宮原 良二

EUS-elastography(EUS-EG)による膵線維化診断について検討した。術前に腫瘍尾側膵に対しEUS-EGを施行し、その4週間以内に腫瘍を含めた膵切除術を実施した58例を後ろ向きに検討した。膵線維化の進行に伴うグレースケールヒストグラムの形状変化では、膵線維化の進行に伴い、ヒストグラムの平均値は小さくなり、形状はグレースケール値の小さい方向に歪み、裾野は長くなる傾向を認めた。膵線維化の進行により、腫瘍尾側膵のEUS-EG画像は硬く不均一になるものと考えられた。

OBJECTIVES: Protein-losing enteropathy (PLE) is often difficult to diagnose. We evaluated the diagnostic yields of underlying diseases of PLE among esophagogastroduodenoscopy, colonoscopy, fluoroscopic conventional enteroclysis (FCE), videocapsule endoscopy (VCE), and double-balloon enteroscopy (DBE) and prognosis after treatment. METHODS: Between June 2003 and August 2010, 25 consecutive patients with PLE confirmed by fecal α1-antitrypsin clearance (n=18) and technetium 99m human serum albumin scintigraphy (n=19) were enrolled, investigated, and treated. RESULTS: Of 25 patients, 4 (16%) with intestinal lymphangiectasia secondary to macroglobulinemia (n=1), amyloidosis (n=2), and strongyloidiasis (n=1) were diagnosed at preceding esophagogastroduodenoscopy or colonoscopy, and 7 (32%) with primary intestinal lymphangiectasia and chronic nonspecific multiple ulcers unrelated to nonsteroidal anti-inflammatory drugs of the small intestine were newly diagnosed at FCE or VCE. Other 11 (44%) patients with primary intestinal lymphangiectasia, small-bowel tumors, amyloidosis, chronic nonspecific multiple ulcers unrelated to nonsteroidal anti-inflammatory drugs of the small intestine, Crohn's disease, and small-bowel ulcers due to polyarteritis nodosa were diagnosed only at DBE with biopsy. Three patients with primary intestinal lymphangiectasia, cirrhosis after living donor liver transplantation, and congestive heart failure were not diagnosed at any small-bowel examination. The overall diagnostic yield of FCE, VCE, and DBE was 62% (8/13), 83% (14/17), and 88% (22/25), respectively. Eight patients (32%) died of underlying disorders regardless of medical treatment over the follow-up period. CONCLUSIONS: DBE with pathologic findings of biopsy specimens was useful for the differential diagnosis of PLE. Noninvasive VCE might be preferable and useful for screening and follow up of PLE without stricture. Prognosis of a subgroup of PLE was poor regardless of treatment.

OBJECTIVES: The natural history of branch duct-type intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas remains unclear. We conducted a retrospective long-term follow-up study for malignant transformation (MT) of BD-IPMNs focusing on morphological changes. METHODS: The subjects consisted of 142 patients who underwent contrast-enhanced endoscopic ultrasonography for initial diagnosis from January 2001 with more than 12 months of follow-up. The MT rate, including the co-occurrence of invasive ductal cancer, was evaluated by univariate and multivariate analysis. In addition, on the basis of morphological changes in patients who underwent surgery, the predictive factors for malignant IPMNs were evaluated. RESULTS: Median follow-up term was 42.5 months (range, 12-105 months). Thirty patients who exhibited morphological changes underwent surgery. Malignant transformation occurred in 9 patients (6.3%), and 5-year MT rate was 10.7%. The co-occurrence of invasive ductal cancer was seen in 5 patients. Multivariate analysis showed that the existence of mural nodules at initial diagnosis and involvement of main pancreatic duct were significant predictors of MT of BD-IPMN. CONCLUSIONS: Malignant transformation of BD-IPMN is not rare. The observation of morphological changes of main pancreatic duct and nodules, mainly on contrast-enhanced endoscopic ultrasonography, is practical and useful for predicting MT of BD-IPMN itself.

