ABSTRACT Background Immune checkpoint inhibitors have demonstrated efficacy against various cancers; however, there is a rising incidence of immune‐related colitis. Some cases of immune‐related colitis prove resistant to treatment, even with the administration of glucocorticoids or infliximab, and there is currently no established standard treatment for such cases. Case The patient, a 73‐year‐old male, had undergone combination therapy for malignant pleural mesothelioma for 2 years, utilizing both ipilimumab (a CTLA‐4 inhibitor) and nivolumab (a PD‐1 inhibitor). Unfortunately, the treatment led to side effects, specifically immune‐related adverse event (irAE) enterocolitis. Steroid and infliximab treatment failed to improve the patient's condition. Treatment with tacrolimus was attempted, but the patient remained unresponsive. Subsequently, 45 mg of upadacitinib, a Janus kinase (JAK) inhibitor, was administered. Symptoms improved rapidly following upadacitinib administration, and endoscopy also revealed positive results. With the increasing incidence of immune‐related colitis, some patients have become resistant to treatment with glucocorticoids and infliximab. In this case, the irAE enterocolitis was improved by upadacitinib administration. Conclusion In cases where immune‐related colitis proves resistant to treatment with glucocorticoids, infliximab, or tacrolimus, upadacitinib represents a potential option as a JAK inhibitor.

Introduction: Ustekinumab is an IgG1 kappa monoclonal antibody directed against the common p40 subunit of interleukin-12 and interleukin-23, which activate Th1- and Th17-mediated immune responses, respectively. It has proven efficacy for the treatment of moderate to severe ulcerative colitis (UC) in the UNIFI Phase III clinical trial; however, data on its efficacy in the real world is limited. In this study, we aimed to assess the real-world efficacy of ustekinumab.Methods: This observational study included 30 patients with UC who received ustekinumab from April 2020 to April 2022. We examined demographic information, disease type and activity (Mayo score, partial Mayo score [PMS]), use of biologics, concomitant use of predonisolone (PSL), 8-week ustekinumab clinical response rate, remission induction rate, 44- and 152-week remission maintenance rate, continuation rate, and 44-week steroid-free remission rate. The primary outcomes were the short- and long-term efficacy of ustekinumab.Results: Included patients (53% women; mean age: 41.2 years [16–80 years]) had an average disease duration of 86 weeks. Mayo’s score (median) was 7.4 and the PMS was 5.4. Two (7%), 24 (80%), and four (13%) patients had a Mayo endoscopic sub-score (MES) of MES1, MES2, and MES3, respectively. The median serum CRP was 1.0 mg/dL. Five patients had no history of biotherapy (naive), while 8 and 17 had a history of one and two or more biologic agents, respectively. Eight patients were PSL-resistant and 22 were PSL-dependent. The 8-week clinical response rate was 73%, and the clinical remission induction rate was 70%. The remission maintenance rates at 44 and 152 weeks were 67% and 63%, respectively. The ustekinumab retention rate was 67% (86-week mean follow-up period). Regarding biologic failure cases, the clinical response rate in the failure group with up to one biologic agent (including naive cases) was 84.6%, which was higher than the 58.0% rate in the failure group with two or more biologic agents (p=0.06). Steroid-free remission rates at 44 and 152 weeks were 63% each. In the logistic regression analysis parameters for discontinuation of ustekinumab, only PMS remained significant after multivariate analysis (p=0.018).Conclusion: Our study showed short-term and long-term ustekinumab effectiveness, especially with comparative low disease activity.

Abstract Background and Aim Serum leucine‐rich alpha‐2 glycoprotein level has been reported to be a useful biomarker in assessing mucosal healing in patients undergoing biotherapy, where mucosal lesions caused by ulcerative colitis are difficult to assess endoscopically. However, no such reports have been reported in biotherapy‐naïve cases. Methods Sixty‐eight patients with ulcerative colitis (UC) who were biotherapy‐naïve at Kindai University Hospital between October 2021 and October 2022 were enrolled. We prospectively examined the correlation between leucine‐rich alpha‐2 glycoprotein (LRG), C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR), and Geboes scores with clinical endoscopic activity using the Mayo endoscopic subscore (MES). Results Mucosal healing was achieved in 39 (57%) patients. Univariate analysis revealed that the factors associated with mucosal healing were LRG (P = 0.0024), CRP (P = 0.1078), ESR (P = 0.0372), and Geboes scores (P = 0.0075). Logistic regression analysis identified LRG and Geboes scores as independent factors associated with mucosal healing assessed using MES (P = 0.0431 for LRG and P = 0.0166 for Geboes scores). Conclusion LRG was found to be the easiest marker to monitor disease activity and mucosal inflammation in UC patients with biotherapy‐naïve cases, with a performance equivalent to that of Geboes scores.

A 76-year-old woman presented with lower abdominal pain and nausea and was referred to the gastroenterology department in our institution. Previous contrast-enhanced computed tomography (CE-CT) for follow-up after breast cancer surgery had indicated a soft tissue mass below the right diaphragm, which was considered a benign change. CE-CT performed at the first visit to our department revealed further thickening of the soft tissue mass with extension to the liver surface. In addition, ascites and nodules were observed in the abdominal cavity. Histopathological examination of a biopsy specimen revealed peritoneal invasion of atypical epithelioid cells with trabecular and glandular patterns. The tumor cells were positive for AE1/AE2, calretinin, WT-1, D2-40, HEG1, EMA, BAP1, and MTAP and negative for carcinoembryonic antigen, MOC-31, Ber-Ep4, ER, PgR, TTF-1, claudin 4, and desmin. A diagnosis of epithelioid mesothelioma was made. The patient received chemotherapy with cisplatin (75 mg/m2) and pemetrexed (500 mg/m2). After six courses of combined chemotherapy, pemetrexed was administered as a single agent. At the time of writing this report, she was undergoing over the 30th course of chemotherapy without any significant side effects. Diffuse malignant peritoneal mesothelioma is a rare, fatal, and progressive disease. Our patient achieved long-term survival of more than 5 years with maintenance therapy using single-agent pemetrexed.

<b><i>Introduction:</i></b> Sessile serrated lesions (SSLs) have malignant potential for colorectal cancer in the serrated pathway. Selective endoscopic resection of SSLs would reduce medical costs and procedure-related accidents, but the accurate endoscopic differentiation of SSLs from hyperplastic polyps (HPs) is challenging. To explore the differential diagnostic performance of magnifying colonoscopy in distinguishing SSLs from HPs, we conducted a multicenter prospective validation study in clinical practice. <b><i>Methods:</i></b> Considering the rarity of diminutive SSLs, all lesions ≥6 mm that were detected during colonoscopy and diagnosed as type 1 based on the Japan narrow-band imaging expert team (JNET) classification were included in this study. Twenty expert endoscopists were asked to differentiate between SSLs and HPs with high or low confidence level after conventional and magnifying NBI observation. To examine the validity of selective endoscopic resection of SSLs using magnifying colonoscopy in clinical practice, we calculated the sensitivity of endoscopic diagnosis of SSLs with histopathological findings as comparable reference. <b><i>Results:</i></b> A total of 217 JNET type 1 lesions from 162 patients were analyzed, and 114 lesions were diagnosed with high confidence. The sensitivity of magnifying colonoscopy in detecting SSLs was 79.8% (95% confidence interval [CI]: 74.7–84.4%) overall, and 82.4% (95% CI: 76.1–87.7%) in the high-confidence group. These results showed that the sensitivity of this study was not high enough, even limited in the high-confidence group. <b><i>Conclusions:</i></b> Accurate differential diagnosis of SSLs and HPs using magnifying colonoscopy was challenging even for experts. JNET type 1 lesions ≥6 mm are recommended to be resected because selective endoscopic resection has a disadvantage of leaving approximately 20% of SSLs on site.

BACKGROUND: The standard therapy for acute severe ulcerative colitis (ASUC) is intravenous corticosteroids; however, 30% of ulcerative colitis (UC) patients do not recover with corticosteroids alone. Few studies have reported the efficacy and safety of tofacitinib for ASUC with steroid resistance. We report a case series of successful first-line treatment consisting of tofacitinib (20 mg/day) administered to ASUC patients with steroid resistance. METHODS: Patients diagnosed with ASUC at our institution between October 2018 and February 2020 were retrospectively evaluated. They were administered a high dose of tofacitinib (20 mg) after showing no response to steroid therapy in a dose of 1-1.5 mg/kg/day. RESULTS: Eight patients with ASUC, 4 (50%) men, median age 47.1 (range 19-65) years, were included. Four patients were newly diagnosed, and the median UC duration was 4 (range 0-20) years. Six of the 8 patients were able to avoid colectomy. One patient (patient 2) had no response; however, remission was achieved after switching from tofacitinib to infliximab. One patient (patient 6) with no response to tofacitinib underwent total colectomy. Only one patient (patient 4) experienced an adverse event, local herpes zoster, treated with acyclovir without tofacitinib discontinuation. CONCLUSIONS: Clinical remission without serious adverse events can be achieved with high probability and colectomy can be avoided by first administering high-dose tofacitinib to steroid-resistant ASUC patients. Tofacitinib may be one of the first-line treatment options for steroid-resistant ASUC.

BACKGROUND: Total colectomy is the standard treatment for familial adenomatous polyposis (FAP). Recently, an increasing number of young patients with FAP have requested the postponement of surgery or have refused to undergo surgery. We aimed to evaluate the effectiveness of intensive endoscopic removal for downstaging of polyp burden (IDP) in FAP. METHOD: A single-arm intervention study was conducted at 22 facilities. Participants were patients with FAP, aged ≥ 16 years, who had not undergone colectomy or who had undergone colectomy but had ≥ 10 cm of large intestine remaining. For IDP, colorectal polyps of ≥ 10 mm were removed, followed by polyps of ≥ 5 mm. The primary end point was the presence/absence of colectomy during a 5-year intervention period. RESULTS: 222 patients were eligible, of whom 166 had not undergone colectomy, 46 had undergone subtotal colectomy with ileorectal anastomosis, and 10 had undergone partial resection of the large intestine. During the intervention period, five patients (2.3 %, 95 % confidence interval [CI] 0.74 %-5.18 %) underwent colectomy, and three patients died. Completion of the 5-year intervention period without colectomy was confirmed in 150 /166 patients who had not undergone colectomy (90.4 %, 95 %CI 84.8 %-94.4 %) and in 47 /56 patients who had previously undergone colectomy (83.9 %, 95 %CI 71.7 %-92.4 %). CONCLUSION: IDP in patients with mild-to-moderate FAP could have the potential to be a useful means of preventing colorectal cancer without implementing colectomy. However, if the IDP protocol was proposed during a much longer term, it may not preclude the possibility that a large proportion of colectomies may still need to be performed.

Aspirin has gained great attention as a cancer preventive agent. Our previous study revealed that the low-dose aspirin prevents colorectal tumor recurrence in Japanese patients with colorectal adenomas and/or adenocarcinomas, whereas aspirin increases risks in smokers and has no effects on regular drinkers. Our recent study revealed that aspirin reduces polyp growth in Japanese patients with familial adenomatous polyposis (FAP). In this study, we have studied the association of genotypes of alcohol metabolizing enzymes (ADH1B and ALDH2) on aspirin's efficacy of suppressing polyp growth (≥5 mm) in a total of 81 Japanese patients with FAP. Our study revealed that aspirin showed significant preventive effects for patients with ADH1B-AA and AA+GA types [OR = 0.21; 95% confidence interval (CI), 0.05–0.95, and OR = 0.31; 95% CI, 0.10–0.95, respectively], and for patients with ALDH2-GG and GG+GA types (OR = 0.10; 95% CI, 0.01–0.92, and OR = 0.29; 95% CI, 0.09–0.94, respectively), but not for patients with ADH1B-GG and GA+GG types, and ALDH2-AA and GA+AA types. In addition, substantial preventive effects of aspirin were seen for patients with ADH1B-AA type who do not drink regularly (&lt;3 times/week, OR = 0.11; 95% CI, 0.02–0.78), where a statistically significant interaction between aspirin and ADH1B was observed (Pinteraction = 0.036). Results from this exploratory study strongly indicate that aspirin is beneficial in prevention of polyp growth for patients with FAP with ADH1B-AA and AA+GA types, and ALDH2-GG and GG+GA types. Taken together, we propose ADH1B and ALDH2 as candidate markers for the personalized prevention by aspirin. Significance: Aspirin is beneficial to patients with FAP with ADH1B-AA and AA+GA types or ALDH2-GG and GG+GA types. ADH1B and ALDH2 genotypes can be the markers for the personalized prevention of colorectal cancer by aspirin.

