CURRENT STATUS OF DOUBLE BALLOON ENDOSCOPY

Yamamoto and colleagues have developed a novel insertion method of the endoscope, the ‘double balloon method’ for enteroscopy and, recently, a specialized system for the ‘double balloon method’ has been commercialized by Fujinon. The double balloon endoscopy enables visualization of the entire small bowel and also allows for interventional therapy in the small intestine. This method could be used either from the oral or anal approach. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, hemostasis, balloon dilatation, stent placement, polypectomy, and endoscopic mucosal resection. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

SURVEILLANCE BY MAGNIFYING ENDOSCOPY IN PATIENTS WITH ULCERATIVE COLITIS

Background: Patients with total or left‐sided ulcerative colitis (UC) for more than 10 years have an increased risk of colon cancer. We studied usefulness of magnifying chromoendoscopy for the surveillance of dysplasia and colitic cancer associated with UC. Methods: From April 2003 through February 2004, 39 patients who had total or left‐sided UC for at least 7 years were prospectively enrolled in an endoscopic surveillance program, including target biopsy. All patients were examined by chromoendoscopy and magnifying endoscopy. Sites showing abnormal mucosal surface patterns or pit patterns suggestive of dysplasia underwent biopsy. Results: Of the 39 patients, 26 had total UC and 13 left‐sided UC. The mean time elapsed since the onset of UC was 16.2 ± 5.9 years. Disease activity at examination was remission in 22 patients, mild in 15, and moderate in two. Dysplasia was diagnosed in two patients (three lesions), dysplastic changes were suspected in two (two lesions), and sporadic adenoma was diagnosed in four (five lesions). On endoscopic examination, dysplasia appeared as flat elevated lesions with types IIIl and IV pit patterns. Resected specimens showed low‐to‐high‐grade dysplasia. The four patients presenting with a type III to IV mucosal pit pattern during remission were evaluated as sporadic adenoma on pathological findings. Conclusions: A combination of chromoendoscopy and magnifying endoscopy is useful for the detection of dysplasia and colitic cancer in patients with UC.     

A REVIEW OF CURRENT CLINICAL APPLICATIONS OF UPPER GASTROINTESTINAL ZOOM ENDOSCOPY

Current clinical applications of upper gastrointestinal (GI) zoom endoscopy were reviewed. The objective of upper GI zoom endoscopy has been the diagnosis of neoplastic lesions as well as the diagnosis of minute inflammatory mucosal change. The target organ and pathology of the neoplastic lesions have been squamous cell carcinoma in the oro‐ and hypo‐pharynx and in the esophagus; intestinal metaplasia, dysplasia, and adenocarcinoma in Barrett's esophagus; and adenocarcinoma in the stomach. For analyzing the magnified endoscopic findings, there were two different basic principles (mucosal microstructural change and subepithelial microvascular changes). Overall diagnostic accuracy for diagnosing a neoplastic lesion was above 80% throughout the upper GI tract. Although the diagnostic accuracy of the zoom endoscopy technique seems to be superior to that of the ordinary endoscopy technique alone, the continuous efforts to establish standardized guidelines and procedures are mandatory in order to lead to the routine use of upper GI zoom endoscopy in clinical practice.     

LONG INTESTINAL TUBE INSERTION WITH THE ROPEWAY METHOD FACILITATED BY A GUIDEWIRE PLACED BY TRANSNASAL ULTRATHIN ENDOSCOPY FOR BOWEL OBSTRUCTION

Aim: For patients with bowel obstruction, intestinal decompression by a long tube is recommended. We assessed the usefulness of a new technique for insertion of a long tube with a guidewire placed by transnasal ultrathin endoscopy. Methods: Nineteen patients who had been diagnosed as suffering from bowel obstruction underwent long‐tube insertion with the ropeway technique using a guidewire placed by transnasal endoscopy. Thirty‐three patients who had undergone conventional insertion of a long tube were included as controls. The success rate of intubation of the small bowel and the time required for the procedure were compared between the subjects and controls. Results: The success rate of intubation was 94.7% (18/19) in subjects and 84.8% (28/33) in controls (P = 0.53). The time required for insertion in the subjects and controls was 24.1 ± 8.1 min and 48.7 ± 25.3 min, respectively, with a statistically significant difference (P < 0.001). No complications relevant to the procedure were encountered in either of the groups. Conclusion: Long‐tube insertion facilitated by transnasal endoscopy reduces the time required for insertion in comparison with the conventional technique without endoscopy. Endoscopy‐assisted long‐tube insertion with the ropeway method is a safe and useful procedure for decompression in patients with bowel obstruction.     

