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We present the case of an 82-year-old female with obstructive jaundice secondary to a malignant distal biliary stricture. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed. The presence of a giant hiatal hernia induced dynamic liver movement during respiration, leading to unstable scope positioning. Despite the successful placement of a long, partially covered metal stent from the left intrahepatic bile duct to the intra-abdominal stomach, computed tomography performed three days later revealed free air and an increased distance between the liver and stomach. A subsequent endoscopy confirmed impending stent migration into the abdominal cavity, necessitating the insertion of an additional metal stent through the existing stent's mesh. The presence of a giant hiatal hernia may be considered a relative contraindication for EUS-HGS due to dynamic movements of the stomach and liver during respiration, which can cause stent migration, increased air leakage, and difficulty in establishing a stable fistula between these organs., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mandai et al.)

Objective: This study aimed to investigate whether a novel, easy loop-forming guidewire could reduce post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in patients undergoing endoscopic nasopancreatic drainage tube placement for serial pancreatic juice aspiration cytologic examination (SPACE)., Methods: We evaluated patients with suspected pancreatic cancer who underwent SPACE at our institution between January 2015 and April 2023 retrospectively. The patients were divided into 2 groups based on the type of guidewire used, namely, easy loop-forming and control groups. Propensity score matching was used to compare the incidence of PEP between the groups., Results: We included 101 patients, with 51 and 50 in the easy loop-forming and control groups, respectively. After propensity score matching, 29 pairs of patients were selected from each group. Intraductal ultrasonography of the pancreas was performed more frequently in the easy loop-forming group than in the control group (27.6% vs 0%; P = 0.004); however, PEP incidence was significantly lower in the easy loop-forming group than in the control group (3.4% vs 27.6%; odds ratio, 0.097; 95% confidence interval, 0.002-0.82; P = 0.025)., Conclusions: The use of the novel easy loop-forming guidewire decreased PEP occurrence in patients who underwent endoscopic nasopancreatic drainage tube placement for SPACE., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: Endoscopic placement of self-expandable metal stents (SEMSs) for malignant distal biliary obstruction (MDBO) may be accompanied by several types of adverse events. The present study analyzed the adverse events occurring after SEMS placement for MDBO., Methods: The present study retrospectively investigated the incidence and types of adverse events in patients who underwent SEMS placement for MDBO between April 2018 and March 2021 at 26 hospitals. Risk factors for acute pancreatitis, cholecystitis, and recurrent biliary obstruction (RBO) were evaluated by univariate and multivariate analyses., Results: Of the 1425 patients implanted with SEMSs for MDBO, 228 (16.0%) and 393 (27.6%) experienced early adverse events and RBO, respectively. Pancreatic duct without tumor involvement (P = .023), intact papilla (P = .025), and SEMS placement across the papilla (P = .037) were independent risk factors for acute pancreatitis. Tumor involvement in the orifice of the cystic duct was an independent risk factor for cholecystitis (P < .001). Use of fully and partially covered SEMSs was an independent risk factor for food impaction and/or sludge. Use of fully covered SEMSs was an independent risk factor for stent migration. Use of uncovered SEMSs and laser-cut SEMSs was an independent risk factor for tumor ingrowth., Conclusions: Pancreatic duct without tumor involvement, intact papilla, and SEMS placement across the papilla were independent risk factors for acute pancreatitis, and tumor involvement in the orifice of the cystic duct was an independent risk factor for cholecystitis. The risk factors for food impaction and/or sludge, stent migration, and tumor ingrowth differed among types of SEMSs., Competing Interests: Disclosure The following author disclosed financial relationships: M. Kitano: Speaker for Olympus Corporation; research support from Boston Scientific, Zeon Medical Inc, and Medico’s Hirata Inc. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

We present the case of a 72-year-old woman with elevated hepatobiliary enzymes and a small mass in the distal bile duct near the papilla. Fluoroscopy-guided forceps biopsy initially yielded insufficient tissue. After endoscopic papillary large balloon dilation with sphincterotomy, a stone retrieval balloon was used to expose the tumor to the duodenum. Biopsy under direct visualization using standard forceps revealed adenocarcinoma. The technique may be useful for the biopsy of lesions located in the terminal segment of the distal bile duct., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Mandai et al.)

