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Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location. It is often found incidentally at different sites in the gastrointestinal (GI) tract. The incidence of ectopic pancreatic tissue in autopsy series is 1% to 2%, with 70% of the ectopic lesions found in the stomach, duodenum and jejunum. Although it is usually a silent anomaly, an ectopic pancreas may become clinically evident when complicated by inflammation, bleeding, obstruction or malignant transformation. We report a case of ectopic pancreas located in the jejunum and presenting as an obscure GI bleeding, which was diagnosed by capsule endoscopy.

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• Clinical features and treatment of heterotopic pancreas in children: a multi-center retrospective study
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Inflammatory fibroid polyps are rare benign tumors of the GI tract, that commonly present with intestinal obstruction as a result of intussusceptions in the small bowel. A 39-year old man visited our clinic with an asymptomatic polypoid mass in the distal ileum that was identified on abdominal computed tomography for postoperative surveillance after total gastrectomy due to previously diagnosed early gastric cancer. Retrograde double-balloon enteroscopy was performed to diagnose the ileal mass and a complete resection of the polyp was performed using snare for polypectomy without complications. The final histological finding was an ileal inflammatory polyp. Balloon-assisted enteroscopy is a valuable modality to diagnose and treat small bowel lesions in lieu of surgical procedures in selected cases.

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Non-traumatic intramural duodenal hematoma (IDH) with duodenal obstruction caused by acute pancreatitis is rare. Most patients with non-extensive hematoma show improvement with non-operative treatments. Percutaneous drainage or surgery may be necessary in cases with suspected malignancy, perforation, or intestinal tract obstruction. We present a case of IDH caused by acute pancreatitis that led to obstruction of the duodenum and an experience of successful endoscopic decompression of the hematoma.

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This special September issue of Clinical Endoscopy will discuss various aspects of diagnostic and therapeutic advancement of gastrointestinal (GI) endoscopy, explaining what is new in digestive endoscopy and why international network should be organized. We proposed an integrated model of international conference based on the putative occurrence of Digestive Endoscopy Networks. In International Digestive Endoscopy Network (IDEN) 2012, role of endoscopy in gastroesophageal reflux disease and Barrett's esophagus, endoscopy beyond submucosa, endoscopic treatment for stricture and leakage in upper GI, how to estimate the invasion depth of early GI cancers, colonoscopy in inflammatory bowel disease (IBD), a look into the bowel beyond colon in IBD, management of complications in therapeutic colonoscopy, revival of endoscopic papllirary balloon dilation, evaluation and tissue acquisition for indeterminate biliopancreatic stricture, updates in the evaluation of pancreatic cystic lesions, issues for tailored endoscopic submucosal dissection (ESD), endoluminal stents, management of upper GI bleeding, endoscopic management of frustrating situations, small bowel exploration, colorectal ESD, valuable tips for frustrating situations in colonoscopy, choosing the right stents for endoscopic stenting of biliary strictures, advanced techniques for pancreaticobiliary visualization, endoscopic ultrasound-guided biliopancreatic drainage, and how we can overcome the obstacles were deeply touched. We hope that IDEN 2012, as the very prestigious endoscopy networks, served as an opportunity to gain some clues for further understanding of endoscopic technologies and to enhance up-and-coming knowledge and their clinical implications from selected 25 peer reviewed articles and 112 invited lectures.

International Digestive Endoscopy Network (IDEN) is an international meeting covering scientific subjects of diverse topics about upper gastrointestinal (GI) endoscopy, colonoscopy, endoscopic ultrasonography, and PB endoscopy. IDEN is organized by Korean Society of Gastrointestinal Endoscopy and the Korean Gastrointestinal Endoscopy Research Foundation, and took its first step in 2011 in Seoul, Korea. IDEN inaugurated a new era of diagnostic and therapeutic GI endoscopy. IDEN 2012 was designed to offer participants from all over the world with opportunities to share up-to-date knowledge about basic and clinical aspects of GI endoscopy and to engage in in-depth discussion with worldwide well-known experts. During the 2 days of meeting, there were 62 invited lectures, 28 case-based discussions, 20 video lectures, and 6 breakfast with the experts. There were a total of 598 participants registered from 12 countries, including Asian countries, Europe, and USA as well as Korea.