BACKGROUND: This is the first report from a multicenter prospective cohort study of colorectal neuroendocrine tumor (NET), the C-NET STUDY, conducted to assess the long-term outcomes of the enrolled patients. This report aimed to elucidate the clinicopathological features of the enrolled patients and lesions. METHODS: Colorectal NET patients aged 20-74 years were consecutively enrolled and followed up at 50 institutions. The baseline characteristics and clinicopathological findings at enrollment and treatment were assessed. RESULTS: A total of 495 patients with 500 colorectal NETs were included. The median patient age was 54 years, and 85.3% were asymptomatic. The most frequent lesion location was the lower rectum (88.0%); 99.4% of the lesions were clinically diagnosed to be devoid of metastatic findings, and 95.4% were treated with endoscopic resection. Lesions < 10 mm comprised 87.0% of the total, 96.6% had not invaded the muscularis propria, and 92.6% were classified as WHO NET grade 1. Positive lymphovascular involvement was found in 29.2% of the lesions. Its prevalence was high even in small NETs with immunohistochemical/special staining for pathological assessment (26.4% and 40.9% in lesions sized < 5 mm and 5-9 mm, respectively). Among 70 patients who underwent radical surgery primarily or secondarily, 18 showed positive lymph node metastasis. CONCLUSIONS: The characteristics of real-world colorectal NET patients and lesions are elucidated. The high positivity of lymphovascular involvement in small NETs highlights the necessity of assessing the clinical significance of positive lymphovascular involvement based on long-term outcomes, which will be examined in later stages of the C-NET STUDY. TRIAL REGISTRATION NUMBER: UMIN000025215.

Convolutional neural networks (CNNs) are widely used for artificial intelligence (AI)-based image classification. Residual network (ResNet) is a new technology that facilitates the accuracy of image classification by CNN-based AI. In this study, we developed a novel AI model combined with ResNet to diagnose colorectal polyps. In total, 127,610 images consisting of 62,510 images with adenomatous polyps, 30,443 with non-adenomatous hyperplastic polyps, and 34,657 with healthy colorectal normal mucosa were subjected to deep learning after annotation. Each validation process was performed using 12,761 stored images of colorectal polyps by a 10-fold cross validation. The efficacy of the ResNet system was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy. The sensitivity, specificity, PPV, NPV, and diagnostic accuracy for adenomatous polyps at WLIs were 98.8%, 94.3%, 90.5%, 87.4%, and 92.8%, respectively. Similar results were obtained for adenomatous polyps at narrow-band imagings (NBIs) and chromoendoscopy images (CEIs) (NBIs vs. CEIs: sensitivity, 94.9% vs. 98.2%; specificity, 93.9% vs. 85.8%; PPV, 92.5% vs. 81.7%; NPV, 93.5% vs. 99.9%; and overall accuracy, 91.5% vs. 90.1%). The ResNet model is a powerful tool that can be used for AI-based accurate diagnosis of colorectal polyps.

Given that sustained remission is the ultimate treatment goal in the management of patients with ulcerative colitis (UC), the decision to stop anti-tumor necrosis factor (anti-TNF) treatment in UC patients is difficult. The aim of this study was to evaluate mucosal microbiota and gene expression profiles associated with long-term remission after discontinuation of anti-TNF therapy. In nine UC patients who received anti-TNF therapy for 6 months, microbiota isolated from uninflamed mucosae and gene expression in inflamed and uninflamed mucosae were investigated at week 0 and at week 24. At treatment initiation, Fusobacterium sp. and Veillonella dispar were over-represented in the relapse group compared with the non-relapse group. After treatment, Dorea sp. and Lachnospira sp. were over-represented in the non-relapse group. In the relapse group only, a significant shift in gut bacterial community composition was found between week 0 and week 24. Gene expression of ALIX (PDCD6IP) and SLC9A3 was significantly higher in the non-relapse group than in the relapse group. Lastly, we used machine learning methods to identify relevant gene signatures associated with sustained remission. Statistical analyses of microbiota and expression profiles revealed differences between UC patients who did or did not keep remission after the discontinuation of TNF inhibitors. Trial registration: UMIN000020785: Evaluation of adalimumab therapy in mesalazine-resistant or -intolerant ulcerative colitis; an observational study (EARLY study).

Five years have passed since the Japan Narrow Band Imaging Expert Team (JNET) classification was proposed in 2014. However, the diagnostic performance of this classification has not yet been established. We conducted a retrospective study and a systematic search of Medical Literature Analysis and Retrieval System On-Line. There were three retrospective single center studies about the diagnostic performance of this classification. In order to clarify this issue, we reviewed our study and three previous studies. This review revealed the diagnostic performance in regards to three important differentiations. (1) Neoplasia from non-neoplasia; (2) malignant neoplasia from benign neoplasia; and (3) deep submucosal invasive cancer (D-SMC) from other neoplasia. The sensitivity in differentiating neoplasia from non-neoplasia was 98.1%-99.8%. The specificity in differentiating malignant neoplasia from benign neoplasia was 84.7%-98.2% and the specificity in the differentiation D-SMC from other neoplasia was 99.8%-100.0%. This classification would enable endoscopists to identify almost all neoplasia, to appropriately determine whether to perform en bloc resection or not, and to avoid unnecessary surgery. This article is the first review about the diagnostic performance of the JNET classification. Previous reports about the diagnostic performance have all been retrospective single center studies. A large-scale prospective multicenter evaluation study is awaited for the validation.

BACKGROUND: Risk factors for local recurrence after polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) have not been identified. Additionally, the appropriate interval for endoscopic surveillance of colorectal tumors at high-risk of local recurrence has not been established. AIM: To clarify the clinicopathological characteristics of recurrent lesions after endoscopic colorectal tumor resection and determine the appropriate interval. METHODS: Three hundred and sixty patients (1412 colorectal tumors) who underwent polypectomy, EMR, or ESD and received endoscopic surveillance subsequently for more than one year to detect local recurrence were enrolled in this study. The clinicopathological factors associated with local recurrence were determined via univariate and multivariate analyses. RESULTS: Local recurrence was observed in 31 of 360 (8.6%) patients [31 of 1412 (2.2%) lesions] after colorectal tumor resection. Piecemeal resection, tumor size of more than 2 cm, and the presence of villous components were associated with colorectal tumor recurrence after endoscopic resection. Of these three factors, the piecemeal resection procedure was identified as an independent risk factor for recurrence. Colorectal tumors resected into more than five pieces were associated with a high risk of recurrence since the average period from resection to recurrence in these cases was approximately 3 mo. The period to recurrence in cases resected into more than 5 pieces was much shorter than that in those resected into less than 4 pieces (3.8 ± 1.9 mo vs 7.9 ± 5.0 mo, P < 0.05). CONCLUSION: Local recurrence of endoscopically treated colorectal tumors depends upon the outcome of first endoscopic procedure. Piecemeal resection was the only significant risk factor associated with local recurrence after endoscopic resection.

BACKGROUND: Although Gankyrin is overexpressed in many malignancies, the role of Gankyrin for tumorigenesis and chemoresistance remains to be elucidated in sporadic colorectal cancer (CRC). AIMS: We investigate whether Gankyrin affects Adenomatous polyposis coli (Apc) inactivation-induced tumorigenesis and therapeutic response to anti-angiogenic agents. METHODS: Epithelial cell-specific APC and/or Gankyrin-deficient mice were used. The patients with metastatic CRC (n = 53) who were enrolled in this study underwent resection of primary cancer followed by systemic chemotherapy containing bevacizumab. We determined whether gene expression in CRC tissues before chemotherapy is associated with radiological responses. RESULTS: Deletion of Gankyrin in epithelial cell reduced the expression of c-Myc, a critical mediator of the APC signaling pathway, and interleukin-6. Gankyrin deficiency decreased the expression of Bmi1, a downstream molecule of c-Myc, and the activity of V-Akt murine thymoma viral oncogene homolog and extracellular signal-regulated protein kinase, leading to reduced Apc inactivation-induced tumorigenesis. Of 53 patients, 38 (72%) had increased Gankyrin expression in tumor cells. The enhanced Gankyrin expression in tumor cells was associated with unfavorable progression-free survival (log-rank test p = 0.026). CONCLUSION: Gankyrin in epithelial cell contributes to the development of sporadic CRC and the expression could serve as a biomarker to predict therapeutic response in patients with metastatic CRC.

Autoimmune diseases including inflammatory bowel disease (IBD) occur in association with myelodysplastic syndrome (MDS). MDS-associated IBD frequently demonstrates a complicated course. We herein report the first case with MDS-associated IBD that was successfully treated with ustekinumab (UST), an anti-interleukin (IL) 12/23p40 monoclonal antibody. A 63-year-old man with a 7-year history of MDS was referred for examination of diarrhea, abdominal pain and fever. A blood examination revealed a marked elevation of C-reactive protein. Colonoscopy showed multiple ulcers in the terminal ileum. He was resistant to anti-tumor necrosis factor (TNF)-α antibody and azacitidine. Subsequently, UST treatment reduced colonic IL-17 and IL-6 expression and the patient currently maintains a state of remission.

OBJECTIVE: To investigate the success rate of cold snare polypectomy (CSP) for complete resection of 4-9 mm colorectal adenomatous polyps compared with that of hot snare polypectomy (HSP). DESIGN: A prospective, multicentre, randomised controlled, parallel, non-inferiority trial conducted in 12 Japanese endoscopy units. Endoscopically diagnosed sessile adenomatous polyps, 4-9 mm in size, were randomly assigned to the CSP or HSP group. After complete removal of the polyp using the allocated technique, biopsy specimens from the resection margin after polypectomy were obtained. The primary endpoint was the complete resection rate, defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps. RESULTS: A total of 796 eligible polyps were detected in 538 of 912 patients screened for eligibility between September 2015 and August 2016. The complete resection rate for CSP was 98.2% compared with 97.4% for HSP. The non-inferiority of CSP for complete resection compared with HSP was confirmed by the +0.8% (90% CI -1.0 to 2.7) complete resection rate (non-inferiority p<0.0001). Postoperative bleeding requiring endoscopic haemostasis occurred only in the HSP group (0.5%, 2 of 402 polyps). CONCLUSIONS: The complete resection rate for CSP is not inferior to that for HSP. CSP can be one of the standard techniques for 4-9 mm colorectal polyps. (Study registration: UMIN000018328).

Copyright© 2018 Japan Gastroenterological Endoscopy Society. All rights reserved. Background and Aim: Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for diagnosis of localized gallbladder lesions. Methods: One hundred and twenty-five patients with localized gallbladder lesions were evaluated by CH-EUS between March 2007 and February 2014. This was a single-center retrospective study. Utilities of fundamental B-mode EUS (FB-EUS) and CH-EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images. Results: In the differentiation between gallbladder lesions and sludge plug, FB-EUS had a sensitivity, specificity, and accuracy of 82％, 100％, and 95％, respectively, whereas CH-EUS had a sensitivity, specificity, and accuracy of 100％, 99％, and 99％, respectively. FB-EUS-based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61-87％, 71-88％, and 74-86％, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH-EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90％, 98 ％, and 96％, respectively. There was a significant difference between FB-EUS and CH-EUS in terms of carcinoma diagnosis. Conclusion: CH-EUS was useful for the evaluation of localized gallbladder lesions.

Background and Aim: Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for diagnosis of localized gallbladder lesions. Methods: One hundred and twenty-five patients with localized gallbladder lesions were evaluated by CH-EUS between March 2007 and February 2014. This was a single-center retrospective study. Utilities of fundamental B-mode EUS (FB-EUS) and CH-EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images. Results: In the differentiation between gallbladder lesions and sludge plug, FB-EUS had a sensitivity, specificity, and accuracy of 82%, 100%, and 95%, respectively, whereas CH-EUS had a sensitivity, specificity, and accuracy of 100%, 99%, and 99%, respectively. FB-EUS-based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61–87%, 71–88%, and 74–86%, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH-EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90%, 98%, and 96%, respectively. There was a significant difference between FB-EUS and CH-EUS in terms of carcinoma diagnosis. Conclusion: CH-EUS was useful for the evaluation of localized gallbladder lesions.

