Since duodenal stenting became covered by health insurance in 2010, stent insertion has been performed for pyloric and duodenal stenosis. Of the patients who developed pyloric and duodenal obstruction associated with a malignant tumor between April 2010 and October 2012, we attempted to insert duodenal stent in 22 patients who were unwilling to undergo bypass surgery ; the stents were successfully placed in 19 patients.
The number of males with successful stent insertion was higher than that of females, with a male-to-female ratio of 15 : 4. Average patient age was 73.7 years, and mean stenosis length was 39.95 mm (minimum 20 mm, maximum 100 mm) . Oral intake was reinitiated within an average of 2.25 days ; 84% (16/19) patients were able to consume 100% rice gruel. The average rate of successful stent insertion was 86% (19/22) . However, gastrointestinal perforation occurred as a serious complication in one patient. Our study results suggest that duodenal stent insertion can be considered as an effective therapeutic approach for pyloric and duodenal stenosis associated with high-grade advanced cancer.

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Although EC-590ZW3 by Fujifilm Medical Company is normally used as a colonoscope in our clinic, there are some cases in which loss of endoscope flexibility occurs─due to stenosis, crookedness and adhesion of the colon─and it is difficult to insert the endoscope into the cecum. The endoscope EI-530B is a double balloon endoscope, thinner than EC-590ZW3, and is used as a backup endoscope in our clinic due to improved endoscope flexibility. A disadvantage of this endoscope is the stiffness of the endoscope which means it is not possible to insert beyond the splenic flexure. A carbon rod-which has strong stability─has been used as a stylet in order to overcome this disadvantage. In 488 cases of colonoscopy in our clinic over a period of four months, 34 cases required use of the backup endoscope─due to severe diverticulosis in the sigmoid colon, in cases with adhesions, or in thin patients. In 29 cases where a carbon stylet was used, the patients were more comfortable with the thin endoscope than with the regular colonoscope. The thin endoscope with carbon stylet enabled improved insertion rate of the entire colon. This equipment is useful for difficult colonoscopy cases, such as diverticulosis and adhesion in the sigmoid colon, and in thin patients.

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We have investigated retrospectively about peroral pancreatoscopy (POPS) , that performed at our hospital 33 examinations and 31 cases. We classified main duct type (21 examinations, 19 cases) and branch duct type (12 examinations, 12 cases) intraductal papillary mucinous neoplasm (IPMN) , and whether POPS was adequate for evaluating the spreading of IPMN or not. We investigated the efficacy of POPS about evaluation for the spreading of IPMN, accuracy of preoperative pathological findings compared with postoperative ones and post-POPS pancreatitis. We were able to perform adequate surveys for tumor spreading in 20 cases (main duct 15 cases, branch duct 5 cases) , and inadequate ones are 11 cases (main duct 4 cases, branch duct 7 cases) . Postoperative pathological findings revealed 2 cases were cut end positive, which were adenoma. In these cases, adequate evaluations of the spreading of IPMN have not been performed. Adenocarcinoma was confirmed in 8 cases after surgery, and in only 2 cases adenocarcinoma has been detected preoperatively. Post-POPS pancreatitis was complicated in 5 cases of main duct type, and those severities were mild. Diagnostic accuracy of preoperative pathological testing was inadequate, but preoperative POPS was useful in evaluation for the spreading of IPMN, which was confirmed pathologically after surgical operations.

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A total of 187 patients who underwent ESD for gastric neoplasms between January 2009 and December 2011 were included in this retrospective analysis of risk factors associated with delayed bleeding. Delayed bleeding was defined as clinically evident bleeding that required emergency endoscopy and/or blood transfusion with a decline of more than 2g/dl in serum hemoglobin concentration. Incidental bleeding cases were counted separately when active bleeding corresponding to or beyond Forrest IIa was incidentally found and resulted in additional hemostatic procedures during second-look endoscopy. The following variables were analyzed to determine factors leading to delayed bleeding : patient background (age, and anticoagulants/antiplatelets) , and procedural conditions (specimen size, duration of procedure and location of lesion) , and comorbidities (hypertension, diabetes mellitus, liver cirrhosis and, chronic renal failure with dialysis) . Delayed bleeding occurred in 5 cases (2.7%) . Maximum diameter of the resected specimen was identified as a sole predictor of delayed bleeding by Fisher test while multivariate analysis failed to statistically establish any particular variables predictive of delayed bleeding, although it demonstrated correlation between specimen size and delayed bleeding. Incidental bleeding was observed in 59 cases (31.6%) . In these hypertension, age, and maximum diameter of resected specimen were identified as predictive parameters by chi-squared test, while age and hypertension were identified as predictive parameters by multivariate analysis.─In view of the relatively frequent occurrence of incidental bleeding, additional prophylactic hemostasis immediately following ESD procedures may be useful in preventing delayed bleeding─.

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Background and Aim : Although development of endoscopic procedures enables hemostasis to be achieved endoscopically, some cases still prove difficult for this procedure. Re-bleeding or even fatal cases have occurred. We retrospectively analyzed endoscopic hemostasis for hemorrhagic peptic ulcer bleeding in our department.
Subjects and Method : A total of 141 patients underwent endoscopic hemostasis for hemorrhagic gastroduodenal ulcer in our department between January 2008 and November 2012. These patients were divided into two groups : successful and re-bleeding. Multivariate analysis was used to examine various factors─patient background, endoscopy-related and surgeon-related─as risk factors for rebleeding.
Results : In the 141 cases, the average age was 67.2±16 and the male-to-female sex ratio was 104 : 37. In the successful group, average age was 66.5±16 and male-to-female ratio was 88 : 34. In the re-bleeding group, average age was 71.7±16, and male-to-female ratio was 16 : 3. In the re-bleeding group, there were significantly more patients with comorbidity, and patients who received transfusions. Multivariate analysis results suggest that comorbidity is a risk factor for rebleeding.
Conclusion : Patients with comorbidity may be at increased risk of re-bleeding. Strict observation of patients is necessary after endoscopic hemostasis procedures.

