An increasing number of reports have recently been published on hybrid natural orifice transluminal endoscopic surgery (NOTES). These reports do not address how to complete an operation with a flexible endoscope alone (pure NOTES), but rather how to combine use of an endoscope and a laparoscope. Surgical procedures using flexible and rigid endoscopes have been developed using different processes and concepts. Recognizing this conceptual difference, we conducted a study to address how to establish a pure NOTES procedure. Six patients with gastric gastrointestinal stromal tumors (GISTs) underwent hybrid NOTES. Each case was retrospectively reviewed to determine the appropriateness of the treatment and the usefulness of the endoscopic submucosal dissection (ESD) method, double-scope method, spaced perforation method, duodenal balloon occlusion method, and loop clip technique. The development of operative procedures that take advantage of the characteristics of flexible endoscopes, even with conventional flexible endoscopic devices and conventional endoscopes alone, may contribute to the realization of pure NOTES.

Our new technique has several advantages, including reduction in the frequency of postoperative abdominal symptoms, and will be useful and safe for gastric ESD.

Endoscopic submucosal dissection (ESD) has enabled the collective resection and increased the accuracy of pathological diagnosis. However, ESD requires a long operation time, which results in increased doses of analgesics/sedatives, and causes worsening of respiratory and hemodynamic statuses. To reduce postoperative complications, we have applied ESD with CO2 insufflation and general anesthesia. This study included 50 patients who underwent ESD for early gastric cancer, 25 with air insufflation and intravenous anesthesia (Air/IV group), and the remaining 25 with CO2 insufflation and general anesthesia (CO2/GA group). Postoperative enlarged feeling of the abdomen was observed only in 1 of 25 patients in the CO2/GA group (P = 0.0416). Postoperative severe unrest was observed in none of the patients in the CO2/GA group and in 4 of 25 (16%) patients in the Air/IV group (P = 0.0371). CO2 insufflation and general anesthesia are useful in stabilizing intraoperative conditions and reducing postoperative complications.

diseases. Direct 2 retroperitoneal pelvic access seems interesting in children when low urinary tract malformations are concerned. We report a case of a 12-year-old boy with a blind ectopic ureter managed by pelvic retroperitoneoscopy. We describe the surgical technique, focusing on the di culty in the pediatric population. Nevertheless, retroperitoneoscopy is an excellent alternate way to manage such ureteral malformations. Abstract Ectopic liver has been but rarely described usually in the vicinity of liver such as on the gallbladder, hepatic ligaments, diaphragm, thoracic cavity, adrenal glands, pancreas, omentum, spleen, esophagus and umblical cord. A simple classi®cation for anomalous liver tissues found on the wall of gallbladder is 1. Accessory liver lobe 2. Ectopic nodule 3. Aberrant microscopic tissue. Ectopic nodules of liver tissue attached to the gallbladder are completely detached from the liver and has been described by various names such as accessory lobe, ectopic liver, accessory liver and heterotopic liver but the speci®c pathological term for this entity is choristoma introduced by Albert in 1904 meaning displacement. Several possible mechanisms may explain ectopic liver at various sites such as the development of an accessory lobe of the liver with atrophy or regression of the original connection to the main liver or migration of pars hepatica to the rudiment of various organs. In this paper we present a case of ectopic liver or choristoma attached to the gallbladder encountered during an elective laparoscopic cholecystectomy which was successfully removed with the gallbladder. Abstract Spontaneous hemopneumothorax is a rare clinical entity sometimes requiring an operation in the early stage. Two patients who underwent successful video-assisted thoracic surgery (VATS) for spontaneous hemopneumothorax are presented. In both cases, the bleeding point was clearly identi®ed, and hemostasis was easily obtained by clipping the point and 1 placing three access ports in the usual fashion. Furthermore, the evacuation of clotted blood and resection of bulla were performed with no di culties. The postoperative courses were smooth, and no complications occurred, although the preoperative general condition in the second case was hemodynamically unstable. The advantages of VATS over conventional thoracotomy include less time required to access the pleural cavity, a better view, and more facilitated manipulation during surgery. Because spontaneous hemopneumothorax is a benign disease, VATS should be considered an initial treatment option in all patients with this condition, even those with active bleeding.

We have developed a new endotriptor that can be used through the instrument channel of the duodenoscope. The coiled metal sheaths are 53 cm long and 2.4 mm in diameter (Figure 1 a), and fit over the remaining wire of the basket catheter. "Remaining wire" here means the length of wire between the entrance of the in− strument channel port on the duodeno− scope and the cut end of the wire. The sheaths are designed to be slightly shorter than the "remaining wire". This allows easy insertion of a sheath over the wire and into the endoscope. An Olympus JF− 200 duodenoscope and an FG 22−Q−1 or 403Q basket catheter (Olympus, Tokyo, Japan), the length and diameter of which are suitable for the new endotriptor, were used.When basket impaction occurs with a bile stone in the distal common bile duct, the basket catheter is cut at the handle. Only the tube sheath should then be pulled out, leaving the wire inside the endo− scope. Three coiled metal sheaths from the endotriptor are inserted over the bas− ket wire and into the duodenoscope. The end of the sheath is then gripped with a vise (Figure 1 b). The endotriptor can be pulled out with the basket catheter after the stone has been crushed. In 20 patients who had basket impaction after endo− scopic sphincterotomy and underwent lithotripsy with the new endotriptor, the stones were crushed successfully in all cases. There were no complications such as biliary perforation or bleeding.The endotriptors currently available can− not be used without withdrawing the duodenoscope from the patient [1]. The duodenoscope then has to be reinserted to extract the fragments of a stone imme− diately after traditional lithotripsy. With the new endotriptor, the required maneu− vers can be carried out without removing the duodenoscope ± a considerable ad− vantage. There is no chance of injuring the mucosa of the upper gastrointestinal tract with the new endotriptor, as it pas− ses through the endoscope. In addition, the distal common bile duct is never at risk of being perforated by the tip of the new endotriptor, as the impacted basket can be returned to the upper bile duct by pushing the endotriptor.