Background: Techniques and devices for endoscopic ultrasound (EUS)-guided hepaticoenterostomy (EUS-HES) procedures, including EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided hepaticojejunostomy (EUS-HJS), have been developed; however, the optimal timing to begin oral intake after EUS-HES remains unknown. This study aimed to evaluate the safety of early oral intake after EUS-HES., Methods: We retrospectively investigated patients who underwent EUS-HES (EUS-HGS or EUS-HJS) between March 2015 and March 2022. Patients who had no problems with the results of blood tests and computed tomography examinations on the morning of day 1 after EUS-HES were classified as either the early intake group (started oral intake on day 1 after EUS-HES) or the late intake group (started oral intake on day 2 or later after EUS-HES). Patients' characteristics, procedure characteristics, and early postprocedural adverse events (within 14 days after the procedure) were compared between groups., Results: Fifty patients were enrolled in this study. Forty-three patients had no problems with the results of examinations performed on the morning of day 1 after EUS-HES. Twenty-one patients comprised the early intake group and 22 comprised the late intake group. Adverse events that developed within 14 days after EUS-HES were not significantly different between groups (early 4.7% vs. late 9.0%; odds ratio, 0.50; 95% confidence interval, 0.0080-10.49; P = 1.00)., Conclusions: Starting oral intake on day 1 after EUS-HES did not increase postprocedural adverse events compared with starting oral intake on day 2 or later after EUS-HES., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Competing Interests: The authors declare that they have no conflict of interest.

Background/purpose: Whether a fully covered self-expanding metal stent (FCSEMS) or plastic stent (PS) is preferable for preoperative biliary drainage in patients with resectable pancreatic cancer (RPC) is controversial. This study aimed to evaluate the safety and efficacy of drainage with FCSEMS for obstructive jaundice caused by RPC without neoadjuvant chemotherapy., Methods: Seventy patients with RPC who required preoperative biliary drainage were randomly assigned 1:1 to the FCSEMS or PS group. The primary endpoint was endoscopic re-intervention rate during the waiting period for surgery. Secondary endpoints were drainage procedure time, drainage-related adverse events (AE), waiting period for surgery, operative time, intraoperative blood loss, surgery-related AE, and postoperative hospital stay., Results: Thirty-nine patients underwent surgery. None required re-intervention in the FCSEMS group, whereas five PS patients underwent re-intervention (P = .023). The FCSEMS group had significantly more intraoperative blood loss (P = .0068) and AE (P = .011) than the PS group. Postoperative hospital stay was significantly longer in the FCSEMS group (P = .016)., Conclusions: Fully covered self-expanding metal stent had a lower rate of endoscopic re-intervention during the waiting period for surgery than PS, but showed more intraoperative blood loss, higher incidence of surgery-related AE, and longer postoperative hospital stays., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Conventional gallbladder re-intervention along the naso-gallbladder drainage tube may result in dislocation of the tube during scope insertion or failure of guidewire insertion into the gallbladder. Mandai et al report a simple method for transferring a transpapillary naso-gallbladder drainage tube to the mouth that facilitates reliable re-intervention for gallbladder lesions., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Highlight Duodenal invasion has been reported to be a risk factor for early biliary stent dysfunction in patients with pancreatic cancer. Mandai and colleagues describe their method of transpapillary biliary drainage using a long plastic stent as a potentially useful treatment option to avoid early stent dysfunction in such patients., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Background and Aim: International consensus on the definition and classification of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been reached. However, the diagnosis and severity of PEP are often assessed according to the diagnostic criteria and classification for acute pancreatitis (AP). This study determined the incidence, severity, and risk factors of PEP diagnosed according to the diagnostic criteria and classification for AP in a large cohort., Methods: This prospective, multicenter, observational cohort study conducted at five high-volume centers included 1932 patients who underwent ERCP-related procedures. The incidence, severity, and risk factors for PEP were evaluated., Results: PEP occurred in 142 patients (7.3%); it was mild in 117 patients (6.0%) and severe in 25 patients (1.3%). According to the Cotton criteria, PEP occurred in 87 patients (4.5%); it was mild in 54 patients (2.8%), moderate in 20 patients (1.0%), and severe in 13 patients (0.7%). In the multivariate analysis, female sex (odds ratio [OR] 2.239; 95% confidence interval [CI] 1.546-3.243), naïve papilla (OR 3.047; 95% CI 1.803-5.150), surgically-altered gastrointestinal anatomy (OR 2.538; 95% CI 1.342-4.802), procedure time after reaching the papilla (OR 1.009; 95% CI 1.001-1.017), pancreatic duct injection (OR 2.396; 95% CI 1.565-3.669), and intraductal ultrasonography (OR 1.641; 95% CI 1.024-2.629) were independent risk factors., Conclusion: According to the diagnostic criteria and classification for AP, the incidence of PEP was higher than that according to the Cotton criteria and the severity of PEP tended to be severe., (© 2021 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Highlight Mandai and colleagues describe EUS-guided antegrade pancreatic guidewire placement followed by the double-guidewire technique in balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography in a patient with recurrent gastric cancer. This case suggests that EUS-guided antegrade pancreatic guidewire placement can be useful for the subsequent double-guidewire technique when EUS-guided biliary access has failed., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Background: The efficacy and safety of peroral direct cholangioscopy (PDCS) in patients with surgically altered anatomy (SAA) are unclear. The present study aimed to evaluate the efficacy and safety of short-type single balloon enteroscope (s-SBE)-assisted PDCS using an ultra-slim endoscope in patients with SAA., Materials and Methods: We retrospectively analyzed 12 sessions of PDCS performed in 8 patients with surgically altered gastrointestinal or pancreatobiliary anatomy between November 2017 and September 2019 at our institution. Endoscopic retrograde cholangiopancreatography using s-SBE was initially performed. Subsequently, the s-SBE was exchanged for an ultra-slim endoscope through an overtube with an inflated balloon to perform PDCS. We analyzed the success rates and adverse events resulting from the procedure., Results: Six patients had biliary stones and 2 had biliary strictures. The types of reconstruction were Roux-en-Y choledochojejunostomy (n=5), Billroth II gastrectomy (n=2), and Roux-en-Y gastrectomy (n=1). Biliary insertion of the ultra-slim endoscope was successful in all 12 sessions. Biliary interventions included electronic hydraulic lithotripsy in 5 sessions, stone removal using basket catheter in 3 sessions, biopsy in 2 sessions, and diagnosis of no residual stones in 2 sessions. Complete stone removal was finally achieved in all 6 patients with biliary stones. Biliary strictures in 2 patients were diagnosed as adenocarcinoma following a biopsy. The adverse events were cholangitis of mild severity in 3 sessions., Conclusion: S-SBE-assisted PDCS using an ultra-slim endoscope was useful and safe in patients with SAA, although care should be taken to avoid adverse events.

