矢野 智則

背景及び目的：ダブルバルーン内視鏡（double-balloon endoscopy：DBE）は処置能を備え，全小腸における直接的な精密検査を可能にした．その有用性は認識されているものの，その効果と安全性を前向き多施設研究として大規模には評価されていない．DBEが熟練及び非熟練内視鏡医によって施行された場合の効果と安全性を評価するために，前向き多施設共同研究が日本の5つの大学病院とひとつの一般病院において実施された．<BR>方法：179件のDBEが施行された合計120人の患者がこの研究に登録された．このうち129件を熟練者が，50件を非熟練者が施行した．主要および副次的評価項目は安全性評価，検査目的の達成率（新たな病変の同定，治療方針決定に寄与する詳細な観察，もしくは全小腸内視鏡観察による有意な病変の除外），全小腸観察率とした．<BR>結果：検査目的達成率は全体で82.5％（99/120）

背景及び目的：ダブルバルーン内視鏡（double-balloon endoscopy：DBE）は処置能を備え，全小腸における直接的な精密検査を可能にした．その有用性は認識されているものの，その効果と安全性を前向き多施設研究として大規模には評価されていない．DBEが熟練及び非熟練内視鏡医によって施行された場合の効果と安全性を評価するために，前向き多施設共同研究が日本の5つの大学病院とひとつの一般病院において実施された．<BR>方法：179件のDBEが施行された合計120人の患者がこの研究に登録された．このうち129件を熟練者が，50件を非熟練者が施行した．主要および副次的評価項目は安全性評価，検査目的の達成率（新たな病変の同定，治療方針決定に寄与する詳細な観察，もしくは全小腸内視鏡観察による有意な病変の除外），全小腸観察率とした．<BR>結果：検査目的達成率は全体で82.5％（99/120）

capsule endoscopy（CE）とdevice assisted enteroscopy（DAE）の登場により，小腸疾患の診断・治療戦略は大きく変化してきた．2012年7月にはpatency capsuleの本邦導入に伴って，CEの保険適応が拡大され，多くの小腸疾患に使用可能になった．低侵襲なCEと，内視鏡処置が可能なDAEはお互いに補完し合うものであり，両者をうまく組み合わせて診療を行っていくべきである．小腸内視鏡は小腸出血，小腸腫瘍・ポリープ，ポリポーシス，炎症性腸疾患の診療に有用である．さらには，小腸疾患だけに留まらず術後再建腸管を有する例でのERCPや，挿入困難例での大腸内視鏡へも応用され，革命的な成果が報告されている．

Primary small intestinal lymphoma (PSIL) is often treated with surgical resection, and therefore response to non-surgical treatment is rarely known. We retrospectively analyzed the clinicopathological features of 19 patients with PSIL, who had been diagnosed by double-balloon endoscopy (DBE) and had not received surgical treatment. The immunohistological phenotypes of 18 patients were B-cell lymphomas. Five patients had tumors within the jejunum, nine within the ileum and five in multiple sites including the duodenum. Most cases were in the low or low-intermediate risk group of the International Prognostic Index score. Seventeen patients received chemotherapy, with an overall response rate of 82.4%. The estimated overall survival at 5 years was 72.2%. Response to initial chemotherapy and levels of hemoglobin (Hb) and albumin (Alb) were identified as favorable prognostic indicators. We conclude that PSIL can be effectively diagnosed by DBE and shows a good prognosis with chemotherapy alone.

症例は10歳女児で、腹痛に対する消化管内視鏡で過誤腫性ポリープを認めてPeutz-Jeghers症候群と診断され、精査目的で入院した。入院直前より反復する右下腹部痛と血便が生じ、画像診断で空腸に腫瘤を先進部とする小腸腸重積を認め、小腸内視鏡による診断・治療を予定した。ダブルバルーン内視鏡を経口的に挿入し、幽門から50cmの空腸の内腔が狭小化し粘膜浮腫を認めたため、腸重積起始部と考えられた。内視鏡先端を慎重に進めて約10cmにわたる重積部を通過させた後、バルーンを拡張して内視鏡を口側へ引き抜き、腸重積を整復した。先進部は4cm大と3cm大の二つの有茎性ポリープからなり、内視鏡下に切除した。術後3日目より経口摂取を再開し5日目に退院した。病理検査結果は過誤腫性ポリープであった。退院後、腹痛や血便はなく、3ヵ月後に再入院してダブルバルーン内視鏡で全小腸を観察し、ポリープ切除術を追加した。その後も定期的に内視鏡検査を行っている。

Double-balloon endoscopy (DBE) was developed as a new technique for visualization and intervention of the entire small intestine. It has been world-widely reported that DBE is very useful for not only diagnosis but also endoscopic therapy. In this paper, the principle of the DBE system and indication for DBE are described introductory. DBE should be performed considering differential diagnosis based on clinical information such as episode of bleeding, detailed case history and CT findings for making diagnosis efficiently.

Background: The early diagnosis of small-bowel tumors (SBT) was a difficult task until the advent of capsule endoscopy (CE) and double-balloon endoscopy (DBE) allowed access to the disease sited. However, although CE and DBE have greatly simplified the task, DBE studies have yet to provide sufficient data on the diagnosis and outcome of patients with SBTs. Objective: To determine the efficacy of DBE examination in the detection and diagnosis of SBT. Design: A retrospective analysis of cross-sectional case series. Setting: Seven major medical centers in Japan. Patients: The first 1035 consecutive DBE cases at these major Japanese centers since the introduction of DBE. Main Outcome Measurements: The percentage of subjects with SBT and a diagnosis of SBT, their indications for DBE, and diagnostic and therapeutic DBE procedures carried out for SBT. Results: SBTs were identified in 144 of 1035 Subjects (13.9%) who underwent DBE between September 2000 and December 2005. For subjects with SBT, the most common indication for DBE was the Suspected presence of a SBT (61/144 [42.4%]). For subjects without SBT, the most common indication was obscure GI bleeding (OGIB) (419/891 [47.0%]). Malign

Double balloon endoscopy (DBE) was developed as a new technique for visualization and intervention of the entire small intestine. It has been world-widely reported that DBE is very useful for not only diagnosis but also endoscopic therapy. In this chapter, hemostatic procedure, polypectomy, dilation therapy for benign strictures, reduction of intussusception, removal of foreign bodies, and therapeutic ERCP in long-limb surgical bypass patients are described introductively. Diagnostic DBE is thought to be safe with a low complication rate, but it is reported that the complication rate in therapeutic DBE is higher than that associated with colonoscopy. The thin wall of the small intestine can explain this. Endoscopic therapy in the small intestine should be performed with special care to avoid complications such as bleeding and perforation.

Small-intestinal vascular lesions accounted for the bleeding source in a large percentage of the patients with mid-GI-bleeding. The progress of enteroscopy has been changing the diagnostic and therapeutic algorithm for them. There are 3 pathological conditions of vascular lesions. Angioectasia is characterized by venous/capillary lesions, Dieulafoy' s lesion is characterized by arterial lesions, and AVM is a condition in which arteries and veins are directly connected without capillary beds. We classified vascular lesions with consideration of the presence or absence of pulsatility. The presence or absence of arterial components provides important information in understanding the pathological conditions. This classification will be useful for selecting hemostatic procedure and outcome studies.