矢野 智則

Balloon enteroscopy-assisted endoscopic retrograde cholangiography (BEA-ERC) is useful and feasible in adults with pancreatobiliary diseases, but its efficacy and safety have not been established in pediatric patients. We compared the success rate and safety of BEA-ERC between adults and pediatric patients. This single-center retrospective study reviewed 348 patients (pediatric: 57, adult: 291) with surgically altered gastrointestinal anatomies who underwent BEA-ERC for biliary disorders from January 2007 to December 2019. The success rate of reaching the anastomosis or duodenal papilla was significantly lower in pediatric patients than in adult patients (66.7% vs. 88.0%, p < 0.01). The clinical success rate was also significantly lower in pediatric patients (64.9% vs. 80.4%, p = 0.014). The rate of adverse events was significantly higher in pediatric patients than in adults (14.2% vs. 7.7%, p = 0.037). However, if the anastomotic sites were reached in pediatric patients, the treatment was highly successful (97.3%). The time of reaching target site was significantly longer in pediatric patients than in adult patients. This study shows that BEA-ERC in pediatric patients is more difficult than that in adult patients. However, in patients where the balloon enteroscope was advanced to the anastomosis, clinical outcomes comparable to those in adults can be achieved.

BACKGROUND: This study aimed to compare the markers of potential pancreatic injury during antegrade double-balloon endoscopy (DBE) using the newly developed ultrathin EN-580XP system and the conventional EN-580T system. METHODS: Patients who were scheduled for antegrade DBE during daily clinical practice were enrolled. Clinical background, adverse events, and laboratory data of patients were compared between those who underwent endoscopy using the EN-580XP system and those in whom the EN-580T system was used. The primary end points were pancreatic hyperamylasemia and hyperlipasemia after DBE. RESULTS: A total of 295 cases were registered. Pancreatic hyperamylasemia occurred in 2 of 92 patients (2.2 %) in the EN-580XP group and in 28 of 147 patients (19.1 %) in the EN-580 T diagnosis group (P < 0.001). Hyperlipasemia was significantly different between the two groups (1.1 % [EN-580XP] vs. 13.6 % [EN-580 T diagnosis]; P < 0.001). Acute pancreatitis occurred in four patients (7.1 %) in the EN-580 T therapy group. Multiple logistic regression analyses revealed that the endoscope type EN-580 T was significantly associated with pancreatic hyperamylasemia (adjusted odds ratio [OR] 8.63, 95 % confidence interval [CI] 1.97 - 37.70; P < 0.01) and hyperlipasemia (adjusted OR 13.10, 95 %CI 1.70 - 100.70; P = 0.01). CONCLUSIONS: The EN-580XP system seemed less harmful to the pancreas during antegrade DBE.

Adenocarcinoma in a Meckel's diverticulum is rare and difficult to diagnose preoperatively. We report the first case of a metachronous Krukenberg tumor from adenocarcinoma in a Meckel's diverticulum. A 45-year-old woman was admitted for recurrent abdominal pain. Computed tomography scan showed a lesion with contrast enhancement, and a Meckel's diverticulum-associated tumor was suspected. Double-ballon enteroscopy revealed intestinal stenosis and biopsy showed adenocarcinoma. Operative findings showed a Meckel's diverticulum with tumor. Histopathological evaluation revealed well-differentiated adenocarcinoma, interrupted by ectopic gastric mucosa, diagnosed as adenocarcinoma in a Meckel's diverticulum. Two years postoperatively, a multi-cystic mass with contrast enhancement was observed in the pelvis on imaging evaluation and oophorectomy performed. Histological examination of the resected ovary showed proliferation of atypical glandular ducts, consistent with metastatic adenocarcinoma. This case demonstrates that adenocarcinoma in a Meckel's diverticulum may result in distant metastases and requires appropriate follow-up.