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Endoscopic submucosal dissection (ESD) has been established as a standard endoscopic method for treatment of esophageal and gastric neoplasms, and as such has made rapid progress. However, colorectal ESD requires a high level of technical skill because of anatomical features of the colon. ESD becomes more difficult when fibrosis is present in the submucosal layer (sm fibrosis) . We compared the en bloc resection rate according to degree of fibrosis in the submucosal layer in 392 patients─totalling 401 lesions─who underwent colorectal ESD. The en bloc resection rate of severe fibrosis lesions was low (Table 1) . Between March 2011 and April 2012, colorectal ESD was performed in 110 cases at our hospital. Among the 23 cases (20.9%) with sm fibrosis, a severe degree of fibrosis was recognized in nine. Of these nine cases, the rate of en bloc resection was 55.6% (5/9) . The four cases in which en bloc resection was not possible were: two LST-G (Nodular mixed type) , one LST-NG (flat elevated type) and one Isp. Two of four lesions showed severe irregular type V_I pit pattern and were deep SM invasive cancers. From a technical viewpoint, if the muscle layer could not be detected, en bloc resection without complications was very difficult. Hence colorectal ESD is not indicated in lesions which show severe irregular type VI pit pattern and severe sm fibrosis. It is necessary to clarify clinicopathological characteristics of lesions which present as severe sm fibrosis, and establish a therapeutic strategy for such cases.

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There is currently no established scoring method for colonic stricture and/or obstruction. The Colonic Stent Safe Procedure Research Group, a research group belonging to the Japan Gastroenterological Endoscopy Society, proposed a draft Colorectal Obstruction Scoring System (CROSS) . In this system, five scores were determined according to the following conditions : score 0 “Requiring continuous decompressive procedure” ; score 1 “No oral intake”, score 2 “Liquid or enteral nutrient”, score 3 “Soft solids, low-residue, and full diet with symptoms of stricture” and score 4 “Soft solids, low-residue, and full diet without symptoms of stricture”. To verify the feasibility of CROSS, we retrospectively evaluated 66 obstructive colorectal cancer cases treated with extendable metallic stent (EMS) as a bridge to surgery (BTS) . Clinical success rate─remission of obstruction─was 89.4% (59/66 cases) and clinical failure rate was 10.6% (7/66 cases) . In clinical success cases, the CROSS score improved in all cases when colorectal obstruction before and after stent placement was compared. In addition, the score improved from 0 to 4 in 90% of the success cases. On the other hand, 71% of the failure cases demonstrated no improvement of CROSS score when comparing before and after stent placement. We conclude that these results show CROSS is feasible to assess the BTS cases of EMS placement.

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Recently, use of a colonic stent (SEMS, self-expandable metallic stent) has become one of the standard treatments for colonic malignant obstruction, including cases with colon cancer-related ileus. We investigated the usefulness of the recently-introduced Niti-S colonic stent.
Results : We trialed SEMS in 156 cases of colorectal stenosis during the period 1993 to 2011. Several types of SEMS were used in the colon : Z-stent, Wallstent, Ultraflex, WallFlex and Niti-S. In 146 cases of the 156 cases (94%) , stents were successfully inserted.
The Niti-S through the scope (TTS) type of stent (TaeWoong Medical Co., Ltd, South Korea) was introduced in 2006 and successful insertion was performed in 26 of 27 cases (96%) . In one case the stent migrated from the stenosis site after initial insertion, but correct positioning was possible at the second attempt. It suggested that it is better to improve the SEMS visibility. No serious complications such as perforation were seen after the insertion procedure. Final results of the procedure were : technical success rate 96.3%, clinical success 85.2%, early complications 3.7% and late complications 7.4%.
Conclusion : Clearly colonic SEMS is a low invasive procedure, and is effective for improvement of patient QOL. Niti-S─a new TTS type of SEMS-has showed feasibility for use as an effective and safe stent.

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The aging society is rapidly growing in Japan. Nevertheless, there is no consensus in the country for age limits to screen for colorectal cancer in elderly people. We investigated-among 18 primary care physicians and six hospital endoscopists in Setagaya city-opinions on screening for colorectal cancer in elderly people. 22.2% of the physicians responded that there is a need for fecal occult blood testing (FOBT) in people over 90 years (vs. 0% in the endoscopists) and 15.4% of the physicians responded that there is a need for colonoscopy (CS) in those over 90 years (vs. 0% in the endoscopists) . Japanese people over 90 years still have a life expectancy of 4.41 years in men and 5.76 years in women (Japanese Ministry of Health, Labour and Welfare, 2010) . We suggest that local physicians cease to recommend CS in citizens over the age of 90 years or in adults with a life expectancy of less than 10 years, and in elderly patients who are unable to consume a gallon jug of fluid (Golytely) by themselves in preparation for the procedure. Furthermore, the Japan Gastroenterological Endoscopy Society should recommend an upper age limit on screening for colorectal cancer, such as those seen in the Guidance Statement from the American College of Physicians (2012) .

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Since April 2011 we have been utilizing radial type endoscopic ultrasound (EUS) for diagnosis of pancreatic intraductal papillary mucinous neoplams (IPMN) at our hospital. Over this period, we have performed radial EUS in 22 patients with pancreatic IPMN. These patients were 13 men and 9 women with a mean age of 70 years old (41 to 80 years old) , including 2 cases with main duct type IPMN, 16 cases with branch duct type IPMN , and 4 cases with mixed type. EUS examination revealed a mural nodule of the cyst, in 9 of the 22 patients with pancreatic IPMN.
Due suspicion of malignancy after EUS, CT and MRI examinations, 10 patients were considered for surgical intervention. Of these, 6 patients underwent surgical resection.
In 9 cases were identified mural nodules in EUS examination. But in 7 cases of these 9 cases, could not detected mural nodules in CT or MRI examinations. It had been reported that the detection rate of mural nodules in pancreatic IPMN is 78% by EUS, 35% by conventional US, 24% by CT, and 19% by MRI. In terms of strategy for management of pancreatic IPMN, the existence of mural nodules is one of the high-risk factor for malignancy, and EUS is important and useful modality for the their diagnosis.
International consensus guidelines 2012 for the management of IPMN and mucinous cystic neoplasm (MCN) of the pancreas , EUS examination is recommended for patients with worrisome feature (cyst diameter greater than 30mm , main duct diameter 5-9 mm) , and for patients with cyst diameter greater than 20mm at follow up examinations. Using EUS, we were able to detect small mural nodule in cyst diameter from 15 mm, which is not regarded as high-risk stigmata or worrisome features according to the guidelines. We performed surgical resection of this lesion and it was diagnosed pathologically as intraductal papillary mucinous carcinoma (IPMC) . Therefore, although not currently recommended by international consensus guidelines, we would like to recommend EUS in patients with all pancreatic IPMN cysts.
We believe EUS evaluation is one of the most useful and significant modalities for management of patients with pancreatic IPMN.

