矢野 智則

Background and study aims Small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) are sometimes difficult to reach using double-balloon enteroscopy (DBE). However, they can induce intussusception, especially when ≧15 mm. This study aimed to review the outcomes of patients with such polyps. Patients and methods All patients with PJS with small-bowel polyps that bidirectional DBE failed to reach and were ≧5 mm as shown by DBE enterography at our institution from May 2006 to April 2022 were retrospectively evaluated. The endpoint was the earliest occurrence of symptomatic intussusception induced by the polyp, endoscopic removal by repeat DBE or intraoperative endoscopy, or the last medical record describing the patient's condition. Results This study included 27 polyps in 13 patients. All patients had extraluminal adhesions. None developed symptomatic intussusception, eight patients underwent endoscopic removal at repeat DBE without surgery, two patients underwent removal with intraoperative endoscopy, two patients were observed without polyp removal, and one patient had a polyp removed at repeat DBE and three unreachable polyps remained. Repeat DBE without surgery was able to remove 14 polyps (52%). Polyps ≧15 mm included 11 lesions in eight patients and were observed for a median of 14 months without symptomatic intussusception. Conclusions The difficult-to-reach polyps may have a low risk of immediate symptomatic intussusception, possibly due to limited bowel mobility by extraluminal adhesions, and the likelihood of reaching them at repeat DBE was substantial. Hence, repeat DBE 1 year later may be proper in such patients with PJS.

During balloon enteroscopy-assisted endoscopic retrograde cholangiography, the minimal water exchange method facilitates reaching the site and prevents pneumobilia, hepatic portal venous gas, and air embolism. However, the water may mix with bile or blood, obscuring the visual field. Yokoyama and colleagues demonstrate how the gel immersion method helps overcome this problem.

BACKGROUND: Endoscopic balloon dilation (EBD) is an effective, minimally invasive treatment for Crohn's disease (CD) related intestinal strictures. However, restenosis frequently occurs and requires repetitive EBD or surgical resection. Since previous studies could not evaluate restenosis based on stricture diameter, factors affecting restenosis after EBD were unclear. This study aimed to identify these factors by precisely measuring the diameter of small intestinal strictures in patients with CD. METHODS: This single-center retrospective study enrolled patients with CD with de novo small intestinal strictures who underwent two double-balloon enteroscopy sessions (EBD and follow-up) between January 2016 and October 2021. Clinical and endoscopic data were obtained from electronic medical records. A calibrated small-caliber-tip transparent hood was used to precisely measure stricture diameters. Multivariate analysis was performed to identify factors associated with restenosis. RESULTS: Forty-eight patients (37 male) were analyzed. The total number of strictures detected decreased from 162 to 143. The mean diameter of all strictures and the narrowest stricture in each patient increased significantly from 8.6 to 9.8 mm and from 7.6 to 8.7 mm, respectively. Thirty-two (67%) patients developed endoscopic restenosis. Multivariate analysis showed that the presence of ulcers at the follow-up session was a risk factor for restenosis (odds ratio 9.4, p = 0.01). Patients with complete mucosal healing at both sessions (n = 21) showed significant improvement in the narrowest stricture (+1.7 mm, p = 0.001). CONCLUSIONS: Maintenance of complete mucosal healing is significantly associated with avoiding restenosis after EBD in CD-related small intestinal strictures.

BACKGROUND AND AIMS: Acid suppression improves dyspepsia symptoms but the efficacy of vonoprazan for functional dyspepsia remains unclear. The aim of this study is to evaluate the effectiveness of vonoprazan therapy for functional dyspepsia without heartburn. METHODS: Patients receiving vonoprazan 10 mg once daily or acotiamide 100 mg three times daily for more than one month were included and retrospectively reviewed. Functional dyspepsia was diagnosed based on the ROME IV criteria. Patients with heartburn were excluded. Eighty-five patients were divided into vonoprazan (n=48) and acotiamide (n=37) groups. RESULTS: There were no significant differences at baseline between the vonoprazan and acotiamide groups. The functional dyspepsia score significantly improved in both groups (p<0.001). The degree of score reduction (55% vs 59%, p=0.559) and the resolution rates (21% vs 30%, p=0.345) were similar. Epigastric pain and postprandial distress scores were significantly improved in both groups, and the degree of improvement of each score was similar. Constipation and diarrhea scores were significantly improved in both groups, and the degree of improvement similar. CONCLUSION: These preliminary results suggest that vonoprazan is effective for the treatment of functional dyspepsia without heartburn in the short-term, with results similar to acotiamide therapy.

Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.

Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.

BACKGROUND: Long-term acid suppression during vonoprazan therapy causes hypergastrinemia which may induce gastric mucosal changes such as fundic gland and hyperplastic polyps. The aim of this study is to clarify the long-term changes in serum gastrin levels and risk factors for hypergastrinemia. METHODS: From July 2016 to April 2020, 48 patients receiving vonoprazan 10 mg once daily for more than one year were reviewed. Serum gastrin level was evaluated by radioimmunoassay in a fasting condition (reference range 37-172 pg/ml). RESULTS: The baseline median gastrin level was 100 (range, 54-415) pg/ml. The gastrin level over 4 years was 700-1200 pg/ml, which plateaued at 1.5 years. Multivariate analysis revealed factors associated with gastrin levels 12 months after starting vonoprazan and identified severe gastric atrophy as a significant positive risk factor (p = .046). The gastrin level over 4 years in patients with severe gastric atrophy and no atrophy was approximately 900-1500 and 500-1000 pg/ml, respectively. Female gender was also identified as a positive factor, although it was not statistically significant (p = .087). The gastrin level over 4 years in females was approximately 900-1300 pg/ml, greater than in males (500-900 pg/ml). CONCLUSION: A continued increase in gastrin levels was not found during long-term vonoprazan therapy. Severe gastric atrophy is a significant risk factor for hypergastrinemia.

肝移植後胆道合併症は依然として発症率が高く、予後に影響する重要な合併症である。胆道合併症は胆管狭窄、胆汁瘻に大別されるが、肝内結石はまれであり、とくに小児肝移植後肝内結石の診断・治療は確立されていない。小児肝移植症例の胆道再建は胆管空腸吻合がほとんどであるため、胆道合併症に対する治療は経皮経肝的胆道ドレナージ(PTBD)下カテーテル治療か外科的治療に限られていた。近年、ダブルバルーン小腸内視鏡(DBE)の改良とデバイスの進歩により、小児肝移植後胆道合併症においてもDBE下カテーテル治療が可能になってきている。低侵襲治療であるDBE下治療により、小児肝移植後肝内結石に対しても早期発見治療が可能となり、今後長期予後の向上が期待できる。(著者抄録)

The safety of long-term proton pump inhibitor (PPI) and vonoprazan (VPZ) use is a relatively recent concern. Gastric mucosal redness was reported as a VPZ-associated lesion in a previous study. The aim of this study was to investigate the prevalence and risk factors for gastric mucosal redness. Between December 2020 and November 2021, 1,101 patients who underwent esophagogastroduodenoscopy were reviewed. The cohort was divided into four groups: Control (n=580), histamine-2 receptor antagonist (H2RA) (n=65), PPI (n=146) and VPZ groups (n=310). Gastric mucosal redness was present in 48/1,101 patients (4%). The prevalence in controls, H2RA, PPI and VPZ groups was 1.9% (11/580), 1.5% (1/65), 6.2% (9/146) and 8.7% (27/310), respectively. Both the PPI and VPZ groups had a significantly higher prevalence of gastric mucosal redness compared with the control group (P<0.001). In the multivariate analysis, PPI and VPZ use were significantly associated with gastric mucosal redness. Fundic gland polyps, gastric hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like mucosa, and stardust gastric mucosa were also significantly associated with PPI and VPZ use in the multivariate analysis. Back-to-back analysis showed that gastric mucosal redness was not seen before starting PPI/VPZ in most patients. The duration of treatment with VPZ was investigated to determine if it affected the prevalence of gastric mucosal redness. There were no significant differences in treatment duration among patients with and without gastric mucosal redness (mean ± standard deviation: 3.0±1.5 vs. 2.5±1.4 years, P=0.077). In conclusion, the prevalence of gastric mucosal redness was low but was associated with PPI and VPZ use.

