2010年に十二指腸ステントが保険収載されて以来，幽門狭窄や十二指腸狭窄に対してステントの挿入が行われるようになってきている。当院では2010年4月から2012年10月までの間，悪性腫瘍にて幽門や十二指腸の通過障害を生じた症例のうち，バイパス手術を選択しなかった22例に対して十二指腸ステントの挿入を試み，19例に留置した。男女比は15：4で男性が多く，平均年齢は73.7歳。平均狭窄長は39.95mm（最短20mm，最長100mm）であった。
　食事再開までの平均日数は2.25日であり，挿入完遂率は86％（19/22）。全粥摂取可能となったのは84％（16/19）。重篤な合併症は消化管穿孔が1例であった。また，生存日数は平均166.7日であり，最短は1日。最長で807日（現在生存中）であった。
　十二指腸ステントは幽門や十二指腸狭窄を伴う高度進行癌に対して有効な治療法の1つであると考えられた。

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　当院での大腸内視鏡検査では富士フイルムメディカル社製EC-590ZW3を通常スコープとして使用しているが，狭窄，屈曲，癒着のためスコープと大腸壁との間に余裕（自由度）がなく挿入困難となる症例がみられる。当院では自由度を上げる目的で細径であるダブルバルーン用スコープEI-530B（富士フイルムメディカル社製）をバックアップスコープとして使用している。脾彎曲部から以深の挿入時には，スコープの硬度不足のためスコープがたわみやすい欠点があり，その欠点を補うべく弾発力の強いホビー用カーボンロッドをスタイレットとして使用した。4カ月間の検査症例488例を検討した結果，バックアップスコープを使用した症例は34例であり，原因の多くはS状結腸憩室症，癒着，小さい体型であった。カーボンスタイレットを併用した症例は29例であり，細径スコープとの組み合わせで被検者の苦痛は軽減され挿入率を高めているので報告した。

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　当院で経口膵管鏡（POPS）を施行したIPMN全33回31症例（男性22例，女性9例）を対象とし検討を行った。対象を主膵管型21回19例と混合型12回12例の2群に分け，さらにPOPSの目的である範囲診断を十分に遂行できた群とできなかった群に分け，観察範囲，手術成績，生検および細胞診の正診率，POPS後膵炎の頻度で検討を行った。結果：POPS下に腫瘍の範囲診断を行うことができた症例は20例（主膵管型15例：混合型5例），十分な範囲診断を行えなかった症例は11例（主膵管型4例：混合型7例）であった。手術成績は膵尾側までPOPSを挿入できなかった混合型の2症例で断端陽性（adenoma）であった。また，生検と細胞診を合わせたadenocarcinomaの正診率は8例中2例だった。POPS後の膵炎は主膵管型の5例で軽症膵炎を合併した。結論：病理学的正診率は低かったものの，内視鏡下に腫瘍の範囲診断を遂行できた症例の手術成績は良好であった。

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　当院にて2009年1月から2011年12月までに胃ESDを施行した187症例における後出血の危険因子をretrospectiveに検討した。輸血や緊急内視鏡を要したもの，Hb2g/dl以上の低下を認めたものを後出血とした。術後内視鏡にて，ForrestⅡa以上の出血を認め追加止血を行った症例を偶発出血とした。患者背景（年齢，抗血小板薬/抗凝固薬内服），治療内容（切除標本径，切除時間，占拠部位），併存疾患（高血圧，糖尿病，肝硬変，透析）の有無について検討した。後出血は5例（2.7％）に認め，Fisher検定では切除長径が危険因子であり，多変量解析では有意な因子は認めなかったが，切除長径30mm以上のものに後出血が多い傾向があった。偶発出血は59例（31.6％）に認め，χ²検定では年齢，切除長径，高血圧が危険因子であり，多変量解析では年齢と高血圧が危険因子であった。偶発出血は比較的多く，術後内視鏡にて追加止血処置を行うことが後出血の抑制に寄与する可能性が示唆された。

