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症例は39歳，女性．右臀部圧迫感を主訴に当院を受診した．CTおよびMRIでは後直腸部に嚢胞性腫瘤があり，超音波内視鏡検査では下部直腸後壁側の壁外に多房性で内部が不均一な腫瘤像として観察された．tailgut cystを強く疑い，経仙骨的腫瘍摘出術を施行した．病理組織学的にも合致する所見であり悪性所見は認めなかった．超音波内視鏡検査は腫瘤内部の詳細な観察が可能であり，本疾患の有用な補助診断法と考えた．

We carried out a retrospective questionnaire survey of 792 submucosal colorectal carcinoma (CRC) cases from 15 institutions affiliated with the Colorectal Endoscopic Resection Standardization Implementation Working Group in Japanese Society for Cancer of the Colon and Rectum. In these cases, endoscopic resection (ER) and surveillance was carried out without additional surgical resection. Local recurrence or metastasis was observed in 18 cases. Local submucosal recurrence was observed in 11 cases, and metastatic recurrence was observed in 13 cases. Among the 15 cases in which the depth of submucosal invasion was measured, two cases showed depth less than 1000 µm, which has other risk factors for metastasis. Metastatic recurrence was observed in the lung, liver, lymph node, bone, adrenal glands, and the brain; in some cases, metastatic recurrence was observed in multiple organs. Death due to primary disease was observed in six cases. The average interval between ER and recurrence was 19.7 ± 9.2 months. In 16 cases, recurrence was observed within 3 years after ER. Thus, validity of ER without additional surgical resection for cases with the conditions that the depth of submucosal invasion is less than 1000 µm and the histological grade is well or moderately differentiated adenocarcinoma with no lymphatic and venous involvement was proven.

Bleeding, perforation, and residual/local recurrence are the main complications associated with colonoscopic treatment of colorectal tumor. However, current status regarding the average incidence of these complications in Japan is not available. We conducted a questionnaire survey, prepared by the Colorectal Endoscopic Resection Standardization Implementation Working Group, Japanese Society for Cancer of the Colon and Rectum (JSCCR), to clarify the incidence of postoperative bleeding, perforation, and residual/local recurrence associated with colonoscopic treatment. The total incidence of postoperative bleeding was 1.2% and the incidence was 0.26% with hot biopsy, 1.3% with polypectomy, 1.4% with endoscopic mucosal resection (EMR), and 1.7% with endoscopic submucosal dissection (ESD). The total incidence of perforation was 0.74% (0.01% with the hot biopsy, 0.17% with polypectomy, 0.91% with EMR, and 3.3% with ESD). The total incidence of residual/local recurrence was 0.73% (0.007% with hot biopsy, 0.34% with polypectomy, 1.4% with EMR, and 2.3% with ESD). Colonoscopic examination was used as a surveillance method for detecting residual/local recurrence in all hospitals. The surveillance period differed among the hospitals; however, most of the hospitals reported a surveillance period of 3-6 months with mainly transabdominal ultrasonography and computed tomography in combination with the colonoscopic examination.

Background and Aims: The aim of the study was to examine whether the change in the prevalence of Helicobacter pylori infection had influenced upper gastrointestinal diseases in a recent 17-year period. Methods: The prevalence of H. pylori infection was examined by serum H. pylori antibody tests in the subjects undergoing annual health checks at the Social Insurance Shiga Hospital in 1998 and 2005 (142 and 242 subjects, respectively). The prevalence of H. pylori infection in 1988 was estimated by parallel translation from the prevalence in 1998. A total of 2833 records of endoscopy performed in 1988 and 2005 at Otsu Municipal Hospital were studied. The age-adjusted prevalence of peptic ulcer, gastric cancer and reflux esophagitis were compared between 1988 and 2005. Results: The age-adjusted prevalence of H. pylori infection significantly decreased in 2005 compared with 1988 (70.5–52.7%). The endoscopic records of 937 and 1246 patients in 1988 and 2005, respectively, were included in the analysis. The age-adjusted prevalence of peptic ulcer significantly decreased 0.34-fold in both men and women in 2005 compared with 1988. The age-adjusted prevalence of gastric cancer significantly decreased 0.44-fold in men, but did not change in women (0.99-fold), and overall significantly decreased 0.56-fold. The age-adjusted prevalence of reflux esophagitis significantly increased 6.6-, 2.7- and 4.8-fold in men, women and total, respectively. The increase was dominant in men aged 30–69 years. Conclusion: Over the 17-year period, accompanying the decreasing prevalence of H. pylori infection, the age-adjusted prevalence of peptic ulcer and gastric cancer decreased, but that of reflux esophagitis increased.

