An 86-year-old man diagnosed with distal cholangiocarcinoma was treated with uncovered biliary metal stent placement. The metal stent was occluded due to growth of the tumor into the stent. Although he underwent placement of two additional plastic stents in the metal stent, the plastic stents were also rapidly occluded. He was admitted and underwent transpapillary exchange of the plastic stents. Five days later, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed using a plastic stent. The patient had no recurrence of cholangitis thereafter and was discharged 42 days after EUS-HGS.

A 77-year-old woman was referred to our hospital because of general malaise and appetite loss for 3 months. Contrast-enhanced computed tomography showed a gallbladder tumor and multiple tumors in the liver. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for the gallbladder tumor. Histopathologically, the tumor was diagnosed as poorly differentiated adenocarcinoma. There were no complications of EUS-FNA. While waiting for the histopathological results of EUS-FNA, her appetite loss gradually became severe, so she declined systemic chemotherapy. She was discharged from the hospital 15 days after EUS-FNA. EUS-FNA for gallbladder lesions is useful when pathological diagnosis is required.

An 85-year-old man who developed sudden neck pain after ingesting walnuts visited our hospital. Computed tomography showed food impaction in the cervical esophagus. Upper gastrointestinal endoscopy revealed a walnut half that was not chewed at all in the cervical esophagus. The walnut half was pushed into the stomach with the endoscope and removed using a retrieval net. No strictures, neoplastic lesions, or ulcerations were found in the esophagus. The neck pain improved after the procedure.

An 83-year-old woman who vomited blood was taken to our hospital by ambulance. She was taking oral ticlopidine for chronic arterial occlusion of the lower extremities. Emergency upper gastrointestinal endoscopy revealed bleeding from a gastric polyp. Following endoscopic mucosal resection, the clinical course was uneventful and she was discharged 7 days after admission. Histopathology revealed that the resected gastric polyp was a hyperplastic polyp with no malignant findings.

An 86-year-old man was diagnosed with obstructive jaundice due to extrahepatic bile duct tumor. Percutaneous transhepatic biliary drainage (PTBD) was performed following failed transpapillary biliary drainage. The next day, a biliary metal stent was placed by rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and a tube was also placed via the PTBD route. Two days later, a computed tomography scan showed emphysema in the abdominal wall where the PTBD tube was inserted. He was diagnosed with cellulitis. The PTBD tube was removed and incisional drainage was performed. Klebsiella oxytoca was cultured from the pus. He subsequently improved and was discharged 22 days after the rendezvous ERCP.

A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord. If a semen analysis is not obtained from the adolescent male, in the absence of other symptoms, the main clinical indication used by many urologists to recommend repair is testicular atrophy. The varicocele may result in testicular damage in some males causing testicular atrophy with impaired sperm production and decreased Leydig cell function, while in other males the varicocele may seemingly cause no ill effects. In adult men, varicoceles are frequently present and surgically correctable, yet the measurable benefits of surgical repair are slight according to a Cochrane review. While occurring more commonly in infertile men than fertile men, only 20% of men with a documented varicocele will suffer from fertility problems. Most varicoceles found in adolescents are detected during a routine medical examination, and it is difficult to predict which adolescent presenting with a varicocele will ultimately show diminished testicular function in adolescence or adulthood. As in adults, the mainstay of treatment for varicocele in adolescents is surgical correction. However, unlike an adult varicocelectomy (the microsurgical approach is the most common), treatment for an adolescent varicocele is more often laparoscopic. Nevertheless, the goals of treatment are the same in the adolescent and adult patients. Controversy remains as to which patients to treat, when to initiate the treatment, and what type of treatment is the best. This review will present the current understanding of the etiology, diagnosis and treatment of the adolescent varicocele.

Objectives: Duodenal perforation as a complication of endoscopic ultrasound-guided fine needle aspiration may progress to acute peritonitis and septic shock. Open surgery, the standard treatment, can be avoided by performing closure during endoscopy using endoscopic clips.Patient: A 77-year-old woman was referred to our hospital with salivary gland swelling. She had elevated hepatobiliary enzymes and jaundice. Computed tomography (CT) revealed pancreatic head swelling and bile duct dilation. Endoscopic ultrasonography revealed a hypoechoic mass in the pancreatic head. The pancreatic head mass was punctured twice using a 22-gauge Franchine-type puncture needle at the duodenal bulb. The endoscope was advanced to the descending part of the duodenum, and part of the superior duodenal angle was perforated (diameter approximately 15 mm) with the endoscope. The duodenal mucosa around the perforation was immediately closed using endoscopic clips.Results: Abdominal CT showed gas in the peritoneal and retroperitoneal spaces. The patient experienced abdominal pain and fever and was treated with fasting and antibiotics. The gas gradually decreased, symptoms improved, and she was discharged 18 days after the perforation. Histopathologically, the pancreatic tissue was consistent as autoimmune pancreatitis.Conclusion: Endoscopic closure using endoscopic clips may be a better therapeutic option for duodenal perforation caused by endoscopy.