BACKGROUND: Small-bowel tumors (SBTs) represent a diagnostic challenge. OBJECTIVE: To evaluate the usefulness of contrast-enhanced CT (CECT), fluoroscopic enteroclysis (FE), videocapsule endoscopy (VCE), and double-balloon endoscopy (DBE) and the outcome after treatment. DESIGN: Single-center, retrospective study. SETTING: Tertiary-care referral hospital. PATIENTS: Between June 2003 and May 2011, 159 consecutive patients with SBTs (93 malignant and 66 benign) were enrolled. MAIN OUTCOME MEASUREMENTS: Comparison of diagnostic yields among CECT, FE, VCE, and DBE and the prognosis. RESULTS: CECT and FE had significantly lower diagnostic yields of SBTs ≤ 10 mm, but VCE and DBE had high yields of SBTs regardless of size. CECT had a significantly lower diagnostic yield of epithelial tumors compared with subepithelial tumors. When stratified by the site, the diagnostic yield of VCE for SBTs located only in the distal duodenum/the proximal jejunum (73%) was significantly lower than that for SBTs located in other areas (90%). Comparisons among the 4 methods revealed that VCE and DBE had significantly higher diagnostic yields than CECT, and DBE had significantly higher diagnostic yields than VCE, but a combination of CECT and VCE had a diagnostic yield similar to that of DBE. The histologic diagnostic yield of SBTs by DBE was 92%, and 25% of SBTs were enteroscopically treated. Metastatic tumors had the poorest overall survival, followed by adenocarcinomas and malignant lymphomas. LIMITATIONS: Retrospective comparative study. CONCLUSION: For the detection of SBTs, a combination screening method by using VCE and CECT is recommended. DBE is useful for histologic diagnosis and endoscopic treatment.

Backgrounds/Aims: Flexible spectral imaging color enhancement (FICE) is an image enhancement system that can obtain bright and high-contrast images. FICE for capsule endoscopy (CE) is available during interpretation of Given Imaging, but its usefulness is rarely reported. The aim of this study is to evaluate the preview of angiodysplasia by FICE in comparison with the conventional preview. Methodology: The accumulated CE data of 50 patients with angiodysplasia were randomly assigned to 2 equally sized groups of conventional reading and FICE reading. One experienced doctor analyzed them for the first time in a quick-view mode and the mean reading time, sensitivity and specificity for detecting angiodysplasia by each method were evaluated for comparisons including suspected blood indicator. Results: The mean reading time was 14min for both conventional reading and FICE reading. The two previews of angiodysplasia were significantly superior to the function of suspected blood indicator (p<0.01). The sensitivity and specificity of conventional reading for detecting angiodysplasia were 80% and 100%, respectively. Those of FICE reading were 91% and 86%, respectively. FICE reading was superior in term of sensitivity, while it resulted in more false-positive lesion findings and lower specificity. However, such false-positive findings by FICE reading can be correctly identified at a glance by converting the image to conventional mode. Conclusions: This study demonstrates that FICE enables accurate detection of angiodysplasia in the preview of CE.

BACKGROUND AND AIMS: The number of patients with Crohn's disease (CD) and the number of cases of intestinal cancer associated with CD have both been increasing in Japan. However, the number of reported cases is lower than for ulcerative colitis-associated cancer. The aim of this study was to identify the clinical picture of CD-associated intestinal cancer in a consecutive series of patients with CD and to stress the importance of surveillance. METHODS: We enrolled 174 consecutive patients (130 men, 44 women, mean age 25 years) diagnosed with CD and investigated the development of intestinal cancer from October 1998 to July 2010. There were 104 cases of the ileocolitis type, 47 of ileitis, and 23 of colitis. RESULTS: Intestinal cancer developed in two male patients (1.5% of the total), whose respective ages at onset of CD were 41 and 19 years, and 55 and 37 years at onset of cancer. Both cases were of ileocolitis-type CD; one cancer developed in the rectum and the other in the small bowel, and both were accompanied by severe stricture. Histopathological results revealed well and moderately differentiated adenocarcinoma, respectively. CONCLUSIONS: Intestinal cancer developed in patients with ileocolitis-type CD of more than 10 years' duration. Our findings suggest that patients with chronic, widespread CD should be under cancer surveillance.

A 77-year-old man was found to have a duodenal tumor by duodenoscopy. A biopsy specimen was histo-pathologically diagnosed as adenocarcinoma. Hypotonic duodenography showed that this tumor was located in the second portion of the duodenum, and was very close to the papilla duodeni. Preoperative endoscopic ultrasonography revealed that the tumor had deeply invaded the muscularis propria. We decided to resect the tumor with a minimal operation because the patient was elderly and he had multiple organ dysfunction. We performed distal gastrectomy with partial duodenectomy. We separated the duodenal second portion from the pancreatic head widely, and resected the tumor while preserving the papilla duodeni. Histopathological examination showed that this tumor arose from Brunner's glands of the duodenal lamina propria. According to the Japanese Classification of Gastric Carcinoma the case was: pTis pNO HO PO CYO MO lyO vO pPM (-) pDM (-), pStage 1 A. Duodenal carcinoma of Brunner's glands is very rare. We report this case and review previously reported cases in the literature. © 2012 The Japanese Society of Gastroenterological Surgery.