Background: Endoscopic ultrasonography (EUS) is widely accepted as a diagnostic tool for bilio-pancreatic and gastrointestinal tract diseases. Recently, an ultrasound endoscope with an electronic radial scan transducer has been developed. To evaluate the clinical usefulness of this system, its image quality, advantages and disadvantages were evaluated. Materials and methods: Ultrasound endoscope with electronic radial scan transducer and its monitor unit were used. The direction of the imaging plane was similar to that of the mechanical radial models. Color Doppler function and tissue harmonic imaging were feasible by this system. To evaluate this endoscope, we investigated the image quality and distance resolution by in-vitro study using thin papers, and 50 patients were examined by this system. Results: Comparison with the mechanical radial endoscope GF-UM2000 revealed that the image quality was almost equivalent. However, the ultrasound penetration of the electronic radial scanner was better and more satisfactory with less echoic reduction. In addition, the blood-flow signal could be obtained by using the color Doppler function. In contrast, the diameter of the new endoscope was bigger than the advanced mechanical radial models, the monitor unit was bigger than that of the mechanical radial system, and the operation of this unit was complicated. Conclusion: A prototype of the ultrasound endoscope with electronic radial scan showed satisfactory results regarding the image quality, ultrasound penetration, and clinical diagnosis. The blood flow could be investigated by using the color Doppler function, which is useful to diagnose lesions and detect involvement of the blood vessels in cancers.

Background: Intraductal papillary-mucinous tumor (IPMT) of the pancreas has a broad spectrum of histology ranging from hyperplasia to adenocarcinoma. Therefore, it is important to differentiate between the malignant and benign lesions to determine the therapeutic strategy for IPMT. Patients and Methods: Thirty-nine patients with IPMT (27 men and 12 women, mean age: 63.3 years) underwent surgery between January 1985 and March 2002. The size of the cystic lesion, the maximum diameter of the main pancreatic duct (MPD), and the height of the papillary tumor inside the cyst were investigated by endoscopic ultrasonography (EUS) and/or intraductal ultrasonography (IDUS) before operation. These preoperative clinical findings were compared with the pathological findings of the resected specimen. Results: The size of the cystic lesion, the diameter of MPD, and the height of the papillary tumor in cases with malignant IPMT (invasive and non-invasive carcinoma) were larger than those in cases with benign IPMT (adenoma and hyperplasia). Analysis of the images of the lesions revealed that the following three factors are important for diagnosing IPMT: (i) the size of the cystic lesion is ≥ 30 mm; (ii) the diameter of MPD is ≥ 8 mm; (iii) the height of the papillary tumor inside the cyst is ≥ 3 mm. It was not significant to differentiate between benign and malignant IPMT based on factor (i), but statistically significant (P

患者は68歳女性で, 右季肋下で5横指, 心窩部で4横指にわたる肝腫大を認めた. 血液検査成績では, 血清アルブミンの著しい低下と胆道系酵素の上昇を認めた. 腹部造影CT検査にて肝右葉と左葉の一部に造影効果の乏しい部分を認め, dynamic MRIでも同様の部位に著しい造影効果の低下を示した. また, 99mTc-PYP (ピロ燐酸) シンチグラムにて肝に取込みを認め, 肝アミロイドーシスを疑った. 超音波下肝生検像では, アミロイドの沈着および肝細胞の圧迫と萎縮を認めた. 免疫組織学的検討では, 沈着物質はκ型AL蛋白であり, 原発性アミロイドーシスと診断し, 腎生検でも同様の所見が得られた. アミロイドーシスの確定診断は組織学的手段によるが, 近年の画像診断の進歩はめざましく, 各種の画像診断法を駆使することで肝生検に迫る診断が可能であると考える.