BACKGROUND AND AIM: The Japan narrow-band imaging (NBI) Expert Team (JNET) was organized to unify four previous magnifying NBI classifications (the Sano, Hiroshima, Showa, and Jikei classifications). The JNET working group created criteria (referred to as the NBI scale) for evaluation of vessel pattern (VP) and surface pattern (SP). We conducted a multicenter validation study of the NBI scale to develop the JNET classification of colorectal lesions. METHODS: Twenty-five expert JNET colonoscopists read 100 still NBI images with and without magnification on the web to evaluate the NBI findings and necessity of the each criterion for the final diagnosis. RESULTS: Surface pattern in magnifying NBI images was necessary for diagnosis of polyps in more than 60% of cases, whereas VP was required in around 90%. Univariate/multivariate analysis of candidate findings in the NBI scale identified three for type 2B (variable caliber of vessels, irregular distribution of vessels, and irregular or obscure surface pattern), and three for type 3 (loose vessel area, interruption of thick vessel, and amorphous areas of surface pattern). Evaluation of the diagnostic performance for these three findings in combination showed that the sensitivity for types 2B and 3 was highest (44.9% and 54.7%, respectively), and that the specificity for type 3 was acceptable (97.4%) when any one of the three findings was evident. We found that the macroscopic type (polypoid or non-polypoid) had a minor influence on the key diagnostic performance for types 2B and 3. CONCLUSION: Based on the present data, we reached a consensus for developing the JNET classification.

＜文献概要＞EUSは上部消化管粘膜下腫瘍(SMT)の診断に用いられているが,上部消化管SMTの良悪性鑑別には限界がある.本稿では,造影ハーモニックEUSによる上部消化管粘膜下腫瘍の診断に関する前向き研究1報と後ろ向き研究6報の合計7報の研究をもとに上部消化管SMTの鑑別診断について調べた.造影ハーモニックEUSによるGISTとそれ以外の上部消化管SMTの鑑別診断に関する3つの報告では,hyper-enhancementがGISTの造影ハーモニックEUS所見であり,診断能は感度84.5〜100%,特異度73.3〜100%であった.一方,low-grade malignancy GISTとhigh-grade malignancy GISTの鑑別診断に関する4つの報告では,造影ハーモニックEUSによるhigh-grade malignancy GISTの診断能は感度53.8〜100%,特異度63〜100%であった.またhigh-grade malignancy GISTでは造影ハーモニックEUSにおいてirregular vesselsが高率に認められた.hyper-enhancementか否かおよびirregular vesselsの有無を確認することで上部消化管SMTの鑑別診断が可能であることが示唆された.

BACKGROUND AND AIM: Computer-aided diagnosis (CAD) is becoming a next-generation tool for the diagnosis of human disease. CAD for colon polyps has been suggested as a particularly useful tool for trainee colonoscopists, as the use of a CAD system avoids the complications associated with endoscopic resections. In addition to conventional CAD, a convolutional neural network (CNN) system utilizing artificial intelligence (AI) has been developing rapidly over the past 5 years. We attempted to generate a unique CNN-CAD system with an AI function that studied endoscopic images extracted from movies obtained with colonoscopes used in routine examinations. Here, we report our preliminary results of this novel CNN-CAD system for the diagnosis of colon polyps. METHODS: A total of 1,200 images from cases of colonoscopy performed between January 2010 and December 2016 at Kindai University Hospital were used. These images were extracted from the video of actual endoscopic examinations. Additional video images from 10 cases of unlearned processes were retrospectively assessed in a pilot study. They were simply diagnosed as either an adenomatous or nonadenomatous polyp. RESULTS: The number of images used by AI to learn to distinguish adenomatous from nonadenomatous was 1,200:600. These images were extracted from the videos of actual endoscopic examinations. The size of each image was adjusted to 256 × 256 pixels. A 10-hold cross-validation was carried out. The accuracy of the 10-hold cross-validation is 0.751, where the accuracy is the ratio of the number of correct answers over the number of all the answers produced by the CNN. The decisions by the CNN were correct in 7 of 10 cases. CONCLUSION: A CNN-CAD system using routine colonoscopy might be useful for the rapid diagnosis of colorectal polyp classification. Further prospective studies in an in vivo setting are required to confirm the effectiveness of a CNN-CAD system in routine colonoscopy.

AIM: To compare the efficacy and safety of cold snare polypectomy (CSP) and hot forceps biopsy (HFB) for diminutive colorectal polyps. METHODS: This prospective, randomized single-center clinical trial included consecutive patients ≥ 20 years of age with diminutive colorectal polyps 3-5 mm from December 2014 to October 2015. The primary outcome measures were en-bloc resection (endoscopic evaluation) and complete resection rates (pathological evaluation). The secondary outcome measures were the immediate bleeding or immediate perforation rate after polypectomy, delayed bleeding or delayed perforation rate after polypectomy, use of clipping for bleeding or perforation, and polyp retrieval rate. Prophylactic clipping after polyp removal wasn't routinely performed. RESULTS: Two hundred eight patients were randomized into the CSP (102), HFB (106) and 283 polyps were evaluated (CSP: 148, HFB: 135). The en-bloc resection rate was significantly higher with CSP than with HFB [99.3% (147/148) vs 80.0% (108/135), P < 0.0001]. The complete resection rate was significantly higher with CSP than with HFB [80.4% (119/148) vs 47.4% (64/135), P < 0.0001]. The immediate bleeding rate was similar between the groups [8.6% (13/148) vs 8.1% (11/135), P = 1.000], and endoscopic hemostasis with hemoclips was successful in all cases. No cases of perforation or delayed bleeding occurred. The rate of severe tissue injury to the pathological specimen was higher HFB than CSP [52.6% (71/135) vs 1.3% (2/148), P < 0.0001]. Polyp retrieval failure was encountered CSP (7), HFB (2). CONCLUSION: CSP is more effective than HFB for resecting diminutive polyps. Further long-term follow-up study is required.

Although long-standing colonic inflammation due to refractory inflammatory bowel disease (IBD) promotes the development of colitis-associated cancer (CAC), the molecular mechanisms accounting for the development of CAC remains largely unknown. In this study, we investigated the role of gankyrin in the development of CAC since gankyrin is overexpressed in sporadic colorectal cancers. We analyzed gene expression of colon tissues obtained from 344 patients with IBD and CAC and found that expression of gankyrin was much higher in colonic mucosa of patients with refractory IBD than in those with IBD in remission. Expression of gankyrin was upregulated in inflammatory cells as well as tumor cells in colonic mucosa of patients with CAC. Over-expressing studies utilizing tagged ganlyrin-cDNA identified physical interaction between ganlyrin and Src homology 2-containing protein tyrosine phosphatase-1 (SHP-1). Importantly, the interaction between ganlyrin and SHP- 1 leads to inhibition of STAT3 activation and to enhancement of TNF-α and IL-17 in inflammatory cells. To further address the role of gankyrin in the development of CAC, we created mice with intestinal epithelial cell-specific gankyrin ablation (Vil-Cre;Gankyrinf/f) and deletion of gankyrin in myeloid and epithelial cells (Mx1- Cre;Gankyrinf/f). Gankyrin deficiency in myeloid cells, but not in epithelial cells, reduced the activity of mitogen activated protein kinase and the expression of stem cell markers, leading to attenuated tumorigenic potential. These findings provide important insights into the pathogenesis of CAC and suggest that gankyrin is a promising target for developing therapeutic and preventive strategies against CAC.

Many clinical studies on narrow-band imaging (NBI) magnifying endoscopy classifications advocated so far in Japan (Sano, Hiroshima, Showa, and Jikei classifications) have reported the usefulness of NBI magnifying endoscopy for qualitative and quantitative diagnosis of colorectal lesions. However, discussions at professional meetings have raised issues such as: (i) the presence of multiple terms for the same or similar findings; (ii) the necessity of including surface patterns in magnifying endoscopic classifications; and (iii) differences in the NBI findings in elevated and superficial lesions. To resolve these problems, the Japan NBI Expert Team (JNET) was constituted with the aim of establishing a universal NBI magnifying endoscopic classification for colorectal tumors (JNET classification) in 2011. Consensus was reached on this classification using the modified Delphi method, and this classification was proposed in June 2014. The JNET classification consists of four categories of vessel and surface pattern (i.e. Types 1, 2A, 2B, and 3). Types 1, 2A, 2B, and 3 are correlated with the histopathological findings of hyperplastic polyp/sessile serrated polyp (SSP), low-grade intramucosal neoplasia, high-grade intramucosal neoplasia/shallow submucosal invasive cancer, and deep submucosal invasive cancer, respectively.

Conventional endoscopic resection (CER) includes polypectomy and endoscopic mucosal resection. The most common complications related to these techniques are post procedure bleeding and perforation. The aim of this study was to evaluate the outcomes of CER for colorectal neoplasms a parts per thousand 20 mm and to clarify predictive factors for complications. We conducted a multicenter prospective study at 18 specialized institutes. From October 2007 to December 2010, 1,029 CERs were performed at participating institutes. We collected the data prospectively and analyzed gender, age, tumor size, gross appearance, mode of resection, etc. The mean size of polyps resected was 26.4 +/- A 8.6 mm (range 20-120 mm). The final pathology was Vienna classification category 1 or 2 in 24, category 3 in 502, and category 4 or 5 in 503 lesions. Post procedure bleeding and intra procedure perforation occurred, respectively, in 16 (1.6 %) and 8 cases (0.78 %). The overall complication rate was 2.3 %. Risk factors for bleeding in multivariate analysis were only patients under 60 years of age. Risk factors for perforation in multivariate analysis were en bloc resection and Vienna classification category 4-5. The difference of complication rate was not statistically significant regarding gender, size, tumor location, gross appearance, treatment method, and kind of insufflation. CER is a safe, efficient, and effective minimally invasive therapy for large colorectal lesions. However, care should be taken for post procedure bleeding in patients under 60 years of age and for perforation in cases of Vienna classification category 4-5 or when an en bloc resection is tried.

Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence-based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas.

Background: Expression of heat shock protein A4 (HSPA4, also called Apg-2), a member of the HSP110 family, is induced by several forms of stress. The physiological and pathological functions of HSPA4 in the intestine remain to be elucidated. Methods: We assessed HSPA4 expression and function by generating HSPA4-deficient mice and using 214 human intestinal mucosa samples from patients with inflammatory bowel disease (IBD). Results: In the colonic mucosa of patients with IBD, a significant correlation was observed between the expression of HSPA4 and antiapoptotic protein Bcl-2, a T-cell-derived cytokine IL-17 or stem cell markers, such as Sox2. In refractory ulcerative colitis, a condition associated with increased cancer risk, expression of HSPA4 and Bcl-2 was increased in inflammatory cells of colonic mucosae. HSPA4 was overexpressed both in cancer cells and immune cells of human colorectal cancers. Patients with high expression of HSPA4 or Bmi1 showed significantly lower response rates upon subsequent steroid therapy as compared with patients with low expression of each gene. HSPA4-deficient mice exhibit more apoptosis and less expression of IL-17/IL-23 in inflammatory cells and less number of Sox(2+) cells after administration of dextran sodium sulfate than control mice. Transduction of HspaA4(+/-) bone marrow into wild-type mice reduced the immune response. Conclusions: Upregulation of Bcl-2 and IL-17 by HSPA4 would control apoptosis of inflammatory cells and immune response in the gut, which might develop treatment resistance in IBD. HSPA4 and Bmi1 would be a useful biomarker for refractory clinical course and a promising approach for a therapeutic strategy in patients with IBD.

Aims and Methods Heat shock protein A4 (HSPA4, also called Apg-2), a member of the HSP110 family, regulates the immune response in the gut. Here, we assessed the involvement of HSPA4 in gastric ulcer healing by using fibroblasts from wild-type and HSPA4-deficient mice, a murine gastric ulcer model, and samples from 65 patients with gastric cancer.Results HSPA4 expression was inversely correlated with gastric ulcer healing following endoscopic resection of gastric cancer. In the human gastric mucosa, the expression of HSPA4 was inversely correlated with the expression of stromal cell-derived factor 1 (SDF-1), its cognate receptor CXC chemokine receptor 4(CXCR4), the stromal cell marker vimentin, and the epithelial-mesenchymal transition regulator Twist. HSPA4 was overexpressed in stromal cells as well as in human gastric cancer cells. HSPA4 deficiency increased the expression of SDF-1 and CXCR4, as well as the number of fibroblast-specific protein 1-positive cells, leading to accelerated ulcer healing in the murine gastric ulcer model. Deletion of HSPA4 promoted cell migration in mouse fibroblasts through increased expression of SDF-1 and Twist.Conclusion HSPA4 regulates the expression of SDF-1 and Twist in fibroblasts, thereby controlling gastric ulcer healing.