Background and study aims  Endoscopic submucosal dissection (ESD) is a standard method for minimally invasive resection of superficial gastrointestinal tumors. The pocket creation method (PCM) facilitates ESD regardless of location in the gastrointestinal tract. The aim of this systematic review and meta-analysis is to evaluate the effectiveness and safety of ESD for superficial neoplasms in the upper and lower gastrointestinal tract comparing the PCM to the non-PCM. Methods  Randomized controlled, prospective, and retrospective studies comparing the PCM with the non-PCM were included. Outcomes included en bloc resection, R0 resection, dissection speed, delayed bleeding and perforation. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) using the Mantel-Haenszel random effect model were documented. Results  Eight studies including gastric, duodenal, and colorectal ESD were included. The en bloc resection rate was significantly higher in the PCM group than the non-PCM group (OR 3.87, 95 %CI 1.24-12.10 P  = 0.020). The R0 resection rate was significantly higher in the PCM group than the non-PCM group (OR 2.46, 95 %CI 1.14-5.30, P  = 0.020). The dissection speed was significantly faster in the PCM group than the non-PCM group (mean difference 3.13, 95 % CI 1.35-4.91, P  < 0.001). The rate of delayed bleeding was similar in the two groups (OR 1.13, 95 %CI 0.60-2.15, P =  0.700). The rate of perforation was significantly lower in the PCM group than the non-PCM group (OR 0.34, 95 %CI 0.15-0.76, P =  0.009). Conclusions  The PCM facilitates high-quality, fast and safe colorectal ESD. Further studies are needed regarding the utility of PCM in ESD of the upper gastrointestinal tract.

Yuki and colleagues report a case of successful endoscopic hemostasis of post-papillectomy bleeding with the gel immersion method and an endoscope with an attached balloon and a cylindrical hood. The visual field was improved with gel and maneuverability was improved using the cylindrical hood and the semi-inflating balloon.

When performing endoscopic reduction in patients with gastric volvulus, it is important to maintain a low level of intragastric pressure and to fix the endoscope in the duodenum. Gel immersion endoscopy is a new method for securing the visual field by injecting clear gel. The balloon-attached endoscope makes it easier to fix the tip in the duodenum without mucosal damage. We report successful reduction of a mesenteroaxial gastric volvulus using an endoscope with a balloon in combination with gel immersion endoscopy. A 3-year-old Japanese male developed gastric volvulus. Since gastric decompression using a nasogastric tube failed to reduce the volvulus, endoscopic reduction was performed under general anesthesia. After aspiration of intragastric gas, clear gel was injected through the accessory channel which secured the visual field in the stomach even with residue while maintaining low intragastric pressure. After reaching the descending portion of the duodenum, the balloon attached to the tip of the endoscope was inflated and fixed in the duodenum. The volvulus was successfully reduced by pulling back the endoscope with clockwise torque. Acute mesenteroaxial gastric volvulus has the potential to cause ischemia and perforation which can be life-threatening, so most patients are treated with surgical intervention. Gel immersion endoscopy is safe and effective to secure the visual field, even in children. Endoscopic reduction may be a viable treatment option for reducing gastric volvulus in non-emergent patients.