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Upper gastrointestinal (GI) endoscopy is the most basic part of endoscopy field. Although old and basic procedures are still in use, a line of innovative techniques and devices are being introduced to allow much complex and difficult procedures in endoscopy unit. High quality upper endoscopic procedures can replace or obviate surgical treatment. Selected reviews dealing with non-variceal upper GI bleeding, challenging esophageal stenting, endoscopic management of subpeithelial tumor, and endoscopic evaluation for candidate lesions of endoscopic submucosal dissection were selected among the topics from International Digestive Endoscopy Network 2012.

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Upper gastrointestinal bleeding (UGIB) is a critical condition that demands a quick and effective medical management. Non-variceal UGIB, especially peptic ulcer bleeding is the most significant cause. Appropriate assessment and treatment have a major influence on the prognosis of patients with UGIB. Initial fluids resuscitation and/or transfusion of red blood cells are necessary in patients with clinical evidence of intravascular volume depletion. Endoscopy is essential for diagnosis and treatment of UGIB, and should be provided within 24 hours after presentation of UGIB. Pre-endoscopic use of intravenous proton pump inhibitor (PPI) can downstage endoscopic signs of hemorrhage. Post-endoscopic use of high-dose intravenous PPI can reduce the risk of rebleeding and further interventions such as repeated endoscopy and surgery. Eradication of Helicobacter pylori and withdrawal of non-steroidal anti-inflammatory drugs are recommended to prevent recurrent bleeding.

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Endoscopic treatment for non-variceal upper gastrointestinal bleeding has evolved over decades. Injection with diluted epinephrine is considered as a less than adequate treatment, and the current standard therapy should include second modality if epinephrine injection is used initially. Definitive hemostasis rate following mono-therapy with either thermo-coagulation or hemo-clipping compares favorably with dual therapies. The use of adsorptive powder (Hemo-spray) is a promising treatment although it needs comparative studies between hemospray and other modalities. Stronger hemo-clips with better torque control and wider span are now available. Over-the-scope clips capture a large amount of tissue and may prove useful in refractory bleeding. Experimental treatments include an endoscopic stitch device to over-sew the bleeding lesion and targeted therapy to the sub-serosal bleeding artery as guided by echo-endoscopy. Angiographic embolization of bleeding artery should be considered in chronic ulcers that fail endoscopic treatment especially in elderly patients with a major bleed manifested in hypotension.

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Endoscopy has its role in the primary diagnosis and management of acute non-variceal upper gastrointestinal bleeding. Main roles of endoscopy are identifying high risk stigmata lesion, and performing endoscopic hemostasis to lower the rebleeding and mortality risks. Early endoscopy within the first 24 hours enables risk classification according to clinical and endoscopic criteria, which guide safe and prompt discharge of low risk patients, and improve outcomes of high risk patients. Techniques including injection therapy, ablative therapy and mechanical therapy have been studied over the recent decades. Combined treatment is more effective than injection treatment, and single treatment with mechanical or thermal method is safe and effective in peptic ulcer bleeding. Specific treatment and correct decisions are needed in various situations depending on the site, location, specific characteristics of lesion and patient's clinical conditions.

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• Endoscopic thermocoagulation hemostasis for acute non-varicose upper gastrointestinal hemorrhage: a randomized controlled study
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Tumors in the cervical portion of the esophagus have traditionally been more difficult to manage. The implantation in the cervical esophagus is a technically demanding procedure. The implantation of modified self-expandable metal stents (SEMSs) was very effective perorally under endoscopic and fluoroscopic guidance. Experience with SEMS has revealed an increased risk of migration when either covered stents are used or a stent is implanted across the gastroesophageal junction. The modified, covered, esophageal stents appear to prevent stent migration and improve dysphagia in patients with malignant tumor stenosis at the esophagogastric junction. Besides heartburn, regurgitation is sometimes very distressing to patients and may lead to fatal aspiration due to reflux after stenting in esophagogastric junction. These symptoms can be reduced by the use of valved stent. The long S-shape valve is very effective in preventing acid reflux and valve inversion.

