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Background and study aims: Endoscopic resection is one treatment option for residual or locally recurrent esophageal cancer after definitive chemoradiotherapy or radiotherapy alone. However, little is known about the clinical benefit of salvage endoscopic resection for these lesions. Therefore, the effectiveness and prognostic factors of salvage endoscopic resection were investigated. Patients and methods: A total of 37 patients with esophageal squamous cell carcinoma (SCC) who underwent salvage endoscopic resection after definitive chemoradiotherapy or radiotherapy alone were reviewed. The method of salvage endoscopic resection was endoscopic mucosal resection using a cap (EMR-C), strip biopsy, or endoscopic submucosal dissection. The effectiveness and prognostic factors of salvage endoscopic resection were retrospectively analyzed. Results: A total of 37 patients with 49 lesions underwent salvage endoscopic resection. Baseline clinical stages were I in 23 patients, II in 3 patients, III in 9 patients, and IV in 2 patients. The number of locoregional recurrences and residual lesions were 35 and 14, respectively. The curative en bloc resection rate was 53.1 % (26/49). The total incidence of complications was 18.9 % (7/37); all were successfully managed conservatively. The 3-year and 5-year overall survival rates were 72.9 % and 53.3 %, respectively, with a median follow-up period of 54 months. Baseline clinical T1 – 2 and N0 were significant factors for good prognosis in terms of overall survival on univariate analysis. Conclusions: Salvage endoscopic resection, especially EMR-C, is a safe and feasible procedure to control residual or recurrent superficial esophageal SCC after definitive chemoradiotherapy or radiotherapy alone. The present results showed that baseline clinical T1 – 2 and N0 before chemoradiotherapy or radiotherapy were significant prognostic factors.

BACKGROUND AND STUDY AIM Malignancy in pancreatic neuroendocrine tumors (PNETs) is graded by assessing the resected specimens according to the World Health Organization (WHO) 2010 criteria. The feasibility of such grading using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) specimens remains unclear. The aim of this study was to ascertain the optimal method of measuring the Ki-67 index in EUS-FNA specimens, using resected specimens as the criterion standard. PATIENTS AND METHODS A total of 58 consecutive patients diagnosed with PNETs between March 1998 and May 2011 were included. The study measured intratumoral Ki-67 index heterogeneity, concordance rates of PNET grading by EUS-FNA with grade of the resected tumor, optimal method of measuring the Ki-67 index in EUS-FNA specimens, and survival analysis based on EUS-FNA specimen grading. RESULTS Intratumoral dispersion of Ki-67 index in resected specimens was 0.033 for Grade 1 and 0.782 for Grade 2 tumors (P

We evaluated the efficacy of endoscopic ultrasonography (EUS) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy for the diagnosis of lower digestive tract lesions. Between 1997 and 2001, ten patients whose barium enema or colonoscopy results were highly suspicious of lower digestive tract disease underwent EUS and EUS-FNA biopsy. In all these ten patients, while endoscopic biopsy could not provide a definitive diagnosis, mass lesions were detectable by EUS. However EUS images alone were insufficient for accurate diagnosis. The diagnostic accuracy rate of EUS-FNA biopsy was 90% (9/10).

Endoscopic ultrasound-guided fine-needle tattooing (EUS-FNT) is an ideal technique for preoperative marking of lesions detected on preoperative examination. Although India ink has been used for endoscopic tattooing, there have been numerous reports of complications associated with its use. This is the first report of EUS-FNT using indocyanine green (ICG) and describes its use for preoperative marking of a tumor in a 78-year-old man with multiple pancreatic tumors. There were no complications associated with the EUS-FNT procedure and it is suggested that ICG is a more suitable dye for tattooing of pancreatic lesions than India ink, being far less frequently associated with side effects.

Intraductal ultrasound (IDUS) probes mounted with 30 MHz or 20 MHz transducers were evaluated in the diagnosis of 239 patients with pancreatic disease (including 48 cancers, 90 mucin-producing tumors, seven islet-cell tumors, two metastatic pancreatic tumors, seven serous cystadenomas, one pancreatic teratoma, three solid cystic tumors, 49 cases of chronic pancreatitis, 25 cases of focal pancreatitis, and seven cases of pancreatolithiasis). The probe was inserted via the papilla into the main pancreatic duct. In terms of resolution, IDUS at 20 MHz was able to image cystic lesions of less than 30 mm in diameter and solid lesions of less than 20 mm in diameter. With regard to vessels, IDUS was able to image the entire cross-section of the portal vein and other large veins. IDUS was useful in detecting carcinoma in situ and small tumors, in assessing the intraductal spread of the tumor and its pancreatic parenchymal invasion in mucin-producing tumors of the main duct, and in assessing the indications for surgery by revealing mural nodules in mucin-producing tumors of the ductal branches. IDUS was also useful in evaluating the feasibility of partial resection of the tumor in mucin-producing tumors of the ductal branches and pancreatic islet-cell tumors, in accurately locating multiple lesions in pancreatic islet-cell cancer, and in differentiating benign from malignant cases of localized stenosis of the main pancreatic duct related to pancreatic stenting. With IDUS, the site of pancreatic stones could be identified in order to assess the need for endoscopic treatments such as stenting of the pancreatic duct and the bile duct, and the use of pulsed-dye laser treatment under pancreatoscopy for pancreatic stones. Acute pancreatitis as a complication occurred in one of the 239 patients who underwent IDUS (0.4%). An awareness of the limitations and usefulness of IDUS in evaluating pancreatic diseases can contribute to the treatment of these conditions.