BACKGROUND: Helicobacter pylori (H. pylori) eradication success increases the incidence of erosive esophagitis by normalization of gastric acid secretion. The aim of this study is to clarify predictors and timing for the development of symptomatic gastroesophageal reflux disease (GERD) after successful H. pylori eradication based on long-term follow-up. METHODS: From April 2014 to October 2020, 330 patients with H. pylori infections treated with a standard triple-drug regimen were enrolled, and their records retrospectively reviewed. Development of symptomatic GERD was defined as requiring proton pump inhibitor or vonoprazan therapy to treat symptoms. RESULTS: The mean follow-up period was 2.8 years, and symptomatic GERD developed in 41 (12%) patients during the study period. Overall rates of GERD-symptom free patients at 6 months, 1, and 2 years after eradication were 97%, 93%, and 89%, respectively. We evaluated predictors for the development of symptomatic GERD using a Cox proportional hazards regression model. In multivariate analysis, being a current smoker, having functional dyspepsia, hiatal hernia, and severe gastric atrophy were identified as significant predictive factors. The GERD domain score in the Izumo scale was significantly decreased 1 month after vonoprazan therapy consistent with effective treatment of symptomatic GERD. CONCLUSIONS: The rate of development of symptomatic GERD after successful H. pylori eradication is low over long-term follow-up and is easily controlled by vonoprazan therapy. However, patients with smoking habits, functional dyspepsia, hiatal hernia, or severe gastric atrophy should be followed carefully after eradication.

Peutz-Jeghers症候群では、小腸内に多発する過誤腫性ポリープにより腸重積をきたすことが問題となる。バルーン内視鏡により小腸ポリープに対する内視鏡的治療を行うことで、腸重積の発生リスクを低減し外科的治療の必要性を減らすことができる。外科的治療を繰り返し行ってしまうと、術後癒着により深部挿入が困難となり、その後の内視鏡治療に支障をきたすこともあるため、可能な限り内視鏡的治療を優先して行っていく必要がある。内視鏡的治療は、ポリープの茎にクリップや留置スネアを留置することによる阻血治療(ischemic polypectomy)を行うことで、ポリペクトミー/EMRより効率的に偶発症の少ない内視鏡的治療が実現可能となっている。小腸ポリープは一度治療しても新しく発生することが多く、また内視鏡は繰り返し施行可能な手技であるため、偶発症のリスクを冒して1回の手技ですべての治療を完結させることよりも、長期的に腸重積の危険性を減らしていくことを目標とすることが肝要である。(著者抄録)

家族性大腸腺腫症では、大腸外随伴病変として十二指腸にも腺腫が認められる。十二指腸癌はデスモイド腫瘍とともに大腸癌を除く家族性大腸腺腫症の主要な死因であり、定期的なサーベイランスを行うことが推奨されている。さらに上部空腸や回腸嚢内にも腺腫が発生することが知られている。これらの腺腫の治療方針については現在のところ明確なコンセンサスが得られていないが、内視鏡的に切除することでSpigelman分類ステージの進行を予防し、スコアを減少させる効果があることが報告されている。十二指腸・空腸腺腫の内視鏡的治療にバルーン内視鏡を用いることは内視鏡の操作性が安定し、より効率的に安全な治療ができる点で有用である。大腸腺腫と同様、従来の通電するポリペクトミーよりもcold snare polypectomyがより安全に効率的な治療を実現できる可能性がある。今後、小腸腺腫の内視鏡的切除により長期的に小腸癌発症リスクを低減できるか評価される必要がある。(著者抄録)

Peutz-Jeghers症候群では、小腸内に多発する過誤腫性ポリポーシスにより腸重積をきたすことが臨床的に問題となる。小腸内視鏡の開発により内視鏡的治療が可能となり、過誤腫性ポリポーシスに対するマネージメントに、従来の外科的治療から内視鏡的治療へと大きな変革がもたらされている。また従来のポリペクトミー、EMRによる切除から、ポリープの茎に留置スネアやクリップを留置することによる阻血治療を行うことで、より効率的に偶発症の少ない内視鏡的治療が実現可能となっている。家族性大腸腺腫症では大腸外随伴病変として小腸にも腺腫が認められ、小腸内視鏡による切除が試みられている。大腸腺腫と同様、従来の通電するポリペクトミーよりもcold snare polypectomyのほうが安全に効率的な治療を実現できる可能性がある。小腸腺腫の内視鏡的切除によって長期的に小腸癌発症リスクを低減できるか、今後評価されていく必要がある。(著者抄録)