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A 27-year-old man undergoing conventional esophagogastroduodenoscopy due to epigastric discomfort was discovered to have a reddish protruded lesion on the right wall at the esophagogastric junction (EGJ) . The background mucosa of the tumor was diagnosed as short segment Barrett’s esophagus (SSBE) . Using magnifying endoscopy with narrow band imaging (NBI) , the tumor was shown to have an absence of surface pattern and an irregular microvascular pattern. The tumor was diagnosed as Barrett’s esophageal adenocarcinoma in SSBE, and endoscopic submucosal dissection (ESD) was performed. Pathological analysis of the resected specimen diagnosed 0-IIa+IIc, Barrett’s esophageal adenocarcinoma tub1>tub2, pT1b (SM2) , ly0, v1, pHM0, pVM0, pR0, with a tumor size of 27×15 mm. Barrett’s esophageal adenocarcinoma in younger patients is rare and this case raises the possibility of a new clinical presentation of the condition.

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A 72-year-old man suffered severe Candida esophagitis, which was associated with food saburra in the esophagus and caused by esophageal achalasia. A balloon extension procedure was performed and treatment of the Candida esophagitis was eventually successful. Achalasia is one risk for Candida esophagitis, although it rarely causes severe infection.

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A 52-year-old woman presented at our hospital with cramping abdominal pain associated with bloody diarrhea. Laboratory data revealed leukocytosis, elevated serum CRP level, microcytic anemia and hypoproteinemia. Upper GI endoscopy revealed esophageal superficial aphthous ulcers while lower GI endoscopy revealed active colitis with longitudinal apthous ulcers extending from rectum through to sigmoid colon. Histological examination of biopsy specimens taken from both esophagus and sigmoid colon showed non-caseating epithelioid cell granuloma. A diagnosis of Crohn’s disease with esophageal lesions was determined, and treatment was initiated with mesalazine (3,000 mg/day) and nutritional support for 4 weeks. Despite treatment compliance, endoscopic examinations at this time showed slight worsening of mucosal lesions, hence infliximab was started at a dose of 5mg/kg/8 weeks. Endoscopy performed a year after infliximab therapy commenced demonstrated ulcer scars and the patient had no symptoms for more than a year.

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A 27-year-old woman was diagnosed with epidermolysis bullosa acquisita (EBA) in 2007 and received medical treatment since that time. In April 2011, she developed erythematous bullous eruption and erosion covering her whole body, and was admitted as an emergency to the department of dermatology in our hospital. After admission, the patient had dysphagia and vomiting. Upper gastrointestinal endoscopy showed mucosal edema and stenosis associated with esophageal erosion in the middle esophagus. Dysphagia improved after treatment of the EBA, mucosal edema disappeared and the esophageal erosion visible on upper gastrointestinal endoscopy regressed. In July 2011, the patient had acute onset discomfort in her throat and dysphagia recurred. Upper gastrointestinal endoscopy revealed esophageal stenosis─with circumferential extent of one half─around a tense bulla in the upper esophagus. The bulla was ruptured by pressure from the endoscope, removing the stenosis. Subsequently dysphagia quickly disappeared, and the patient was discharged symptom-free. This is the first case of esophageal stenosis caused by a bulla in the esophagus, where the clinical condition may have been due to a previous esophageal erosion and ulcer lesion.

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An aysmptomatic 59-year-old man was referred to our hospital after esophageal abnormality was detected during a medical check-up. GI tract survey revealed a 5cm diameter submucosal tumor （SMT） in the middle to lower thoracic esophagus. Chest CT, MRI and FDG-PET examinations showed no distant organ metastasis or lymphadenopathy. In order to obtain pathological information preoperatively, we performed endoscopic ultrasound （EUS） and fine-needle aspiration biopsy under ultrasound （EUS-FNAB） on the esophageal SMT. Histopathological examination of the EUS-FNAB showed spindle cells positive for c-kit and CD34, and esophageal GIST was diagnosed. MIB-1 index of the FNAB specimen was less than 2％ of the tumor cells. Esophagectomy with gastric tube reconstruction was performed. The SMT was found to be 54×45×35 mm in size. The number of mitosis was 4 per 50 HPFs and the MIB-1 index of the resected specimen was less than 2％. The final risk classification was intermediate and no adjuvant chemotherapy was administered. According to guidelines for management of patients with GIST, preoperative diagnosis is considered the first step in therapy and optimal management is based on risk evaluation after tumor resection. Sensitivity of pathological diagnosis by FNAB of the tumor is not high；EUS is merely a useful adjunct to preoperative diagnosis. Adequate specimen size may be utilized to diagnose GIST and possibly evaluate risk classification by MIB-1 index.

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Submucosal hematoma of the esophagus is a rare disease. We report two cases which developed spontaneously, presenting with chest/back pain.
Case 1：A 74-year-old woman was admitted to our hospital with acute onset chest/back pain. She had received antiplatelet agents for treatment of angina pectoris. Chest enhanced CT scan showed a non-enhancing mass occupying the esophageal lumen. Endoscopic examination revealed a large, dark red-colored mass filling the entire esophagus, which was diagnosed as submucosal hematoma of the esophagus. The patient was treated with anti-acid drugs, in conjunction with food deprivation and intravenous hyperalimentation. Endoscopy performed 14 days after admission showed development of deep ulceration along the entire esophageal wall. After three months, the esophageal ulcer had disappeared.
Case 2：A 67-year-old woman was referred to our hospital with acute chest/back pain. She had received anticoagulants for treatment of paroxysmal atrial fibrillation. Chest enhanced CT scan and endoscopic examination revealed submucosal hematoma of the esophagus. She was conservatively treated and improved immediately. Examination by endoscopy showed complete improvement of the esophageal lesion two months after onset.
It has been reported that conservative management is successful for this disease. Patients receiving antiplatelet agents or anticoagulants are at increased risk of developing submucosal hematoma of the esophagus.

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Carcinosarcoma of the esophagus is a relatively rare malignant neoplasm. Esophagectomy with regional lymph node dissection has often been performed to cure patients with this condition. Chemoradiotherapy has also been used to treat unresectable carcinosarcoma. This report describes an 83-year-old man with carcinosarcoma of the esophagus who was treated with chemoradiotherapy. Barium swallow examination showed an elevated lesion─measuring about 80 mm in diameter─in the thoracic and abdominal esophagus. Endoscopic examination revealed a type 2 tumor ＋IIb lesion in the esophagus. Histological analysis of a biopsy from the tumor demonstrated a carcinosarcoma. CT scan showed no evidence of lymph node swelling or distant metastasis. Thus, the clinical diagnosis was T3N0M0 cStage II. The patient declined surgery. Chemoradiotherapy─consisting of 5-FU and CDDP with radiotherapy of 60 Gy─was administered to the patient. He did not undergo additional chemotherapy, as he and his family wished to cease therapy. Endoscopic examination revealed that the carcinosarcoma had decreased in size.
The patient has now been alive for 15 months since initiation of treatment.