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Subepithelial tumors (SETs) are often incidentally found during endoscopic examinations. Endoscopic ultrasonography (EUS) is a good method for differential diagnosis of SETs, but a definite diagnosis cannot be made based on EUS features alone in some cases. Periodic follow-up examinations by endoscopy and EUS remains the recommended management strategy, which involves issues related to patient compliance, cost-effectiveness, and the risk associated with repeated endoscopic procedures and delayed diagnosis of malignancy. Endoscopic resection of the SETs is another technique to treat them as well as to obtain tissue specimens for accurate histologic diagnosis. Herein, a various endoscopic techniques ranging from simple snare resection to endoscopic submucosal tunnel dissection for the management of SETs will be reviewed.

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Endoscopic resection has been accepted as both minimally invasive and curative treatment modality for early gastric cancer (EGC). The widely accepted indication of endoscopic resection for EGC is small sized, differentiated mucosal cancer in which the risk of lymph node metastasis is negligible. Tumor size can be measured by conventional endoscopy, and chromoendoscopy, magnifying endoscopy, narrow band imaging, autofluorescence imaging can also be helpful for accurate estimation of tumor size. Pretreatment tumor histology can be assessed with endoscopic biopsy, and also be measured by confocal endomicroscopy (so called "virtual biopsy"). Although endoscopic ultrasonography may be helpful for the assessment of tumor depth in EGC, the accurate assessment of tumor depth can be performed by the typical findings in the conventional endoscopy, by which treatment modality can be decided according to the depth of tumor invasion.

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The International Digestive Endoscopy Network 2012 organized by Korean Society of Gastrointestinal Endoscopy was held at Seoul, Korea on June 9 to 10, 2012, during which invited lectures of world renowned experts on the lower gastrointestinal (GI) tract were given with a wide range of the latest knowledge and novel imaging of inflammatory bowel disease (IBD) and colorectal endoscopic submucosal dissection (ESD). There were very informative five sessions in the lower GI part consisting of: Colonoscopy in IBD; what can we do in 2012?; A look into the bowel beyond colon in IBD; How to estimate the invasion depth of early GI cancer?; No more no man's land: small bowel exploration; and colorectal ESD: can it be a popular procedure?

Colonoscopy plays a crucial role in the diagnosis, treatment and follow-up monitoring of inflammatory bowel disease (IBD). Practitioners should be well informed of the colonoscopic findings of IBD to prevent the misdiagnosis, overtreatment or delayed treatment. Distinguishing between Crohn's disease and ulcerative colitis is essential in terms of pharmacological treatment, surgical decision-making, and prognosis. But there are still lesions with difficulty in differentiation that approximately 10% of the patients fall into the category of indeterminate colitis. Efforts are needed to carefully select treatment approach appropriate for each patient by providing a precise diagnosis on the extent and degree of lesions as well as to accurately delineate the lesions to assure that they are compared in subsequent rounds of follow-up monitoring in order to allow redetermination and adjustment of the treatment.

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Crohn's disease (CD) is an inflammatory bowel disease that can affect the entire gastrointestinal tract, with the small bowel (SB) being the most commonly affected site. In some patients, refractory inflammation or chronic strictures of the SB are responsible for a debilitating course of the disease that might lead to severely reduced quality of life. Therefore, SB imaging is a crucial element in diagnosing and/or managing SB CD, and continues to evolve because of technologic advances. SB endoscopy (capsule endoscopy and device-assisted enteroscopy) and cross-sectional radiologic imaging (computed tomography enterography and magnetic resonance enterography) have become key players to diagnose and/or manage CD. In everyday practice, the choice of the imaging modalities is based on the presence and availability of the techniques and of experienced operators in each institute, clinical usefulness, safety, and cost. Here, SB endoscopy and radiologic imaging in suspected or known CD patients will be addressed and discussed.