Objective: Avoiding injection incompatibilities is important. At our hospital, pharmacists are present at the intensive care unit (ICU),where they manage drip lines and use a lookup table for injection incompatibilities. We assessed the risk of injection incompatibilities in the ICU and the contribution of pharmacists toward their avoidance.Methods: We investigated the number of injections and main drip lines used for outpatients admitted to the general ward and ICU from an emergency setting. We further investigated inappropriate drip line conditions, subsequent interventions by pharmacists, and the actual number of injection incompatibilities. The investigation period lasted 1 year from April 2016 onward.Results: The number of injections and drip lines used in the ICU was significantly higher than that used in the general ward (p<0.001). Patients in the ICU received multiple continuous intravenous injections from one drip line despite the number of main drip lines being high. Even using the lookup table, 78.3% inquiries made by nurses were related to injection incompatibilities. Fourteen inappropriate drip lines selected by nurses were associated with a risk of injection incompatibility; these occurred during the absence of pharmacists and involved a combination of continuous intravenous injections to be administered from a side line. Subsequently,pharmacists intervened and avoided injection incompatibilities. There was no report of injection incompatibilities in the ICU.Conclusion: At ICU, the risk of injection incompatibilities is high and it is necessary to focus on the combination of injections to be administered from main drip lines and side lines as well as incompatibilities of multiple continuous intravenous injections to be administered from side lines. A lookup table is insufficient to avoid injection incompatibilities. Therefore, pharmacists can contribute to avoiding injection incompatibilities by maintaining constant presence in the ICU, designing drip line layouts, and proposing line selections.

Objective: To describe the case of a patient with intraperitoneal bleeding from the gastroepiploic artery by endoscopic ultrasound who was successfully treated with transcatheter arterial coil embolization.Patient and Methods: An 87-year-old man was referred to our hospital for examination of a gallbladder tumor. Endoscopic ultrasonography was performed using an oblique-view echoendoscope. After the endoscopic ultrasound, the patient went into shock. Computed tomography revealed a huge intraperitoneal hematoma and an aneurysm in the right gastroepiploic artery that were not seen on previous computed tomography images. Thus, urgent catheter angiography was performed, which showed a pseudoaneurysm of the right gastroepiploic artery and extravasation of the contrast medium from the pseudoaneurysm.Results: Transcatheter arterial coil embolization was subsequently performed, and the bleeding stopped. Thereafter, his hemodynamics stabilized and his general condition improved. The patient was discharged 22 days post-treatment with an uneventful course.Conclusion: Observation-only endoscopic ultrasound without invasive procedures can cause intraperitoneal bleeding due to a ruptured splanchnic artery. Thus, endoscopic ultrasonography should be performed more carefully in elderly patients.

Objective: Retrieval is challenging once prophylactic pancreatic stents migrate deep into the pancreatic duct. Herein, we describe a case of successful endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter through a biliary plastic stent pusher tube.Patient: A 71 year-old man was referred to our hospital for removal of a straight-shaped migrated 5-Fr 3-cm prophylactic pancreatic stent with a flap on the duodenal side. There were no subjective symptoms at the time of the hospital visit.Results: During endoscopic retrograde cholangiopancreatography, we inserted an 8.5-Fr plastic biliary stent pusher tube in front of the migrated pancreatic stent. The stent was then grasped using a basket catheter for peroral cholangioscopy through the biliary stent pusher tube. The stent was pulled into the pusher tube and was successfully retrieved from the pancreatic duct. No complications were associated with endoscopic retrograde cholangiopancreatography.Conclusion: Although rare, prophylactic pancreatic duct stent migration after pancreatic duct guidewire placement should be noted. In our case, endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter for peroral cholangioscopy through the biliary plastic stent pusher tube was successful.