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An 81-year-old man underwent surgery for esophageal achalasia at 57 years of age. He received periodical endoscopic examination annually. When 75 years old, an irregular slightly depressed lesion was detected on the left esophageal wall at 31-34 cm from the incisors, and pathological examination of a biopsy specimen revealed high grade intraepitherial neoplasia. We performed argon plasma coagulation (APC) on the lesion. When the patient was 76 years old, a superficial protruding lesion with a slightly elevated component was detected at the right esophageal wall at 21-28 cm from the incisors. Pathological examination of a biopsy specimen from this lesion revealed squamous cell carcinoma. As we diagnosed the depth of tumor invasion to be the submucosal layer, we performed chemoradiotherapy. Complete remission was achieved. Endoscopic examination when the patient was 81 years old revealed a flat reddish lesion on the left wall at 30 cm from the incisors; pathological examination of the biopsy specimen was high grade intraepitherial neoplasia. After 6 months, the lesion became a slightly depressed lesion and narrow band imaging (NBI) endoscopy showed irregular intraepithelial papillary capillary loops within a brownish area. Depth of tumor invasion was diagnosed as mucosal layer, and we performed endoscopic submucosal dissection (ESD). Although fibrous change of the submucosal layer was marked, we successfully resected the lesion without perforation or bleeding. Pathological examination of the ESD specimen was squamous cell carcinoma (SCC), INFa, pT1a-EP, ly0, v0, pHM0, pVM0 according to the Japanese Classification of Esophageal Cancer, 10th edition. The patient is well without recurrence after one year.

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During health assessment of an 81-year-old male, endoscopy detected a depressed lesion with ulceration in the lower esophagus. Histological analysis of biopsies diagnosed squamous cell carcinoma, but the findings were atypical and─due to the histological appearance of glandular structures─there was suspicion of basaloid squamous carcinoma (BSC). Lower esophagectomy was performed, and histology of resected tissue demonstrated BSC mixed of trabecular components and glandular structures, with squamous cell carcinoma in-situ at the border of the ulcerative lesion. The final histological diagnosis was：carcinoma with mixed basaloid squamous and glandular differentiation, pT1b(SM3), INFc, ly0, v1, N0, M0. BSC of the esophagus is a rare but distinct variant of esophageal carcinoma, and the incidence of BSC has been reported as 1.3% of total esophageal malignant tumors. Histologically, esophageal BSC displays a variety of features, but few cases show glandular structures. We describe an unusual case report of esophageal BSC with glandular differentiation.

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A pedunculated polyp was identified by gastrointestinal endoscopy in the cervical esophagus of a 60-year-old male. Esophageal adenocarcinoma was diagnosed by analysis of biopsy specimens. The depth of tumor invasion was thought to be within the mucosa and hence endoscopic mucosal resection was performed under general anesthesia, without complication. Histopathological examination revealed that the lesion was a moderately differentiated adenocarcinoma in situ (pT1a-LPM) arising from ectopic gastric mucosa. Lymphovascular invasion was negative and the margins were free from carcinoma. This case of cervical esophageal adenocarcinoma arising from ectopic gastric mucosa is rare, and to our knowledge only 19 cases─including this one─have been reported in Japan. Of these, endoscopic treatment was successful in just three cases. Careful endoscopic observation is required to discover this type of esophageal carcinoma.

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A 14-year-old male patient was admitted to our hospital with upper abdominal pain after accidental ingestion of a fragment from a broken glass cup. Upper gastrointestinal endoscopy confirmed the presence of a piece of glass within a large volume of food remaining in the stomach. We used several devices─including a commercially available cap mounted on the endoscope tip─but could not remove the glass fragment due to difficulty gripping the glass within these devices. Using a skirt-type endoscope hood, the fragment was finally removed safely. The skirt─type hood─which was large enough to wrap the entire fragment─helped to grip the smooth glass, thereby reducing the risk of mucosal damage. We believe that this device can be used effectively in cases where removal of a foreign object is difficult using an ordinary endoscope cap due to the size or shape of the object.

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An 84-year-old man presented to our hospital, complaining of right lower abdominal pain after left chest pain the day before. Blood analysis revealed a leucocyte count of 17,030/mm³ and C-reactive protein (CRP) of 0.32mg/dl. The patient revisited due to persistence of the symptom, and at this time blood analysis revealed a leucocyte count of 15,270/mm3 and CRP of 14.04 mg/dl. The patient was admitted to our hospital and made a rapid improvement after treatment with antibiotics. However, the symptom was still present one day later and a partial peritonitis was suspected. This was confirmed using abdominal CT, which also identified a linear high-density structure penetrating the gastric wall. Emergency gastrointestinal endoscopic examination revealed a fish bone penetrating into the anterior wall of the antrum. After the penetrating bone was removed with grasping forceps, clips were applied at the site of bone removal. The removed bone measured 43 mm in length. 7 days later, the patient had recovered and started to eat.

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An 86-year-old man was admitted to our hospital with bronchial asthma. His medical history included chronic renal failure, carcinoma of the prostate, bronchial asthma and dementia. On the sixth day after admission, the patient suddenly complained of epigastric pain, and muscular defense was detected on physical examination. A chest X-ray and CT scan showed free air in the abdomen and gastric perforation was suspected. Considering the patient’s age and dementia, conservative therapy was elected. Contrast imaging using amidotrizoic acid identified a mass in the fornix which moved according to the patient’s body position. Endoscopic examination revealed a yellow-green colored mass in the fornix and an ulcer associated with perforation in the upper body of stomach. From these findings, a diagnosis of bezoar was made. Endoscopic removal of the bezoar was performed on the 37th day after admission. Chemical analysis of the bezoar revealed tannic acid. The patient reported frequent consumption of a large amount of chestnuts prior to admission.
A bezoar is defined as an indigestible mass composed by hair and vegetable fibers along with other materials. Reported cases of bezoars in Japan comprise those originating from plant material；75% of these cases were from persimmons. Up until now, only 10 cases of bezoar complicated with gastric ulcer and perforation have been reported in the literature, with all cases treated surgically. Endoscopic therapy is one of the options for bezoars with gastric perforation.