Competing Interests: The authors declare that they have no conflict of interest.

Background and Aim: As the significance of the quantitative fecal immunochemical test (FIT) in patients who previously underwent a colonoscopy is unknown, this study aimed at investigating the association between fecal hemoglobin concentration and the risk of colorectal cancer (CRC)., Methods and Results: We retrospectively analyzed FIT-positive patients who underwent a colonoscopy through our opportunistic annual screening program from April 2010 to March 2017 at the Kyoto Second Red Cross Hospital. We stratified them into no colonoscopy and past colonoscopy (>5 years or ≤5 years) groups based on whether they had a history of undergoing a colonoscopy and analyzed the correlation between fecal hemoglobin concentration and advanced neoplasia or invasive cancer detection in each group. We analyzed 1248 patients with positive FIT results. There were 748 (59.9%), 198 (15.9%), and 302 (24.2%) patients in the no colonoscopy, past colonoscopy (>5 years), and past colonoscopy (≤5 years) groups, respectively. In the no colonoscopy group, the advanced neoplasia detection rate significantly increased with the fecal hemoglobin concentration ( P  < 0.001). However, no significant trend was observed in the past colonoscopy (both >5 years and ≤5 years) group ( P = 0.982). No invasive cancer was detected in the past colonoscopy (≤5 years) group., Conclusion: The risk of CRC might be low even if fecal hemoglobin concentration was high, especially in those who underwent colonoscopy within 5 years., Competing Interests: The authors declare no conflicts of interest., (© 2020 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Competing Interests: None