Colitis-associated cancer (CAC) is caused by chronic intestinal inflammation and is reported to be associated with refractory inflammatory bowel disease (IBD). Defective apoptosis of inflammatory cell populations seems to be a relevant pathogenetic mechanism in refractory IBD. We assessed the involvement of stress response protein cold-inducible RNA-binding protein (Cirp) in the development of intestinal inflammation and CAC. In the colonic mucosa of patients with ulcerative colitis, expression of Cirp correlated significantly with the expression of TNF alpha, IL23/IL17, antiapoptotic proteins Bcl-2 and Bcl-xL, and stem cell markers such as Sox2, Bmi1, and Lgr5. The expression of Cirp and Sox2 was enhanced in the colonic mucosae of refractory ulcerative colitis, suggesting that Cirp expression might be related to increased cancer risk. In human CAC specimens, inflammatory cells expressed Cirp protein. Cirp(-/-) mice given dextran sodium sulfate exhibited decreased susceptibility to colonic inflammation through decreased expression of TNF alpha, IL23, Bcl-2, and Bcl-xL in colonic lamina propria cells compared with similarly treated wild-type (WT) mice. In the murine CAC model, Cirp deficiency decreased the expression of TNF alpha, IL23/IL17, Bcl-2, Bcl-xL, and Sox2 and the number of Dclk1(+) cells, leading to attenuated tumorigenic potential. Transplantation of Cirp(-/-) bone marrow into WT mice reduced tumorigenesis, indicating the importance of Cirp in hematopoietic cells. Cirp promotes the development of intestinal inflammation and colorectal tumors through regulating apoptosis and production of TNF alpha and IL23 in inflammatory cells. (C) 2014 AACR.

AIM: To prospectively compare the healing rates of endoscopic submucosal dissection (ESD)-induced ulcers treated with either a proton-pump inhibitor (PPI) or rebamipide. METHODS: We examined 90 patients with early gastric cancer who had undergone ESD. All patients were administered an intravenous infusion of the PPI lansoprazole (20 mg) every 12 h for 2 d, followed by oral administration of lansoprazole (30 mg/d, 5 d). After 7-d treatment, the patients were randomly assigned to 2 groups and received either lansoprazole (30 mg/d orally, n = 45; PPI group) or rebamipide (300 mg orally, three times a day; n = 45; rebamipide group). At 4 and 8 wk after ESD, the ulcer outcomes in the 2 groups were compared. RESULTS: No significant differences were noted in patient age, underlying disease, tumor location, Helicobacter pylori infection rate, or ESD-induced ulcer size between the 2 groups. At both 4 and 8 wk, the healing rates of ESD-induced ulcers were similar in the PPI-treated and the rebamipide-treated patients (4 wk: PPI, 27.2%; rebamipide, 33.3%; P = 0.5341; 8 wk: PPI, 90.9%; rebamipide, 93.3%; P = 0.6710). At 8 wk, the rates of granulation lesions following ulcer healing were significantly higher in the PPI-treated group (13.6%) than in the rebamipide-treated group (0.0%; P = 0.0103). Ulcer-related symptoms were similar in the 2 treatment groups at 8 wk. The medication cost of 8-wk treatment with the PPI was 10945 yen vs 4889 yen for rebamipide. No ulcer bleeding or complications due to the drugs were observed in either treatment group. CONCLUSION: The healing rate of ESD-induced ulcers was similar with rebamipide or PPI treatment; however, rebamipide treatment is more cost-effective and prevents granulation lesions following ulcer healing. (C) 2013 Baishideng. All rights reserved.

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Intestinal-type gastric carcinomas progress through several sequential steps, including atrophic gastritis, intestinal metaplasia, dysplasia, and cancer. We investigated heat shock protein 27 (HSP27) expression in gastric neoplasia and background gastric mucosa to assess its involvement in gastric carcinogenesis. We used real-time quantitative polymerase chain reaction to examine HSP27 expression in gastric neoplasias and background gastric mucosae of 30 patients with intraepithelial neoplasias and in gastric mucosae of 30 patients without gastric neoplasia. Immunohistochemical staining was performed on 30 advanced gastric cancer tissues. HSP27 expression was negatively associated with atrophic gastritis. HSP27 expression in the background gastric mucosa of neoplasia-bearing patients was significantly lower than in the mucosa of those without gastric neoplasia. In tumor necrosis factor alpha-treated gastric cancer cells, HSP27 knockdown increased cell death and accumulation of the reactive oxygen species that link inflammation to cancer. Poorly differentiated tumors most frequently had high HSP27 levels. Dedifferentiation of cancer cells is associated with an epithelial-mesenchymal transition (EMT) signaling pathway. In gastric cancer MKN-1 cells, HSP27 knockdown upregulated E-cadherin and downregulated vimentin and smooth muscle actin, but this did not occur in MKN-74 cells. HSP27 expression in gastric mucosae is inversely correlated with intraepithelial neoplasia, a probable precursor to gastric cancer, and HSP27 expression in cancer is positively correlated with poor differentiation.

大腸腫瘍の内視鏡切除には，有茎あるいは亜有茎性病変に対するポリペクトミー，表面型や広基性病変に対する内視鏡的粘膜切除術：endoscopic mucosal resection（EMR）および分割EMR：endoscopic piecemeal mucosal resection（EPMR），内視鏡的粘膜下層剥離術 endoscopic submucosal dissection（ESD）が存在する．大腸腫瘍の大部分は腺腫であり，また，内視鏡治療の対象となる早期癌もかなりの割合が腫瘍径2cm未満であるため，従来法のEMRで治療可能である．大きくて一括切除が困難な腺腫もしくは粘膜内癌に対して，EPMRが許容される場合もある．ESDは，内視鏡治療の中で，一括切除に最も優れた方法である．EMRでは一括切除が困難な2cm以上の早期大腸癌で，十分な術前評価により根治性が期待できる病変では，ESDが推奨される．

ESD保険承認後の現在でも，EPMRは大腸腫瘍の治療法のひとつとして重要である．大腸腫瘍においてESDの絶対適応症例は限られており，ほとんどの症例はEMR/EPMRで治療できる．EPMRは，ESDに比較して施行時間が短く，穿孔率が低いのが大きな長所であるが，後出血がやや多いこと，局所再発率が明らかに高いことは欠点である．たとえ再発しても，ほとんどの症例において再度の内視鏡治療で制御可能ではあるが，最初から完全かつ安全な切除を施行することが必要である．

We previously reported that detection of desmoplastic reaction (DR) in pretreatment biopsy specimens was useful for predicting the depth of submucosal invasion (SM depth) in nonpedunculated early colorectal cancers (ECRCs) in a retrospective study. Here, we performed a prospective multicenter study for verification of our previous findings. Subjects were diagnosed with ECRC by endoscopy, and with adenocarcinoma from the biopsy specimens. Eleven institutions affiliated with the Japanese Society for Cancer of the Colon and Rectum participated in this collaborative study. A total of 112 patients with ECRC were enrolled. For nonpedunculated ECRCs, presence of DR was significantly correlated with SM depth. The sensitivity and specificity of detection of DR for prediction of pSM2 (tumor invasion =1000 mu m) in nonpedunculated ECRCs were 68.6% and 92.0%, respectively. Evaluation of DR in pretreatment biopsy specimens may be useful for the clinicopathological diagnosis of colorectal carcinoma with massive invasion into the submucosal layer.

大腸病変におけるNBI非拡大観察の病変検出能に関しては意見が分かれるが，腫瘍・非腫瘍の鑑別において特にNBI拡大観察は，色素内視鏡に匹敵することが報告されている．癌の深達度診断能も良好で，治療方針の決定に有用である．しかし，所見分類が統一されておらず，血管模様のみを評価するのか，粘膜模様を加味するのか，意見が分かれている．現在までのところ色素拡大観察によるpit pattern診断の方が若干正診率が高い．NBI拡大観察は，潰瘍性大腸炎関連腫瘍の診断にも寄与することが期待されている．

【目的】大腸病変に対してnarrow band imaging（NBI）拡大内視鏡によるvascular pattern診断と色素拡大内視鏡によるpit pattern診断の有用性を検討した．
【方法】2006年1月より2008年2月にNBI・色素拡大観察した後に切除された1,185症例1,473病変に対してvascular/pit patternの質的・深達度診断の精度を比較した．
【結果】Vascular patternに関して，faintを過形成性ポリープの指標とすれば，感度/特異度は88.9％/98.5％であった．また，irregular/sparseをSM深部浸潤癌（SMm）の指標とした場合，感度/特異度は94.9％/76.0％であった．一方でII型pit patternを過形成性ポリープの指標とすれば，感度/特異度は86.8％/99.2％であった．V_I高度不整/V_N型pit patternをSMmの指標とした場合，感度/特異度は89.7％/88.0％であった．
【結論】NBI・色素拡大観察は両者とも腫瘍・非腫瘍の鑑別に有用であった．SMmの診断に関してはpit pattern診断の方が特異度が高いため，治療方針の決定にはvascular pattern診断に加えてpit pattern診断をすることが有用であると考えられた．

Splanchnic arteriovenous malformation (AVM) is a rare condition in which patients present with portal hypertension, which thus causes bleeding varices and ascites. However, to our knowledge, hepatic nodules associated with splanchnic AVM have not yet been described. We herein first report the case of a 78-year-old man with inferior mesenteric AVM presenting with portal hypertension and multiple hepatic nodules dominantly supplied by the portal vein. This unique case not only extends the spectrum of hepatic nodules resulting from abnormal hepatic circulation, but also provides clues for better understanding the etiology of hepatic nodules.

内視鏡的に逆流性食道炎(RE)と診断され、プロトンポンプ阻害薬(PPI)を継続投与している57例において、GerdQを用いて治療効果の評価および背景因子との関係を検討した。PPI用量は常用量使用例が75.4%と半量使用例よりも多く、また87.7%がPPI単独使用であり、その他の消化器治療薬との併用例は少なかった。食道炎の重症度はLA gradeN例が56.1%と最も多く、gradeCあるいはDは認めなかった。11例がPPIの治療効果不十分と判定された。PPI継続治療後の直近のLA grade別では、gradeの高い症例で効果不十分例を有意に多く認めた。効果十分例についてはgradeNおよびMが69.6%および8.7%、gradeA以上は21.7%であった。また、食道裂孔ヘルニアの有無では、食道裂孔ヘルニアを有する患者で効果不十分例を多く認めた。

大腸病変のNBI(Narrow Band Imaging)や色素観察は,拡大観察を併用することでほぼ正確な質的・深達度診断が可能になる.とくにSM深部浸潤癌では,NBI拡大内視鏡ではirregular/sparse pattern,色素拡大内視鏡ではVI型高度不整およびVN型pit patternを呈する.irregular patternは隆起型,sparse patternは陥凹型の癌に特徴的な所見であるが,pit pattern診断のほうが特異度,正診率が高く,治療方針の決定の際にはpit pattern診断を併用することが必要である.拡大観察の際には通常観察時から病変固有の特徴を捉えながら,遠景から近景へ拡大率を徐々に上昇させて計画性のある観察を行うことで,より正確な診断が可能になる.(著者抄録)

Background/Aims: With the recent changes of pathological concepts, colorectal serrated lesions can, be now divided into traditional serrated adenoma, typical hyperplastic polyp and sessile serrated polyp. The aim of this study is to clarify the endoscopic differences among these three groups. Methodology: A total number of 362 serrated lesions larger than 5mm were evaluated. These were detected with ordinary view and observed also with magnifying chromoendoscopic view. The final pathologic diagnosis of the resected specimens was made blinded. Results: There were significant differences between traditional serrated adenoma and sessile serrated polypconcerning location, configuration and color. In chromoendoscopy, most of sessile serrated polyps and typical hyperplastic polyps showed star-like pattern, in contrast with traditional serrated adenomas most of which had fernor pinecone-like pattern. The differential diagnosis between traditional sessile polyp and the other two was possible with high accuracy. On the other hand, endoscopic distinction between sessile serrated polyp and typical hyperplastic polyp was not easy, except that the location and size were significantly different. Conclusions: We can endoscopically differentiate between traditional serrated adenoma and sessile serrated polyp or typical hyperplastic polyp, but it is difficult to differentiate between the latter two.