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A 71-year-old woman was admitted as an emergency with a three-day history of repeated vomiting and epigastralgia. An upright plain radiograph showed a huge quantity of air and two distinct fluid levels in her stomach, while a CT scan of the abdomen showed the stomach to be significantly dilated. As upper GI series revealed typical features of mesenteroaxial volvulus of the stomach, hence a diagnosis of gastric volvulus was made. Fluoroscopic examination of the stomach also showed a gastric volvulus of mesenteric type and occlusion in the lower body of the stomach. After an endoscope was inserted further into the duodenum, the endoscope was directed into a reverse alpha loop. As the endoscope was retracted with its tip hooking the duodenum, rotation was successfully corrected. This paper describes the classification, diagnosis and treatments of gastric volvulus. We studied the clinical characteristics of the attempted endoscopic reduction of gastric volvulus reported in Japan between 2000 and 2012, identifying 40 cases using the medical journal search engine Ichushi-Web (Japan Medical Abstract Society). The results indicate that mesenteroaxial (86％ of cases) is more prevalent than organoaxial (8％) volvulus of the stomach, and the group of cases with idiopathic volvulus were corrected endoscopically except patients with lax ligaments stabilizing the stomach. We suggest attempting reduction of gastric volvulus endoscopically at first.

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A 60-year-old female with adult-onset Still’s disease developed hematemesis after an increase in steroid dosage. Emergency upper gastrointestinal endoscopy showed a large irregularly shaped shallow A₁ stage ulcer, and hemostatic clipping of the exposed vessel was performed. Intracellular inclusion bodies characteristic of cytomegalovirus (CMV) were not detected, although serum CMV antigen was positive. The patient was treated with proton pump inhibitors (PPI) and discharged. Six weeks later the patient was re-admitted to the hospital for treatment of hemophagocytic syndrome, and steroid dosage was increased. On day 49 after admission the patient had recurrent hematemesis, and endoscopy revealed active bleeding from the same large ulcer. Histological findings of a gastric biopsy showed CMV intracellular inclusion bodies in HE staining and CMV-immunohistochemistry, and serum CMV antigenemia was present. Anti-CMV agents were administered. When serum CMV C7-HRP and CMV-DNA were no longer detected and intracellular inclusion bodies in a gastric biopsy became negative, these medications were ceased. Four weeks later, serum CMV C7-HRP and CMV-DNA became positive and on endoscopy the gastric ulcer also appeared exacerbated. The patient was re-treated with anti-CMV agents, continuing until the gastric ulcer improved to H₁ stage. During treatment of CMV-associated gastric ulceration, treatment should not be ceased when serum CMV antigen and intracellular inclusion bodies in biopsies alone become negative, rather anti-CMV agents should be continued until ulcers improve.

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Gastric hamartomatous inverted polyp is rare and also difficult to diagnose by forceps biopsy due to its submucosal location. We present three cases of gastric hamartomatous inverted polyps which had similar features and were diagnosed by endoscopy. All three cases were pedunculated lesions. One of the lesions had a size of 35mm─which was too large for the endoscopic snare─so was clipped at the base and resected at the peripheral side of the clip with a needle knife. Lesions in the other two cases were 8mm and 15 mm in size, and were resectable by snare. The surfaces of these lesions appeared to be normal mucosa with some slight depressions. Microscopic findings of the resected specimens showed inverted growth of mucosa and muscularis mucosa into the submucosal layer. These pathological features were compatible with the depressions that had been observed by endoscopy, caused by inverted growth into the submucosal layer.

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A 77-year-old male patient was admitted to hospital complaining of epigastralgia and general fatigue. Serum blood analysis showed hepatic dysfunction and hypoalbuminemia. Ulcerative lesions were found in the fornix and gastric angle. Pathological examination of biopsies from the gastric ulcerative lesions revealed lymphoid infiltration. Abdominal US showed multiple low echoic lesions in the liver and contrast-enhanced CT revealed multiple low-density masses in the liver and spleen, suspected to be malignant lymphoma or metastatic tumors. Malignant T-cell lymphoma was immunohistochemically confirmed using samples taken via US-guided liver biopsy. No reactivation of Epstein-Barr virus was present in Epstein-Barr virus-encoded RNA (EBER) in situ hybridization of tumor cells. The patient suffered from rheumatoid arthritis (RA) and had been treated with methotrexate (MTX) for four years. Due to suspicion that MTX was associated with the tumor formation, MTX therapy was discontinued. Subsequently the patient’s symptoms disappeared and laboratory findings improved. Approximately one year later, the gastric ulcers were healing and the hepatic tumors had disappeared. Since that time, the patient has had no recurrence. The final diagnosis was methotrexate-associated lymphoproliferative disorder (MTX-LPD). Several studies have documented that RA itself as well as MTX treatment for RA are risk factors for development of malignant lymphoma. Although case reports of gastric ulcers and hepatic tumors accompanying MTX-LPD are rare, we would suggest that MTX-LPD is included as a differential diagnosis for gastric ulcerative lesions.

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Accurate identification of the point of hemorrhage is important during endoscopic hemostasis of upper gastrointestinal hemorrhage；however, large amounts of food residue and blood clots often make it difficult to detect the source of hemorrhage during an emergency procedure. Changing body position, washing with tap water, attaching a transparent hood, and the use of an oblique- or side-viewing endoscope are recommended to maintain a clear endoscopic view¹⁾. In this case report, we present three cases with hemorrhagic gastric ulcers that could not be identified while the patient was in a left lateral position but were ultimately detected and treated once the patient was repositioned into the right lateral position. In all three cases, endoscopic hemostatic treatment was ultimately performed without complications while the patient was in a right lateral position. Changing from a left lateral position to a right lateral position seems to be an effective option in cases in which the source of hemorrhage is difficult to identify while the patient is in a left lateral position, and this technique should be used more actively in clinical practice.

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A 69-year-old woman who had vomited blood underwent abdominal enhanced computed tomography (CT) examination, which identified a gastric submucosal tumor. On upper gastrointestinal endoscopy, the tumor was found at the anterior wall of the lower gastric body. Arterial bleeding was seen from the tumor surface, but endoscopic hemostasis was unsuccessful. Therefore a distal gastrectomy was performed to enable hemostasis. Histopathological findings confirmed the diagnosis as gastrointestinal stromal tumor (GIST) of the stomach. In cases of gastrointestinal bleeding from tumors which are resistant to endoscopic hemostasis, it is necessary to perform other treatments such as surgery.

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A 70-year-old woman was referred to our hospital for further examination of gastric submucosal tumor (SMT). Esophagogastroduodenoscopy (EGD) revealed the SMT to be approximately 20 mm in diameter and situated on the middle body anterior wall of the lesser curvature, which was steep-sided and covered with normal mucosa. EUS showed the lesion to extend continuously into the fourth layer of the gastric mucosa, with a fairly homogeneous echogenicity. Due to an increase in size of the SMT, we performed an endoscopic mucosal cutting biopsy. The histopathological findings indicated a spindle cell tumor with no mitotic figures. GIST was diagnosed on the basis of positive immunostaining for c-kit and CD34. The patient also underwent laparoscopic and endoscopic cooperative surgery (LECS) in accordance with published therapeutic guidelines for GIST.
The histopathological and immunostaining findings from surgically resected specimens were in agreement with those from the mucosal cutting biopsy specimens.
It is vital to diagnose GIST early, as small lesions are resectable by LECS. Biopsy with incision of the mucosa is useful for early diagnosis of SMT.