QUANTITATIVE ANALYSIS OF LOW‐DOSE ASPIRIN‐ASSOCIATED SMALL BOWEL INJURY USING A CAPSULE ENDOSCOPY SCORING INDEX

Aim: The major limitation of capsule endoscopy (CE) has been the lack of a standardized and validated severity scale for mucosal injury. The aim of the present study was to verify the usefulness of quantifying small bowel mucosal changes associated with giving low‐dose aspirin (LDA) using a CE scoring index. Methods: The CE score for small bowel mucosal injury was investigated to evaluate the severity of mucosal injury. Healthy volunteers and patients suspected of having small bowel disease were recruited for this study. The short‐term LDA group (V + S‐LDA group) consisted of volunteers who took low‐dose aspirin for 14 days; this group was then compared with healthy volunteers who did not receive LDA treatment (V‐Control group). The long‐term LDA group (L‐LDA group) consisted of patients with at least a 3‐month history of daily LDA use; this group was compared with non‐users of LDA (P‐Control group). Results: The CE score was significantly higher in the V + S‐LDA group than in the V‐Control group. In the V‐Control group, almost all the subjects were categorized as exhibiting a ‘normal’ change. ‘Mild’ changes were observed significantly more frequently in the V + S‐LDA group than in the V‐Control group. The CE score was significantly higher in the L‐LDA group than in the P‐Control group. ‘Mild’ or ‘moderate or severe’ changes were observed significantly more frequently in the L‐LDA group than in the P‐Control group. Conclusion: The CE scoring system was useful for evaluating LDA‐associated small bowel mucosal disease activity and for objectively scoring the small bowel inflammatory disease state.     

结肠镜检查394例老人下消化道出血结果分析

引起老年人下消化道出血的常见病因依次为大肠癌（７７例），大肠息肉（７３例），结肠炎症（６６例），痔核等肛周病变（５５例），结肠动静脉畸形（１４例），溃疡性结肠炎等病变（４５例）。未发现病变者（６４例）。３１例大肠癌发生在横结肠至盲肠，提示老年人右半结肠癌并非少见。１９例大肠癌系由腺瘤性息肉恶变所致。５１例大肠息肉及２３例多发性息肉发生在左半结肠，提示老年人息肉或多发性息肉仍以左半结肠多见。为防止息肉恶变，对老年人大肠息肉应尽早行电凝切除术。结肠镜未能发现病因的６４例中，１５例出血系空、回肠病变所致。     

NOVEL AUTOFLUORESCENCE VIDEOENDOSCOPY IMAGING SYSTEM FOR DIAGNOSIS OF CANCERS IN THE DIGESTIVE TRACT

An autofluorescence (AF) endoscopy system produces real‐time pseudocolor images from computation of detecting natural tissue fluorescence from endogenous fluorophores that is emitted by excitation light. The system could specify lesions including malignancies by difference in tissue fluorescence properties and reveal early stage neoplasia not detectable by conventional white light (WL) endoscopy. Image quality of the prior autofluorescence imaging systems including fiber‐optic endoscope was not feasible for general clinical use. The authors investigated the clinical utility of the novel videoendoscopy system using a combination of autofluorescence and reflection imaging (AFI) in diagnosis of cancers in the digestive tract. AFI represented early stage cancers in the digestive tract as purple or magenta areas in a green background. The undifferentiated type early gastric cancers in the fundic mucosa showed a unique pattern; green areas in a purple background. Ulcerations or inflammation caused over‐diagnosis in the AF observation. AFI could reveal flat or isochromatic extensions that were not evident in the WL images. Because the current system of AFI has limitations on resolution and accuracy comparing with chromoendoscopy, it has much to be improved for a good adjunct to standard WL videoendoscopy for diagnosing of early stage digestive tract cancers.     

USEFULNESS OF DOUBLE BALLOON ENTEROSCOPY AND VIDEO CAPSULE ENDOSCOPY FOR THE DIAGNOSIS AND MANAGEMENT OF PRIMARY FOLLICULAR LYMPHOMA OF THE GASTROINTESTINAL TRACT IN ITS EARLY STAGES

Aim: The aim of this study is to evaluate the usefulness of double balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in patients with primary follicular lymphoma (FL) of the gastrointestinal (GI) tract. Furthermore, we estimate the effectiveness of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) including rituximab for them. Methods: Thirteen consecutive patients who were diagnosed of having FL in the duodenum between July 2005 and September 2008 were studied. All patients were given the conventional staging examinations, including total enteroscopy using DBE and/or VCE procedures. Chemotherapy was performed after written informed consent. Response assessment was performed every 6‐12 months. The median follow‐up period was 30.2 months. Results: FL was diagnosed in each patient as low grade (grade 1, n = 7; 2, n = 6) and, in all but 4 patients, localized lymphoma (stage I, n = 8; II₁, n = 1; II₂, n = 4). DBE revealed multifocal lesions in the jejunum in 10 of the patients, and in the ileum in 6. VCE showed similar findings in the jejunum in the recent 2 patients. Eleven of 13 patients finally received chemotherapy, and all of them achieved complete regression. They showed no evidence of recurrence after that. Conclusion: Total examination of the small intestine using DBE should be performed before treatment to choose a suitable treatment procedure for primary FL of the GI tract. On the other hand, VCE is useful for screening and following the small intestine in the patients with it. Chemotherapy is effective to achieve complete regression of primary FL of the GI tract.     