樫田博史，和田祥城，三澤将史，峯 宏昌，永田嘉昭，川崎正憲，朝隈 豊，櫻井俊治，松井繁長，工藤正俊： 23: 790-796, 2011.

北野雅之, 坂本洋城, 樫田博史, 工藤正俊: 23: 1312-1319, 2011.

We have previously demonstrated a relationship between the depth of submucosal invasion (SM depth) and the frequency of lymph node metastasis in resected submucosal invasive colorectal cancers (SICRCs). Here, we assessed the desmoplastic reaction (DR) in pretreatment biopsy specimens of SICRC to predict the SM depth. A total of 359 patients with SICRCs, who had undergone surgical or endoscopic mucosal resection, were enrolled. The SM depth of the SICRC lesions was evaluated according to the procedure established by the Japanese Society for Cancer of the Colon and Rectum, and the patients' corresponding pretreatment biopsy specimens were examined histologically to evaluate the prevalence of DR. For pedunculated SICRCs, the prevalence of DR in pretreatment biopsy specimens was significantly higher in moderately differentiated than in well-differentiated adenocarcinomas, but was not significantly related to SM depth. For nonpedunculated SICRCs, the prevalence of DR in pretreatment biopsy specimens was significantly related to histological type, tumor size, and SM depth. When non-pedunculated SICRCs were further divided using a specific cutoff value of 1000 mu m for SM depth, the DR positivity rate in pretreatment biopsy specimens was significantly higher in SICRCs with an SM depth of a parts per thousand 1000 mu m (termed "SM massive CRCs") than in cases where the SM depth was < 1000 mu m (termed "SM slight CRCs"). Detection of DR in pretreatment biopsy specimens is useful for the prediction of SM depth in nonpedunculated SICRCs, and may be useful for the selection of such cases that would be treatable by endoscopic mucosal resection and endoscopic submucosal dissection (EMR/ESD).

Background:The aim of this prospective study is to compare the usefulness of magnifying narrow band imaging (NBI) and magnifying chromoendoscopy in the diagnosis of colorectal lesions.Methods:The subjects were 1185 patients who underwent a complete colonoscopic examination and endoscopic or surgical treatment, from January 2006 to February 2008. A total of 1473 lesions were evaluated (53 hyperplastic polyps, 1317 adenomas, 103 submucosally invasive cancers). The digital images with NBI or chromoendoscopy were recorded and diagnosed independently from each other by two endoscopists who were blinded to the final pathological diagnosis.Results:We could differentiate between neoplastic and non-neoplastic lesions with sensitivity of 88.9%, specificity of 98.5% and accuracy of 98.2% according to the vascular pattern. By recognizing an irregular or sparse pattern with NBI, massively invasive submucosal cancer could be diagnosed with the sensitivity and specificity of 94.9% and 76.0%. Using chromoendoscopy, we could differentiate between neoplastic and non-neoplastic lesions with sensitivity of 86.8% and specificity of 99.2%. We were able to differentiate between massively invasive cancers and slightly invasive cancers using the pit patterns with sensitivity of 89.7% and specificity of 88.0%. The specificity was superior to that of NBI colonoscopy.Conclusion:Both NBI and chromoendoscopy can be useful for distinguishing between neoplastic and non-neoplastic lesions. In the diagnosis of submucosal cancer, pit pattern diagnosis was slightly superior to vascular pattern diagnosis. It is desirable to perform chromoendoscopy in addition to NBI for distinguishing between slightly and massively invasive submucosal cancer lesions and determining the treatment.

小腸では絨毛の観察がおもな対象である.小腸用拡大内視鏡は市販されていないが,水浸下の観察により拡大効果が得られ,Narrow Band Imaging(NBI)観察でより精細な観察が可能である.染色法も使用される.拡大観察では絨毛辺縁は明るく帯状に縁どられ,NBI観察で内部にループ状の脈管が観察される.上皮性腫瘍では,大小不同のある発赤腫大した絨毛や,拡張した血管がみられる.十二指腸球部では,絨毛に被覆された粘膜に加え,異所性胃粘膜がみられることがある.乳頭部腺癌の特徴に血管の異常拡張,口径不同,異常蛇行,模様の不均一性がある.現段階では,拡大観察による診断能の上乗せ効果は明らかではないが,今後の進歩が期待される.(著者抄録)

LSTの治療法選択(EMR/EPMRかESDかLACか)を明らかにするために,LST亜分類別の臨床病理学的特徴の検討を行った.内視鏡診断においては,拡大内視鏡によるpit pattern診断により質的診断および深達度診断を正確に行うことが肝要である.ESDの普及により腫瘍径の大きい病変においても一括切除ができる時代になったが,LSTの病理学的特徴など,背景をしっかり理解したうえで適切な治療方針を決定することが求められる.(著者抄録)

Recently, the emerging role of nonpolypoid precursors of colorectal cancer has challenged the conventional polyp-cancer sequence. The impact of colonoscopy in cancer prevention depends on its reliability in the diagnosis of colorectal neoplasia when the lesion does not extend beyond the submucosa and is potentially curable. The estimation of the risk of progression is based on the prediction of histology from the morphological appearance of the lesion and includes (1) distinction between neoplastic and non-neoplastic lesions, (2) identification of different categories of non-serrated and serrated lesions, and (3) determination of the localization in the proximal or distal colon, which has an impact on the morphology and behavior of the lesion. The pragmatic classification Of superficial neoplastic lesions proposed in this text takes into account these changes and is based oil a 2-step strategy of endoscopic diagnosis with initial detection and characterization, followed by treatment implementation, Such as endoscopic resection, ablation, and Surgery

下部消化管領域においても、narrow band imaging(NBI)搭載内視鏡が普及しつつあるが、大腸におけるNBI所見の分類はいまだに施設間で統一されていない。われわれは、NBIにおいてはpit patternを類推するのではなく、あくまで血管像に注目している。腫瘍・非腫瘍の鑑別に対するNBIの有用性に関しては諸家の見解が一致している。最近では「顕微内視鏡」や「超拡大内視鏡」などと呼ばれる400〜500倍で観察可能なendomicroscopyやendocytoscopyが開発されている。後者では細胞核や毛細血管内を流れる赤血球までリアルタイムに観察可能であり、生体内で病理組織像とほぼ同等の画像を観察できる。(著者抄録)

大腸癌には腺腫を介さず正常粘膜から直接発生するde novo癌と,腺腫からadenomacarcinoma sequenceを経て発生する癌がある.本邦ではIIcをはめとする陥凹型病変こそがde novo癌であると考えられ,多くの検討が行われてきた.陥凹型病変はほかの肉眼型に比べて担癌率,SM浸潤率が高く腫瘍径が小さいうちに深部浸潤する特徴がある.これらの知見は本邦だけでなく欧米へも広がりつつある.(著者抄録)

【目的】大腸癌スクリーニングにおけるスクリーニングコロノスコピーの意義について当センター初回例で検討した。【方法】対象は2004年1月から2007年12月までに当センターで施行された大腸内視鏡初回例16227例のうち、無症状スクリーニング目的に行われたスクリーニング群3582例と便潜血陽性に対する精検目的に行われたFOBT精検群2130例を比較検討した。また、FOBT陰性大腸癌の実態を検討するために、同時期に施行されたFOBT陰性後1年以内に大腸内視鏡が施行された443例の検討を行った。【結果】初回検査で発見された癌の割合では、スクリーニングコロノスコピー群は、FOBT群と比較して早期癌、特に平坦・陥凹型早期癌の割合が高い結果であった。FOBT陰性大腸癌の特徴として、(1)癌発見率は2.1%、(2)15mm以上の病変が7病変と半数以上、(3)平坦・陥凹型早期癌を4病変認め、全てSM微小浸潤までの病変、(4)進行癌は3例いずれも有症状であった。【結語】有症状者はFOBTが陰性でもコロノスコピーを受ける必要性があることはもちろんであるが、FOBT陰性病変は無視できず、FOBT陰性例においてもスクリーニングコロノスコピーが検討されるべきと考える。FOBT陰性大腸癌の存在を加味するとコロノスコピーを組み入れた「ハイブリット型」大腸癌検診を検討していく必要がある。(著者抄録)

潰瘍性大腸炎(UC)関連腫瘍の診断に,表面微細構造観察の有効性が報告されている.多施設からのUC関連腫瘍のpit patternの解析では,IV型,IIIが8割を占め,IV型はさらに樹枝状,羊歯様,絨毛状に分けられた.UCにおける腫瘍性pit patternを,neoplastic pit pattern of ulcerative colitis(NPUC)とし,不整が目立つこと,大小不同,pitの極性の消失,領域性,疎な腺管密度,大型円形を含む腺口開大,pitの癒合といった特徴がある.非腫瘍性のものをnon-neoplastic pit pattern of ulcerative colitis(nonNPUC)とし,一見腫瘍性にみえても,pit patternは整であり,大小そろった大きさ,均一さ,pitの極性の保持といった特徴がある.背景粘膜に炎症による修飾や再生性の変化があること,粘液癌が多く,また増殖帯が腺管深部にあるなど発育形式が異なる点が診断を困難にする.また孤発性の大腸腫瘍との鑑別が難しいことがある.(著者抄録)

一体型超拡大内視鏡(endocytoscopy;EC)による大腸上皮性病変の有用性を検討するために,詳細な観察がなされた正常粘膜を含む大腸上皮性病変165病変において,病理組織診断との対比を行った.なお,EC画像においては,超拡大内視鏡(EC)分類を用いた.EC0a群およびEC0b群は非腫瘍性病変であり,陽性的中率が100%であった.EC1a群においては,腺腫である陽性的中率が95.1%であり,良好な成績が得られた.また手術絶対適応であるSM深部浸潤癌を示すEC3群の陽性的中率が98.0%であった.ECは,通常内視鏡観察,拡大内視鏡観察,超拡大内視鏡観察までを1本の電子スコープで連続的に観察可能である.また,腫瘍細胞の構造異型・核異型をリアルタイムで観察でき,既存の診断学のレベルを超えた新たな診断学となりうる.(著者抄録)

生体内で450倍の倍率が観察可能な超拡大内視鏡、endocytoscope(EC)が開発された。筆者らは大腸腫瘍の診断にも使用し、その有用性を報告してきた。最初は親スコープの鉗子孔に挿通させて使用するプローブ型であったが、最近、endocytoscopeが内視鏡本体と一体になったものが開発され、1本のスコープで、通常観察、80倍までの拡大観察、約450倍の超拡大観察が、スイッチの切り替えだけで可能である。内視鏡的あるいは外科的に切除された大腸限局性病変のうち、詳細な観察が可能であった上皮性病変159病変を対象とした。ECは、大腸の限局性病変の質的診断、特に腫瘍と非腫瘍、SM深部以深癌とそれ以外の腫瘍の鑑別に有用であった。従来の拡大内視鏡でも診断困難な潰瘍性大腸炎関連腫瘍の早期診断への応用や、NBIとの併用で大腸癌の血流動態解明に寄与することが期待される。(著者抄録)

34歳男性。肺結核で3剤併用療法を行い治癒した。2年後，イレウスの診断で入院し，保存的治療で改善した。CT上，回盲部に腫瘤様所見を認め，下部内視鏡では回盲弁の発赤腫大と潰瘍形成，右側結腸に萎縮瘢痕帯を認めた。腸結核が疑われたが，抗酸菌培養陰性，生検では非特異的炎症の診断であった。1年後の生検で粘液癌，高分化型腺癌と診断され，右結腸切除術を施行した。Colitic cancer様の特徴を有し発癌への腸結核の関与が疑われた。

潰瘍性大腸炎(ulcerative colitis;UC)の長期経過例にdysplasiaやcolitic cancerが高率に合併することはよく知られているが,背景粘膜に炎症を伴うため,早期の内視鏡診断は容易ではない.近年,超拡大内視鏡(endocytoscope;EC)による生体内での細胞レベルの観察が可能となり,今回,UC関連大腸癌(colitic cancer)のEC観察を行った,今後,症例を重ねることで,EC診断の精度が上がり,UC関連大腸腫瘍の早期発見・早期診断に貢献すると考える.(著者抄録)

