A 75-year-old man with the chief complaint of blood stool underwent a total colonoscopy, which revealed a flat elevation spreading in the anal canal and the lower portion of the rectum. It showed non-uniform expanded blood vessels in the surface of the mucosa with the magnifying Narrow band imaging (NBI) .We could not rule out malignancy, therefore we carried out Endoscopic submucosal dissection (ESD) . Histological examination of the resected specimen verified condyloma acuminatum with koilocytosis and mild atypia of the squamous epithelium. No other lesions were found in the vulva or perianal region. NBI and ESD is considered a possible option in selected cases of condyloma acuminatum.

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A 55-year old man consulted medical doctor because fecal occult blood test was positive. Colonoscopy shows a rectal tumor in the lower rectum (Rb,DL3cm) . Pathological findings shows neuroendocrine tumor (NET) . In our hospital, colonoscopy and EUS was performed. Tumor size was 6 mm in diameter. Metastasis was not detected in abdomino-pelvic CT and MRI. We performed endoscopic submucosal resection (ESD) . Resected specimen reveals vascular invasion with Victoria Blue stain. So we decided additional operation. We performed laparoscopic assisted super low anterior resection. We have succeeded complete resection and no recurrence in 6 months after operation. Rectal NET less than 10 mm in diameter with metastasis is not very rare (9.7%) . If there are lymphovascular invasion was positive in specimen of endoscopic resection, it should be indicated additional resection. Because it is difficult that lymph nodes metastasis were detected with CT scan.

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A 70-year-old-women was admitted because of right upper abdominal pain. The patient developed obstructive jaundice with no evidence of choledocholithiasis. The patient’s condition was not improved by antibiotics, then we performed EPBD and tried to remove unidentified bile duct stone. However, stone was not extracted and just juxtrapapillary duodenal diverticulum was recognized by X-ray. After the treatment, the patient was recovered and was discharged. Five months after, similar symptoms like first attack were reccured. This time, a bile duct stone was identified by MRCP and, then we performed EST.
As the duodenal Papilla was located on the boundary of the diverticulum, EST was halfway done and additional EPBD was performed. The stone was removed successfully.
The recurrence of symptoms was not observed 15 months after the treatment.
This case indicated that endoscopic treatment would be considered before referring to surgery.

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A 67-year-old woman who had been treated for intraductal papillary mucinous carcinoma with bile duct jejunum anastomosis was admitted due to fever. She had undergone three sessions of repeated transcatheter arterial chemoembolizations (TACE) and two sessions of repeated radiofrequency ablation for multiple hepatocellular carcinomas at our hospital. We diagnosed biloma with an abdominal CT scan. We performed endoscopic retrograde cholangiopancreatography (ERCP) and detained an endscopic indwelling biloma drainage tube. The biloma rapidly decreased. ERCP and EBD were useful in this case that had difficulty in the endscopic approach.

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We reported the cases of 2 patients who we successfully treated using the rendezvous method from the percutaneous transhepatic gallbladder drainage (PTGBD) route. In case 1, a 69-year-old male with cholangiocarcinoma, we performed PTGBD because bile duct cannulation and percutaneous transhepatic bile drainage (PTBD) were difficult. Later, we successfully placed a metal stent using the rendezvous method via the PTGBD route. In case 2, an 81-year-old female with choledocholithiasis, we performed PTGBD because cholangiography and PTBD were difficult as a result of parapapillary diverticulum. Later, we successfully completed choledocholithotomy by the rendezvous method via the PTGBD route. These cases suggested that the rendezvous method via the PTGBD route should be considered when the transpapillary approach is difficult.

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The patient was an 86-year-old woman who underwent total gastrectomy (Roux-Y reconstruction) . Her previous physician had diagnosed cholangitis caused by common-bile-duct stones. Percutaneous transhepatic biliary drainage was performed, and the patient was transferred to our hospital. We inserted a short-type single balloon enteroscope (SBE) to the duodenal papilla. Cholangiography confirmed the presence of multiple bile-duct stones, with a maximal diameter of 21 mm. After endoscopic papillary large-balloon dilation was performed, lithotripsy was attempted, using a guidewire-type 4-wire basket and a balloon catheter. However, the procedure required a prolonged time and was discontinued without removing all stones. At a later date, direct cholangioscopy was performed using an SBE and confirmed the presence of residual stones. Direct cholangioscopy was then carried out, and the residual stones were directly grasped and crushed with a 5-prong forceps, resulting in complete cure. Direct cholangioscopy is a useful procedure for confirming and treating residual bile-duct stones, even in patients who have undergone gastric surgery with gastrointestinal reconstruction.