Purpose: Pancreatic ductal adenocarcinoma (PDAC) may independently occur in the pancreas separate from an intraductal papillary mucinous neoplasm (IPMN). Therefore, identifying the characteristics of patients with IPMN who will likely develop PDAC is clinically important. Although a recent study found that fatty pancreas correlated with PDAC, no reports have examined this matter in patients with IPMN. A previous study showed that fatty pancreas increased the echogenicity; hence, this study aimed to investigate the association between hyperechogenic pancreas and PDAC in patients with IPMN., Methods: We retrospectively collected data of patients with IPMN who underwent endoscopic ultrasonography (EUS) between January 2012 and November 2018. A case-control analysis was performed between patients with IPMN concomitant with PDAC (cases) and those without PDAC (controls). We identified controls by matching age and sex with cases. The echogenicity of the pancreas was determined using EUS by comparing it with the left kidney or spleen. Echogenicity was determined using transabdominal ultrasonography by comparison with that of the liver when it was difficult to determine using EUS., Results: Among 400 patients with IPMN, 23 cases and 92 controls were identified. The proportion of patients with hyperechogenic pancreas was significantly greater in cases than in controls (91.3% vs. 65.2%, P = 0.02). Multivariate analysis, including family history of pancreatic cancer, multifocal cysts, and hyperechogenic pancreas, showed that hyperechogenic pancreas was correlated with PDAC concomitant with IPMN (odds ratio = 7.07; 95% confidence interval = 1.48-33.80; P = 0.01)., Conclusion: Our analysis demonstrated that hyperechogenic pancreas was associated with concomitant PDAC in patients with IPMN.

Background and Aim: Because the risk of colorectal cancer has not been well examined in fecal immunochemistry test (FIT)-positive patients who previously underwent colonoscopy, this study aimed to investigate this topic., Methods: This was a single-center, observational study of prospectively collected data in Japan. FIT-positive, average-risk patients who underwent colonoscopy were divided into groups as follows: those who never underwent colonoscopy in the past (no colonoscopy group), those with a history of colonoscopy between 6 months and 5 years (0.5- to 5-year colonoscopy group), and those with a history of colonoscopy more than 5 years ago (> 5-year colonoscopy group). We investigated the prevalence of advanced neoplasia and invasive cancer among these groups using multiple logistic regression analysis., Results: Detection rates of advanced neoplasia in the no colonoscopy group, 0.5- to 5-year colonoscopy group, and > 5-year colonoscopy group were 14.8% (240/1626), 3.9% (13/330), and 6.9% (17/248), respectively. Detection rates of invasive cancer in each aforementioned group were 5.7% (92/1,626), 0.3% (1/330), and 1.2% (3/248), respectively. Odds ratios of advanced neoplasia in the 0.5- to 5-year colonoscopy group and > 5-year colonoscopy were 0.23 (95% confidence interval [CI]: 0.13-0.42) and 0.40 (95% CI: 0.24-0.68), respectively, in multivariate analysis. The odds ratios of invasive cancer in each aforementioned group were 0.05 (95% CI: 0.01-0.37) and 0.19 (95% CI: 0.06-0.61), respectively., Conclusion: Re-screening with the FIT should not be recommended for at least 5 years for average-risk patients after colonoscopy without high-risk neoplasms, because the risks of colorectal cancer are low in such patients., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is associated with a relatively high proportion of adverse events, and this is attributable to the lack of standardized protocols and specialized equipment. Although the outcomes of EUS-HGS may differ between patients with and those without surgically altered upper gastrointestinal anatomy, there have been no reports on this topic. The present study aimed to evaluate the efficacy and safety of EUS-HGS using our standardized method and to compare the outcomes between patients with and those without surgically altered upper gastrointestinal anatomy., Methods: In EUS-HGS, we used a long partially covered metal stent, and we kept the gastric wall pressed with the scope tip until the stent was deployed more than 1 cm inside the working channel of the scope to minimize free space between the liver and gastric wall (the intraperitoneal stent length). A total of 12 patients who underwent EUS-HGS using our method were retrospectively studied. Procedural success and adverse events were evaluated, and the outcomes of EUS-HGS were compared between six patients with and six without surgically altered upper gastrointestinal anatomy., Results: The procedural success rate was 100%. Additionally, stent migration or dislocation was not noted in any of the patients. The intraperitoneal stent length was significantly greater in patients without surgically altered upper gastrointestinal anatomy than in those with surgically altered upper gastrointestinal anatomy (19.8 mm vs. 11.6 mm; 95% confidence interval, 2.185 - 14.147; P = 0.012)., Conclusions: EUS-HGS using our method was safe. Our findings suggested that special attention should be paid to stent migration or dislocation in patients without surgically altered upper gastrointestinal anatomy., Competing Interests: All the authors declare no conflict of interest associated with this study.