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A flat elevated whitish lesion of 5 mm in diameter was identified in the greater curvature of the antrum in a 73-year-old woman. The biopsy specimen was diagnosed histologically as tubular adenoma. Two years later, endoscopic re-examination was performed and a biopsy revealed endocrine cell micronests (ECMs) at the base of the tubular adenoma. One of ECMs measured greater than 200μm, suggestive of so-called minute carcinoid. ECMs and some cells in the tubular adenoma were positive for synaptophysin and chromogranin A. The tumor was suspected to be a composite adenoma-carcinoma tumor and was treated by endoscopic mucosal resection. The resected specimen was diagnosed as well-differentiated tubular adenocarcinoma with ECMs at the base of the tubular portion. This case report provides important information on histogenesis and differentiation of gastric neoplasms with endocrine features.

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An 80-year-old woman had been diagnosed with IPMN and suffered from repeated acute pancreatitis since 2009. In 2011, penetration of IPMN into the stomach was found, and she was admitted to our hospital with fever and epigastric pain in May 2012.
During esophagogastroduodenoscopy it was found that the IPMN had penetrated into the stomach and also showed an increase in the tumor size. The patient’s symptoms were successfully treated via endoscopic drainage.
IPMN is partly characterized by expansive mucinous growth that may result in penetration into adjacent organs. The frequency of such penetration has been reported to be 7.9 to 15% of IPMN cases. Penetration occurs most often into the common bile duct, then the duodenum common bile duct, and finally the duodenum and stomach.
This unusual case of IPMN penetration into the stomach was associated with repeated acute pancreatitis.

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The patient was an 80-year-old man who had been treated with anticoagulant and antiplatelet agents for ischemic heart disease. Upper gastrointestinal endoscopy─performed for progressive anemia─revealed a 10 mm-sized pedunculated reddish polyp at the greater curvature of the middle body of the stomach. The polyp had a granular surface with erosion and a friable section. Considering the risk of hemorrhage from the polyp, the patient underwent polypectomy. Histological examination revealed a well-differentiated tubular adenocarcinoma arising within a hyperplastic polyp. This case suggests that a hyperplastic polyp with erosion or friable regions─even if less than 20 mm in diameter─could potentially undergo malignant transformation.

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A 71-year-old man was treated for NSAIDs-induced gastric ulcer and esophagogastroduodenoscopy performed. Endoscopic findings identified a small depressed lesion─approximately 5mm in size─at the lesser curvature of the antrum. Biopsy specimens showed Group 2, but using magnifying endoscopy with NBI we diagnosed the lesion as cancer. ESD was performed and histopathological findings showed a minute well-differentiated adenocarcinoma in the surface of the mucosal layer with neuroendocrine carcinoma invasion to the submucosal layer. The cancer detected on pathological analysis was 2.4 mm in diameter, and therefore a gastric microcancer. Due to the presence of approximately 1,000μm invasion in the submucosal layer with concurrent intravenous invasion, laparoscopy-assisted distal gastrectomy with lymph node dissection was performed. The final lesion was diagnosed as pT1b2N0cM0 in Stage ⅠA. Ten months after surgery, the patient had no recurrence of the lesion. A portion of the tubular adenocarcinoma in this case was immunohistochemically positive for CD56. It was considered that sampling in this case detected an initial transitional change from adenocarcinoma to neuroendocrine carcinoma. The fact that this cancer invaded the submucosal layer─despite being only 2.4 mm in diameter─indicated high grade malignancy of gastric neuroendocrine carcinoma.

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A 64-year-old male patient underwent several endogastroduodenoscopy (EGD) procedures for treatment of multiple gastric hyperplastic polyps. An erosion (2×3mm) was observed on a hyperplastic polyp located in the antrum at the greater curvature of the stomach. Magnifying endoscopy with narrow band imaging (NBI) revealed that superficial formation and fine network pattern of the mucosa had disappeared. This lesion was diagnosed by pathological assessment of a biopsy specimen as adenocarcinoma, including a poorly differentiated component. Although poorly differentiated carcinoma was involved, we elected endoscopic submucosal dissection (ESD) because the cancer was thought to be contained within 20mm mucosal depth. Histopathological analysis of the ESD specimen revealed horizontal and vertical margins of the cancer were negative, but lymphovascular involvement was present. Therefore additional surgical resection was performed. Lymph-node metastasis and residual cancer were not detected. Carcinogenicity of hyperplastic polyps is unknown at present, but recently several cases of poorly differentiated adenocarcinoma developing in hyperplastic polyps have been reported. These polyps were frequently discovered extending deeper than 20mm. In the case reported here, a poorly differentiated adenocarcinoma developed in a hyperplastic polyp less than 10mm in depth and required additional surgical resection. We conclude that it is necessary to monitor hyperplastic polyps strictly regardless of size, especially in cases with existing risks of carcinogenesis such as H. pylori infection and non-uniform or recess type polyp.

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A 64-years old man was admitted to our hospital complaining of appetite loss. His blood test showed anemia. Endoscopic examination revealed a large protruding lesion showing submucosal tumor-like appearance within a deep ulcer. Abdominal enhanced computed tomography showed a tumor with extragastric growth, measuring 10 cm, with necrosis, and showed multiple metastases to the liver. The serum alpha fetoprotein （AFP） level was 31.2 ng/ml. Because the biopsy specimen revealed poorly differentiated adenocarcinoma, the chemotherapy （S1/CDDP） was started. However the treatment was ineffective, the patient died after 47 days. The autopsy findings of the gastric tumor revealed hepatoid adenocarcinoma and tubular adenocarcinoma, and the diagnosis of hepatoid adenocarcinoma was established. Immunostaining for tubular adenocarcinoma lesion was positive for AFP, but for hepatoid adenocarcinoma lesion was negative. Hepatoid adenocarcinoma accounts for 0.2％ of all gastric tumors. In the Japanese literature, 88 cases including our case have been reported, 81％ cases were advanced type and 2％ cases showed submucosal tumor-like appearance, 44％ cases were with liver metastasis. The serum AFP level was more than 1,000 ng/ml in 55％ cases, but in only 10％ cases was less than 50 ng/ml. Hepatoid adenocarcinoma lesion is usually mixed with tubular adenocarcinoma lesion and rarely found in mucosal layer. Therefore only 11％ cases were diagnosed by biopsy specimens.

