A 59-year-old male was admitted with obstructive jaundice, marked eosinophilia (1 343/mm(3)) and hypergammaglobulinemia (4 145 mg/dL). Imaging techniques revealed dilatation of the intrahepatic bile duct, stenosis of the common bile duct with diffuse wall thickening, gallbladder wall thickening, irregular narrowing of the pancreatic duct, and swelling of the pancreatic parenchyma. Multiple liver masses were also demonstrated and diagnosed as IPT by biopsy specimens. Six months later, the abnormal features of the biliary tree remarkably improved by the oral administration of prednisolone, and the liver masses disappeared. The swelling of the pancreatic head also improved. The peripheral eosinophil count normalized. IPT associated with AIP, as we know, has not been reported in the literature. The clinical features of the present case mimicked those of pancreatic cancer with liver metastasis. This case deserves to be documented to prevent misdiagnosis of similar cases.

Video Video 1 Gel immersion endoscopy-facilitated endoscopic mucosal resection of a superficial nonampullary duodenal epithelial tumor.

Objective: Although scissor-type knives such as the Stag-Beetle (SB) Knife Jr are expected to result in a safe and easy colorectal endoscopic submucosal dissection (CR-ESD), information regarding the learning curve is lacking. Therefore, this study evaluated the learning curve with using SB Knife Jr. Materials and methods: We retrospectively reviewed 507 CR-ESD procedures performed in 464 patients using SB Knife Jr. The primary endpoint was a learning curve to achieve a satisfactory complete resection rate. The secondary endpoints were learning curves to achieve a satisfactory en bloc resection rate, curative resection rate, and resection speed. Results: The complete, en bloc, and curative resection rates were 91.9%, 95.9%, and 84.0%, respectively. Moving average analysis showed that 39 cases were required for a complete resection rate of >80%, 41 for an en bloc resection rate of >90%, and 50 for a curative resection rate of >75%. We divided the procedure into three phases using the cumulative sum method: I, II, and III (cases 1-36, 37-119, and 120-507, respectively). Although we found no significant between-phase differences, the complete resection rate showed an increasing trend in Phase III (83.3 vs. 89.2 vs. 93.3%; p ¼ .099). The en bloc resection rate (91.7 vs. 91.6 vs. 97.2%; p ¼ .047) and resection speed (20.5 vs. 7.2 vs. 6.8 min/ cm 2 ; p < .001) were greater in Phase III. Despite the larger specimen size (27.3 vs. 38.2 vs. 40.4 mm; p < .001) and more severe fibrosis (p < .001) in Phase III, the procedure time was shorter (73.8 vs. 57.8 vs. 54.2 min; p ¼ .041). The curative resection rate was not significantly different between phases. Conclusions: SB Knife Jr enables safe and easy CR-ESD during the introductory period compared to the conventional tip-type knife and has an acceptable learning curve. Therefore, using this knife will encourage the widespread adoption of CR-ESD in Asian general hospitals and non-Asian countries.

Objective: Although prophylactic clip closure after endoscopic mucosal resection may prevent delayed bleeding, information regarding colorectal endoscopic submucosal dissection (CR-ESD) is lacking. Therefore, this study evaluated the effect of prophylactic clip closure on delayed bleeding rate after CR-ESD. Materials and methods: A total of 614 CR-ESD procedures performed in 561 patients were retrospectively reviewed. The primary outcome, which was delayed bleeding rate, was analyzed between the prophylactic clip closure and non-closure groups. Furthermore, the predictors of delayed bleeding were also evaluated. Results: The patients were divided into the clip closure group (n ¼ 275) and non-closure group (n ¼ 339). Delayed bleeding rate was significantly lower in the closure group than in non-closure group (6 cases [2.2%] vs. 20 cases [5.9%], p ¼ .026). The univariate logistic regression analyses revealed that delayed bleeding was significantly associated with laterally spreading tumor-granular-nodular mixed type (LST-G-Mix; odds ratio [OR], 3.77; 95% confidence interval [CI], 1.70-8.34; p ¼ .001). By contrast, prophylactic clip closure was significantly associated with low delayed bleeding rate (OR, 0.36; 95%CI, 0.14-0.90; p ¼ .029). The multivariate logistic regression analyses revealed LST-G-Mix as a significant independent delayed bleeding predictor (OR, 3.25; 95%CI,; p ¼ .004), whereas, prophylactic clip closure was identified as a significant independent preventive factor of delayed bleeding (OR, 0.39; 95%CI, 0.15-1.00; p ¼ .049). Conclusions: Prophylactic clip closure after CR-ESD is associated with low delayed bleeding rate. LST-G-Mix promotes delayed bleeding, and performing prophylactic clip closure may be advisable.

Background: Although gel immersion endoscopic resection (GIER) is a potential alternative to underwater endoscopic mucosal resection (UEMR) for superficial nonampullary duodenal epithelial tumor (SNADET), comparisons between the two are insufficient. Methods: Forty consecutive procedures performed in 35 patients were retrospectively reviewed; primary outcome was procedure time and secondary outcomes were en bloc and R0 resection rates, tumor and specimen size, and adverse events. Results: Lesions were divided into GIER (n = 22) and UEMR groups (n = 18). The procedure time was significantly shorter in the GIER group than that in the UEMR group (2.75 [1–3.5] min vs. 3 [2–10] min, p = 0.010). The en bloc resection rate was 100.0% in the GIER group but only 83.3% in the UEMR group. The R0 resection rate was significantly higher in the GIER group than that in the UEMR group (95.5% vs. 66.7%, p = 0.033). The specimen size was larger in the GIER group than that in the UEMR group (14 mm vs. 7.5 mm, p < 0.001). The tumor size was not significantly different between the groups and no adverse events were observed. Conclusions: GIER is efficacious and safe to treat SNADET, although additional studies are needed.