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Background: Peutz-Jeghers syndrome (PJS) is a rare disease characterized by the presence of hamartomatous polyposis throughout the gastrointestinal tract, except for the esophagus, along with characteristic mucocutaneous pigmentation. It is caused by germline pathogenic variants of the STK11 gene, which exhibit an autosomal dominant mode of inheritance. Some patients with PJS develop gastrointestinal lesions in childhood and require continuous medical care until adulthood and sometimes have serious complications that significantly reduce their quality of life. Hamartomatous polyps in the small bowel may cause bleeding, intestinal obstruction, and intussusception. Novel diagnostic and therapeutic endoscopic procedures such as small-bowel capsule endoscopy and balloon-assisted enteroscopy have been developed in recent years. Summary: Under these circumstances, there is growing concern about the management of PJS in Japan, and there are no practice guidelines available. To address this situation, the guideline committee was organized by the Research Group on Rare and Intractable Diseases granted by the Ministry of Health, Labour and Welfare with specialists from multiple academic societies. The present clinical guidelines explain the principles in the diagnosis and management of PJS together with four clinical questions and corresponding recommendations based on a careful review of the evidence and involved incorporating the concept of the Grading of Recommendations Assessment, Development and Evaluation system. Key Messages: Herein, we present the English version of the clinical practice guidelines of PJS to promote seamless implementation of accurate diagnosis and appropriate management of pediatric, adolescent, and adult patients with PJS.

We report the case of a video capsule endoscope lodged within a Zenker diverticulum. The system that was equipped with a real-time viewer showed an unchanging image unlike esophageal or gastric mucosa, suggesting that the capsule was elsewhere. The presence of cervical discomfort suggested video capsule retention in a Zenker diverticulum. The capsule was removed endoscopically and reinserted using a hood-assisted endoscope and the procedure was completed.

Background and Aim: The ideal method to remove small colorectal polyps is unknown. We compared removal by colon snare transection without electrocautery (cold snare polypectomy) with conventional electrocautery snare polypectomy (hot polypectomy) in terms of procedure duration, difficulty in retrieving polyps, bleeding, and post-polypectomy symptoms. Methods: Patients with colorectal polyps up to 8 mm in diameter were randomized to polypectomy by cold snare technique (cold group) or conventional polypectomy (conventional group). The principal outcome measures were abdominal symptoms within 2 weeks after polypectomy. Secondary outcome measures were the rates of retrieval of colorectal polyps and bleeding. Results: Eighty patients were randomized: cold group, n = 40 (101 polyps) and conventional group, n = 40 (104 polyps). The patients’ demographic characteristics and the number and size of polyps removed were similar between the two techniques. Procedure time was significantly shorter with cold polypectomy vs. conventional polypectomy (18 vs. 25 min, p < 0.0001). Complete polyp retrieval rates were identical [96% (97/101) vs. 96% (100/104)]. No bleeding requiring hemostasis occurred in either group. Abdominal symptoms shortly after polypectomy were more common with conventional polypectomy (i.e. 20%; 8/40) than with cold polypectomy (i.e. 2.5%; 1/40; p = 0.029). Conclusion: Cold polypectomy was superior to conventional polypectomy in terms of procedure time and post-polypectomy abdominal symptoms. The two methods were otherwise essentially identical in terms of bleeding risk and complete polyp retrieval. Cold polypectomy is therefore the preferred method for removal of small colorectal polyps.

The course of patients with advanced ovarian carcinoma is often complicated by bowel obstruction and/or massive ascites. A transnasal long tube may be placed to relieve bowel obstruction, but produces nasal discomfort and pain. Recently, the effectiveness of percutaneous endoscopic gastrostomy (PEG) tube placement for malignant bowel obstruction due to ovarian carcinoma has been reported, but not all patients received effective decompression. Diversion of a transnasal long tube to the PEG site in this case provided a useful method of long-term decompression while providing improved quality of life.

Background and Aim: There are only a few studies on propofol sedation for very elderly patients. The present study was undertaken to evaluate the safety of propofol sedation in patients 90 years of age and older undergoing endoscopic procedures. Methods: We prospectively assessed endoscopic procedures for patients 90 years of age and older using propofol sedation. Endoscopic procedures, dosage used, respiratory depression, complications and 30-day mortality were evaluated. In a subset of the enrolled patients, the blood concentrations of propofol were measured. Results: All 241 patients completed endoscopic procedures. For esophagogastroduodenoscopy, percutaneous endoscopic gastrostomy, colonoscopy, and endoscopic retrograde cholangiopancreatography, the mean propofol doses used were 22, 24, 46 and 42 mg, respectively. Four patients required oxygen and 1 patient was treated by short periods of mask ventilation. There was no perforation, bleeding, pancreatitis or 30-day mortality. In diagnostic esophagogastroduodenoscopy, the level of sedation and propofol blood concentrations after administration of propofol (24 ± 6.8 mg) in patients 90 years of age and older corresponded to those of propofol (61 ± 13 mg) in middle-aged patients (control). Conclusion: Low-dose propofol sedation is safe and may be enough for patients 90 years of age and older undergoing endoscopic procedures.

Background and Aim: Automobile driving is prohibited after midazolam sedation because of the slow recovery of psychomotor function. This study prospectively assessed the safety of low-dose propofol sedation (study 1) and compared driving ability following propofol and midazolam sedation (study 2). Methods: Study 1: We prospectively investigated bolus injection of a low-dose of propofol (40–80 mg for Results: Study 1: Only 1.1% of 12,031 healthy subjects developed transient oxygen desaturation. Full recovery was present in 97.5% 30 min after the procedure; 99.8% were willing to repeat the same procedure. The blood levels of propofol (40–80 mg) at 60 min were Conclusion: Low-dose propofol sedation was safe and recovery including driving ability was with 60 min.