ENDOSCOPIC FINDINGS OF ENTEROPATHY‐TYPE T‐CELL LYMPHOMA BY DOUBLE‐BALLOON ENTEROSCOPY AND CAPSULE ENDOSCOPY

Enteropathy‐type T‐cell lymphoma (ETL) is a rare primary intestinal disorder, particularly in Japan, and there have been few reports on the endoscopic findings of the disease. Here we report detailed endoscopic findings of ETL based on double‐balloon enteroscopy and capsule endoscopy. Double‐balloon enteroscopy and capsule endoscopy may be useful tools for diagnosing and monitoring the effects of therapy in patients with ETL.     

ULTRATHIN ENDOSCOPE‐ASSISTED ERCP FOR INACCESSIBLE PERIDIVERTICULAR PAPILLA BY A SINGLE‐BALLOON ENTEROSCOPE IN A PATIENT WITH ROUX‐EN‐Y ANASTOMOSIS

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux‐en Y (R‐Y). A 73‐year‐old man who had total gastrectomy with R‐Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre‐cutting, the ultraslim endoscope was replaced with a conventional forward‐viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure‐related complication.     

磁共振胆胰管成像对老年性胆总管扩张患者诊断价值

目的老年性胆总管扩张患者磁共振胆胰管成像（magnetic resonance cholangiopancreatography，MRCP）的诊断和鉴别诊断价值评估。方法回顾性分析197例老年性胆总管扩张患者MRCP检查及临床诊断与治疗结果进行比较。结果MRCP诊断为胆总管下端结石68例，急性胆囊炎，胆囊结石伴胆总管扩张57例，胆囊切除术后改变38例，胆囊颈管结石22例，胆道系统肿瘤7例，胰腺占位性病变5例，诊断符合率99．5％结论MRCP在老年性胆总管扩张的病因诊断和鉴别诊断中有重要价值。     

CLINICAL EVALUATION OF EMERGENCY ENDOSCOPIC HEMOSTASIS WITH BIPOLAR FORCEPS IN NON‐VARICEAL UPPER GASTROINTESTINAL BLEEDING

The present study was designed to evaluate the usefulness and safety of bipolar hemostatic forceps, known as a less invasive and highly safe means of thermal coagulation used for hemostasis in cases of non‐variceal upper gastrointestinal bleeding. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis. The study involved 39 cases where hemostasis was attempted with bipolar forceps to deal with non‐variceal upper gastrointestinal bleeding, including 28 cases of gastric ulcer, six cases of duodenal ulcer, three cases of bleeding after endoscopic submucosal dissection (ESD), one case of Mallory‐Weiss syndrome and one case of postoperative bleeding from the anastomosed area. There were 34 males and five females, with a mean age of 63.6 years. Bipolar forceps were the first‐line means of hemostasis in cases of oozing bleeding (venous bleeding), pulsatile or spurting bleeding (arterial bleeding) and exposed vessels without active bleeding. The primary hemostasis success rate was 92.3%, and the re‐bleeding rate was 0%. In cases where the bleeding site was located along the tangential line or in cases where large respiration‐caused motions hampered identification of the bleeding site, hemostasis by means of coagulation was easily effected by application of electricity while the forceps were kept open and compressed the bleeding area. In addition, there were no complications. This technique of bipolar forceps is simple, safe and unlikely to induce complications, and is therefore promising as a new technique of endoscopic hemostasis.     

BLUE RUBBER BLEB NEVUS SYNDROME: TREATMENT OF MULTIPLE GASTROINTESTINAL HEMANGIOMAS WITH ARGON PLASMA COAGULATOR

Blue rubber bleb nevus syndrome is a rare clinical entity characterized by the formation of multiple blue or purplish rubbery cavernous hemangiomas on the skin and other epithelial surfaces. Involvement of the gastrointestinal tract is common and often presents with crippling anemia as a result of chronic occult blood loss. While surgical extirpation is an option for symptomatic hemangiomas in the intestine, endoscopic therapy is more appealing for lesions found in the stomach and colon. Here we report the successful use of argon plasma coagulation in the management of an adult with multiple hemangiomas in her colon and terminal ileum.     

ENDOSCOPIC PANCREATIC SPHINCTEROTOMY PLUS LARGE‐BALLOON DILATION FOR REMOVAL OF A LARGE IMPACTED PANCREATIC DUCT STONE (WITH VIDEO)

Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large‐balloon dilation in combination with pancreatic sphincterotomy. A 63‐year‐old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire‐guided pull‐type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20‐mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure‐related complication.