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Objectives There are patients who do not undergo colonoscopy even if the fecal immunochemistry test (FIT) results are positive and even with repeated positive test results the following year. We aimed to investigate colorectal cancer (CRC) risk in examinees with positive FIT results in our annual screening program. Methods We analyzed patients who underwent initial colonoscopy from April 2010 to March 2017 because of positive FIT results using an endoscopy database in our hospital. We investigated the difference in the risk of advanced colorectal neoplasia as a surrogate marker of CRC between those who had an initial positive test and those who had repeated positive tests. Results A total of 748 patients were included in this analysis. The advanced neoplasia detection rates were 7.6% (50/656) and 18.5% (17/92) for the initial and repeated positive test groups, respectively. Subgroup analysis of those with repeated positive tests revealed that the detection rates in examinees with positive tests 1-2 and >2 years ago were 16.7% (6/36) and 19.6% (11/56), respectively. The odds ratios for advanced neoplasia detection in patients with positive tests 1-2 and >2 years ago compared with those in the initial positive test group were 2.72 (95% confidence interval [CI], 1.04-7.10) and 3.09 (95% CI, 1.47-6.48), respectively. Conclusions The risk of CRC appears more than doubled in patients with a repeated positive FIT result. Prompt colonoscopy is recommended for FIT-positive cases.

Background Ischemic colitis is an adverse event which may occur during bowel preparation for colonoscopy. This study aims to clarify both the incidence and the risk factors of this complication. Methods This was a single-center, retrospective, observational study. All outpatients who were prescribed standardized preparation drugs for colonoscopy at the Kyoto Second Red Cross Hospital between November 2011 and March 2020 were included in the study. A split bowel preparation was carried out as follows; magnesium citrate with or without sodium picosulfate hydrate was/were used as a preparation drug on the day before the colonoscopy, and polyethylene glycol electrolyte solution or sodium phosphate was used on the morning of the endoscopic procedure. Patients were extracted from the electronic medical records and matched with the endoscopy database by examination date and hospital identification number. Following the endoscopic findings, both the incidence and risk factors for ischemic colitis arising after bowel preparation were examined. Results Among the 14,924 patients analyzed, ischemic colitis was observed in 14 patients (0.09%). Multivariate analysis revealed that old age (≥ 75 years old) and strong preparation (magnesium citrate with sodium picosulfate and polyethylene glycol electrolyte solution) for constipated patients were independent risk factors for ischemic colitis (odds ratio: 3.64 (95% confidence interval (CI): 1.36 - 9.77) and 4.27 (95% CI: 1.45 - 12.53), respectively). Conclusions The age 75 years and above and strong preparation for patients with constipation were independent risk factors for ischemic colitis prior to colonoscopy. Careful attention should be paid to bowel preparation before colonoscopy for patients aged ≥ 75 years and for those with constipation.

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 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., We retrospectively analyzed fecal immunochemistrytest positive patients who underwent a colonoscopy. We stratified them into the 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 detection in each group. In the no colonoscopy group, the advanced neoplasia detection rate significantly increased with the fecal hemoglobin concentration. However, no significant trend was observed in the past colonoscopy (both ≥5 years and ≤5 years) group. Especially in those who underwent colonoscopy within 5 years, risk of colorectal cancer might be low even if fecal hemoglobin concentration was high.

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. 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. 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). Our analysis demonstrated that hyperechogenic pancreas was associated with concomitant PDAC in patients with IPMN.

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.

The usefulness of endoscopic ultrasound (EUS)‐guided gastrojejunostomy (EUS‐GJ) using a lumen‐apposing metal stent (LAMS) has been reported. However, LAMS is not available in many countries and is more expensive than a conventional fully covered self‐expandable metal stent (FCSEMS). We treated cases of malignant afferent loop obstruction after Roux‐en‐Y reconstruction: three patients underwent EUS‐guided hepaticoenterostomy (EUS‐HES) and one patient underwent EUS‐GJ with a conventional biliary FCSEMS, instead of EUS‐GJ with a LAMS. In two of the cases, EUS‐GJ or EUS‐guided jejunojejunostomy was not indicated because the afferent loop was far from the stomach or jejunum, and EUS‐HES was performed. In one case, in which both EUS‐HES and EUS‐GJ were feasible, EUS‐HES was performed because of unavailability of LAMS for EUS‐GJ in Japan. In another case, EUS‐HES was not indicated because of massive ascites around the liver, and thus, EUS‐GJ using a 10 mm FCSEMS combined with a 7 Fr large‐loop double‐pigtail plastic stent was performed. In all four cases, the patients’ symptoms improved without any adverse events. Stent occlusion did not occur in three of the four cases until the patients died of advanced cancer progression. EUS‐GJ using a 10 mm FCSEMS with a 7 Fr large‐loop double‐pigtail plastic stent or EUS‐HES is likely safe and effective for managing malignant afferent loop obstruction.