OBJECTIVES: This study aimed to investigate the usefulness of contrast-enhanced endoscopic ultrasonography (EUS) with time-intensity curve (TIC) in differentiating pancreatic diseases. METHODS: Patients who underwent contrast-enhanced EUS between January 2007 and June 2009 were analyzed retrospectively, including 48 with pancreatic ductal cancer (PC), 14 with autoimmune pancreatitis (AIP), 13 with mass-forming pancreatitis (MFP), and 16 with pancreatic endocrine tumor (PET). After intravenous injection of contrast agent, contrast imaging pattern, TIC-based quantitative evaluation, and diagnostic ability of EUS in combination with TIC to diagnose benignancy or malignancy were assessed. RESULTS: Hypovascular and heterogeneous pattern (42/48) in PC, isovascular and homogenous (21/27) in AIP and MFP, and hypervascular and rapid stained (16/16) in PET were observed. The echo intensity reduction rate from the peak at 1 minute was the greatest in PC followed by MFP, AIP, and PET (P < 0.05). The diagnostic accuracies based on contrast imaging pattern (84.0%) and TIC (88.0%) were higher than those based on B-mode imaging (82.6%) and dynamic computed tomography (81.3%). In EUS in combination with TIC, sensitivity, specificity, and accuracy rose up to 95.8%, 92.6%, and 94.7%, respectively. CONCLUSIONS: Contrast-enhanced EUS with the dynamic quantitative analysis preparing TIC increased the diagnostic accuracy for pancreatic diseases.

OBJECTIVE: The objectives of this study were to retrospectively evaluate the lesion detection rate of gastric cancer using only virtual gastroscopy generated from MDCT images and the accuracy of invasion depth diagnosis (T staging) using virtual gastroscopy together with contrast-enhanced MDCT with multiplanar reconstruction (MPR) images (virtual gastroscopy with MPR), and to compare the diagnostic performance between virtual gastroscopy with MPR images and endoscopic ultrasound. MATERIALS AND METHODS: The subjects consisted of 175 patients with a total of 186 endoscopically proven gastric cancer lesions. All patients underwent dynamic MDCT (arterial and venous phase) for preoperative staging and underwent surgery or endoscopic treatment. In 129 patients (135 lesions) who were also examined using endoscopic ultrasound, the T staging accuracy was also compared between the two modalities. Two endoscopists independently evaluated the lesion detection rate on virtual gastroscopy images alone and determined the T stage on virtual gastroscopy with MPR images. The T staging included the ability to differentiate T1a from T1b lesions. RESULTS: The overall lesion detection rate was 67.7% (126/186). The detection rates of T1a, T1b, and T2 or deeper were 37.8% (28/74), 75.0% (39/52), and 98.3% (59/60), respectively, showing statistically significant differences (p < 0.001). The T staging accuracies were 82.2% (111/135) using virtual gastroscopy with MPR images and 83.7% (113/135) using endoscopic ultrasound, showing no statistically significant difference (p = 0.850). The main causes of over- and understaging were an ulcer or ulcer scar and poorly differentiated adenocarcinomas, non-solid type, respectively. CONCLUSION: Virtual gastroscopy with MPR imaging is a useful modality in the T staging of gastric cancer.

We used contrast-enhanced endoscopic ultrasonography (CE-EUS) to diagnose a case of solid-pseudopapillary neoplasm (SPN) in an adult man. A 58-year-old man was referred to our hospital because of a pancreatic mass found by positron emission tomography (PET) using (18)F-fluorodeoxyglucose (FDG) during a medical checkup in 2009. Trans-abdominal ultrasonography revealed a 24-mm hypoechoic mass at the pancreatic tail with calcification inside. Multiphasic computed tomography (CT) showed a solid mass with delayed enhancement. EUS revealed a hypoechoic mass without lateral shadowing, and neither a septum nor cystic component was detected. CE-EUS using Sonazoid(®) showed a hypovascular mass compared with the surrounding pancreatic parenchyma, and the inside of the mass was enhanced like an alveolus nest, suggesting pseudopapillary change. Diagnosis of a solid-pseudopapillary neoplasm and a concomitant small neuroendocrine tumor was made by distal pancreatectomy.