Background: Underwater endoscopic mucosal resection (U-EMR) has emerged as an alternative technique for the resection of colorectal lesions. This study aimed to evaluate our initial experience using U-EMR., Methods: This is a single-center, retrospective case series study. We analyzed the clinical outcomes of consecutive patients who underwent U-EMR in our endoscopy center, from December 2015 to February 2017., Results: Our analysis included 64 lesions, contributed by 38 patients, with a mean age of 68.6 years (range, 25 to 90 years). The study sample included 33 right-sided and 25 left-sided colon lesions, and seven rectal lesions, with an average size of 16.2 mm (6 - 40 mm). Of these, 46 lesions were polypoid and 18 ones non-polypoid. Histologically, 31 lesions were low-grade adenomas, eight ones were high-grade adenomas, 11 were mucosal cancers, four were submucosal cancers, and 10 were classified as "others". En bloc resection was achieved in 52 (81%) lesions, with an en bloc resection rate of 95% for lesions < 20 mm and 55% for lesions ≥ 20 mm. Complete resection of neoplastic epithelial lesions, defined by a negative pathological margin, was achieved in 32 of 59 neoplastic epithelial lesions (54%). We identified three cases (5%) of post-procedural bleeding and one case of perforation (2%)., Conclusions: U-EMR can be feasibly used for resection of colonic lesions, including lesions ≥ 20 mm, although the en bloc resection rate for these lesions was lower than for lesions < 20 mm., Competing Interests: The authors declare there is no conflict of interest.

Background: Efficacy of a physician-controlled wire-guided cannulation of the bile duct has been reported. This study aimed to evaluate a novel sphincterotome with a short tip and a short wire, which can be bowed compactly compared to conventional sphincterotomes., Methods: This was a single-arm, single-center, prospective study. We enrolled patients with choledocholithiasis and/or obstructive jaundice and/or cholangitis for whom endoscopic sphincterotomy was planned. The main outcome measurement was the proportion of successful selective bile duct cannulation by physician-controlled wire-guided cannulation within 10 min., Results: The study cohort consisted of 40 patients. The proportion of successful selective bile duct cannulation within 10 min was 72.5% (n = 29). The proportion of post-endoscopic retrograde cholangiopancreatography pancreatitis was 2.5% (mild, n = 1) and the proportion of hemorrhage was 2.5% (moderate, n = 1)., Conclusions: Although physician-controlled wire-guided cannulation using a novel sphincterotome with a short tip and a short wire was not superior to wire-guided cannulation using conventional sphincterotomes reported in a previous study, it remains a safe and efficacious alternative in terms of successful biliary cannulation., Competing Interests: All the authors declare no conflict of interest.

Background and Aim: The significance of examination time of esophagogastroduodenoscopy (EGD) for asymptomatic examinees is yet to be established. We aimed to clarify whether endoscopists who allot more examination time can detect higher numbers of neoplastic lesions among asymptomatic examinees., Methods: We reviewed a database of consecutive examinees who underwent EGD in our hospital from April 2010 to September 2015. Staff endoscopists were classified into fast, moderate, and slow groups based on the mean examination time of EGD without a biopsy. Neoplastic lesion detection rate among these groups was compared using multiple logistic regression., Results: Of the 55 786 consecutive examinees who underwent EGD, 15 763 asymptomatic examinees who were screened by staff doctors were analyzed. Mean examination time of 13 661 EGD without biopsy was 6.2 min (range, 2-18 min). When cut-off times of 5 and 7 min were used, four endoscopists were classified into the fast (mean duration, 4.4 ± 1.0 min), 12 into the moderate (6.1 ± 1.4 min), and four into the slow (7.8 ± 1.9 min) groups. Neoplastic lesion detection rates in the fast, moderate, and slow groups were 0.57% (13/2288), 0.97% (99/10 180), and 0.94% (31/3295), respectively. Compared with that in the fast group, odds ratios for the neoplastic lesion detection rate in the moderate and slow groups were 1.90 (95% confidence interval [CI], 1.06-3.40) and 1.89 (95% CI, 0.98-3.64), respectively., Conclusion: Endoscopists who do not allot adequate examination time may overlook neoplastic lesions in the upper gastrointestinal tract., (© 2017 Japan Gastroenterological Endoscopy Society.)