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【目的】上部消化管出血に対する内視鏡的止血術は確立された手技であり，技術・機器の進歩により多くの症例で止血可能であり，成功率も向上している。しかし，再出血例，止血困難例も存在し，IVR（interventional radiology）や外科的治療が必要になる症例もみられる。当院における内視鏡的止血術の現状と止血成績について検討し，再出血の危険因子を明らかにする。【対象と方法】2008年1月〜2012年11月に当院で内視鏡的止血術を施行した出血性胃・十二指腸潰瘍141例を対象としretrospectiveに検討した。対象例を永久止血例，再出血例の2群に分け患者背景，止血方法，病変部位などについて比較を行った。また，再出血の危険因子を患者背景因子，内視鏡関連因子，術者関連因子から多変量解析で検討した。【結果】内視鏡的止血術を施行した141例の内訳は平均年齢67.2±16歳，男女比は104：37であった。再出血例は13.5％（19/141）であった。止血成功例，再出血例で比較検討した結果，基礎疾患を有する症例，輸血を施行した症例で有意差を認めた。多変量解析では基礎疾患を有する症例が独立した危険因子となる可能性が示唆された。【結論】基礎疾患を有する症例は再出血を来す可能性があり，厳重な経過観察が必要である。

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　大腸ESDの適応と限界を明らかにする目的で，粘膜下層に高度な線維化を伴う病変の臨床病理学的特徴を検討した。対象は，2011年3月〜2012年4月に大腸ESDを施行した110例110病変のうち，粘膜下層に線維化を認めた23例の内視鏡像をretrospectiveに検討し，ESDによる一括切除の成否を分けた要因を分析した。高度線維化は9例に認められ，5例は一括切除が可能であったが，4例で分割切除あるいはESDの中止を余儀なくされた。一括切除例5例の内訳は，LST-NG：2例，LST-G：2例，Isp：1例で，pit patternは全例Ⅴ_I軽度不整，深達度はpM癌3例，pSM1癌2例であった。分割切除/中止4例の内訳は，LST-NG：1例，LST-G：2例，Isp：1例で，pit patternはⅤ_I軽度不整2例，Ⅴ_I高度不整2例，深達度はpM癌2例，pSM2癌2例で，Ⅴ_I高度不整の2例がいずれもpSM2癌であった。手技的側面からの検討では，一括切除例5例では線維化領域における剥離線の設定が可能であったが，分割切除/中止の4例では剥離線の設定が困難であった。
　以上よりⅤ_I高度不整を呈する高度線維化例は，根治的ESDの適応外であるSM高度浸潤癌の可能性が高く，撤退を考慮する指標になると考えられた。また高度線維化病変に対する一括切除の成否は，線維化領域の剥離線の設定が可能か否かによると考えられた。

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　現在大腸狭窄・閉塞に対する評価方法は確立しておらず，大腸ステント安全手技研究会では大腸閉塞スコアCROSS（colorectal obstruction scoring system）を提唱している。その内容はscore0：継続的な腸管減圧を要する，score1：経口摂取不能，score2：水分摂取可能，score3：食事摂取可能で腸管狭窄症状あり，score4：食事摂取可能で腸管狭窄症状なしである。CROSSの有用性を検証するために，2001年から2012年8月までに閉塞型大腸癌の術前処置（bridge to surgery：BTS）として金属ステント（expandable metallic stent：EMS）留置術を施行した66例について，各症例のCROSSをretrospectiveに検討した。臨床的成功（閉塞解除成功）例は59/66例：89.4％，臨床的不成功例は7/66例：10.6％であり，成功例のCROSSはステント留置前後で全例が改善しており，90％がCROSS0からCROSS4へ改善していた。一方不成功例のCROSSは留置前後で71％に改善が認められない結果となり，CROSSは大腸ステントBTS症例で有用であった。

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【目的】大腸狭窄に対するself expandable metallic stent（SEMS）留置術は近年注目されている治療法である。今回は最近導入された大腸Niti─S stentの成績を検討した。【成績】1993年から2011年までに大腸狭窄に対するSEMS留置術施行156回中，Niti-Sは27回17％であった。韓国Taewoong社製TTS（Through the scope）typeのNiti-S stentは2006年から導入され，27回施行26回に良好留置が成功し留置率は96％であった。1例は初回で狭窄部からずれて留置されたが，再度の留置で対処可能であった。透視下のSEMS視認性にやや改善の余地があると思われる。穿孔など重篤な合併症はなく，最終的な成績は技術的成功率96.3％，臨床的成功率85.2％，早期合併症率7.4％，晩期合併症率3.7％であった。【結論】大腸狭窄に対するSEMS留置術は低侵襲性で患者QOL向上に有効な手技である。その中でも新しいTTS typeのNiti-S stentは十分な有効性と安全性を示した。