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Today, cross-sectional imaging modalities, such as computed tomography enterography (CTE) and magnetic resonance enterography (MRE), are particularly suited to evaluate small bowel diseases, especially Crohn's disease (CD). It is well known that CTE/MRE can provide excellent assessment of disease activity as well as the macroscopic features, extramural abnormalities, and complications of the small intestine in patients with CD. In general, CTE is considered as the first-line modality for the evaluation of suspected inflammatory bowel disease and for long-term assessment or follow-up of these patients. Because of the advantage of lack of radiation, MRE is being used more frequently, especially in children or young patients with CD.

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Colonoscopy based colitis surveillance is widely accepted to try to prevent development of and ensure early detection of colitis-associated colorectal cancer. Traditionally this has been performed with quadrantic random biopsies throughout the colon. Chromoendoscopy "dye-spray" with targeted biopsies only has been shown to increase dysplasia detection 4 to 5 fold on a per lesion basis. It has therefore been suggested that random biopsies should be abandoned as they do not increase dysplasia detection nor change patient clinical course. Recent British guidelines for colitis surveillance have strongly endorsed chromoendoscopy. This short review summarizes current international guidelines and looks at how to optimize white light colonoscopy in colitis considering: bowel preparation, withdrawal time, high definition, and structure enhancement. Data for advanced imaging techniques are reviewed including positive evidence in favor of chromoendoscopy, and limited data suggesting autofluoresence imaging may be promising. Narrow band imaging does not increase dysplasia detection in colitis. Confocal endomicroscopy might potentially reduce biopsies beyond that of chromoendoscopy but does not offer a clear detection advantage. Pan-colonic chromoendoscopy with targeted biopsies increases dysplasia detection and is the standard of care in the United Kingdom. It is likely that the use of chromoendoscopy for colitis surveillance will become widely accepted internationally.

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Demand for colonoscopy is increasing because it is an important tool not only for screening of colorectal neoplasm but also for resection of such lesions in early stage. Cecal intubation requires expertise on shortening of the examination time and improvement of the cecal intubation rate without causing pain to the patients. About 5% to 10% of patients still experience difficulties or failure of the cecal intubation. There are number of factors that affect the difficulty of the colonoscopy such as technical skill of the endoscopist, angulated sigmoid, redundant colon, advanced age, female gender, diverticular disease, and inadequate bowel preparation. In an effort to overcome these situations and to and aiding colonoscope insertion with reducing pain, various methods have introduced. Like this review discusses ways to approach patients with technically difficult colons for achieving the successful cecal intubation.

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Colonoscopic polypectomy is an effective method for prevention of colorectal cancer and has become one of the most common procedures worldwide. Most colorectal polyps can be removed safely by various polypectomy techniques; however, serious complications can occur. Postpolypectomy bleeding is the most common complication of colonoscopic polypectomy, accounting for 0.3% to 6.1% of polypectomy. This issue summarizes various endoscopic techniques to treat postpolypectomy bleeding.

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Endoscopic submucosal dissection (ESD) was developed to overcome the limitations of conventional endoscopic mucosal resection (EMR), and ESD has been also applied for large colorectal neoplasms. Since colorectal ESD is still associated with higher perforation rate, a longer procedure time, and increased technical difficulty, the indications should be strictly considered. Generally, colorectal tumors without deep submucosal invasion or minimal possibility of lymph node metastasis, for which en bloc resection using conventional EMR is difficult, are good candidates for colorectal ESD. The ideal knife for colorectal ESD should avoid making perforations but can make a clean cut of optimal depth at one time. The ideal current for ESD differs depending on the procedure used, the surgical devices used, the tissue to be dissected, and the operator's preference. Application of the optimal indications and improvements in the technical skill and surgical devices are required for easier and safer colorectal ESD.

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Colorectal endoscopic submucosal dissection (ESD) is not yet fully popularized in Korea, but is increasing steadily. The outcomes of colorectal ESD in Korea are comparable to those in Japan and other countries. ESD-related complication rates are decreasing as experiences accumulate. Particularly for rectal laterally spreading tumors, ESD is becoming more prevalent than transanal endoscopic microsurgery. Standard indication, qualified training system, and full medical insurance coverage should be established for the procedure to become popular in the long run.

