvage method for cases in which ERCP is difficult, including those in which the hepaticojejunostomy anastomosis is difficult to identify.

A 93-year-old man who had undergone distal gastrectomy with Billroth II reconstruction was admitted with calculous cholangitis complicated by septic shock. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed using a 7-Fr plastic stent. As bleeding was observed via the endosonographically created route on day 14, a self-expandable metallic stent (SEMS) was placed. On day 59, the patient was re-admitted for cholangitis and hematemesis. Emergency endoscopy revealed hemobilia in the SEMS and a large hematoma in the stomach; therefore, endoscopic nasobiliary drainage was performed. As contrast-enhanced computed tomography revealed an aneurysm adjacent to the SEMS, transarterial embolization was performed. Here, we report a rare case of delayed bleeding with a pseudoaneurysm after EUS-HGS.