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Introduction Insufficiency of pancreas exocrine function leads to malnutri- tion and causes a worse prognosis in patients with chronic pan- creatitis or pancreatic cancer. Therefore, it is important to un- derstand the mechanism of malnutrition, especially in patients with pancreatic disease [1, 2]. The pancreas and small intestine play central roles in digestion and absorption of nutrients, and a
close interaction between these organs is likely. For example, pancreatic juice containing digestive enzymes is considered to be an important factor for small intestinal villous growth [3, 4]. However, since an endoscopic approach to the small intestine is anatomically difficult, there are only a few studies on the inter- action of these organs, and most interactions in humans have not been defined [4, 5].
Objective evaluation of blood flow in the small-intestinal villous: quantification of findings from dynamic endoscopy with concomitant narrow-band imaging
Tomoaki Takeyama1, Yoshiki Hirooka2, Hiroki Kawashima1, Eizaburo Ohno1, Takuya Ishikawa1, Takeshi Yamamura1,
Kazuhiro Furukawa1, Kohei Funasaka2, Masanao Nakamura3, Ryoji Miyahara1, Masatoshi ishigami1, Hidemi Goto1
1 Department of Gastroenterology and Hepatology,
Nagoya University Graduate School of Medicine,
Nagoya, Aichi, Japan
2 Department of Endoscopy, Nagoya University Hospital,
Nagoya, Aichi, Japan
3 Department of Internal Medicine, Division of
Therapeutic Medicine, Nagoya University Graduate
School of Medicine, Nagoya, Aichi, Japan
accepted after revision 9.4.2018
DOI https://doi.org/10.1055/a-0619-4965 |
Endoscopy International Open 2018; 06: E941–E949
© Georg Thieme Verlag KG Stuttgart · New York
Yoshiki Hirooka, Department of Endoscopy, Nagoya
University Hospital, 65, Tsuruma-Cho, Showa-Ku, Nagoya,
Aichi 466-8550, Japan
Background and aims We have previously shown that the increase in blood flow volume in jejunum villi after spraying
of 10% dextrose solution correlates with pancreatic exo-
crine function (PEF). The aim of this study was to establish
an objective method to evaluate the amount of jejunum vil-
lous blood flow using a novel image analysis system.
Patients and methods The subjects were 26 patients who underwent upper gastrointestinal endoscopy with a newly
developed small intestine endoscope (SIF-Y0007, Olympus,
Tokyo, Japan). By defining the ratio of capillary occupancy
in each villus at levels from 1 to 5, villous blood flow was
evaluated subjectively on the villous blood flow scale
(VBFS). Objective evaluation was performed based on lumi-
nance analysis. The morphological opening process was
used to make images with leveled brightness. A histogram
was prepared from the luminance information and the
standard deviation was determined and defined as SDOV
(Standard Deviation calculated from a histogram made by
luminance analysis Of Villi). PEF was evaluated by measur-
ing the BT-PABA (N-benzoyl-L-tyrosyl-p-aminobenzoic
acid) excretion rate.
Results There was a significant positive correlation be- tween VBFS and SDOV (P
A prototype endoscope for the small intestine (SIF-Y0002, Olympus, Tokyo, Japan) can be used to observe the proximal je- junum without use of a balloon, and allows morphological eval- uation of villi by biopsy . This approach has shown significant atrophy in small-intestinal villi in patients with chronic pancrea- titis with reduced pancreatic exocrine function (PEF); the villus form was closely correlated with PEF; and incretin-secreting cells, which are also likely to be correlated with PEF, were found to be expressed in the upper small intestine .
Using a recently developed small intestine endoscope (SIF- Y0007, Olympus, Tokyo, Japan) with 80×magnification power for optical zooming, the capillary network and blood flow in each villus can be observed in magnified observation with con- comitant use of narrow-band imaging (NBI) (▶Video 1). In ad- dition, we found that the blood flow volume in villi increased when 10% dextrose solution was applied to the small intestine mucosa (thicker blood vessels and a deeper brown color in the image were seen in magnified observation with NBI). To clarify the relationship between this phenomenon and small-intestinal mucosal function, subjective changes in blood flow (changes in color) before and after spraying dextrose solution were exam- ined in animated observation of endoscopic findings, using an ascending scale of 1 to 5. This was defined as the villous blood flow change. That study showed that villous atrophy had a neg- ative correlation with villous blood flow change and a positive correlation with the PABA excretion rate in urine, an index of PEF (that is, an increase in blood flow was correlated with PEF) .