A 78-year-old man with hypertension, nephrosclerosis, and angina pectoris visited his family doctor with a history of fatigue and leg edema. He had a history of percutaneous coronary intervention 5 years prior, and was taking low-dose aspirin. Blood tests revealed hypoalbuminemia, gastrointestinal 99m Tc-HSA scintigraphy was positive, and alpha-1 antitrypsin clearance was high;therefore, the hypoalbuminemia was thought to be secondary to a protein-losing enteropathy. A small bowel series revealed multiple, ring-shaped, longitudinal ulcers in the ileum. Balloon-assisted enteroscopy from the anus showed severe stenosis with an ileal ulcer. Since we were not able to diagnose the ulcers, mesalazine and supplemental nutritional care were provided. Four years after the hypoalbuminemia had been diagnosed, the patient died because of pulmonary congestion secondary to renal failure. An autopsy revealed severe atherosclerosis in his aorta and multiple cholesterol embolisms in his small intestine, kidney, stomach, colon, liver, and spleen. The multiple ulcers in the small intestine were thought to be caused by cholesterol crystal embolism, which should be considered in the differential diagnosis of small intestinal ulcers in elderly men or patients after cardiovascular intervention.

Background. Several previous studies assessed the competence in endoscopic retrograde cholangiopancreatography (ERCP) using the bile duct cannulation success rate. However, the cannulation time is also important, because a long cannulation time was reported to be a risk factor for post-ERCP pancreatitis. Aim. To determine the number of ERCP procedures required for short cannulation time of the bile duct. Methods. We retrospectively analyzed 605 ERCP procedures performed for bile duct cannulation in patients with native papilla at our institution between March 2012 and December 2015. The successful procedures were divided into 2 groups: group L and group S (cannulation time > 15 minutes and ≤15 minutes, resp.). An analysis of the relationship among the biliary cannulation time, ERCP experience, and other factors was then conducted. Results. Multivariate analysis showed that the ERCP experience of ≤300 procedures (odds ratio, 2.080; 95% confidence interval, 1.337-3.142; P = 0.001) and malignant biliary stricture due to pancreatic cancer (odds ratio, 1.912; 95% confidence interval, 1.072-3.412; P = 0.028) were found to be significantly associated with a cannulation time of >15 minutes. Conclusions. Our findings suggested that an ERCP experience of ≤300 procedures and malignant biliary stricture due to pancreatic cancer were associated with prolonged biliary cannulation time.

A gastric wall abscess is rare and it can reportedly appear similar to a submucosal tumor on endoscopy. Few reports have described endoscopic ultrasonographic findings for a gastric wall abscess. An 84-year-old man was admitted to our hospital for tarry stools. Esophagogastroduodenoscopy showed an elevated lesion similar to a submucosal tumor at the posterior wall of the stomach. Erosion and a white coat were observed on top of the lesion. Endoscopic ultrasonography showed an anechoic lesion connected to the proper muscular layer with a hyperechoic area in the center of the lesion. The lesion was diagnosed as a gastric wall abscess using endoscopic ultrasound-guided fine-needle aspiration and was treated with endoscopic ultrasound-guided drainage. The final diagnosis was a gastric wall abscess presenting as gastrointestinal hemorrhage. The patient was discharged with internal drainage stents. Computed tomography performed 3 months after discharge did not show recurrence of the abscess.

Although endoscopic ultrasound (EUS)-guided drainage has become the standard procedure for pancreatic pseudocysts in recent years and is generally regarded as a safe and effective method, there have been few reports of EUS-guided drainage of postoperative intra-abdominal abscesses. Here we report our experience with 4 cases of postoperative intra-abdominal abscesses for which EUS-guided drainage was performed between May 2011 and May 2014. Distal pancreatectomy had been performed in 3 cases, whereas low anterior resection for rectal cancer was performed in the remaining case. All patients underwent transgastric naso-cystic drainage, which resulted in clinical improvement without complications, even when performed within 4 wk after surgery. On average, the naso-cystic drain was removed 10 d after placement, with no abscess recurrence. Based on these findings, we believe that EUS-guided drainage of postoperative intra-abdominal abscesses is a safe and effective method, although further large-scale investigations are required to confirm our findings.