The ultrasonograms of ulcerative colitis (UC) in active stage show hypoechoic changes of the colorectal wall from the mucosal layer to the deeper layers. These endoscopic ultrasound (EUS) changes of the wall recognized in active stage disappear or normalize in the stage of remission. When the stage of UC is exacerbated, the hypoechoic changes of the wall extend from the mucosal layer to the deeper layers with the increase of wall thickness. These EUS images of active UC are classified into the following types: UC-M, thickening of the whole wall with the structure preserved; UC-SM, hypoechoic changes reach the superficial portion of third layer with the thickening of whole wall; UC-SM deep, hypoechoic changes reach the deeper portion of third layer with the thickening of whole wall; UC-MP, hypoechoic changes reach the fourth layer with the thickening of whole wall; UC-SS/SE, hypoechoic changes penetrate through the fourth layer with the thickening of whole wall. With the help of EUS we can demonstrate the severity of inflammation in UC. Moreover, in severe cases of UC, the treatment strategy including emergency surgery can be determined. EUS is a valuable method in the management of UC.

Recently, an indication of gastrointestinal stenting is not only esophageal stenosis but it extends from the esophagus to the gastric outlet and duodenum. However, there are some problems such as shortness of the device for esophageal stenting, angulations of stenotic sites, and so on, when we perform the stenting for stenoses of the gastric outlet and duodenum. Until now, some refinements of stent insertion technique have been attempted to solve these problems. In this paper, we report three cases in which self-expanding metallic stents were placed for stenoses of the gastric outlet and duodenum with refinements of stent insertion technique. Our attempts in these patients were an extension of stenting device to insert stents easily, and placement of covered metallic stent inside non-covered metallic stent or a fixation of covered metallic stent to the gastrointestinal wall by means of endoclips to avoid dislocation of stents. Stents were inserted successfully in all patients, and the nutrition of these patients was improved after the placement of stents. Further refinements of stents and stent insertion technique are expected to achieve easy manipulation.

We have experienced a case with perforation after endoscopic balloon dilatation. The patient was diagnosed as having malignant lymphoma in the terminal ileum, and treated with eradication of H. Pylori and chemotherapy. The severe stenosis appeared at the same site of the tumor after the medical treatment. The first dilatation with a 15 mm balloon was successful. The lower small bowel obstruction occurred 14 months after the first balloon dilatation. The second dilatation with an 18 mm balloon was performed. The stricture site was remarkably dilated and could be passed by the scope. Perforation was confirmed because of the complaint of severe abdominal pain. The laparotomy finding showed the hole at the stricture site and remarkable fibrosis without tumorous tissue. The fragility of the tissue, the excessive inflation of the balloon and the insertion of the scope might be causes of the perforation. The case with severe stricture having almost no flexibility should be considered carefully in the determination of treatment procedures for the balloon dilatation.

We applied a newly developed endoscopic resection technique for a rectal mucosal cancer of 4.2 cm. This method resulted in a curable treatment and provided precise information for histological examinations. This technique, using IT-knife, may involve the risk of bleeding and perforation compared with conventional methods. Further improvements are needed to make this technique safer and more reliable for a standard endoscopic method for large colorectal tumors.

Bleeding, perforation, and residual/local recurrence are the main complications associated with colonoscopic treatment of colorectal tumor. However, current status regarding the average incidence of these complications in Japan is not available. We conducted a questionnaire survey, prepared by the Colorectal Endoscopic Resection Standardization Implementation Working Group, Japanese Society for Cancer of the Colon and Rectum (JSCCR), to clarify the incidence of postoperative bleeding, perforation, and residual/local recurrence associated with colonoscopic treatment. The total incidence of postoperative bleeding was 1.2% and the incidence was 0.26% with hot biopsy, 1.3% with polypectomy, 1.4% with endoscopic mucosal resection (EMR), and 1.7% with endoscopic submucosal dissection (ESD). The total incidence of perforation was 0.74% (0.01% with the hot biopsy, 0.17% with polypectomy, 0.91% with EMR, and 3.3% with ESD). The total incidence of residual/local recurrence was 0.73% (0.007% with hot biopsy, 0.34% with polypectomy, 1.4% with EMR, and 2.3% with ESD). Colonoscopic examination was used as a surveillance method for detecting residual/local recurrence in all hospitals. The surveillance period differed among the hospitals; however, most of the hospitals reported a surveillance period of 3-6 months with mainly transabdominal ultrasonography and computed tomography in combination with the colonoscopic examination.