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Herein we report a case of mixed adenoneuroendocrine carcinoma of the stomach. An 80-year-old man was referred for treatment of early gastric cancer detected by periodical medical assessment. Using upper gastrointestinal tract endoscopy, an irregular elevated tumor was observed at the lesser curvature of the lower third of the stomach. Pathological examination of biopsy specimens revealed well-differentiated tubular adenocarcinoma (tub1). Although pretreatment diagnosis was early gastric cancer (type 0-I) invading to the submucosal layer (SM2), diagnostic endoscopic submucosal dissection (ESD) was carried out as the patient declined curative surgery. Pathological examination of the ESD specimen demonstrated mucinous carcinoma together with tub1. In addition, at the deepest part of the tumor (SM1), neuroendocrine carcinoma was observed; immunohistochemistry revealed positive staining for synaptophysin, chromogranin A, and CD56. Using the latest WHO NET classification, we diagnosed the tumor as mixed adenoneuroendocrine carcinoma. Furthermore, vascular involvement (ly2 and v1) was observed in the neuroendocrine carcinoma. Additional resection was recommended but the patient declined to re-visit. Fourteen months later, he presented with general malaise. Upper gastrointestinal tract endoscopy revealed a tumor at the ESD scar site and pathological examination of biopsy specimens confirmed recurrence of neuroendocrine carcinoma. Concurrently multiple liver metastases, peritoneal disseminations and lymph nodes metastases were observed, and best supportive care policy was elected until the patient died eighteen months after the ESD.

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A 75-year-old man underwent upper gastrointestinal endoscopy for health screening. Endoscopic examination showed a lesion with the appearance of a submucosal tumor─an elevated area with a slightly depressed and erythematous portion─at the anterior wall of the lower body of the stomach. Histological analysis of biopsy specimens revealed the possibility of a gastric carcinoma. Endoscopic ultrasonography identified a hypoechoic mass which invaded deeply into the submucosal layer. However, histological findings from biopsy specimens taken at that time revealed normal gastric mucosa. ESD was performed for the purposes of diagnosis and treatment. Histopathological findings of the resected specimen revealed a well to moderately differentiated adenocarcinoma, and a regenerative epithelium distributed on the surface of the cancerous lesion. Immunohistochemical staining for the proton pump and Pepsinogen I was positive, suggesting a gastric adenocarcinoma of fundic gland type. Adenocarcinoma of fundic gland type was first reported by Ueyama and Yao in 2010, but endoscopic findings have not yet been established. Accumulation of characteristic endoscopic findings for this tumor is required to assist future diagnosis.

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A 72-year-old man was diagnosed by endoscopy─which suggested well differentiated tubular adenocarcinoma Group 4─and admitted to our hospital. The lesion was located in the upper third of the stomach on the posterior wall, was flatly depressed (0-IIc), and had an undefined margin under indigo carmine dyeing. Histologically, the lesion was composed of cells resembling chief cells and indicated differentiation to fundic glands. Immunohistochemically the lesion indicated MUC6(+), MUC5AC(-), CD10(-), MUC2(-), gastric phenotype. We diagnosed this lesion as gastric adenocarcinoma, fundic gland type. Gastric adenocarcinoma of fundic gland type was proposed by Ueyama and Yao et al in 2010, and its clinicopathologic features reported. This type of lesion tends to invade submucosally and it is recommended to treat using ESD. For this reason we elected to perform endoscopic submucosal dissection (ESD) rather than endoscopic mucosal resection (EMR). The lesion─SM1 (250μm)─was completely excised. No relapse has been detected from surgery until follow up examination. Most of these cancers originate from normal mucous membrane, and are thought to be unassociated with H. pylori. As infection rate of H. pylori decreases, this type of adenocarcinoma should be considered in the future.

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A 68-year-old man was admitted to our hospital with anorexia and weight loss. Hematology showed marked leukocytosis (95,620/µl).
Esophagogastroduodenoscopy (EGD) revealed a large raised lesion with the appearance of a gastric submucosal tumor on the anterior gastric wall at the lesser curvature. Laboratory data revealed a high serum level of granulocyte-colony stimulating factor (G-CSF)(584 pg/ml). CT scan showed multiple liver metastases and generalized lymph node metastases. Although a submucosal tumor was suspected based on endoscopic appearance, pathological diagnosis was of a non-solid type poorly differentiated adenocarcinoma. Positive G-CSF immunological staining characterized the tumor as a G-CSF-producing gastric cancer.
Despite chemotherapy, the patient died on day 45 after admission.

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A 70-years-old woman in her seventies─who had received wide resection of the stomach with Billroth-II reconstruction for peptic ulcer perforation approximately 40 years previously─was referred to our hospital for epigastralgia. Gastrointestinal tract examination revealed remnant gastric cancer, and peritoneal dissemination was diagnosed at exploratory laparotomy. The patient developed gastric outlet obstruction after poor response to chemotherapy and a self-expandable metallic duodenal stent was placed. Upper gastrointestinal radiography with a flexible cannulation device was necessary for identification of the afferent and efferent loops. An uncovered metallic duodenal stent was inserted into the efferent loop to maintain flow of duodenal fluid from the afferent to efferent loop. Placement of the stent improved the patient’s oral intake and quality of life. She was capable of oral intake until just prior to death from progressive disease. We successfully managed malignant gastric outlet obstruction after Billroth-II reconstruction with SEMS placement using a flexible cholangiography catheter.

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A 75-year-old woman was admitted for investigation of appetite loss and diarrhea. Chest X-ray and CT showed multiple patchy shadows in bilateral lungs. Gastrointestinal endoscopy showed multiple flat elevated lesions with the appearance of submucosal tumors in the gastric body, and a flat elevated lesion and an ulcerative lesion with the appearance of IIa and IIc tumors in the duodenum. Colonoscopy identified a flat elevated lesion in the cecum. Malignant lymphoma (diffuse large B-cell lymphoma : DLBCL) was diagnosed by histological analysis of the stomach, duodenal and large intestinal lesions. Gastric malignant lymphomas have been classified according to macroscopic appearance by Sano and Yao. Sano classified them into five categories (superficial, ulcer, polypoid, fungated and giant fold types). Gastrointestinal endoscopic findings of gastric DLBCL often reveal a single lesion, of the ulcer type according to Sano’s classification. This case is rare in that elevated lesions with the appearance of a submucosal tumor were observed relatively uniformly throughout the gastric body, along with endoscopic findings of gastric DLBCL and various other lesions extending to the duodenum and large intestine. This case of malignant lymphoma presented with various endoscopic findings extending to the stomach, duodenum and large intestine.