These data indicate that PEF can be measured using magni- fying endoscopy with concomitant use of NBI in small-intestinal mucosa. However, villous blood flow change is based on subjec- tive evaluation, and is not an objective index. Therefore, the current study was performed to develop a method to quantify blood flow in small-intestinal villi objectively, based on the depth of brown color in endoscopic findings after processing of images obtained using magnified observation with NBI.
Patients and methods Study design
This was a retrospective, observational, open label, single cen- ter, phase I study.
Among 30 patients who underwent small intestinal endoscopy with a prototype small intestinal endoscope with a magnifying function (SIF-Y0007, Olympus) from August 2015 to Septem- ber 2016, 26 who could be favorably followed by magnified ob- servation with concomitant NBI were selected as the subjects. The inclusion criteria were patients with pancreatic disease such as pancreatitis and pancreatic cancer or patients without pancreatic disease as controls and adults aged≥20 years who gave informed consent to the study and who required upper gastrointestinal tract endoscopy for screening for upper gas- trointestinal disease (e. g. gastric cancer or gastric ulcer). The exclusion criteria included premenopausal women, patients with severe malnutrition, a history of surgery for the stomach/ duodenum/small intestine, internal administration of antiplate- let drugs or anticoagulants, routine use of NSAIDs, severe chronic cardiac failure/chronic renal failure, and no provision of written informed consent.
Favorable magnified observation was defined as continuous video uptake in a 3-minute interval after spraying dextrose so- lution with a sharp focus on the image center and no halation (▶Fig. 1) in the central part of the image taken at the highest magnification (see ▶Video 1: example of favorable observa- tion; and ▶Video 2: example of inappropriate observation be- cause of halation). Subjects with autoimmune or chronic pan- creatitis were diagnosed based on ICDC2011 [8, 9], and those with pancreatic cancer were histopathologically diagnosed with pancreatic duct cancer by surgery or endoscopic ultra-
▶ Fig. 1 Example of halation (circles). Halation is a phenomenon that causes whiteout of an image because of the reflection of light from the endoscope.
Video 1 Example of favorable magnified observation with a sharp focus on the image center and no halation in the central part of the image.
E942 Takeyama Tomoaki et al. Objective evaluation of… Endoscopy International Open 2018; 06: E941–E949
sound (EUS)-guided fine needle aspiration. Subjects with non- pancreatic disease included those with unexplained abdominal pain, abdominal symptoms such as diarrhea, and a need to re- ceive an endoscopic examination of the upper digestive tract for preoperative screening for conditions such as gallstones. In all subjects, the absence of pancreatic disease was shown based on the results of blood tests, abdominal ultrasonography, and computed tomography (CT).
Data for sex, date of birth, age, height, and weight were collec- ted for all patients. Blood tests (red blood cell count, hemoglo- bin level, white blood cell count, platelet count) and biochem- ical tests (GOT, GPT, ALP, γGTP, LDH, total bilirubin, AMY, li- pase, elastase 1, total protein, albumin, prealbumin (TTR), reti- nol-binding protein (RBP), vitamin D3 (VitD3), Fe, UIBC, Zn, Mg, ferritin, transferrin, total cholesterol level, LDL cholesterol level, HDL cholesterol level, triglyceride, blood glucose level, HbA1c, INS, C-peptide, IgG, IgA, IgM, IgE, BUN, Cr, Na, Cl, K, Ca, PT, APTT) were performed in all patients. All data were collected retrospectively.
Pancreatic exocrine function (PEF) test
PEF was evaluated by measuring the PT-PABA excretion rate. This was measured twice and the mean value was used as the PEF value.
The procedure was performed with an improved enteroscope with 80×magnification function in optical zooming (SIF- Y0007: working length 2000mm, outer diameter 9.2mm, and channel size 2.8mm; Olympus), which can reach the jejunum without balloon assistance. The endoscopy video system was an Evis Lucera Spectrum (CV-260/CLV-260SL) (Olympus) and the NBI image was created using the sequential scanning meth- od. Using the SIF-Y0007, push enteroscopy was performed with the oral method without any overtube or balloon assistance,