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Background Interventions for necrotizing pancreatitis have undergone a recent paradigm shift toward minimally invasive techniques, including endoscopic transluminal necrosectomy (ETN). The optimal stent for endoscopic transmural drainage remains unsettled. Objective To evaluate a novel large-bore, fully covered metal through-the-scope (TTS) esophageal stent for cystenterostomy in large walled-off necrosis (WON). Design Retrospective case series. Setting Single tertiary care academic center. Patients Ten patients with large (>10 cm) WON collections who underwent endoscopic transmural drainage and ETN. Intervention Initial cystenterostomy was performed by using EUS, and in the same session, a TTS (18 × 60 mm), fully covered esophageal stent was placed to create a wide-bore fistula into the cavity. In 1 or more later sessions, the stent was removed, and ETN was performed as needed. Main Outcome Measurements Technical and clinical success rates and adverse events. Results The TTS stent was successfully deployed at the initial cystogastrostomy in all 10 patients. All patients had large WON (median size 17 cm, range 11-30 cm) and underwent intervention at a median of 30 days (range 12-117 days) after onset of acute pancreatitis. Resolution of WON was achieved in 9 of the 10 patients (90%) after a median of 3 endoscopic sessions. There were no early adverse events. Late adverse events occurred in 3 patients (30%); worsening of infection from stent migration and occlusion of cystogastrostomy (2 patients), and fatal pseudoaneurysmal bleeding from erosion of infected necrosis into a major artery distant from the stent (1 patient). The stent was easily removed in all the cases after resolution or improvement of the necrotic cavity. Limitations Retrospective, single-center evaluation of a small number of cases. No comparative arm to determine the relative efficacy or cost-effectiveness of these stents compared with conventional plastic stents. Conclusions Endoscopic therapy using a large-bore TTS, fully covered esophageal stent is feasible for use in the treatment of large WON. Further studies are needed to validate these findings.

Objectives The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. Methods Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. Results Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. Conclusions An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.

目的:下部直腸癌の傍直腸リンパ節転移診断における試作3次元(3D)直腸プローブの有用性を評価することである.方法:下部直腸癌14症例に対し術前に3D直腸プローブでリンパ節を描出,切除標本を再走査して描出リンパ節を一致させ摘出し,検体を病理所見と比較した.転移陽性,陰性リンパ節について術前超音波画像の短径,扁平率(短径/長径)を2次元(2D)画像と3D画像で比較検討した.結果:超音波像における短径3mm以上かつ扁平率0.75以上を転移陽性リンパ節とすると,感度100%,特異度71.2%,正診率74.1%であった.考察:2D画像より3D画像で検討し特異度,正診率が有意に上昇した.また,短径3mm以上かつ扁平率0.75以上を転移陽性リンパ節とすると,短径5mm以上より診断率が上昇し,3mm以上のリンパ節を3D走査で積極的に拾い上げ,扁平率を検討することが微小リンパ節転移の診断に重要と考えられた.

A case was 23 years old woman. She came to our hospital with complain of continuing fever after common cold and mass like an egg was touched in right lower abdomen. No other surface lymph node was swelling. Abdominal US, CT and MRI showed that the mass was existed in the front of the psoas muscle and the maximum diameter of it was 6 cm in which necrotizing lesion was recognized. The size of the lymph node became smaller slowly but we could not perfectly exclude malignant disease, we examined needle biopsy for the diagnosis. The histopathological findings showed the histiocytic necrotizing lymphadenitis (HNL). HNL usually appears in the neck area, but in this case it was detected only in the abdomen. This case was very rare and we reported.

Endoscopic mucosal resection (EMR) allows the removal of flat or sessile lesions, laterally spreading tumors, and carcinoma of the colon or the rectum limited to the mucosa or the superficial submucosa. Acute appendicitis is the most common abdominal emergency requiring emergency surgery, and it is also a rare complication of diagnostic colonoscopy and therapeutic endoscopy, including EMR. In the case presented here, a 53-year-old female underwent colonoscopy due to a positive fecal occult blood test and was diagnosed with cecal adenoma. She was referred to our hospital and admitted for treatment. The patient had no other symptoms. EMR was performed, and 7 h after the surgery, the patient experienced right -lower abdominal pain. Laboratory tests performed the following day revealed a WBC count of 16000/mm(3), a neutrophil count of 14144/mm(3), and a C-reactive protein level of 2.20 mg/dL, indicating an inflammatory response. Computed tomography also revealed appendiceal wall thickening and swelling, so acute appendicitis following EMR was diagnosed. Antibiotics were initiated leading to total resolution of the symptoms, and the patient was discharged on the sixth post-operative day. Pathological analysis revealed a high-grade cecal tubular adenoma. Such acute appendicitis following EMR is extremely rare, and EMR of the cecum may be a rare cause of acute appendicitis.

Aims: We have studied a manufactured rigid rectal probe enabling three-dimensional (3D) scanning since Jun 2001. The novel 3D rectal probe (7.5MHz, XRU-75M-DP2, Olympus) has a 15-mm outside diameter, and the form of its tip and the hand-operated swiveling part have been modified. When the rectal probe is used, there may be multiple echoes around its surface that can obscure the image, in which case a standoff produced by the balloon or the acoustic silicone coupler can be useful. Aims: The aims of this study were to assess the resolution of the 3D rectal probe by performing basic examinations with or without the silicone coupler, and to assess the value of the rectal probe in clinical cases. Materials and Methods: As a basic experiment to evaluate the influence of the multiple echoes, we compared scanning by the 3D rectal probe under water immersion with scanning by the probe covered by a silicone tube, of specimens excised from normal large intestine. We used the balloon method to scan eighteen rectal lesions through deaerated water; we inserted the 3D rectal probe covered by a silicone tube and scanned from the upper to the lower rectum. Results: A silicone tube attached with the probe could facilitate the scanning by suppressing the multiple echos, and enable the analysis of the structures from the mucous membrane to the submucosal layer. The diameter of the new modified probe is thinner, permitting easy insertion of the probe into the anal canal even surrounded by a silicone tube. All rectal lesions could be detected, except one lesion on the rectosigmoid (Rs) because the probe was too short to reach. There were no complications during this procedure. Conclusion: The probe with a silicone tube attached could be used to evaluate of proctorectal lesions.