PURPOSE: S-1 is one of the second-line candidate agents for gemcitabine-refractory unresectable pancreatic cancer. Two phase II studies have been reported for second-line chemotherapy with S-1, but these studies did not investigate introduction rate and suitable dose of second-line S-1. Therefore, we conducted a prospective multicenter study in which chemo-naïve patients were enrolled and had two levels of S-1 dose. METHODS: Chemo-naïve patients with unresectable pancreatic cancer were enrolled. This study started with 80 mg/m(2)/day dose of S-1 as second-line chemotherapy and tolerability was checked. When tolerability was not confirmed in initial patients, the dose of S-1 was shifted to 60 mg/m(2)/day. When tolerability was confirmed at 80 or 60 mg/m(2)/day, the study continued, and up to 20 patients were accumulated with the dose. In addition, the introduction rate of second-line S-1 was examined. RESULTS: Six of the initial 7 patients with 80 mg/m(2)/day dose of S-1 completed one course of second-line chemotherapy. Twenty patients were accumulated with an 80 mg/m(2)/day dose of S-1. With the exception of one patient continued gemcitabine chemotherapy, two of the remaining 19 patients withdrew from this study because of toxicity during the period of gemcitabine chemotherapy. Fifteen of the remaining 17 gemcitabine-refractory patients could complete one course of S-1 as second-line chemotherapy with acceptable toxicity. CONCLUSIONS: This prospective multicenter study showed that 15 (78.9%) out of 19 chemo-naïve unresectable pancreatic cancer patients could complete one course of 80 mg/m(2)/day dose of S-1 as second-line chemotherapy after first-line gemcitabine chemotherapy failure with tolerable toxicity.

副乳頭部カルチノイドは非常に稀な疾患であり、癒合不全に合併した報告はこれまでに10例に満たない。本例は膵管非癒合に合併したために主膵管拡張をきたし診断しえた貴重な症例と考える。またこれまでの報告で副乳頭部カルチノイドでは高率にリンパ節転移を認めるため、積極的に根治的な外科治療を第一選択にすべきであると思われる。(著者抄録)

In the early 2000s, the main stream of endoscopic ultrasonography (EUS) changed from a mechanical scanning method to electronic radial or linear scanning methods. Subsequently, useful applications in trans-abdominal ultrasonography came within reach of EUS. In particular, contrast-enhanced EUS (CE-EUS) and EUS-elastography became cutting-edge diagnostic modalities for pancreatic disorders. Each type of pancreatic disorder has characteristic hemodynamics. CE-EUS uses color Doppler flow imaging and harmonic imaging to classify pancreatic lesions. EUS-elastography can assess tissue hardness by measuring its elasticity. This parameter appears to correlate with the malignant potential of the lesions. Tissue elasticity studies can provide information on both its pattern and distribution. The former is the conventional method of morphological diagnosis, but it is restricted to observations made in a region of interest (ROI). The latter is an unbiased analysis that can be performed by image analysis software and is theoretically constant, regardless of the ROI. Though EUS-fine needle aspiration (FNA) is also a very useful diagnostic tool, there are several limitations. Diagnostic EUS-FNA of pancreatic cystic lesions has marginal utility mainly due to low sensitivity. Therefore, in particular, endoscopists should keep this limitation in mind.

In this case, narrow-band imaging helped to distinguish esophagitis. The case involved an 81-year-old female was being seen as an outpatient because of Gastroesophageal Reflux Disease (GERD) symptoms associated with an esophageal hiatal hernia. Endoscopy showed long reddish lesions on the posterior wall of the lower thoracic esophagus. Non-magnifying endoscopic images with white light initially suggested reflux esophagitis. Magnifying endoscopy with narrow-band imaging showed proliferation of intraepithelial papillary capillary loop-like vessels as well as irregular widening and narrowing of vessels, so the patient's condition was diagnosed as superficial esophageal cancer. Endoscopic submucosal dissection was carried out.