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.

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.

The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.

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.

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

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.

AIM : Limited evidence exists on the relationship between colonoscopy withdrawal time and adenoma detection rate in Japan. We aimed to clarify the clinical impact of colonoscopy withdrawal time in a Japanese setting. MATERIALS AND METHODS : We recruited 6,919 consecutive patients from four Japanese endoscopic centers between April 2010 and April 2011. Colonoscopists were divided into the following groups based on the median withdrawal time of a negative colonoscopy

Gastrointestinal perforation is a serious adverse event that occurs in approximately 1% of patients receiving ramucirumab and paclitaxel. A 67-year-old man with unresectable advanced gastric cancer was admitted to our hospital and treated with ramucirumab and paclitaxel. Gastric perforation occurred during the second cycle of chemotherapy. Although the patient’s condition improved without surgery, an abscess developed in the intra-abdominal fluid collection resulting from the perforation. We performed endoscopic ultrasound-guided abscess drainage. The patient improved and was discharged in satisfactory condition. Endoscopic ultrasound-guided drainage is a treatment option for patients with intra-abdominal abscess following gastric perforation due to ramucirumab.

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.

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.

Mechanical lithotripsy is usually employed for the fragmentation of large common bile duct (CBD) stones. However, refractory CBD stones, stones larger than 2 cm in size, those firmly impacted, those located above a bile duct stricture, and those located in the intrahepatic bile duct, or cases of Mirizzi syndrome are difficult to treat. Recently, electrohydraulic lithotripsy (EHL) or laser lithotripsy has been indicated for the foregoing cases. EHL and laser lithotripsy are usually performed under cholangioscopic guidance with irrigation inside the CBD in order to clearly visualize the lumen and remove debris. The stone clearance rates of EHL and laser lithotripsy range from 74% to 95% and from 88% to 97%, respectively. Most complications related to EHL or laser therapy are associated with endoscopic retrograde cholangiopancreatography or percutaneous transhepatic biliary drainage, such as pancreatitis, hemorrhage, perforation, and sepsis. The overall complication rate of EHL or laser lithotripsy was reported to be 7–9%, including hemobilia and cholangitis. Perforation of the bile duct due to EHL or laser lithotripsy is rare. Further refinements of the EHL instruments, laser lithotripsy instruments, and cholangioscope are required for improving the ease of use of EHL and laser lithotripsy.

ObjectivesInterventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures.MethodsFormulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question.ResultsA total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required.ConclusionsThe current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.

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.

Background and Aim A limited number of endoscopic retrograde cholangiopancreatography (ERCP) accessories are compatible with the conventional single-balloon enteroscope (SBE) because of the latter's dimensions. The aim of the present study was to assess the utility of a prototype SBE that has a shorter working length and a wider channel than the conventional SBE. Methods ERCP procedures carried out between January 2012 and July 2013 using the short SBE prototype were reconstructions such as Billroth II (B-II), post-gastrectomy with Roux-en-Y (RY-G), and post-choledochojejunostomy with Roux-en-Y (RY-CJ). We retrospectively analyzed the rate of reaching the blind end of the intestine, the diagnostic success rate, the interventional success rate, and the frequency of related complications. Results Twenty-seven ERCP procedures on 18 patients analyzed comprised two B-II, 15 RY-G, and 10 RY-CJ reconstructions. With a mean procedure time of 56 min (range 40–150 min), the rate of reaching the blind end, the diagnostic success rate, and the interventional success rate were 24/27 (89%), 20/27 (74%), and 19/27 (70%), respectively. There were no major ERCP-related complications in any patient. Conclusions The prototype short-type SBE appears safe and effective for use in ERCP, and is compatible with conventional endoscopy accessories.