We have used endoscopic ultrasonography (EUS) for all the colorectal diseases. For cancer, we determined the treatment method by evaluating the depth of cancer invasion. Moreover, we have applied EUS for submucosal cancer to decide whether the depth of submucosal invasion was superficial and thus to estimate the indication of endoscopic resection. Lymph node metastasis has been examined for staging in cases with invasive cancer. We have performed EUS for active ulcerative colitis in observing the depth of inflammation and determined treatment strategy by diagnosing clinical severity. Submucosal tumorous lesions and extramural lesions have been examined to clarify the site and inner condition. EUS is an essential method that leads to accurate diagnosis of any colorectal disease by delineating pathological conditions precisely. With improvement of the instrumentation, EUS can be used as a routine diagnostic tool as is colonoscopy.

Mucin-producing cholangiocarcinoma, which excretes excessive amounts of mucin into the biliary tract and causes obstructive jaundice and cholangitis due to the mucin retention, is rare. In this paper, we report two cases of this disease, which were demonstrated by peroral cholangioscopy (POCS). The radiologic features of these tumors show the diffuse dilatation of the bile ducts demonstrated by computed tomography (CT) and ultrasonography (US), the amorphous filling defects in the dilated bile ducts revealed by cholangiography. Their endoscopic features are mucin flowing out from the papilla of Vater during endoscopic retrograde cholangiography (ERC), and the papillary tumor with contiguous superficial spread in the bile ducts observed by cholangioscopy, although removal of mucin in the biliary tract is sometimes necessary before cholangioscopy in order to examine the lesion sufficiently. According to the previous reports, prognosis after curative resection of these tumors is better than that of ordinary type of cholangiocarcinoma. Therefore, it is important to examine the tumor extension in the bile ducts by cholangioscopy, although a selection of route inserting cholangioscope is controversial.

The c-K-ras 2 gene mutations were examined in colorectal tumours from patients with synchronous or metachronous tumours in order to investigate tumorigenesis. Sixty-seven colorectal carcinomas from patients with a single lesion, 50 from patients with synchronous lesions, and 12 from patients with metachronous lesions were analysed for the presence of point mutations in codons 12 and 13 of c-K-ras proto-oncogene. In the patients with metachronous or synchronous lesions, the finding of the mutation in one tumour was not associated with a greater frequency of the mutation in other carcinomas from the same patient. In the patients with tumours that each contained the mutation, the mutations were not always the same. In tumours from the patients with original and synchronous lesions, the mutation frequency was significantly lower in advanced carcinomas invading through the entire muscularis propria (10.5%) than in early carcinomas confined to the mucosa (47.8%), and the mutation frequency in carcinomas invading through the entire muscularis propria was significantly lower in patients with synchronous lesions (10.5%) than in patients with a single lesion (37.7%). These results suggest that the tumorigenesis of colorectal carcinomas from patients with synchronous lesions is different from that in patients with a single lesion.

Purpose: To clarify the usefulness of EOCT in the diagnosis of colorectal diseases compared with EUS using ultrasonic probes.

The use of endoscopic ultrasonography (EUS) in the diagnosis of submucosal upper gastrointestinal tract lesions was examined in 308 patients. Two-hundred ten submucosal tumors, 89 cases of esophagogastric varices, and 9 cases of non-Hodgkin's lymphoma were found. EUS images were interpreted based upon a five-layer EUS structure of the normal gastrointestinal wall. A characteristic EUS image was seen with leiomyoma, cysts, lipoma, and varices. EUS had an accuracy of 80% in staging nine cases of lymphoma. EUS is a valuable technique for the evaluation and diagnosis of submucosal upper gastrointestinal tract lesions.