In Asian countries, squamous cell carcinoma is the most common type of esophageal cancer, and the incidence of gastric cancer remains have plateaued. To synthesize current information and to illustrate its clinical benefit of narrow band imaging (NBI) for diagnosis of superficial esophageal squamous carcinoma (SESCC) and early gastric cancer (EGC), a consensus conference was held by a panel of nine experts from Asian-Pacific countries. The expert's agreement suggested importance of interpretation of both vascular architecture and surface structure of the lesions and proper processor settings for endoscopic images. Zoom endoscopy was not regarded as absolutely necessary for detection of SESCC, but magnifying observation provided valuable information for characterization of detected lesions in the esophagus and the stomach. In general, NBI is useful for detection and characterization of SESCC, whereas it is beneficial mainly for characterization of EGC. Chromoendoscopy was found to be still worthwhile in certain situations, such as determination of the extent of SESCC by Lugol's staining, or detection and delineation of EGC by indigo carmine. NBI could replace chromoendoscopy in routine examination because it is easy to use and adds much information to conventional WLI, but it cannot eliminate chromoendoscopy when we make a final diagnosis for treatment decision-making. Consequently, the benefit of NBI or magnifying NBI is specific for the organ and the purpose of the examination, thus optimum indication and usage should be understood for maximum clinical benefit.

Reported herein is the case of a 80-year-old man who had small squamous cell carcinoma in the esophagus. The lesion was initially detected as a irregular reddish elevated and flat area depicted by non-magnified white light endoscopy and observed as a brownish area with the narrow-band imaging system (NBI). The depth of elevated and depressed area in the lesion was predicted to be LSM to MM due to Inoue's classification of morphologic change of intrapapillary capillary loop (IPCL) under magnified NBI observation. The depth of another flat area was not able to predicted by Inoue's classification, and we used Arima's classification. We predicted the depth of invasion to be MM to SM1.by this classification. Endoscopic submucosal dissection (ESD) was carried out for the lesion. As a result, the endoscopic diagnosis completely accorded with pathological diagnosis. We could diagnose correctly by adding Arima's classification to Inoue's classification.

BACKGROUND: Real-time tissue sonoelastography (EG) is a new non-invasive technique that visualizes differences in tissue strain. We evaluated the usefulness of EG in patients with ulcerative colitis (UC) by investigating the association between EG and colonoscopic findings and disease activity. METHODS: Thirty-seven UC patients undergoing EG and colonoscopy were invited to enroll. EG findings were classified as normal, homogeneous, random, or hard, and colonoscopic findings as normal, mucosal edema and erosion, punched-out ulcer, and extensive mucosal abrasion. Clinical findings were evaluated using clinical activity index (CAI) scores for each patient at colonoscopy. RESULTS: On EG, 10 cases were classified as normal, 11 as homogeneous, 6 as random, and 10 as hard. EG findings showed a significant correlation those of colonoscopy (p < 0.001). Seven of 10 (70%) normal-type patients were in the remission phase, while all 6 random-type patients were in the active phase. Among active-phase patients, 4 of 7 (57%) homogeneous-type patients responded to steroid or leukocytapheresis therapy, while 3 of 6 (50%) random-type patients required treatment with cyclosporine. Three of 10 (30%) hard-type patients required colectomy. CONCLUSIONS: In this small series, EG findings reflected colonoscopic findings and correlated with disease activity among patients with UC.

Backgrounds/Aims: A prospective correlation study of symptomatic changes due to administration of prokinetic drugs and changes of transit time of capsule endoscopy (CE), for patients with constipation-predominant irritable bowel syndrome (IBS-C), and examination of usefulness of CE in the objective evaluation of IBS-C. Methodology: Mosapride citrate was administered to ten subjects and CE transit evaluated together with a symptom questionnaire before and after administration. Frequency and severity of abdominal pain, times of defecation and Bristol stool scales were listed and scored. Primary and secondary endpoints were the correlation between symptomatic changes due to the administration and changes of CE transit and the effect of mosapride citrate on IBS-C, CE findings, and gastric and small bowel transit time (GTT, SBTT). Results: After administration for 4 weeks, the mean scores of evaluated symptoms all improved. GTT was not significantly changed, but SBTT showed significant shortening post-administration (p=0.02). In only one patient&apos;s CE, three small erosions were detected. The changes in the times of defecation before and after the administration were significantly correlated with those in the SBTT of CE (R=0.888, p=0.0006). However, other symptoms were not significantly correlated with SBTT. Conclusions: CE transit correlated with intestinal motility in symptomatic changes and could be a possible index for the objective assessment of motility in IBS-C.