大腸鋸歯状病変をSA,THP,AHPの3群に分けて検討した.SA,THPは左側結腸に多いが,AHPは右側結腸に多かった.肉眼形態では,SAでは隆起型が,THP,AHPでは平坦型が多かった.色調では,SAは発赤型が,THP,AHPは褪色・常色調が多かった.平均腫瘍径は,SA,AHPがTHPより有意に大きかった.拡大所見では松毬状や羊歯状を呈した病変の約90%がSAであり診断容易であるが,星芒状を呈した病変にはTHP以外にAHP,SAも少なからず含まれ診断困難であった.SAにはTHP由来とそうでないものがあると考えられた.鋸歯状病変の担癌例を13例経験した.5mm以上のSAのうち6.3%,5mm以上のAHP中7.4%であったが,同時期の早期大腸癌991病変中1.1%,0.2%を占めるにすぎなかった.担癌AHP病変にはSA部分を認めず,SAを介した癌化とは別のpathwayが存在するのではないかと思われた.鋸歯状病変の病理診断基準には大きな混乱が存在する.概念の整理・統一と,症例の集積が必要である.(著者抄録)

大腸病変の拡大内視鏡によるpit pattern診断は質的診断にきわめて有用である.近年,Narrow Band Imaging(NBI)systemが普及し,粘膜表面の微細血管の観察が可能になった.大腸においてvascular pattern診断は腫瘍・非腫瘍の鑑別には非常に有用であった.癌の深達度診断についてはpit pattern診断と比較すると正診率では及ばなかったものの,irregular/sparse patternを呈する血管所見を拾い上げていくことにより,高い正診率を得ることができた.irregular/sparse patternを呈する病変の治療方針の決定には,pit pattern診断を併用することが望ましい.(著者抄録)

拡大内視鏡を用いれば大腸粘膜表面の陰窩開口部(腺口:pit)を認識できる.複数の腺口が集まって織り成すpit patternは組織学的な腺管構造を反映し,大腸正常粘膜や種々上皮性病変の組織型に対応するpit pattern分類(I〜V型)が提唱された.I〜V型pitは原則として粘膜内限局性病変に相当し,これらいずれにも合致しないV型pitには粘膜内癌や粘膜下層(SM)以深浸潤癌が含まれる.pitが消失し表面無構造となったV non-structure(N)型では,SM浸潤部間質が表面に露出しており,SM深部以深浸潤癌の指標となる.pit pattern診断によって,大腸上皮性病変の組織型を推定し,大腸癌の深達・浸潤度を把握できる.(著者抄録)

Narrow Band Imaging(NBI)によるvascular patternがpit patternとどう対応するか、病変の質的診断において、いかに有効であるかについて検討した。NBI拡大観察所見をもとに、血管像と病理組織像をprospectiveに比較検討した。切除した大腸限局性病変(884病変)を対象とした。NBIはボタン一つで通常内視鏡画像から切り替えることができ、また粘液の付着の影響が少ないというメリットがあった。vascular pattern診断は腫瘍・非腫瘍の鑑別において非常に有用であった。しかし、色素内視鏡によるpit pattern診断学に比べると歴史が浅く、各施設で分類が異なり、経験も検討もまだまだ不十分であると考えられた。また、NBIは病変内微細血管構造の描出に優れてはいるが、癌の深達度診断における正診率はpit pattern診断には及ばなかった。

【症例1】患者:77歳、女性。2年前から腹痛、嘔吐を繰り返していたが、上部、下部内視鏡検査では異常を認めなかった。腸閉塞となり当院受診し、シングルバルーン内視鏡検査を施行した。回盲弁より120cm口側に1cm長の狭窄があり、バルーン拡張術にて腸閉塞は治癒した。【症例2】63歳男性。数ヵ月前から上腹部痛があったが、上部、下部内視鏡検査では異常を認めなかった。腸閉塞をきたすため、シングルバルーン内視鏡検査を施行したところ回盲弁より80cm口側に全周性の狭窄を認めた。小腸造影で狭窄は5cm長あり、腹腔鏡補助下回腸部分切除術を施行した。病理組織学所見では虚血性狭窄であった。(著者抄録)

endocytoscopy(XCF-260EC1,Olympus)で観察した大腸上皮性病変129病変の画像を解析し超拡大内視鏡EC分類を行った.EC0aおよびEC0bは非腫瘍性病変であり,陽性的中率が100%であった.EC1〜EC3は腫瘍であり,主として内腔スリット形成および核の濃染から分類した.その結果EC1a群においては,91.4%が低異型度腺腫であり,EC1bは76.9%が高異型度腺腫であった.EC2は高異型度腺腫M癌,SM癌と様々であるがEC3はほとんど(97.4%)がSM massive癌であった.enodocytoscopyは,通常内視鏡観察,拡大内視鏡観察,超拡大内視鏡観察までを簡単に1本の電子スコープで連続的に観察可能であり,かつ生きた腫瘍細胞そのものの細胞異型・核異型の診断が可能である.さらに,生きた腫瘍細胞の動き,血管血流も観察できる.500倍倍率の超拡大内視鏡EC分類により,既存の内視鏡診断学のレベルを越えた,新たなより精度の高い診断が可能となった.(著者抄録)

大腸sm癌207病変から有茎性病変を除外し,pit patternの評価とsm浸潤距離の計測が可能であった128病変を検討の対象とした.箱根シンポジウムでのコンセンサスに従い,明らかな無構造領域を有するVN型pit patternをsm浸潤1,000μm以上の指標と仮定した場合,陽性的中率と特異度が高率であるのに対し,感度はあまり高くなかった.次に,VI型pit patternのうち,sm浸潤1,000μm未満と以上を鑑別する所見に関して検討を行った.「辺縁不整」と「内腔狭小」の2項目のうち1項目以上陽性であればVI高度不整とし,VN型pit patternないしVI高度不整をsm浸潤1,000μm以上の指標と仮定したところ,高い正診率が得られた(著者抄録)

内視鏡的,外科的に切除した大腸sm癌104病変(陥凹型31病変,平坦型31病変,隆起型42病変)を対象に,リンパ節転移陽性例の臨床病理学的特徴を検討した.リンパ節転移陽性例は12病変でn1(+)9病変,n2(+)3病変であった.肉眼形態別ではn1(+)9病変は陥凹型2病変,平坦型2病変,隆起型5病変,n2(+)3病変では陥凹型1病変,平坦型1病変,隆起型1病変であり,特に多い肉眼形態については指摘されなかった.リンパ節転移陽性例の深達度は全てsm深部浸潤癌であり,11病変にリンパ管侵襲を認めた.リンパ節転移陽性例の主組織の分化度は高分化腺癌10病変,中分化腺癌2病変であり,先進部組織は高分化腺癌6病変,中分化腺癌5病変,低分化腺癌1病変であった.簇出とリンパ節転移症例については+1が6病変,+2が4病変,+3が2病変であり,リンパ節転移症例はいずれも簇出を認めた.外科的切除後リンパ節転移陽性sm癌はリンパ管侵襲,sm浸潤度,組織型がリンパ節転移に関係すると考えられた

【目的】潰瘍性大腸炎（UC）患者が増加しているが，それに伴うcolitic cancerの診断は容易ではない。発見のためStep biopsyが行われてきたが，狙撃生検が望ましい。そこでUC粘膜，dysplasia，colitic cancerのpit patternを観察し早期診断への有効性を検討した。【方法】当院で大腸内視鏡検査を行った罹患年数4年以上の緩解期の全結腸型と左側結腸型の潰瘍性大腸炎患者44名を検討対象とした。平均罹患年数は7.4±3.8年であった。盲腸，上行結腸，横行結腸，下行結腸，S状結腸，直腸でpit patternを観察し，生検標本と比較した。次に，dysplasia，colitic cancer9症例10病変についてpit patternを観察し肉眼形態とあわせ検討した。【成績】緩解期大腸から264箇所生検し，Ⅰ，Ⅱ型を呈した260箇所からはdysplasiaは検出されなかった。ⅢL，Ⅳ型を呈した4箇所のうち，dysplasiaが1箇所検出された。逆にdysplasia，colitic cancerは，ⅢL，Ⅳ，Ⅴ_I，Ⅴ_N型類似のpit patternを呈していた。進行癌ではⅤ_N型を呈するものが多かったが，Ⅴ型を呈して・型を認識できないものもあった。dysplasiaと診断されたものは，ⅢL，Ⅳ型を呈していた。【結論】ⅢL，Ⅳ，Ⅴ型などの腫瘍性pit patternを呈する箇所より生検すればより効率的にdysplasia，colitic cancerが検出できる可能性がある。

64歳男.背部痛を主訴とし,腹部エコーで左上腹部の巨大な腫瘍性病変と複数の肝腫瘍を認め入院した.肝腫瘍生検にて病理学的に低分化肝細胞癌と診断,左上腹部の腫瘍は画像診断的に後腹膜平滑筋肉腫と診断した.後腹膜腫瘍摘出術を施行し,病理組織学的に副腎皮質癌と診断した.これと術前の肝生検標本を再検討した結果,酷似しており肝腫瘍は副腎皮質癌の肝転移巣と診断した

76歳男.慢性C型肝炎にて他院で経過観察中に,USにて肝後区域に約4cm大の肝腫瘤を指摘され,精査目的にて来院した.画像所見上は診断に難渋し,肝生検を施行したが確定診断は得られなかった.悪性腫瘍が疑われたために,肝後区域切除を施行した.組織は被膜内は広範に壊死と線維化が認められた.被膜内のごく一部に肝細胞癌の増生を認め,肝細胞癌の広範な自然壊死と診断した

症例1は48歳男,AFP上昇の精査目的に来院した.腹部エコー,CT上,腫瘍はみとめなかった.しかし,レクチン分画(L3分画)の上昇により強く肝細胞癌の存在を疑った.引き続きMRIを施行した結果,1cm大の結節を認めた.症例2は53歳男,食道静脈瘤治療の目的で入院した.レクチン分画の上昇が認められ,造影CTを施行したところ,2.5cm大の結節が認められた.いずれも画像診断上,肝細胞癌と診断した.どちらも単発の結節であり,切除し,組織学的にも肝細胞癌と確認された

Background: To clarify the similarities and dissimilarities in the macroscopic classification criteria for early colorectal carcinoma (CRC) between Japan and China. Methods: Six early CRC cases were included in this study. Eleven Japanese and Chinese endoscopists were asked to review the colonoscopic pictures of these cases, including before and after indigocarmine spraying. After viewing the pictures, all the endoscopists individually made their classificatory diagnoses of these cases and indicated the findings on which they based each diagnosis. Results: Some lesions diagnosed by Japanese endoscopists as IIa or IIa +IIc, might be classified as Is or Isp by Chinese endoscopists. For superficial lesions consisting of elevation with central depression, IIa + depression, IIa + IIc or IIc + IIa were classifted according to the ratio of elevated area/depressed area. However, international as well as interobserver differences still existed in the classification of such lesions. In addition, most Chinese endoscopists overlooked the slightly depressed part on the top of a protruded lesion. Conclusion: Discrepancies on macroscopic classification for early CRC do exist between Japanese and Chinese endoscopists, which were found not only in terminology, but also in recognition of some lesions. In order to develop a universal macroscopic classification, there is a great need for international communication and cooperation.

Sonographic examination demonstrated a roundish, well-demarcated hypoechoic nodule approximately around 2cm in diameter in the quadrate lobe (segment IV) of the liver of a 56-year-old man with chronic hepatitis C. Abundant flow signals of constant waveform were detected within the lesion on color Doppler examination. Blood flowed into the lesion from the peripheral side of the quadrate lobe and ran in the opposite direction of normal flow in the pertinent branch of the portal vein. A dynamic helical computed tomographic study failed to depict the nodule. The lesion appeared slightly hyperintense in T1 -weighted images and moderately hypointense in T2-weighted images. The lesion appeared as a hot spot in colloid scintigraphy with 99mTc-phytate as well as in hepatocyte asialoglycoprotein receptor imaging with 99mTc-GSA. X-ray digital subtraction angiography failed to demonstrate the nodule, but ultrasound angiography with intraarterial infusion of carbon dioxide microbubbles confirmed that the lesion was hypovascular. The lesion was demonstrated as a perfusion defect on computed tomography during arterial portography. Ultrasound-guided needle biopsy showed a hyperplastic lesion without malignant findings. The abnormal area in question was not well irrigated by either the artery or the portal vein therefore, the continuous flows shown by color Doppler sonography are attributable to aberrant gastric venous drainage, which has been reported by Matsui et al. The lesion is thus considered to be a focal hyperplasia of hepatocytes that we presume to have been caused by abnormal blood inflow from the stomach.