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Percutaneous endoscopic gastrostomy (PEG) is a safe and easy method of providing enteral nutrition. However, there are some reports of complications including accidental colon puncture. We report two cases where the transverse colon interfered with the puncture route but we were able to perform PEG safely via colonoscopy. In both cases, preoperative CT identified the transverse colon intervening between the stomach and the abdominal wall. We inserted a colonoscope under fluoroscopy, and pulled the transverse colon downwards in order to successfully place a PEG. Preoperative CT examinations can offer valuable information about abdominal organs and are useful to prevent unexpected complications. PEG assisted by colonoscopy is a safe and effective procedure that may be used when the transverse colon intervenes between stomach and abdominal wall.

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A 56-year-old man was hospitalized for treatment of severe acute abdominal pain. Chest X-ray and abdominal CT showed the presence of free air intra-abdominally. A clinical diagnosis of acute generalized peritonitis due to gastro-duodenal perforation was made and emergency surgery was performed. At the time of surgery, a 3 cm-diameter perforation was identified on the anterior wall of the duodenal bulb, and treatment effected by omental patch. On the 12th day post-operatively, endoscopy confirmed that no leakage was present at the previously-perforated site in the duodenum. On day 17, food debris appeared unexpectedly at the surgical site due to wound dehiscence. Abdominal enhanced CT showed the presence of free air from the front of the duodenal bulb extending through the intra-abdominal space to the skin wound. Whilst fasting combined with a course of antibiotics, treatment for the site of leakage was performed. Using regular clips and nylon yarns under endoscopy, the hole was reefed and leakage of contrast medium significantly abated. Subsequently inflammation reduced dramatically. The patient’s condition discernibly improved and finally resolved without the need for invasive surgery.

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Duodenal cancer is a rare disease that accounts for 0.3％ of all primary gastrointestinal tract cancers. We report the case of an elderly patient diagnosed with and treated for early duodenal cancer detected during follow-up after resection of intraductal papillary mucinous neoplasm (IPMN). An 82-year-old man was diagnosed with IPMN during hospitalization for acute pancreatitis in 2004 and underwent pancreatic resection. In 2008, an elevated lesion measuring 15 mm in size was detected at the anterior wall of the duodenal bulb during gastroscopy. A mucosal lesion was also noted during endoscopic ultrasonography. Histopathological examination of a biopsy specimen identified well-differentiated adenocarcinoma. On the basis of these findings, endoscopic mucosal resection was performed. Although the tumor was resected in two parts, no residual malignancy was noted. Histopathological examination of the resected specimen revealed a 20×18 mm well-differentiated adenocarcinoma, pT1a (m), med, INF-α, ly (-), v (-), pHMx, pVM0. Gastrointestinal endoscopy performed two months after surgery and in 2013 did not show any obvious signs of tumor recurrence. IPMN is sometimes reported to occur in combination with cancers of other organs. However, to our knowledge this is the first case report of early duodenal cancer occurring in a patient with IPMN.

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A 51-year-old man complaining of abdominal distention was admitted to our hospital due to duodenal stenosis caused by progression of unresectable advanced gastric cancer. A duodenal self-expandable metallic stent was placed at the stenotic site. However, five months subsequent to this procedure, the duodenal stent was occluded because of tumor ingrowth. Two duodenal stents were inserted using the first ‘stent-in-stent’ method. Three months later the duodenal stents were again obstructed similarly. Another duodenal stent using the second ‘stent-in-stent’ method was inserted, which enabled restoration of the patient’s ability to eat and receive cancer chemotherapy. The ‘stent-in-stent’ method was used twice in this case, demonstrating this to be a useful procedure for duodenal stent occlusion and to significantly improve patient quality of life and dignity.

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A 74-year-old man was admitted to our hospital complaining of bloody stools and anemia. Computed tomography with enhanced contrast showed leakage of contrast media to a diverticulum of the ileum. We suspected hemorrhage from a Meckel’s diverticulum. Bloody stools persisted, precluding small intestinal endoscopy, so emergency surgery was performed. A diverticulum of about 4 cm length was found in the ileum approximately 100 cm from the ileocecal valve. Observation via intraoperative endoscopy identified an ulcer with an exposed blood vessel in the diverticulum. Hemorrhage from a Meckel’s diverticulum was diagnosed, and wedge resection of the diverticulum at the base was performed. Pathological findings confirmed a true diverticulum, and heterotopic pyloric glands were observed in the circumference of the ulcer. When small intestinal endoscopy cannot be performed immediately, computed tomography with enhanced contrast and intraoperative endoscopy are useful techniques to employ in order to diagnose hemorrhage from Meckel’s diverticula.

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Small bowel inflammatory fibroid polyp (IFP) is an idiopathic inflammatory polyp, which usually presents as intussusception and ileus requiring emergency laparotomy. In this study, we report a case of IFP associated with intussusception treated by single port laparoscopy. A woman in her 70’s was referred to our hospital due to ileus. Abdominal CT demonstrated a tumor at the terminal ileum. Initially an ileus tube was inserted to enable decompression. Colonoscopy of the ileum then identified the tumor at the distal end of the intussusception. Duly we elected to perform surgical intervention. In the first stage of surgery, a 3 cm umbilical incision was made and the abdomen insufflated. Using single port laparoscopy the site of intussusception was confirmed, and it was extracorporeally reduced by Hutchinson’s maneuver combined with partial small bowel resection. The patient’s prognosis was favorable and she was discharged on the fifth day postoperatively. Pathologically, the tumor was diagnosed as IFP based on the presence of granulation tissue by inflammatory cell infiltration and fibroblast growth. As the small intestine is not fixed usually, single port laparoscopy is considered to be both appropriate and achievable. Even in cases of ileus, use of laparoscopy is possible after the intestine is fully decompressed.

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An 8-year-old male was referred to our hospital for recurrent upper abdominal pain. Although blood tests and abdominal computed tomography showed no abnormal findings, barium follow-through study identified a submucosal tumor (SMT)-like lesion with a diameter of 20 mm in the proximal jejunum. Single-balloon endoscopy was performed under general anesthesia, and indicated a slightly yellowish SMT with bridging folds. Subsequent endoscopic ultrasonography revealed an echogenic mass derived from the second or third layer of intestine wall, suggesting SMT including ectopic pancreas. We injected Chinese ink into the intestinal submucosa just orally to the tumor. Histological diagnosis based on biopsied specimens was not possible. Laparoscopy-assisted partial resection of the jejunum was performed, with a final diagnosis established as jejunal ectopic pancreas (Heinrich type II). So far there have been no symptoms of recurrence.

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