BACKGROUND: To decrease the risk of bleeding or perforation, ischemic polypectomy is performed using a detachable snare or endoclip with double-balloon endoscopy (DBE) for small-bowel polyps in patients with Peutz - Jeghers syndrome. The aim of this study was to determine the effectiveness and feasibility of ischemic polypectomy. METHODS: We retrospectively reviewed patients who underwent two or more sessions of ischemic polypectomy using DBE from July 2004 to August 2017. RESULTS: 67 therapeutic DBEs were performed in nine patients during the study period and 352 polyps were treated. The median observation period was 34 months (range 12 - 66). There was a declining trend over time in the median number of polyps > 15 mm treated per patient first DBE session 6, second 2, third 1.5, fourth 0.5, fifth 0.5; P = 0.11, Friedman test). No patient required laparotomy due to intussusception during the study period. One patient developed mild acute pancreatitis after the procedure. CONCLUSIONS: Ischemic polypectomy was feasible for the control of small-bowel polyps in patients with Peutz - Jeghers syndrome.

Backgrounds and study aims  Gel immersion endoscopy is a novel technique to secure the visual field during endoscopy. The aim of this study was to develop a dedicated gel for this technique. Methods  To identify appropriate viscoelasticity and electrical conductivity, various gels were examined. Based on these results, the dedicated gel "OPF-203" was developed. Efficacy and safety of OPF-203 were evaluated in a porcine model. Results  In vitro experiments showed that a viscosity of 230 to 1900 mPa·s, loss tangent (tanδ) ≤ 0.6, and hardness of 240 to 540 N/cm 2 were suitable. Ex vivo experiments showed electrical conductivity ≤ 220 μS/cm is appropriate. In vivo experiments using gastrointestinal bleeding showed that OPF-203 provided clear visualization compared to water. After electrocoagulation of gastric mucosa in OPF-203, severe coagulative necrosis was not observed in the muscularis but limited to the mucosa. Conclusions  OPF-203 is useful for gel immersion endoscopy.

BACKGROUND : Many patients with familial adenomatous polyposis (FAP) have adenomatous polyps of the duodenum and the jejunum. We aimed to elucidate the long-term outcomes after double-balloon endoscopy (DBE)-assisted endoscopic resection of duodenal and jejunal polyps in patients with FAP. METHODS : We retrospectively reviewed patients who underwent more than two sessions of endoscopic resection using DBE from August 2004 to July 2018. RESULTS : A total of 72 DBEs were performed in eight patients (median age 30 years, range 12-53; 1.4 DBE procedures/patient-year) during the study period, and 1237 polyps were resected. The median observation period was 77.5 months (range 8-167). There were 11 adverse events, including seven delayed bleeds and four episodes of acute pancreatitis. No delayed bleeding occurred after cold polypectomy. Although, in one patient, one endoscopically resected duodenal polyp was diagnosed as being intramucosal carcinoma, none of the patients developed an advanced duodenal or jejunal cancer during the study period. CONCLUSIONS : Endoscopic resection of duodenal and jejunal polyposis using DBE in patients with FAP can be performed safely, efficiently, and effectively.

慢性炎症性腸疾患の一つであるクローン病は主に小腸と大腸を侵す疾患であり、大腸内視鏡で到達困難な小腸にも病変が多い。バルーン小腸内視鏡は診断のみならず、狭窄に対する内視鏡的バルーン拡張術(endoscopic balloon dilation;EBD)を施行することができ、これにより外科的切除を回避もしくは遅らせることができる。CASThood(calibrated small-caliber-tip transparent hood)は腸管狭窄に対して開発されたバルーン内視鏡用フードで、狭窄内径の正確な測定が可能で、先端細径によるブジー効果や高い挿入効率が期待でき、効率的なEBDを可能にする。多数の小腸狭窄が存在する場合には連続的に多くの狭窄をEBDする必要があり、そのためには適切なデバイスとストラテジーを用いる必要がある。日本を含む東アジア諸国ではクローン病の症例は増加しており、小腸内視鏡の必要性はさらに高まると思われる。(著者抄録)