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A 78-year-old man was admitted to our hospital with complaint of right hypochondralgia. Laboratory data showed the elevation of transaminase and biliary tract enzymes. Abdominal CT showed stones in the common bile duct (CBD) and gallbladder (GB) . In addition, significant amount of gas was present in the bile duct while the gas in the GB was much less. Therefore the diagnosis of as acute cholangitis (Grade III) with pneumobilia was made. Endoscopic retrograde cholangiography (ERC) and ENBD were performed. Endoscopic view and ERC showed no evidence of choledochoduodenal fistula as the cause of pneumobilia. After the procedures, the patient’s symptoms disappeared. After a week, endoscopic sphincterotomy and lithotripsy were carried out. Bile culture was positive with Clostridium perfringens thus we concluded the acute cholangitis (Grade III) with pneumobilia was accounted for by the gas-producing Clostridium perfringens.

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A 63-year-old male was conducted Corticosteroid Therapy (CST) in the diagnosis of autoimmune pancreatitis (AIP) . After recurrence as AIP with IgG4-SC, CST was resumed. Serum IgG4 level was deteriorated at the maintenance corticosteroid dose at 7.5mg then, enhanced computed tomography indicated thickening of hilar bile duct. Endoscopic retrograde cholangiographic image showed a long stricture of the bile duct, except for the lower bile duct. IDUS showed uniformity thickening of the bile duct wall. Endoscopic examination of the bile duct failed to obtain histopathological diagnosis. Steroid trial was started. At 14 days after CST, ERC showed improvement. Therefore the case was diagnosed as probable IgG4-SC.
It is not easy to discriminate IgG4-SC without AIP from primary sclerosing cholangitis (PSC) , and cholangiocarcinoma. This case suggests the effectiveness of IDUS and steroid trial for diagnosis of IgG4-SC.

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A 75-year-old male patient, who presented with umbilica pain, was diagnosed with acute pancreatitis. Magnetic resonance cholangiopancreatography findings indicated saccular dilatation of the lower bile duct. After the pancreatitis improved, endoscopic retrograde cholangiopancreatography (ERCP) was performed. ERCP showed that the bile duct and pancreatic duct were separately contrasted, and saccular dilatation of the lower bile duct was noted. The patient was diagnosed with choledochocele with no formation of a common duct. Considering that the pancreatitis may have been caused by physical exclusion of the pancreatic duct by the choledochocele, endoscopic sphincterotomy was performed. No pancreatitis recurrence has occurred over the 9 months following treatment. Our findings suggest that choledochocele should be considered when conducting differential diagnosis for cases of pancreatitis of unknown cause.

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An 84-year-old man with hilar cholangiocarcinoma received endoscopic biliary drainage with an expandable metallic stent (EMS) and subsequent radiotherapy. Six months later, he presented with hematemesis. Immediate esophagogastroduodenoscopy and capsule endoscopy failed to reveal the bleeding source. Two weeks later, he presented with obstructive jaundice due to clogging of the EMS. Endoscopic removal of the clogged stents caused massive bleeding from the bile duct. Emergent angiography revealed a pseudoaneurysm of the right hepatic artery and leaking blood. Hemostasis was achieved by a transcatheter coil embolization. After that, no bleeding occured until he died 5 months later due to cancer progression. The pseudoaneurysm may have been caused by mechanical compression of the EMS on the adjacent tissue, and radiotherapy might have enhanced the development of the aneurysm.

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A 77-year-old male was admitted to our hospital with a chief complaint of jaundice. Abdominal computed tomography scans showed a cystic lesion containing some enhanced parts in the pancreas head and dilated main pancreatic duct. Endoscopy showed an enlarged orifice of the papilla of Vater with mucous secretion and fistula formation between the duodenum and the cystic lesion. Endoscopic retrograde cholangiopancreatography showed a filling defect in the common bile duct and contrast medium flowing into the cystic lesion from the common bile duct via a fistula. He was diagnosed with intraductal papillary-mucinous carcinoma (IPMC) penetrating into the common bile duct and duodenum. It was difficult to control the obstructive jaundice, but after a fully covered self-expandable metallic stent was placed in the lower common bile duct there was a good clinical outcome.

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A 29-year-old man who had a history of hospitalization due to alcoholic acute pancreatitis in another hospital. The patient complained of fatigue, and pleural effusion was observed. He was hospitalized with a diagnosis of reactive pleural effusion associated with recurrent pancreatitis. He then started a conservative treatment. Following pleural effusion puncture, he was diagnosed with pancreaticopleural fistula with a pancreatic fistula that reached the thoracic cavity, rather than reactive pleural effusion associated with pancreatitis. An ENPD tube was inserted after pancreatic duct drainage. In addition, thoracic drainage was performed for the pleural effusion. Because the drainage was favorable, the ENPD tube was replaced with a pancreatic duct stent. The thoracic drain was removed after the disappearance of pleural effusion, and the patient was then discharged.