We evaluated size, hemodynamic pattern, and histologic findings of 26 nodules associated with liver cirrhosis from which color Doppler imaging obtained afferent continuous waveform signals. Nodule size ranged from 0.8 to 3.0 cm (2.1 ± 0.6 cm (SD)). Arterial vascularity determined by US angiography was hypovascular, 16 noeules vascular spot in hypovascular, 7 nodules and isovascular, 3 nodules. No hypervascular nodules were observed. CT conducted during arterial portgraphy showed portal supply in 25 (96%) of the 26 nodules. Slightly increased portal perfusion was observed in 6 nodules slightly decreased portalperfusion, in 5 nodules. Portal perfusion in the remaining 14 nodules was identical to that of the surrounding liver parenchyma, partial portal perfusion defects were observed in the 2 cases with increased portal perfusion and in 1 case with identical portal perfusion. Histologic diagnosis showed 12 cases to be hyperplastic nodules and 14 cases to be well-differentiated HCC. No moderately or poorly differentiated HCC was obsened, we conclude that nodules that produced afferent intratumoral continuous waveform signals are either hyperplastic nodules or well-differentiated HCCs, not typical, classical HCC.

Color Doppler sonography was used to clarify the origin and significance of the efferent flow signal from the gallbladder wall. The efferent flow from the gallbladder wall was detected in 25 cases: 13 with acute cholecystitis, 1 with benign gallbladder polyp, 1 with adenomyomatosis, 1 with gallbladder cancer, 5 with focal spared area in diffuse fatty liver, 3 with liver cirrhosis (2 with hepatocellular carcinoma), and 1 with chronic hepatitis. The efferent flows communicated with the intrahepatic portal branch (9 cases), the hepatic vein (2 cases), or both (1 case). Furthermore, regurgitating flow of intrahepatic portal branch (P 5) was shown in 3 cases with acute cholecystitis. We conclude that the efferent flow from the gallbladder wall identified by color Doppler sonography corresponded to the cystic vein, which is difficult to detect with other imaging modalities. Color Doppler imaging may also be useful in assessing the severity of such pathologic conditions as acute cholecystitis or gallbladder cancer, and also in clarifying the cause of the focal spared area found in diffuse fatty liver or cystic vein hypertension.

Obliteration of portal systemic shunts surgically or by interventional radiological techniques is fairly effective in reversing intractable portal- systemic encephalopathy (PSE), but is often associated with ascites accumulation and/or formation of esophageal varices. This study reports four patients with incapacitating PSE who were treated by interventional radiological techniques via percutaneous transhepatic route. One case had the shunt embolized directly. In the other three the blockage was placed on the proximal part of the splenic vein, whereby disconnecting the mesenteric- portal blood flow from the systemic circulation while preserving the shunt. The patient of shunt closure showed transient correction of encephalopathy, but developed massive ascites and esophageal varices, encephalopathy recurred, resulting in death from hepatic failure two months after the procedure. In the cases of shunt preserving disconnection of portal and systemic circulation (SPDPS) immediate and permanent clearing of encephalopathy was achieved without manifestation of ascites or esophageal varices during the follow-up period of 10 to 31 months. The difference of portal pressure between before and after the procedure was 18mmHg in the shunt closed patient and 3 mmHg in SPDPS group. We conclude from this limited experience that SPDPS can be an effective and safe method in treating PSE in adequately selected patients.

The outcome of 45 small hepatic nodules diagnosed as hypovascular by US angiography were studied with clinical and ultrasonic follow-up carried out more than 1 years. Out of 45 nodules, 23 nodules were performed biopsy under US guidance at first detection, and hypercellularities and/or increasing in N/C ratio were observed in all 23 nodules. Enlargement of the nodule size was observed in 7 (16%) of 45 nodules, while the size has not changed in 20 (44%) nodules. Eighteen nodules (40%) become undetectable with US. Six nodules out of 7 enlarged cases developed into advanced HCCs. Four out of these malignant change group showed “vascular spot” on US angiography and/or perfusion defects on CTAP at the first detect. The remaining two cases also acquired such vascular findings at the later stage when they have enlarged. In this study, the twos of development and extension of HCCs were proved: (1) advanced HCC appear as a hypervascular spot in a benign hypovascular nodule, (2) portal perfusion in the tumor as a whole decreases and arterial vascularity increases in stead in the process of cancer development. It is concluded that, if the nodules which show “vascular spot” on US angiography and/or perfusion defect on CTAP exclude from the subject, only 5% (2/40) of the hypovascular nodules develop into advanced HCC. © 1994, The Japan Society of Hepatology. All rights reserved.

Ultrasound angiography (USAG), sonographic imaging of the blood flow in an organ or tissue obtained by carbon dioxide infusion into the supplying artery, was performed on 28 pancreatic nodular lesions less than 3 cm in diameter. The hemodynamics of tumors observed with USAG were divided into three groups : hypovascular, isovascular, and hypervascular, compared with the adjacent pancreatic tissue. Most of hypovascular nodules were duct cell carcinoma (sensitivity 94.1%, specificity 90.4%), while isovascular lesion was the characteristic of inflammatory masses (sensitivity 100%, specificity 95.8%). Hypervascular cases included all of the mucin producing tumors and islet cell tumors but only one case of duct cell carcinoma. So you can almost exclude duct cell carcinoma as an diagnosis in vascular rich tumors (negative predictive value 83.3%). These results were compared with those on conventional x-ray angiograms and incremental CT scans. Ultrasound angiography enabled us to detect more slight differences of tumor vascularity than the other modalities. Thus we conclude that USAG can be a useful diagnostic aid in small mass lesions of the pancreas. © 1994, The Japanese Society of Gastroenterology. All rights reserved.

It is considered that retrograde portal flow is an evidence for the existence of arterio-portal (A-P) shunt. Fifteen patients with hepatocellular carcinoma (HCC), in whom retrograde portal flow was detected by color Doppler flow imaging, were studied. The correspondence between existence of A-P shunt on angiogram and retrograde portal flow identified by spectral analysis with pulsed Doppler was evaluated. A-P shunt was observed in all 4 cases with pulsatile retrograde portal flow. Out of 11 cases with continuous retrograde portal flow, A-P shunt was observed in 5 cases (45%). In 11 cases with continuous retrograde portal flow, case with A-P shunt showed Mean ± SD of maximum velocity of 10.6 ± 5.3cm/sec, which is significantly higher than that of in cases without A-P shunt. A-P shunt was observed in all cases with maximum velocity of retrograde portal flow more than 10cm/sec. We concluded that pulsatile retrograde portal flow or continuous retrograde portal flow faster than 10cm/sec in velocity is diagnostic of the existence of A-P shunt relating to HCC. © 1993, The Japan Society of Hepatology. All rights reserved.

Presented two cases in this report are 36-year-old man and 78-year-old man with asymptomatic intrahepatic portal-hepatic venous shunt, diagnosed by color Doppler imaging. The patients were admitted for further evaluation of intrahepatic aneurysmal cystic lesion detected by screening ultrasonography. Liver biopsy and laboratory tests showed no abnormality in the liver, and case 1 had no episode of hepatic encephalopathy. Case 2 had an episode of slight encephalopathy. The color signals were obtained in the aneurysmal lesion, which communicates with the portal vein branch and the hepatic vein, on color Doppler imaging. Continuous waveform signals were detected in the aneusysm, the shunt orifice, and the adjacent region in the hepatic vein with the Doppler spectral analysis. The diagnosis was made as intrahepatic portal-hepatic shunt with aneurysmal dilatation by these findings with color Doppler imaging. Color Doppler imaging using pulsed Doppler analysis was also useful in the measurement of shunt ratio, which was calculated by deviding blood flow rate at the shunt orifice by total portal blood flow rate. We conclude that color Doppler imaging is extremely useful in the diagnosis, follow-up, and the determination of the therapeutic indication of the intrahepatic portal-hepatic venous shunt. © 1992, The Japan Society of Hepatology. All rights reserved.

Hemodynamic characteristics were studied by using in vivo vascular imaging techniques in 17 resected early stage hepatocellular carcinoma (e-HCC) by comparing them with 49 resected advanced HCCs (ad-HCC) less than 3 cm in diameter. In this study, e-HCC was defined as the nodule being uniformly composed of well-differentiated HCC or adenomatous hyperplastic nodule containing well-differentiated HCC foci within the nodule. In vivo vascular imaging techniques are as follows US angiography with intraarterial CO2 microbubbles were performed to assess the tumor arterial vascularity, and CT during arterial portography (CTAP) was performed to assess the portal perfusion within the nodule. of 17 e-HCC nodules 5 were hypervascular, 5 were isovascular, 4 were hypovascular, and 3 were vascular spot in hypovascular pattern in contrast to 49 ad-HCC nodules, 43 of which were hypervascular and 6 were isovascular. of 14 e-HCCs, 9 nodules showed perfusion defect and 5 did not on CTAP, whereas all 37 ad-HCCs on which CTAP was performed, showed perfusion defect. Forty-one percent (7/17) of e-HCC showed fatty metamorphosis in contrast to 8% (4/49) of ad-HCC. In conclusion, hemodynamic characteristics of e-HCC are summarized as follows. (1) Arterial tumor neovascularization is relatively low. (2) Portal perfusion is present in some of e-HCC cases. (3) Hypoperfusion state both from arterial and portal supply is present in some of e-HCC cases. (4) Vascular spot in hypovascular pattern is characteristic arterial pattern in AH containing HCC foci. (5) Fatty metamorphosis may be related with hypoperfusion state of the nodule in e-HCC. © 1992, The Japan Society of Hepatology. All rights reserved.

Technetium-99m diethylene triamine pentaacetic acid-galactosyl human serum albumin (TcGSA) is a newly developed receptor-binding radiopharmaceutical, specific for the asialogycoprotein receptor, which resides exclusively on the plasma membrane of hepatocytes. Clinical utility of TcGSA was evaluated in 3 control subjects with normal livers and in 54 patients with various liver diseases. The parameter, Receptor Index, was derived from liver and heart time-activity data and is the ratio of radioactivity of the liver over the radioactivity of the liver plus heart at 15 min after the intravenous injection of 3 mg of TcGSA. Receptor concentration ([R]0) was obtained by kinetic analysis of liver and heart time-activity data using pharmacokinetic nonlinear modeling. Values for the Receptor Index and [R]0 were statistically different in the control subjects and in patients with mild, moderate, and severe liver diseases. Good correlations were obtained between the Receptor Index, [R]G and conventional liver function tests, such as Child-Turcotte criteria score, prothrombin time, and indocyanine green test. Receptor Index and [R]G were properly estimated even in patients with obstructive jaundice or remarkable portocaval shunt. These data suggest that the receptor imaging as well as its parameters, Receptor Index and [R]G, is a potentially practical and reliable diagnostic method for estimating the functioning hepatocyte mass and for assessing liver function. © 1992, The Japanese Society of Gastroenterology. All rights reserved.

Technetium-99m galactosyl human serum albumin (TcGSA) is a synthesized radiolabeled analog ligand to asialoglycoprotein receptor, which resides only at a mammalian hepatocyte. TcGSA studies were performed on 16 patients with various acute liver disease and 3 controls with normal livers. Dynamic data were obtained by a gamma camera during 35 minutes after an intravenous injection of 3 mg (185 MBq) of TcGSA. The parameters of TcGSA timeactivity curves were obtained by dividing radioactivity of the liver by that of the liver plus heart at 15 min (Receptor Index), and by dividing radioactivity of the liver at 15 min by that at 3 min post injection (Clearance Index). The two parameters correlated well with prothrombin time, clinically estimated staging, and severity of acute liver disease. We have concluded that liver function study by the newly developed receptor imaging with TcGSA can be a sensitive and promising tool in estimating the severity and prognosis of acute liver disease. © 1992, The Japanese Society of Gastroenterology. All rights reserved.

Relationship between arterial vascularity and tumor growth speed was evaluated in 41 hepatocellular carcinomas (HCC). Arterial vascularity of HCCs was classified into 3 patients with US angiography during intraarterial carbon dioxide microbubbles: hypervascular (n=25), isovascular (n=7), and hypovascular (n=9) HCCs. Tumor growth speed was determined by the tumor volume doubling time (TVDT) with measuring by US. The logarithmic mean of the doubling time in hypervascular HCCs was statisticaly more rapid than that in isovascular or hypovascular HCCs (p< 0.05, p< 0.001) respectively. Furthermore, the logarithmic mean of TVDT in isovascular HCCs was more rapid than that in hypovascular HCCs (p< 0.05). We concluded that positive correlation between tumor vascularity and the tumor growth speed was observed, i.e., the more vascular the tumor is, the more rapid the growth speed becomes. © 1992, The Japan Society of Hepatology. All rights reserved.