Dysbiotic microbiota contributes to the pathogenesis of Crohn's disease (CD) by regulating the immune system. Although pro-inflammatory microbes are probably enriched in the small intestinal (SI) mucosa, most studies have focused on fecal microbiota. This study aimed to examine jejunal and ileal mucosal specimens from patients with CD via double-balloon enteroscopy. Comparative microbiome analysis revealed that the microbiota composition of CD SI mucosa differs from that of non-CD controls, with an increased population of several families, including Enterobacteriaceae, Ruminococcaceae, and Bacteroidaceae. Upon anaerobic culturing of the CD SI mucosa, 80 bacterial strains were isolated, from which 9 strains representing 9 distinct species (Escherichia coli, Ruminococcus gnavus, Klebsiella pneumoniae, Erysipelatoclostridium ramosum, Bacteroides dorei, B. fragilis, B. uniformis, Parabacteroides distasonis, and Streptococcus pasteurianus) were selected on the basis of their significant association with CD. The colonization of germ-free (GF) mice with the 9 strains enhanced the accumulation of TH1 cells and, to a lesser extent, TH17 cells in the intestine, among which an E. coli strain displayed high potential to induce TH1 cells and intestinal inflammation in a strain-specific manner. The present results indicate that the CD SI mucosa harbors unique pro-inflammatory microbiota, including TH1 cell-inducing E. coli, which could be a potential therapeutic target.

＜文献概要＞キャストフードは,狭窄の内径を計測可能とする目盛りが側面に刻まれた先端細径フードである.これを使用することで,無送気でも視野確保が容易で,適切なサイズの拡張用バルーンを選択でき,ガイドワイヤの挿入も容易となり,バルーン拡張後のスコープ通過も容易となる.無送気での腸間膜付着側の病変観察も,透明なフード側面を透して容易に可能であり,有用である.

＜文献概要＞クローン病小腸狭窄性病変に対する内視鏡的バルーン拡張術(EBD)は,腸管を温存する有効な方法として,バルーン内視鏡の普及とともに徐々に広がりを見せている.EBD中およびEBD後の出血は,頻度が低いものの報告されている.予防のためには,狭窄部に深い潰瘍が存在する場合などのEBD除外基準を正しく守ることが必要である.出血を認めた際には,自然止血も期待できるが,持続する場合は内視鏡下のクリップ留置など止血術を考慮する必要がある.

＜文献概要＞キャストフードは,狭窄の内径を計測可能とする目盛りが側面に刻まれた先端細径フードである.これを使用することで,無送気でも視野確保が容易で,適切なサイズの拡張用バルーンを選択でき,ガイドワイヤの挿入も容易となり,バルーン拡張後のスコープ通過も容易となる.無送気での腸間膜付着側の病変観察も,透明なフード側面を透して容易に可能であり,有用である.

＜文献概要＞クローン病小腸狭窄性病変に対する内視鏡的バルーン拡張術(EBD)は,腸管を温存する有効な方法として,バルーン内視鏡の普及とともに徐々に広がりを見せている.EBD中およびEBD後の出血は,頻度が低いものの報告されている.予防のためには,狭窄部に深い潰瘍が存在する場合などのEBD除外基準を正しく守ることが必要である.出血を認めた際には,自然止血も期待できるが,持続する場合は内視鏡下のクリップ留置など止血術を考慮する必要がある.

The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient's history, and physician's experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.