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Since its development, video capsule endoscopy (VCE) introduced a new area in the study of small bowel disease. We reviewed and discussed current issues from Korean capsule endoscopy multicenter studies. Main results are as follows: First, there was no significant difference in diagnostic yield according to the method of bowel preparation. Second, VCE represents a reliable and influential screening measure in patients with chronic unexplained abdominal pain and this technique could successfully alter the clinical course especially for patients with small bowel tumor. Third, the inter-observer variation in the expert group was lower than that in trainee group. Fourth, studies about the spontaneous capsule passage after retention showed 2.5% of retention rate and the size of lumen was an important factor of spontaneous passage. We need larger scale studies on the effect of bowel preparation methods on the diagnostic yield and further studies about the learning curve or unique capsule endoscopic findings for small intestinal diseases in Korean patients.

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The pancreatobiliary organ is composed of one of the most complicated structures and complex physiological functions among other digestive organs in our body. This is why endoscopic procedure in pancreaticobiliary system requires rather complicated techniques. In International Digestive Endoscopy Network (IDEN) 2012, many interesting pancreatobiliay endoscopy related topics were presented. Basic procedures like endoscopic papillary balloon dilation (EPBD), advanced techniques like endoscopic necrosectomy, prevention and management of post-ERCP pancreatitis, and spyglass system are reviewed in this highlight summary.

Since endoscopic papillary large balloon dilation (EPLBD) is used to treat benign disease and as a substitute for conventional methods, such as endoscopic sphincterotomy plus endoscopic mechanical lithotripsy, we should aim for zero mortality. This review defines EPLBD and suggests guidelines for its use based on a review of published articles and our large-scale multicenter retrospective review.

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• Endoscopic Papillary Large Balloon Dilatation (EPLBD) for the Extraction of Common Bile Duct Stones (CBDS).
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Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a spectrum of complications such as pancreatitis, hemorrhage, perforation, and cardiopulmonary events. These complications can range from mild to severe resulting in extended hospitalization, requiring surgical intervention, and leading to permanent disability or even death. Complications of ERCP have been better understood in the past decade, with adoption of standardized consensus-based definitions of complications and introduction of new recommendations to minimize risks of ERCP. Adequate selection of patients undergoing ERCP, skilled operators using novel techniques and prompt identification and treatment are key to successful prevention and management.

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  Seok Ho Dong
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Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.

Citations

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• Wernicke Encephalopathy after Endoscopic Necrosectomy in Acute Necrotizing Pancreatitis with WOPN: A Case Report
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• Highlights of Pancreatobiliary Endoscopy in International Digestive Endoscopy Network 2012: How Much Has It Advanced?
  Seok Ho Dong
  Clinical Endoscopy.2012; 45(3): 297.     CrossRef

Although endoscopic retrograde cholangiopancreatography is considered the gold standard to manage biliary disorders, it has its own limitations. The single-operator cholangioscopy (SOC) system (Spyglass) may offer an interesting compromise for most advanced biliary endoscopists, in terms of size (10 Fr diameter) and complexity of use. SOC is a great step toward intraductal visualization and therapy but the best is yet to come.

Citations

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  Hirohito Minami, Shuntaro Mukai, Atsushi Sofuni, Takayoshi Tsuchiya, Kentaro Ishii, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Kenjiro Yamamoto, Kazumasa Nagai, Yukitoshi Matsunami, Yasutsugu Asai, Takashi Kurosawa, Hiroyuki Kojima, Toshihiro Homma
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• CHOLANGIOSCOPY IN BILE DUCT DISEASE: a case series
  Eduardo Guimarães Hourneaux de MOURA, Tomazo FRANZINI, Renata Nobre MOURA, Fred Olavo Aragão Andrade CARNEIRO, Everson Luiz de Almeida ARTIFON, Paulo SAKAI
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  Seok Ho Dong
  Clinical Endoscopy.2012; 45(3): 297.     CrossRef