This study aimed to evaluate the relationship between pancreatic ductal adenocarcinoma (PDAC) family history and PDAC development in patients followed up for intraductal papillary mucinous neoplasms (IPMNs) and to assess the cyst size relevance in determining follow-up strategies.We analyzed 300 patients with branch duct and mixed-type IPMN who were followed up at our facility.Among the patients aged 70 years or older, the frequency of PDAC did not differ significantly between those with 1 first-degree relative with PDAC and those without a family history. Although patients with IPMNs of greater than or equal to 30 mm were followed up for a significantly shorter duration than those patients with IPMNs of less than 30 mm, the frequency of IPMN progression and malignant IPMN was significantly greater in the former. The frequency of IPMN progression and pancreatic cancer did not differ significantly according to IPMN size (10, 10-20, and 20-30 mm) in cases without mural nodules.Patients with 1 first-degree relative with PDAC can be followed up using the same criteria for patients without a family history. Special attention should be paid to IPMN progression and malignant transformation in patients with IPMNs of greater than or equal to 30 mm, but cyst size need not be considered when determining follow-up strategies for patients with IPMNs of less than 30 mm without mural nodules.

Background and Aim The impact of frequent colonoscopy on colorectal cancer (CRC) remains unclear. The present study aimed to determine the relationship between frequency of surveillance colonoscopy and CRC prevention. Methods From April 2010 to April 2011, patients who underwent surveillance colonoscopy after screening and polypectomy in four Japanese endoscopy centers were enrolled in this multicenter historical cohort study. Patients were classified into the following two groups according to the findings of past colonoscopy: a low-risk group (no neoplasia or 1–2 cumulative adenomas

In Asia, the incidence of pancreatic cancer in some countries has been increasing. Owing to most cases being diagnosed late, prognosis for pancreatic cancer remains dismal. It is clear that the future for pancreatic cancer lies in early detection. While the possible presence of pancreatic masses is often first raised by non-invasive abdominal imaging, such as computerized tomography and magnetic resonance imaging, smaller lesions and locoregional lymph node metastases are often not detectable by these means. Endoscopic ultrasonography (EUS) offers a higher sensitivity (93–100%) for detection of small potentially curable pancreatic masses than other existing imaging modalities. It is also recommended for the evaluation of portal vein confluence, portal vein, celiac axis, and superior mesentric artery origin, and exclusion of resectability. Due to the closer proximity of EUS to the target structure, and lower rate of needle tract seeding, EUS-guided fine-needle aspiration of pancreatic mass is considered the most suitable tissue acquisition technique. Lastly, EUS also enables the performance of endoscopic interventions. Its performance can be further enhanced with newer techniques, including contrast-enhanced ultrasound and elastrography. It is anticipated that in the near future, molecular technologies may make it possible to detect microscopic amounts of cancer in tissue or blood, predict relapse and survival after therapy, as well as determine optimal therapy.

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. The 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. The mean examination time of 13,661 EGDs without biopsy was 6.2 min (range, 2–18 min). When cutoffs of 5 and 7 min were used, 4 endoscopists were classified into the fast (mean duration, 4.4 ± 1.0 min), 12 into the moderate (6.1 ± 1.4 min), and 4 into the slow groups (7.8 ± 1.9 min). The neoplastic lesion detection rates in the fast, moderate, and slow groups were 0.57% (13/2,288), 0.97% (99/10,180), and 0.94% (31/3,295), respectively. Compared with that in the fast group, the 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. This article is protected by copyright. All rights reserved.

The optimal regimen of radiotherapy (RT) for bleeding from gastric cancer (GC) has not yet been established. The aim of this study was to evaluate the usefulness of low-dose, short-course palliative RT (LSP-RT) for bleeding from GC.We reviewed the clinical data of 18 patients (26 courses) who received palliative RT for bleeding from GC between 2004 and 2014. The radiation dose was 6 Gy in three fractions. The total courses of RT for each patient were 1-4 (median, 1).The treatment success rate of the first and the additional RT at two weeks after RT was 55% and 75%, respectively. Regarding first RT, there was a statistically significant increase in the mean hemoglobin level for one month (p = 0.009) and a significant decrease in the mean number of transfused red blood cell units for one month (p = 0.012). Toxicities were observed in two patients: one patient who received chemotherapy developed grade 3 afebrile leukocytopenia and another who had a malignant stricture suffered from a gastric obstruction. The performance status was improved in 3 of the 12 evaluable patients (25%) and dietary intake became possible one month after RT in three of the four patients who had not been able to eat before RT.LSP-RT is expected to be not only an effective and safe treatment option for bleeding from GC, but also repeatable in cases of rebleeding. Furthermore, this treatment modality may be able to improve the patient's quality of life.