Background: The colorectal tumors limited within the mucosa or superficial submucosa(sm-small) can be completely treated endoscopically since the probability of lymph node metastasis is almost nil. Histologically, the depth of submucosal tumor invasion was regulated by equally divided three levels of the submucosa in the vertical direction. Tumors of sm-small were defined as those limited within the superficial 1/3 of the submucosa, tumors of sm-massive, extending from the middle 1/3 of the submucosal layer to the deeper portion near the muscularis propria. Therefore, pretherapeutic diagnosis whether the depth of tumor invasion is limited within sm-small or deeper than sm-massive is extremely important for the treatment strategy. Aims: To evaluate the usefulness of EUS in the diagnosis of depth of colorectal cancer invasion, and compare the ability of EUS with conventional colonoscopy in the diagnosis of submucosal cancer invasion. Methods: Between May 1985 and September 1999, EUS was performed in 563 patients with colorectal cancer. All of the tumors were resected and confirmed histologically. Especially, preoperative EUS diagnosis of submucosal cancer staging was investigated in comparison with conventional colonoscopy in 77 patients with colorectal submucosal cancer. EUS criteria for the depth of submucosal cancer invasion were defined as SM-small and SMmassive according to the deepest portion of the hypoechoic tumorous mass compared with the third hyperechoic layer in the vertical direction. Colonoscopic criteria for the SM-massive were based on the following findings; marginal submucosal elevation, erosion or ulceration on the tumor, marked elevation on the tumor and fold convergence. Results: EUS correctly diagnosed pTis in 98 of 118 patients, pT1 in 62 of 80 patients, pT2 in 42 of 84 patients, pT3 in 248 in 276, and pT4 in 5 of 5 patients. The overall accuracy rate of EUS was 81%(455/563) according to TNM classification. Pretherapeutic diagnosis was investigated whether the depth of tumor invasion was sm-small or sm-massive. The accuracy rates of EUS and colonoscopy were 23/31(74%) and 19/31(61%), respectively, in sm-small, and 41/46(89%) and 38/46(83%), respectively, in sm-massive. The overall accuracy rates with EUS and colonoscopy were 83%(64/77) and 74%(57/77), respectively. Conclusion: EUS is a useful diagnostic method for determining the depth of colorectal cancer invasion according to TNM classification and subclassification of submucosal cancer.

ENDOSCOPIC MUCOSAL RESECTION FOR LARGE SESSILE POLYPS OF THE COLON E. Cho, N. Mochizuki, T. Ashihara, K. Yasuda and M. Nakajima, Department of Gastroenterology, Kyoto Second Red Coss Hospital, Kyoto, Japan With the advances of techniques and instruments, endoscopic electrosurgical polypectomy has become a fundamental procedure in the management of colorectal polypoid lesions. However, large sessile polyps can be technically difficult and sometimes dangerous to endoscopically resect. Recently, endoscopic mucosal resection(EMR) has been developed as a safer method for colorectal polyps. We assessed the usefulness of this technique for large sessile colorectal polyps. From September 1990 to November 1995, we have performed EMR in 32 patients with colorectal sessile polyps larger than 2 cm in size. The procedure was done in a similar fashion of standard snare polypectomy after injection of saline solution into the submucosa just underneath the target lesion. The maximum diameter of resected polyps ranged from 2.0 to 6.0 cm with a mean of 3.1 cm. The procedure was performed in Ii patients with single resection and 21 patients with piecemeal resection. The histological analysis of these lesions consisted of 3 with tubular adenoma, 5 with tubulovillous adenoma, i with villous adenoma, 20 with mucosal carcinoma and 3 with submueosal carcinoma. The complications after EMR occurred in 4 patlents(12.5%) including i patient with bleeding, 2 with transmural burn and i with perforation into the retroperitonetum, all of which required neither transfusion nor laparotomy. Twentyfive of 32 patients underwent colonoscopic management and surveillance. Locally reccurent or persistent neoplasia was discovered in 4 of 25 patients(16%). Three of these four patients subsequently underwent surgical resection. Endoscopic management was ultimately successful in 22 of 25 patients(88%). EMR is a safer and reliable therapeutic procedure for large sessile colorectal polyps. Close follow-up with colonoscopy is essential to evaluate this technique.