Study aim : We retrospectively analyzed the diagnostic yield and accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) for diagnosing gastrointestinal submucosal tumors before surgical resection.
Subjects and Methods : A total of 194 patients with SMT in the gastrointestinal tract were underwent EUS-FNA (208 FNAs) from January 2001 to October 2011 in Kitasato University East Hospital. Sixty three patients (69 FNAs) in whom surgical resection was carried out were included in the final analysis. These subjects included one esophagus, the 57 stomachs, the four duodena, and the one large intestine. Histological diagnosis (mean size : 3.5cm；range : 1.3-16.5cm) are 53 GIST, three Schwannoma, two hamartoma, one granular cell tumor, one glomus tumor, one carcinoid, etc. Puncture was performed with 19-gauge needles and 22-gauge needles and 25-gause needles. A negative pressure of air by 10 or 20 cm syringe was applied in all cases. The needle was passed back and forth in the target lesion 10 to 20 times to obtain a tissue sample. The average of times of puncture was 2.7 times (range : 1-5) .
Results : The overall tissue-sampling rate was 91.3% (63/69) : 100% (1/1) in esophagus, 96.6% (58/60) in stomach, 33.3% (2/6) in duodenum, 100% (2/2) in large intestine. The overall diagnostic yield was 84.1% (53/63) : 100% (1/1) in esophagus, 85.9% (49/57) in stomach, 50% (2/4) in duodenum, 100% (1/1) in large intestine. The diagnostic accuracy was 96.2% (51/53) : 95.9% (47/49) in stomach. Of the total of 69 punctures, 50 (72.5%) had adequate FNA materials for immunohistochemical analysis. That diagnostic accuracy was 97.9% (48/49) : 97.7% (44/45) in stomach.
Conclusions : In our study, comparatively high diagnostic accuracy was obtained and EUS-FNA for gastrointestinal SMT was considered to be the useful diagnosis modality.

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［Introduction］ Group classification was changed with the revision (14th edition, 2010) of the stomach cancer handling agreement and came to include the thing with the neoplastic change in Group 2 by the new Group classification. The Group classification isn′t used than before in our Hospital. Atypical epithelium (become AE) that′s equivalent to new Group 2 in our hospital are included both neoplastic and inflammatory lesions are included. A biopsy result examined the lesion which was AE.
［Object and method］ the AE that pathological diagnosis intended for done 82 cases (0.4%) in 18,930 cases in 31,615 cases of Gastrointestinal endoscopy in two years to December, 2010 from January, 2009, and examined endoscope views and pathology organization views.
［Result］ After it was diagnosed AE, the reexamination was carried out 1-6 months later. We had 66 cases that biopsy was made at reexamination and were cancer 14 cases (21%) and AE 8 cases (12%) . In addition, the magnifying endoscopy with NBI was carried out in 38/82 cases (46%) , we diagnosed the cancer were 35 cases and the case that a last diagnosis agreed with diagnosis using NBI was 23 cases, and the rate was 60.5%. Gastritis or disappeared lesion on last diagnosis were 39/82 cases (47.6%) , cancer were 35/82 cases (42.7%) . It enforced ESD for cancer and diagnosed 38 cases by a case to strongly doubt a cancer in endoscope views or biopsy. The case that didn′t recognize 31 cancers (differentiated types were 27 cases, undifferentiated mixture types were 4 cases) , tubular adenoma with high grade atypia were 3 cases, tubular adenoma with moderate grade atypia was 1 case, no neoplastic lesion were 3 cases by the pathological diagnosis after ESD.
［Conclusion］ There′s a possibility that the neoplastic lesion was included in Group 2. Thus we came to need reexamination clinically. Cases diagnosed for AE were a cancer and inflammation were by about half. The rate of correct diagnosis of cancer at NBI inspection is as low as 60.5% this time, there were many cases also difficult to diagnose pathological population. Although cancer is suspected on clinical presentation, even in patients who repeatedly AE was considered that the surface is due to hyperplasia.

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Aim : The aim of this study is to investigate the detail of complications caused by manipulation of endoscope on ERCP and find ways to cope with complications.
Methods : A total of 1907 patients performed ERCP were enrolled in this study. The mean age of the patients was 69.5 years, and the patients were 1175 men and 732 women. Anatomical characteristic of the patient’s stomach were consisted of normal stomach (n＝1791) , reconstruction by Billroth I (n＝49) , reconstruction by Billroth II (n＝47) , reconstruction by Roux-en-Y (n＝9) , and others (n＝7) . The incidence or details of complications, characteristics of the operators, ways to cope with complications, and outcome were evaluated.
Results : The total incidence of complications was 1.3% (24/1907) , of which laceration in 20 cases and perforation in 4 cases was observed. The incidence of complications in normal stomach was 1.3% (23/1791) with laceration in 20cases and perforation in 3 cases, and in reconstruction by Billroth II was 2.1% (1/47) with perforation in 1 case. The locations of laceration were esophagogastric junction in 19 cases and antrum in 1 case, whereas location of perforation were descending portion of duodenum in 2 cases, superior duodenal angulus in 1 case, and afferent loop in 1 case. The lacerations, duodenal perforations, and afferent loop perforation were caused by push manipulation of scope, stretch manipulation of scope, and contact of a transparent cap attached to the tip of anterior-viewing endoscope, respectively. The median number of the procedure of operators who developed a complication was 32.5, and 75% of operators were considered to be non-expert, who had ERCP experiences of less than 50 times. Laceration was treated with thrombin spraying in 11 cases, clipping in 6 cases, injection of hypersaline with epinephrine in 1 case, whereas no treatment was required in 5 cases. As for perforation, 2 cases were cured by only conservative medical management, although 2 cases immediately required the operation. There was no fatal case associated with manipulation of the endoscope during ERCP.
Conclusions : Extreme care should be taken to insert the scope into the stomach to prevent laceration, and to stretch the manipulation of scope to prevent duodenal perforation, especially the operator is considered to be non-expert. It is important to collaborate closely with surgery in case of development complications caused by ERCP taking surgical treatment into consideration, especially in case of perforation.