十二指腸水平部・上行部の内視鏡観察は、バルーン内視鏡(BAE)やカプセル内視鏡(CE)の開発によって、容易に行えるようになった。BAE、CEを用いなくても従来の上部消化管内視鏡で十二指腸水平部・上行部を観察することは可能であるが、それぞれの特徴をふまえ、目的や部位に応じて適切に検査の選択をする必要性がある。十二指腸は他の臓器に比較すると疾患の頻度が低く、水平部・上行部においては特に低いが、腫瘍性病変から非腫瘍性病変まで多彩な病変がみられる。近年十二指腸病変の症例数は徐々に増えてきていることから、スクリーニングでも、可能なかぎりこの部位も観察すべきである。特に留意すべき疾患として、十二指腸腺腫・癌、悪性リンパ腫、GIST(消化管間質腫瘍)、また全身疾患に伴う病変などがあげられる。十二指腸水平部・上行部の観察はルーチンでは行われないため、進行例で発見されることも多い。この部位をどう観察計断すべきであるか検討するため、今後さらに症例を集積する必要がある。(著者抄録)

十二指腸水平部・上行部の内視鏡観察は、バルーン内視鏡(BAE)やカプセル内視鏡(CE)の開発によって、容易に行えるようになった。BAE、CEを用いなくても従来の上部消化管内視鏡で十二指腸水平部・上行部を観察することは可能であるが、それぞれの特徴をふまえ、目的や部位に応じて適切に検査の選択をする必要性がある。十二指腸は他の臓器に比較すると疾患の頻度が低く、水平部・上行部においては特に低いが、腫瘍性病変から非腫瘍性病変まで多彩な病変がみられる。近年十二指腸病変の症例数は徐々に増えてきていることから、スクリーニングでも、可能なかぎりこの部位も観察すべきである。特に留意すべき疾患として、十二指腸腺腫・癌、悪性リンパ腫、GIST(消化管間質腫瘍)、また全身疾患に伴う病変などがあげられる。十二指腸水平部・上行部の観察はルーチンでは行われないため、進行例で発見されることも多い。この部位をどう観察計断すべきであるか検討するため、今後さらに症例を集積する必要がある。(著者抄録)

Recurrent intestinal inflammation and refractory perianal abscesses are typical manifestations of Crohn's disease. However, these conditions are not always due to Crohn's disease. A 25-year-old male with recurrent perianal abscesses for 1 year, suspected to be due to Crohn's disease, was referred for further evaluation. Computed tomography scan showed a perianal abscess abutting the small intestine. A complicated Meckel's diverticulum was suspected based on these findings. Meckel's diverticulum scintigraphy was negative. Bidirectional double-balloon endoscopy (DBE) identified a long diverticulum in the ileum. In this long diverticulum, a tight stricture was seen 5 cm distal to the diverticular opening. A selective contrast study showed a 10 cm diverticulum distal to the stricture, with three strictures in the long diverticulum. Inflammation of the Meckel's diverticulum due to bacterial overgrowth was suspected as a cause of the refractory perianal abscesses. Laparoscopic diverticulectomy was performed, and the specimen showed a 10 cm diverticulum containing post-inflammatory changes with scar formation. The perianal abscess was confirmed to be caused by an inflamed Meckel's diverticulum. The patient has been asymptomatic for 6 years after resection. DBE before exploratory laparotomy should be considered to investigate the cause of an abscess that could be secondary to small intestinal pathology.

21歳男。発熱、腹痛を主訴とした。4ヵ月前より続く食思不振と腹痛、1ヵ月前より続く発熱にて近医を受診し、下部消化管内視鏡で回盲部中心に高度狭窄を伴う潰瘍を認めた。経肛門的ダブルバルーン内視鏡では回盲部に潰瘍を伴う開口部2ヵ所を認め、一方は約10cmの狭窄、もう一方は回腸末端に繋がる内瘻形成を伴っており、上行結腸粘膜からの生検で非乾酪性類上皮肉芽腫を認めた。疑診に該当するものの中等症のCrohn病として治療を開始し、栄養療法と生物学的製剤の併用により全身状態は安定していた。また、内視鏡的バルーン拡張術(EBD)を繰り返すことで腸閉塞症状なく狭窄部の粘膜治癒と内瘻閉鎖が得られ、初診から18ヵ月後には15mmまで拡張してスコープ通過可能なまでに改善した。以後腸閉塞所見なく寛解を維持しており、初回EBDから30ヵ月間手術を回避できている。