矢野 智則

Background:Crohn's disease (CD) strictures of the small intestine are a feared complication and difficult to treat because of difficulty gaining access to the stricture site. The development of double-balloon endoscopy (DBE) enabled access to the entire small intestine with interventional capabilities. The aim of this study was to assess the long-term outcomes in patients with small intestinal strictures secondary to CD after DBE-assisted endoscopic balloon dilation (EBD).Methods:In this retrospective cohort study, DBE-assisted EBD was performed in 85 consecutive patients with CD strictures of the small intestine from 2002 to 2014. Follow-up data were available for 85 patients for a mean of 41.9 months (range, 0-141), and clinical outcomes were assessed.Results:Overall, 321 DBE-assisted EBD sessions (473 procedures) were performed in 85 patients during the study period. Most CD strictures were de novo (97%). The surgery-free rate after initial DBE-assisted EBD was 87.3% at 1 year and 78.1% at 3 years. The presence of a fistula was significantly associated with the need for surgical intervention (hazard ratio = 5.50, 95% confidence interval: 2.16-14.0, P < 0.01). The surgery-free interval in patients with a fistula was significantly shorter than in patients without a fistula (P < 0.01, log-rank test).Conclusions:DBE-assisted EBD provides a favorable long-term outcome in patients with small intestinal CD-associated strictures. DBE-assisted EBD for CD strictures is a safe and effective treatment to avoid or postpone surgery over the long-term.

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）

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）

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）

Background The long-term outcomes of patients after negative double-balloon endoscopy (DBE) for obscure gastrointestinal (GI) bleeding remain unclear. Aim The aim of this study was to assess the long-term outcomes of patients with negative DBE and clarify the effect of repeat endoscopic work-up. Methods A total of 42 patients with a negative DBE for overt obscure GI bleeding were enrolled, and their clinical data were retrospectively reviewed. The mean (+/- standard deviation) follow-up period is 5.4 (+/- 2.8) years. The outcome measurement was overt rebleeding witnessed by the patient after negative DBE. At the time of rebleeding, further endoscopic work-up and specific treatment were performed. Results Rebleeding occurred in 16 of 42 patients (38 %). At the time of rebleeding, further investigations were made in 14 of 16 patients (88 %), and the bleeding source was identified in 10 of 14 patients (71 %). These 10 patients received specific treatment (endoscopic in five, surgical in two, medical in two, and angiographic in one). The bleeding source was in the small intestine in seven of 10 patients (70 %). Blood transfusion before DBE and multiple bleeding episodes before DBE were significant predictive factors for rebleeding (odds ratio 5.056, 95 % confidence interval 1.158-22.059, p = 0.031 and odds ratio 8.167, 95 % confidence interval 1.537-43.392, p = 0.014, respectively). Conclusions The rebleeding rate after a negative DBE is considerable. Careful long-term follow-up and repeat endoscopic work-up at the time of overt rebleeding are important.

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double-balloon endoscopy (DBE) allows endoscopic access to pancreato-biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux-en-Y or Billroth-II reconstruction, using DBE have been reported. However, two major technical parts are required for double-balloon ERCP (DB-ERCP). One is insertion of DBE and the other is an ERCP-related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux-en-Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB-ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB-ERCP.

Background and Aim: Double-balloon endoscopy (DBE) has enabled direct, detailed examination of the entire small bowel with interventional capabilities. Although its usefulness is recognized, efficacy and safety have not been extensively evaluated by prospective multicenter studies. To evaluate the efficacy and safety of DBE carried out by expert and non-expert endoscopists, a prospective, multicenter study was conducted in five university hospitals and a general hospital in Japan. Methods: A total of 120 patients who underwent 179 procedures were enrolled in the study. Experts carried out 129 procedures and non-experts carried out 50 procedures. Primary and secondary end points were evaluation of safety, the rate of achievement of procedural objectives, namely, identification of a new lesion, detailed examination to establish a therapeutic strategy, or exclusion of significant lesions by total enteroscopy, and rate of successful examination of the entire small bowel and evaluation of safety. Results: Overall rate of achievement of procedural objectives was 82.5% (99/120). Overall success rate for examination of the entire small bowel was 70.8% (34/48). Incidence of adverse events was 1.1% (a mucosal injury and an episode of pyrexia in two of 179 examinations). No severe adverse events were encountered. There were no significant differences in any of the outcome measures comparing expert and non-expert operators. Conclusions: DBE is effective and safe for patients with suspected small bowel diseases, and can be safely carried out even by a non-expert under the supervision of an expert, following a simple training program.