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An 80-year-old-man was admitted because of acute cholecystitis, and PTGBD was performed. However, 6 days later, he presented with abdominal pain and jaundice. CT revealed a 30 mm-sized polycystic lesion at the pancreas head and the main pancreatic duct (MPD) dilated up to 8 mm in diameter. Duodenoscopy showed mucus discharge from the enlarged papilla of Vater. ERCP showed mucus in the dilated MPD regurgitated into the common bile duct (CBD) through the common channel. On EUS, there seemed to be a fistula between the CBD and the pancreatic cysts. Pancreaticoduodenectomy was performed. The resected specimen was histologically diagnosed as IPMN with high-grade dysplasia, and revealed no evidence of fistulization to the CBD. Thus, we concluded that mucus regurgitation into the CBD was likely to have caused jaundice in this case.

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A 95-year-old female was transported by ambulance to our hospital with abdominal pain and hospitalized by diagnosis of severe acute pancreatitis. Two years prior, she had developed severe acute pancreatitis that had improved with conservative treatment. However, the cause of pancreatitis had not been investigated because she was too elderly. This time abdominal contrast-enhanced computed tomography revealed a mass lesion with contrast effect in the main pancreatic duct and endoscopic retrograde cholangiopancreatography was performed. The papilla was enlarged and hemorrhagic. The diagnosis was well-differentiated adenocarcinoma of duodenal papilla by biopsied specimen. Pancreatography revealed mild enlargement of the pancreatic head and the filling defect in the main pancreatic duct. Therefore, invasion of duodenal papilla cancer into the main pancreatic duct could be the cause of the repeated severe acute pancreatitis. A 5Fr 7 cm straight pancreatic duct stent was placed and then, there has been no pancreatitis recurrence since.

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A 65-year-old man was admitted to our hospital in chief complaint for epigastric pain and faeces pale. Laboratory data showed elevation of hepatobiliary enzymes. Abdominal ultrasonography, MRI, PET-CT and endoscopic ultrasonography revealed pancreatic mass located in the pancreatic head. Also, endoscopy showed stenosis of the duodenum and CT showed an annular pancreas.
Pyrolus-preserved pancreoduodenectomy (PpPD) was performed. The histopathological examination showed invasive ductal carcinoma of pancreatic head.
An annular pancreas is a rare congenital anomaly and is classified into neonatal, pediatric, and adult types. In neonatal and pediatric type, severe nausea and vomiting due to duodenal obstruction or stenosis are common at presentation. In adult type, many cases are asymptomatic, and about one-half to two-thirds present with peptic ulcers, gallstone or pancreatitis.
An annular pancreas itself seldom causes obstructive jaundice in adult, so we should consider the coexistence of malignancy in a case of an annular pancreas with obstructive jaundice.

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A 73-year-old man diagnosed with gastric cancer underwent laparoscopic total gastrectomy at our hospital 12 months ago. The histopathological diagnosis was a poorly-differentiated adenocarcinoma limited to the gastric submucosa, pT1b (SM2) , pN0, stage IA. Computed tomography (CT) performed at the outpatient follow-up 6 months after surgery revealed a pancreatic body. No other definite mass shadow was detected. Positron emission tomography (PET) -CT revealed high accumulation (SUVmax) near the site of the pancreatic body. We performed laparoscope-assisted distal pancreatectomy to remove the tumor which had gradually increased over the intervening 6 months. The histopathlogical diagnosis was a poorly-differntiated adenocarcinoma resulting from lymph node metastasis of the gastric cancer. In general, skip metastasis is due to the presence of a metastatic lymph node in an extraperigastric area without perigastric involvement. The mechanism and prognosis are still unknown. The frequency of skip metastasis along the proximal splenic artery is rare. Since adhesions after previous laparoscopic surgery were mild, it was possible to perform laparoscopic surgery once again, taking advantage of its benefits, both during surgery and in the post-operative healing period.

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A patient was referred to our hospital for treatment of obstructive jaundice caused by a pancreatic tumor. Since abdominal CT showed a mass at the head of pancreas and dilatation of the main pancreatic duct, we had to make the differential diagnosis between pancreatic cancer and invasive papillary mucinous carcinoma (IPMC) . We performed ERCP and placed an ENPD to perform cytodiagnosis, but were unable to retrieve any pancreatic juice because it was mucinous. We performed ERCP again, and devised the following way to obtain it. We connected the push catheter of an 11.5-French endoscopic biliary stenting (EBS) to a sample tube and to a suction tube, placed it in the main pancreatic duct, and obtained sufficient mucus. We ultimately made diagnosis of IPMC by cytodiagnosis.

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