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Aim : To clarify the H.pylori eradication ratio between proton-pump inhibitor, ampicillin, metronidazole (PPI/AM : 2^nd line) therapy and PPI, ampicillin, clarithromycin (PPI/AC : 1^st line) therapy.
Method : Patients with H.pylori infection, who were diagnosed by endoscopic biopsy specimen in community doctor office at Katori City of Chiba prefecture, were included in the study. Patients with gastric and/or duodenal ulcer were received PPI/AC therapy. Patients, who were treated PPI/AC therapy, with failed to eradicate H.pylori were then received PPI/AM therapy. Patients without gastric or duodenal ulcer were received PPI/AM therapy if patients were expected to receive H.pylori eradication therapy. H.pylori eradication ratio between PPI/AM and PPI/AC therapy was compared.
Result : The number of the patients treated with primary therapy of PPI/AC was 77, and 61 out of 77 patients (79.8%) were successful to disinfect. Remaining 14 out of 16 patients with failed to disinfect by primary therapy of PPI/AC were treated with second therapy of PPI/AM, and all patients treated second therapy were successful to disinfect.
The number of the patients treated with primary therapy of PPI/AM was eight, and all patients were successful to disinfect. The analysis of eradication ratio in 1st therapy, PPI/AM (100%；8/8) therapy was higher than PPI/AC (79.8% 61/77) therapy (P＝0.15) . The analysis included 14 patients with received second therapy of PPI/AM, PPI/AM therapy (100%；22/22) was statistically higher than PPI/AC therapy (P＝0.01) . There were no side effects in both treatments.
Conclusion : PPI/AM therapy was higher H.pylori eradication ratio than PPI/AC therapy. All patients received PPI/AM therapy were successful to eradicate H.pylori infection.

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Hemoclip therapy is the most commonly used method that have high success rate of endoscopic hemostasis in Japan. Nevertheless, there is no report how to adapt various kinds of hemoclips. From 2004 through 2011, we performed a retrospective study of comparison between groupA (n＝29) ；the Standard type hemoclips (arm length 7.5mm) method using hemoclip of HX-600/610-135 (OLYMPUS) versus groupB (n＝57) ；the both short and long type hemoclips (arm length 6mm and 9mm, respectively) method using two kinds of hemoclips of both HX-600/610-135S and HX-600/610-090L for gastric ulcer with active bleeding. The endoscopic re-treatment for both condition of rebleeding and visible vessel without bleeding at second look endoscopy was achieved 20.7% in groupA vs. 5.3% in groupB (P‹0.05) . In conclusion, the combination of short and long type hemoclips therapy was one of the effective hemostasis method for hemorrhagic gastric ulcer.

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Obstructive colorectal cancer accounts for 3.1-15.8% of total colorectal cancer. It is not rare condition. Though obstructive colorectal cancer was often treated with emergent operation, it has made possible to be treated with elective surgery when utilizing endoscopic metal stent (EMS) placement that decompresses the enlarged intestine by transanal approach. In some cases, obstructive colorectal cancer can be treated with laparoscopic assisted colectomy (LAC) . In this study, we report cases of operable obstructive colorectal cancer that was treated by LAC after EMS placement.
Patients and Methods : We performed 108 EMS placements for operable obstructive colorectal cancer cases；99 cases were successfully performed and 9 cases of them underwent LAC. The patients′ age was between 45 and 93. It included 5 male and 4 female, all of them had 7 cases of sigmoid colon cancer, 1 case of rectum RS, 1 case of transverse colon. Stenting period was 6-13 days. All of the patients could undergo LAC with D3 level lymph node dissection.
Discussion : For obstructed cases, enlarged intestine become an obstacle of operative field view. So, such cases had not been applied to LAC. EMS placement, however, has made intestinal decompression and intestinal edema alleviation to expand the indication of LAC into obstructive colorectal cancer.
Conclusion : LAC is applicable for obstructive colorectal cancer with sufficient decompression by EMS placement or other methods.

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Recent studies show the increase of Single Port Surgery (SPS) for colectomy with lymph node dissection. We have performed 18 SPS cases including 9 colon cancer cases. Most of them were early sigmoid or transverse colon cancer though we have some advanced cancer cases, which were applied to minimal invasive surgery with D2 level lymph node dissection. Mean operative time was 140 minutes and mean blood loss was 23.2ml. There has been no postoperative complication and we found high patients’ satisfaction level. Especially in advanced cancer case, however, skin incision was required to be longer tham 3cm to remove specimen, that is, the skin incision cannot be always invisible. So, we decided not to persist in SPS and introduced a new method, SPS+1, in which we added one 5mm port. Electronic devices inserted from the 5mm port make better manipulation, less stress and higher safety. Furthermore, scar of 5mm port will be almost invisible so that cosmetic results can be equal to SPS. Though SPS has been increasingly applied in wider range, careful patient selection is required.

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[in Japanese]

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