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　高齢化の進む本邦において無症状の高齢者の大腸癌スクリーニング検査は何歳までを対象とすべきかの指標はなく，医療現場の混乱が見受けられる。今回，高齢者の大腸癌検査について世田谷区の中核病院である当院（関東中央病院）に紹介歴のある当院近郊18クリニック医師と，当院大腸内視鏡検査（CS）施行6医師に便潜血検査（FOBT）とCSについてのアンケート調査を実施した。結果は90歳以上の患者にも大腸検査をすべきが，FOBTで22.2％vs.0％（クリニックvs.当院）とCSで15.4％vs.0％（クリニックvs.当院）であった。90歳以上の高齢者について，FOBTとCSスクリーニング検査に対する必要性の認識が，「一部で必要」とするクリニック医師と「全く必要ない」とする当院内視鏡医師との間で大きく意見が異なることがわかった。患者本人の検査希望や血便・腹痛などの自覚症状がある高齢者を排除すべきではないが，今回我々が検討した大腸検査ローカル・ルールとして，①90歳以上または10年予後が見込めない患者にCSスクリーニングは勧めない（必要な場合はCTなどの非侵襲検査），②CS適応は緊急時を除き腸管洗浄液の自己内服が可能な患者，85歳以上の患者には原則的に入院でのCSを勧めるとした。このような無症状の高齢者に対するFOBTを含めた大腸癌スクリーニング検査に対する年齢制限などの指針を日本消化器内視鏡学会主導である「大腸がん検診ガイドライン」での検討が望まれる。今回のローカル・ルールは強制的なものではなく，問題提起も兼ねて内視鏡地域医療連携指標の1つとして作成した。

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　当院では2011年4月よりラジアル型超音波内視鏡検査を導入し，2012年7月までの1年3カ月に膵管内乳頭粘液性腫瘍（膵IPMN）22例に対しEUS検査を行った。対象は男女比13：9で41歳から80歳の22症例であった。主膵管型，分枝膵管型，混合型の比率は2：16：4で，壁在結節は22例中9例に認めた。EUS検査を行った22例中10例は手術適応と判断し，うち6名は切除術を施行した〔膵管内乳頭粘液性腺癌（膵IPMC）5例，膵管内乳頭粘液性腺腫（膵IPMA）1例〕。EUSにて壁在結節を確認できた9症例において，CTやMRI検査にて壁在結節が確認できなかった症例は7例あった。過去の文献においても壁在結節の描出率は78％と報告されており（体外式US 35％，MRI 19％，CT 24％）^1），膵IPMNの悪性度診断における高危険因子である壁在結節の診断においてEUSは非常に有意な検査と考えられる。
　2012年度版IPMN国際診療ガイドライン^2）においてworrisome featureを呈する症例（囊胞径30mm以上，主膵管径5〜9mmなど）にEUS検査が推奨され，経過観察方法についても20mm以上の囊胞径の症例についてEUSが推奨されている。自験例においてはworrisome featureを呈さない囊胞径15mmの症例でもEUSにて壁在結節を認め，病理組織学的に悪性所見を認めた症例もあり，膵IPMNにおいて初回診断時に可及的全例にEUS検査を行うべきと考える。約1年3カ月の期間にてEUSを行った膵IPMN症例22例について検査所見，経過，病理組織検査結果などについて報告する。

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　症例は27歳，男性。心窩部痛を主訴に近医受診。上部消化管内視鏡にて食道胃接合部に粘膜不整を認め，生検にてGroup 4であり悪性疾患が疑われ当院へ紹介受診となった。当院での上部消化管内視鏡では，NBI拡大観察にて血管蛇行や癒合を伴う異型血管を認め，short segment Barrett’s esophagus（SSBE）より発生したBarrett腺癌が疑われ，診断的治療目的に内視鏡的粘膜下層剥離術を施行した。病理組織学的診断にてBarrett腺癌と診断され，粘膜下層浸潤，脈管侵襲を認めたため追加外科的切除となった。本邦では全食道癌の90％以上が扁平上皮癌であり腺癌は比較的稀である。しかしH. pylori感染率低下，食生活欧米化によるGERD増加に伴い，近年Barrett腺癌の増加が懸念されている。一方，若年者におけるBarrett腺癌の報告は本邦，欧米含め散見されるのみである。今回我々は若年者に発生したBarrett腺癌を経験したので文献的考察を含め報告する。

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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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