This retrospective study aimed to clarify the clinical characteristics of advanced colorectal neoplasms after colonoscopy, likely to have been missed on the previous colonoscopy. We reviewed a total of 5,768 consecutive colonoscopies performed from April 2010 to September 2013 in 4,841 patients, and analyzed advanced colorectal neoplasms after colonoscopy, particularly focusing on their morphological characteristics and locations, as compared with primary lesions, defined as lesions detected in their first colonoscopy or in a subsequent colonoscopy5 years after the previous one. Of the 5,768 examinations, 922 advanced neoplasms (including 217 cancers with ≥T2) were detected, and 167 lesions (18.1%) were diagnosed within 5 years after a previous colonoscopy (post-colonoscopy advanced neoplasms). The incidence of right-sided lesions in the post-colonoscopy advanced neoplasms (48.5%, 81/167) was significantly higher than in the primary lesions (34.0%, 257/755; p0.001). We excluded 217 cancers with ≥T2 from the morphological analysis to characterize early-stage post-colonoscopy advanced neoplasms. The incidence of non-polypoid lesions in the post-colonoscopy advanced neoplasms (25.6%, 41/160) was significantly higher than that in the primary lesions (12.3%, 67/545; p0.001). These findings suggest that extra attention should be paid to non-polypoid, right-sided advanced colorectal neoplasms during screening and surveillance colonoscopy. J. Med. Invest. 63: 163-170, August, 2016.

Background and study aims: An iincreasing number of reports describe endoscopic ultrasound-guided hepaticogastrostomy for malignant biliary obstruction in patients with endoscopic retrograde cholangiopancreatography failure. However, this procedure has not yet been standardized; as a result, the rate of adverse events, including bile leakage and stent migration, is relatively high. Here, we report our experience with four cases of endoscopic ultrasound-guided hepaticogastrostomy performed according to our institutional procedure.

Background. Endoscopic resection (ER) for early gastric cancer (EGC) is a minimally invasive and curative treatment. The value of endoscopic ultrasonography (EUS) in determining the therapeutic strategy for EGC was assessed in this study.Materials and Methods. Pretreatment EUS was performed on 406 EGCs. The lesions were divided into the histological categories m/sm1 and sm2. The EUS-determined depths of invasion were classified as EUS-M/SM1, EUS-SM2, and EUS-MP or deeper. An analysis of the factors influencing the EUS-based depth determination was then conducted.Results. Most (92.8%) of the EUS-M/SM1 group belonged to the m/sm1 histological category. Ulcerated lesions, tumor size of larger than 2 cm, and the use of an ultrasound endoscope were independently associated with misdiagnosis of the depth of EGC by EUS. The ulcerated lesions had a significantly higher probability of overestimation.Conclusions. EUS is a useful method for determining the therapeutic strategy for EGC. Special attention should be paid not to overestimate the depth of cancer invasion when determining the ulcerated lesions and the type of curative procedure to be used.

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.

Aim: Peppermint oil solution was found to be effective for reducing gastric spasm during upper gastrointestinal endoscopy. The aim of the present study was to assess whether the gastric peristalsis-suppressing effect is dose-dependently induced by L-menthol, the major constituent of peppermint oil, and to determine the recommended dose of an L-menthol preparation. Methods: In this phase II, multicenter, double-blind, dose–response study, 131 eligible patients were randomly assigned to receive 20 mL of 0.4% L-menthol (n = 32), 0.8% L-menthol (n = 35), 1.6% L-menthol (n = 30), or placebo (n = 34). The primary efficacy measure was the proportion of subjects with no peristalsis in two time periods, 75 to 105 s after treatment and immediately before the completion of endoscopy. Results: The peristalsis-suppressing effect of L-menthol increased dose dependently (5.6%, 32.0%, 47.4% and 52.9% in the 0%, 0.4%, 0.8% and 1.6% groups, respectively: P