Ultrasonographic (US) angiography enhanced with intraarterial CO2 microbubbles, a contrast material used in US imaging, was performed of 103 histologically proved hepatocellular carcinomas (HCCs) smaller than 3 cm in diameter in 95 patients. The detection rate for hypervascular HCC with US angiography was compared with the rate of detection with conventional angiography, digital subtraction angiography (DSA), and computed tomography (CT) after intraarterial injection of iodized oil. Sensitivity in detection of hypervascular HCCs with US angiography was 86% (89 of 103 HCCs), compared with 63% (44 of 70 HCCs) detected with conventional angiography, 70% (23 of 33 HCCs) with DSA, and 82% (75 of 91 HCCs) with CT with iodized oil. US angiography depicted small hypervascular HCCs, especially those less than 1 cm in diameter, and helped clarify vascularity as isovascular or hypovascular in angiographically undetectable HCCs. Findings at US angiography assisted the choice of a therapeutic strategy for treatment of HCC, such as transarterial therapy, percutaneous ethanol injection therapy, or resection.

Differential diagnosis of small liver tumors is important, but is not always possible, even with angiography. To solve this problem, we introduced sonographic angiography, which combines sonography and angiography. The vascular pattern of a variety of hepatic nodules was evaluated with sonographic angiography, and the results were compared with those of conventional angiography. Sonographic angiography (sonography performed during intraarterial infusion of carbon dioxide microbubbles) was performed in 184 patients with a total of 222 hepatic nodules: 139 hepatocellular carcinomas, nine adenomatous hyperplasias, seven regenerative nodules, 21 hemangiomas, 33 metastases, seven lymphomas, one granuloma, and five focal nodular hyperplasias. Sonographic angiography detected a hypervascular pattern with peripheral blood supply in cases of hepatocellular carcinoma (sensitivity, 90%; specificity, 89%). Typical vascular patterns of adenomatous hyperplasia, hemangioma, metastasis, and focal nodular hyperplasia on sonographic angiography were hypovascularity (sensitivity, 100%; specificity, 91%), spotty pooling (sensitivity, 100%; specificity, 100%), peripheral hypervascularity (sensitivity, 64%; specificity, 100%), and a central arterial supply (sensitivity, 100%; specificity, 100%), respectively. The detectability of hypervascularity was greater with sonographic angiography than with conventional angiography in hepatocellular carcinoma, metastasis, and hemangioma. Our experience indicates that sonographic angiography depicts characteristic vascular features that reflect the vascular anatomy of specific types of hepatic tumors, and thus is useful in the differential diagnosis of these lesions.

Dynamic contrast material-enhanced ultrasonography (US) with intraarterial infusion of carbon dioxide microbubbles was performed for four cases of histologically proved focal nodular hyperplasia (FNH) in four patients and for 167 cases of various hepatic nodules in 144 patients. No complications due to dynamic US were observed in any of the 148 patients. All FNH nodules were less than 3 cm in diameter. Consistent specific findings of FNH were not obtained with US, computed tomography, magnetic resonance imaging, radiocolloid scanning, or angiography in the four cases of FNH. In contrast, the characteristic vascular pattern (ie, early central hypervascular supply with centrifugal filling to the periphery at the arterial phase and a uniform or lobulated dense stain at the capillary phase) was observed in all four cases of FNH with dynamic US. This vascular pattern demonstrated in FNH with dynamic US was not seen in any of the 167 hepatic nodules, including 44 small hepatocellular carcinomas less than 3 cm in diameter. Therefore, the newly developed, dynamic contrast-enhanced US technique seems to be extremely sensitive and specific for diagnosing FNH and is useful in the differentiation of FNH from other hepatic tumors, especially hepatocellular carcinoma.

In this report the arterial vascularity within the nodule in small hepatocellular carcinoma (HCC) was evaluated in comparison with histopathological study. For this goal, dynamic contrast-enhanced ultrasonography with intraarterial CO2 microbubbles infusion (US angiography) was performed on 39 patients with surgically resected 44 small HCCs smaller than 3 cm in diameter. The results are as follows: 1) Out of 44 HCCs, 35 were demonstrated as hypervascular, 5 as isovascular, 3 as vascular spot in hypovascular, and 1 as hypovascular. 2) Out of 11 HCCs, which were pathologically classified into Grade I on Edmondson-Steiner scale, 4 were demonstrated as isovascular, 6 were demonstrated as hypervascular, and 1 were demonstrated as hypovascular. 3) Almost all Grade II-III HCCs (29/30) were demonstrated as hypervascular. 4) Out of 13 angiographically undetected HCCs, 4 were isovascular nodules, 3 were hypovascular nodules including vascular lesions, 5 were hypervascular nodules, and 1 was hypovascular nodule. 5) Out of 13 angiographically undetected HCCs, 9 nodules including 2 hypervascular nodules were nonencapusulated HCCs on pathological study of the resected specimen. 6) Sensitivity in demonstrating hypervascularity of the HCC improved to 80% (35/44) by the use of US angiography, compared to 70% (31/44) with conventional angiography or 73% (30/41) with Lipiodol CT. Moreover, sensitivity in evaluating tumor vascularity with US angiography was 100% (44/44). Our conclusions based on these results are as follow: 1) All HCCs except one have arterial vascularity within the tumor. 2) Half of well-differentiated HCC exhibited isovascualr or hypovascular, suggesting immature neovascularization within the tumor. 3) Tumors undetected with angiography or Lipiodol CT are isovascular, non-encapsulated, or considerably small HCCs. 4) US angiography is sensitive in the detection of arterial vascularity within the HCC nodules, and hence, contributory to the diagnosis of small HCCs. © 1991, The Japan Society of Hepatology. All rights reserved.

Tumor hemodynamics including arterial vascularity (AV) and portal perfusion (PP) were evaluated in histologically confirmed 55 hepatic nodules associated with cirrhosis using ultrasonographic (US) angiography during intraaterial carbon dioxide microbubbles injection and CT during arterial portography. Tumor hemodynamic patterns were classified into 6 types as follows: Type I (n=10): PP (+), AV (hypo) Type I' (n=2): PP (+), AV (iso) Type II (n=5): PP (-), AV (hypo) Type III (n=8): PP (-), AV (iso) Type IV (n=25): PP (-), AV (hyper), Type V (n=5): PP (partially +), AV (vascular spot in hypovascular). Eight nodules of Type I were diagnosed as benign nodules histologically including adenomatous hyperplasia (AH) (n=6) and regenerative nodule (n=2). Hundred percent (5/5) of Type II and 88% (7/8) of Type III nodules were well-differentiated HCC, in contrast to 8% (2/25) of Type IV nodules, typical HCCs. Fatty metamorphosis was observed in 75% (6/8) of Type III nodules, in contrast to 16% (4/25) of typical (classical) HCC nodules (Type IV). We concluded that at the malignant transformation from AH to HCC, reduction of portal blood flow in the nodule precedes the initiation of the increase of the arterial tumor vessel. Moreover, early stage HCC could exhibit hypovascular (Type I, II), isovascular (Type III), or vascular spot in hypovascular pattern (Type V) compared with a typical HCC (Type IV). It was also suggested that the more mature as a neoplams the HCC becomes, the more the arterial tumor vessel in the nodule increases and fatty metamorphosis of well-differentiated HCC is highly related with tumor hemodynamic condition, i.e., hypoperfusion state from both arterial and portal vessel. © 1991, The Japanese Society of Gastroenterology. All rights reserved.

A 72-year-old female was admitted to our hospital with complaints of general malaise, appetite loss, nausea, and vomiting in January, 1984. CT showed large tumor in the right lobe. Ultrasound revealed large tumor in the right lobe, tumor thrombi in the right main branch of the portal vein, and ascites. A sign of mild hepatic encephalopathy was also observed. Serum α-fetoprotein level was 25118 ng/ml. Angiography revealed multiple small hypervascular nodules in the right lobe and extremely extended arterio-portal shunting (A-P shunt), which is consistent with the diagnosis of hepatocellular carcinoma (HCC). The tumor and A-P shunt drastically disappeared on US, CT, colloid liver scan, and angiography a few months after the injection of 10 mg of mitomycine C through the common hepatic artery. Five years and 9 months after one shot arterial infusion chemotherapy, the recurred HCC, measuring 1.9 cm in size was treated with the second arterial infusion chemotherapy combined with lipiodol followed by a right lobectomy. The histopathology showed total necrosis of HCC, multiple organization and fibrosis in the right lobe, and thickened organized lesion with fibrosis within the portal vein. This case is considered to be rare since stage IV HCC responded extremely well to the single arterial infusion chemotherapy as well as the scars of HCC lesion and tumor thrombi in the portal vein were recognized pathologically more than 5 years later. © 1990, The Japan Society of Hepatology. All rights reserved.

Using the relaxing effect of nitrate on the smooth muscle of the Oddi's sphincter, we were able to eliminate stones in four patients with common bile duct stones without endoscopic sphincterotomy (EST). This method employs intravenous injections of nitrate and uses a basket catheter endoscopically inserted into the bile duct to grasp the stone. Removal of the stone can also be accomplished by endoscopically inserting a balloon catheter into the bile duct and pulling out the stone with the catheter. There was no evidence of adverse side effects such as lowered blood pressure excessively. This method was used on a small stone in the bile duct, but is especially useful in cases where EST is contraindicated or inappropriate. The application of this method is also beneficial when catheter insertion is difficult due to strong tension of the Oddi's sphincter during ERCP or EST. © 1988, Japan Gastroenterological Endoscopy Society. All rights reserved.

Asialoglycoprortecien pto(rA SGPR)r esideast t hec elslu rfacoef h epatocytewsh,e rei tr ecognizes and binds galactose-terminatgeldy coproteinAs.f ter binding,t he ligand-receptcoor mplex is transported to hepaticl ysozomesw here the ligandi s catabolizedA.l terationo f ASGPR binding has been demonstrated in variousp athologicc onditionso f the liver. Tc-99m-Galactosyl-Neoglycoalbum(iTnc -99m-NGA) is a newly developeda nalog ligando f galactose-terminategdl ycoproteinsW.e evaluatedc linicault ilitoyf Tc-99m-NGA in estimatingh epatic functionalr eServei n 23 clinicacla ses. NGA ReceptorI ndex,w hich isg iven by the radioactivitoyf the liverd ividedb y that of the liver plush earta t 30 min afteri ntravenousi njectioonf Tc-99m-NGA, was decidedt o be a preliminariy ndex of liverf unctionp rovidedb y NGA studiesi n thisr eport-Apositivceo rrelatiowna s observedb etween NGA ReceptorI ndex and CholinesteraseH,e paplastint est,T hrombotest,P rothrombin time and KICG. A negativec orrelatiowna s observed between NGA Receptor Index and ICG R15 and Child- Turcotte CriteriaS core. Analysis of the NGA dynamic curye is a promising method for the estimation of the heaptic functionalr eserve,a s the dynamic curves correlatteo the Asialogycoproteirne ceptorc oncentration. © 1987, The Japan Society of Hepatology. All rights reserved.

本研究では、テレカンファレンスやe-learningなどインターネットを用いた遠隔医療を活用することで継続的かつ効果的な国際医療教育を構築し、アジアにおける大腸がん診療の格差解消を目指している。 2年目となる2021年度もコロナ禍による渡航制限が継続されたため、共同研究者とともにアジア各国の拠点施設の訪問、大腸内視鏡検査を中心とした大腸がん診療の実態調査、インターネットやPCを含めた技術インフラの実地調査、海外医師と医療データの抽出・提出方法などについての検討、これらすべてを実施するこができなかった。また世界では、感染拡大予防のため緊急時以外の内視鏡検査について検査制限が継続されている国が未だにあることから、遠隔医療教育による内視鏡検査の質の向上に関する評価が困難な状況で、データ収集と教育を開始する時期でないと判断している。 渡航制限や各国の内視鏡検査制限が緩和された時点で速やかに研究が実施できるよう、今年度は教育に用いるコンテンツ作成とe-learningを実施するためのオンラインプラットフォームの確認作業と選定を行っている。また、アジア各国の医療機関を接続した内視鏡診療に関するテレカンファレンスを2度、中国とのテレカンファレンスを3度実施し、アジアを中心に培ってきた内視鏡医師とのネットワークを維持・拡充した。テレカンファレンスにおける内視鏡画像および音質の品質については参加者の満足度も高く、ネットワークの帯域は十分に確保されていることが推察される。