Double-balloon endoscopy (DBE) has been a significant advancement in the endoscopic diagnosis and treatment of small intestinal disorders. What makes the device particularly remarkable is not only its ability to perform deep enteroscopy, but also the fact that it has therapeutic capabilities as well. The new therapeutic EN-580T has improved intervention capability with a 3.2 mm accessory channel and improved image quality as well, despite maintaining the same outer diameter of 9.4 mm as the previous model. The new diagnostic EN-580XP has the same improved image quality as EN-580T despite having a much smaller outer diameter of 7.5 mm. These new enteroscopes are expected to improve clinical management as well as the research of small intestinal disorders. Double-balloon endoscopy for evaluation of the small intestine can also be performed in patients with surgically altered anatomy and difficult colons. A short EI-530B or EC-450BI5 scope is useful for ERCP in patients with a Roux-en-Y anastomosis and also in patients who have had prior difficult colonoscopies. Future technology may allow for automated insertion of the enteroscopes.

Pulmonary complications of ulcerative colitis (UC) are relatively rare. Generally, pulmonary lesions with cavity formation are difficult to distinguish from infections or Wegener’s granulomatosis lesions. A 15-year-old female with no remarkable past medical history had multiple pulmonary nodules on chest X-ray. Since empirical treatment with wide-spectrum antibiotics did not improve her symptoms, she was transferred for further evaluation. Chest radiography and computed tomography (CT) scan showed multiple bilateral pulmonary nodules with cavity formation, 8–65 mm in diameter, located mainly in the right lung. She was diagnosed with UC based on sigmoidoscopy. She was treated with mesalazine and granulocyte–monocyte apheresis (GMA). Steroids were not administered, because an infectious disease could not be excluded. Seven days after starting GMA, her symptoms and laboratory findings improved, and she was discharged. After the completion of 10 courses of GMA, chest radiography and CT scan showed marked diminution of the pulmonary lesions. UC-associated pulmonary lesions can be treated without steroid administration, and we suggest that this strategy is an option for a patient with UC-associated pulmonary lesions that cannot be differentiated from an infection.

Background: GI bleeding secondary to small-intestine vascular lesions (SIVLs) is associated with rebleeding despite initial hemostasis by endotherapy applied at double-balloon endoscopy (DBE). Objective: To evaluate the long-term outcomes of DBE endotherapy of SIVL (as described by the YanoYamamoto classification). The impact of repeat DBE endotherapy for recurrent bleeding also was assessed. Design: Retrospective cohort study. The mean (+/- standard deviation [SD]) follow-up period was 4.9 (+/- 1.7) years (range 2.4-9.1 years). Setting: Tertiary-care referral center. Patients: A total of 43 patients, who underwent 69 sessions of DBE endotherapy of SIVLs. Intervention: DBE endotherapy. Main Outcome Measurements: Frequency of overt rebleeding after the initial DBE endotherapy. Results: Overt rebleeding occurred in 16 of 43 patients (37%). Patients with multiple SIVLs showed a significantly higher rate of overt rebleeding than did those with a solitary SIVL (12/23 [52%] vs 4/20 [20%]; P = .017). The trend toward frequency of rebleeding after the first DBE hemostasis appeared to be higher for patients with type 1a SIVLs than for those with type 1b or type 2 lesions: type 1a (8/16, 50%) versus type 1b (5/19, 26%) (P = .12) and type 1a (8/16, 50%) versus type 2 (2/7, 29%) (P = .31), respectively. In 12 of 16 patients (75%) who underwent repeat DBE endotherapy at each episode of overt rebleeding (median 3 times, range 2-6), the frequency of rebleeding decreased significantly after the first year of follow-up, as compared with the remaining 4 patients who did not undergo repeat DBE; mean (+/- SD) 0.12 (+/- 0.19) versus 0.52 (+/- 0.33) times per year per patient (P = .006). Limitations: Single-center, retrospective study. Conclusion: Although the presence of multiple SIVLs was associated with rebleeding, repeat DBE endotherapy resulted in an improved long-term outcome in patients with refractory SIVL bleeding.