A new method for measuring distances using electrically charged jets of water is described, and its precision examined. When combined with endoscopy, this method can be utilized to measured the lengths and areas of objects inside human body cavities. The apparatus used consists of a catheter with three metal needles at the tip, a personal computer, and a commercially available videoendoscopy system. To test the system, a regulated voltage was passed between the catheter tip and a wooden board, and two salt solutions of different concentrations were ejected at three different angles from the catheter to the board. The coordinates of the board were then computed from the amperages of the currents passing through the three jets of saline, and optical distortion was corrected using the computer. The length and area of an object could be measured rapidly by setting electrically the coordinates to match the endoscopic image. Lengths ranging from 10 to 50 mm were measured while varying the distance between catheter tip and board (10, 20, and 30 mm), as well as the angle formed by the catheter and the board (45, 60, and 90 degrees). The mean measurement error was less than 5.6% and accuracy was relatively independent of the angle between catheter and target.

Endoscopic ultrasonography (EUS) was evaluated in the detection of anomalous connection of the pancreatobiliary duct (ACPBD), which is known to cause cholangitis and has been found to be associated with cholangiocarcinoma. Fourteen patients with ACPBD were examined preoperatively by EUS in addition to ERCP and/or PTC. In all cases, the anomalous connections between the biliary and pancreatic duct were demonstrated to be located outside the proper muscle of the duodenal wall and within the pancreatic parenchyma. EUS classification of ACPBD corresponded well with the findings obtained by retrograde ductal opacification on ERCP and PTC. Biliary malignancy complicating ACPBD was detected correctly by EUS in two patients. In contrast, no connections between biliary and pancreatic ducts were found by EUS in 13 normal controls. It is concluded that EUS is highly sensitive in detecting ductal anomaly in ACPBD. Further studies will show if EUS can replace ERCP in the diagnosis of ACPBD.

It is not always possible to perform endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided biliary drainage (EUS-BD) has been performed as an alternative to percutaneous or surgical approaches [1,2]. The 2008 EUS Working Group summarized the indications, techniques, and complications of EUS-guided hepaticogastrostomy (EUS-HGS) [3]. The rate of complications reported for EUS-BD performed by experts was 0%–30%. Major complications included stent migration, bile leakage, peritonitis, and cholangitis [3,4]. A 58-year-old man had unresectable pancreatic cancer. He had undergone EUSguided choledochoduodenostomy and duodenal stent placement. Because obstructive jaundice was recurrent, EUSHGSwasperformedwith thepatient’s consent. A linear EUS scope was used. The intrahepatic bile duct (B3) was punctured with a 19-gauge needle (SonoTip Pro Control 19G; Medi-Globe GmbH, Rosenheim, Germany; Medico’s Hirata Inc., Osaka, Japan). After contrast mediumwas injected, a 0.025-inch guide wire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) was introduced through the needle and placed into the common bile duct. The fistulawas dilated using a 9-Fr tapered biliary dilation catheter (Soehendra biliary dilation catheter; Cook Endoscopy; Bloomington, Indiana, USA). Finally, a fully covered metallic stent (8mm×8cm Wallflex; Microvasive Endoscopy, Boston Scientific, Natick, Massachusetts, USA) was placed. Inward stent migration occurred immediately (●" Fig.1), which would be a fatal complication [4,5], and thereafter open surgical drainage was performed (●" Fig.2). Fortunately, the man was able to resume oral intake after surgery; however, 44 days later, he died as a result of peritonitis carcinomatosa. Anatomically, the stomach is not directly attached to the liver, and during EUS-HGS there is no space between these organs when the echoendoscope is pressed against the stomach wall. Pulling back the echoendoscope for stent placement creates space between the liver and stomach wall. Given this complication, stents with lengths of 10 or 12cm should be used to avoid inward stent migration.

dle aspiration (EUS-FNA) is a safe procedure, although major complications do rarely occur. Pseudoaneurysm rupture is an emergency that can cause life-threatening hemorrhage. An exceedingly rare case of ruptured pseudoaneurysm of the splenic artery following EUS-FNA is described. A 62-year-old man was referred for investigation of a pancreatic tumor. On abdominal computed tomography (CT), a lowdensity area was seen running from the pancreatic body, involving the celiac and splenic arteries (●" Fig. 1). Angiography showed encasement of the splenic artery (●" Fig. 2). Therefore, EUS-FNA was performed with two separate passes into the lesion using a 22-gauge needle. Cytological analysis showed a pancreatic adenocarcinoma. Nineteen days later abdominal CT showed a pseudocyst in the pancreatic body and tail (●" Fig. 3), and 30 days later (i. e., 30 days after EUS-FNA) the patient developed hematemesis and hemorrhagic shock. Upper gastrointestinal endoscopy showed a hemorrhagic gastric ulcer in the posterior wall of the middle body (●" Fig. 4). Since endoscopic treatment was unsuccessful, angiography was performed and showed a pseudoaneurysm of the splenic artery. Coil embolization was performed in and around the pseudoaneurysm. After 7 days the pancreatic pseudocyst had narrowed (●" Fig. 5); there was no further recurrence. The overall complication rate of EUS-FNA is 1%–2% [1]. The major complications are postaspiration infection in cystic lesions, bleeding, pancreatitis, and cervical and duodenal perforation [2]. Three different mechanisms are recognized as causing pseudoaneurysm formation [3], but all are called pseudoaneurysm because the end result is a cystic vascular structure surrounded by a fibrous wall. Pseudoaneurysms can rupture into the peritoneal cavity, retroperitoneum, gastrointestinal tract, biliary tract, and pancreatic duct. The most common vessel involved is the splenic artery as it runs along the pancreatic bed before reaching the spleen [4]. To our knowledge, this is the Ruptured pseudoaneurysm of the splenic artery complicating endoscopic ultrasound-guided fineneedle aspiration biopsy for pancreatic cancer