GI peristalsis during GI endoscopy commonly requires intravenous or intramuscular injection of antispasmodic agents, which sometimes cause unexpected adverse reactions.Our ultimate goal was to evaluate whether the antiperistaltic effect of L-menthol-based preparations facilitates endoscopic examinations in a clinical setting.Multicenter, randomized, double-blind, placebo-controlled study.Six Japanese referral centers.A total of 87 patients scheduled to undergo upper GI endoscopy were randomly assigned to receive 160 mg of L-menthol (n=45) or placebo (n=42). Both treatments were sprayed endoscopically on the gastric mucosa. The degree of gastric peristalsis was assessed by an independent committee.The proportion of subjects with no peristalsis 90 to 135 seconds after administration and at the end of the endoscopic examination (complete suppression of gastric peristalsis). Other outcomes were the proportion of subjects with no or mild peristalsis (adequate suppression of gastric peristalsis) and the ease of intragastric observation as evaluated by the endoscopist who performed the procedure.Gastric peristalsis was completely suppressed in 35.6% (21.9, 51.2) of the L-menthol group compared with only 7.1% (1.5, 19.5) of the placebo group (P.001). In the L-menthol group, 77.8% (62.9, 88.8) (35/45 subjects) of the subjects had no or mild peristalsis at the completion of endoscopy. Minor peristalsis interfered with intragastric examination in only 1 of these 35 patients (2.9%). The incidence of adverse events did not differ significantly between the groups (P=.512).Small sample size.During upper GI endoscopy, L-menthol sprayed on the gastric mucosa significantly suppresses peristalsis with minimal adverse drug reactions compared with placebo. (NCT00742599.).

Background & Aims We evaluated the diagnostic ability of a newly developed peroral video cholangioscopy (PVCS) in patients with pancreaticobiliary disorders. Methods We retrospectively evaluated data from 144 patients with pancreaticobiliary disorders, collected from 5 tertiary referral centers. Endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilation (EPBD) was performed before PVCS. We performed 2 types of PVCS, using a conventional therapeutic duodenoscope. If tissue samples were needed, cholangioscopy-assisted biopsy or fluoroscopy-guided biopsy was performed. Results PVCS was advanced into the bile duct in all cases after patients received EST (n = 134 cases), EPBD (n = 2), a combination of EST and EPBD (n = 1), or without treatment of the major papilla (n = 7). Biopsy samples were collected successfully from 112 of 120 cases in which endoscopists considered tissue sampling necessary. Endoscopic retrograde cholangiopancreatography (ERCP)/biopsy correctly identified 83 of 96 malignant lesions and 19 of 24 benign lesions (accuracy = 85.0%; sensitivity=86.5%; specificity=79.2%; positive predictive value=94.3%; negative predictive value=59.4%). Endoscopic retrograde cholangiopancreatography (ERCP)/biopsy plus PVCS correctly identified 95 of 96 malignant lesions and 23 of 24 benign lesions (accuracy = 98.3%; sensitivity=99.0%; specificity=95.8%; positive predictive value=99.0%; negative predictive value=95.8%). Procedure-related complications included pancreatitis (4 cases, 2.8%) and cholangitis (6 cases, 4.3%). Conclusions PVCS is an accurate diagnostic tool for patients with pancreaticobiliary disorders; resolution was well-defined when combined with biopsy analysis. Prospective multicenter clinical trials should evaluate the clinical utility of PVCS in diagnosis of biliary tract diseases.

A case of basket catheter impaction was experienced during treatment for a common bile duct (CBD) stone. In cases of large CBD stones, mechanical basket lithotripsy or extracorporeal shock wave lithotripsy (ESWL) is usually carried out. However, once basket catheter impaction occurs, ESWL should be performed in the remaining basket catheter, which is passed through the patient's nose, and further ESWL basket lithotripsy must be carried out at a later time. On one occasion, a mechanical lithotripter was inserted along-side the conventional basket catheter through the incised papilla. This procedure is a safe and useful method for the clearance of CBD stones that cannot be removed with standard endoscopic procedures due to an impacted basket catheter.

Endoscopic hemostasis is widely performed for nonvariceal upper gastrointestinal (UGI) bleeding. As the aged Japanese population rapidly increases, the number of patients experiencing complications increases. The aim of this study was to evaluate the recent results of endoscopic hemostasis for nonvariceal UGI bleeding. A retrospective analysis of patients who underwent endoscopic procedures for nonvariceal UGI bleeding was performed. We performed 223 endoscopic procedures on 217 patients between January 1995 and July 2000, and 238 endoscopic procedures on 236 patients between January 2006 and September 2009 at the Kyoto Second Red Cross Hospital. We divided the patients into the 1995–2000 group and the 2006–2009 group. Patient characteristics, hemostasis methods chosen, rates of temporary hemostasis and rebleeding, and mortality were analyzed. There were many serious and actively bleeding cases in the 2006–2009 group (P