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.

Double-balloon enteroscopy (DBE) has enabled theendoscopic diagnosis and treatment ofsmall bowelconditions. Indications for DBE include scrutiny for midgut bleeding, small bowel tumor, and small bowel stricture, and follow-up evaluation of small bowel diseases. Contraindications to DBE are essentially similar to those in conventional upper endoscopy and colonoscopy. DBE is a safe procedure with low complication rates. Because DBE has an accessory channel and good maneuverability in the distal small bowel, it enables endoscopic treatment, including hemostasis, balloon dilation, polypectomy, mucosal resection, and retrieval of foreign bodies. © 2012 Blackwell Publishing Ltd.

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。

Human intestinal spirochetosis (HIS) is a colorectal infectious disease caused by Brachyspira species. We describe HIS in an immunocompromised, 62-year-old Japanese man who presented at Jichi Medical University Hospital with symptoms of diarrhea and bloody stool. He had rheumatoid arthritis that had been treated with immunosuppressive drugs for 10 years. Colonoscopy revealed multiple erythematous spots in the cecum and colon. A histopathological examination identified intestinal colonization by spirochetes, and Brachyspira pilosicoli was isolated from biopsy specimens, indicating a diagnosis of HIS. Metronidazole eradicated the spirochetes, the intestinal mucosa recovered to normal, and the clinical symptoms disappeared. This case suggests that it is important to keep in mind HIS in the differential diagnosis of immunocompromised patients with chronic diarrhea and bloody stool. © 2011 Springer.

大腸癌の予後および治療法の選択は深達度と密接に関係している.CT colonographyでは,MDCTの技術革新に伴って,短時間で仮想内視鏡像や仮想注腸像,MPR像といった様々なpost processing imageの作成が可能となった.一方,大腸内視鏡や注腸造影検査においては,これまでに培われたそれぞれの診断基準が存在する.CT colonographyにおける大腸癌の深達度診断においては,得られた様々なpost processing imageに,従来のモダリティで培われた診断基準を用いて,総合的に診断することで的確な深達度診断が可能と考える.(著者抄録)

Objectives. To describe our experience with 126 consecutive living-donor liver transplantation (LDLT) procedures performed because of biliary atresia and to evaluate the optimal timing of the operation. Patients and Methods. Between May 2001 and January 2010,126 patients with biliary atresia underwent 130 LDLT procedures. Mean (SD) patient age was 3.3 (4.2) years, and body weight was 13.8 (10.7) kg. Donors included 64 fathers, 63 mothers, and 3 other individuals. The left lateral segment was the most commonly used graft (75%). Patients were divided into 3 groups according to body weight: group 1, less than 8 kg (n = 40); group 2,8 to 20 kg (n = 63); and group 3, more than 20 kg (n = 23). Medical records were reviewed retrospectively. Follow up was 4.5 (2.7) years. Results. All group 3 donors underwent left lobectomy, and all group 1 donors underwent left lateral segmentectomy. No donors required a second operation or died. Comparison of the 3 groups demonstrated that recipient Pediatric End-Stage Liver Disease score in group 1 was highest, operative blood loss in group 2 was lowest (78 mL/kg), and operative time in group 3 was longest (1201 minutes). Hepatic artery complications occurred more frequently in group 1(17.9%), and biliary stenosis (43.5%) and gastrointestinal perforation (8.7%) occurred more frequently in group 3. The overall patient survival rates at 1, 5, and 9 years was 98%, 97%, and 97%, respectively. Five-year patient survival rate in groups 1,2, and 3 were 92.5%, 100%, and 95.7%, respectively. Gastrointestinal perforation (n = 2) was the primary cause of death. Conclusions. Living-donor liver transplantation is an effective treatment of biliary atresia, with good long-term outcome. It seems that the most suitable time to perform LDLT to treat biliary atresia is when the patient weighs 8 to 20 kg.