Haruhiro Inoue

A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC)

We have previously reported on our novel esophageal mucosal resection technique using a specially devised tube (EMRT) for early-stage esophageal cancer [1, 2]. Acquired specimens lent themselves well to accurate histopathological diagnosis, such as the depth of cancer invasion, type of cancer, grade of differentiation, and vascular involvement. EMRT has been confirmed to be a safe and reliable procedure. There has been no experience of perforation or massive bleeding in six early esophageal cancer cases demonstrated, though EMRT demands a certain degree of skill from the endoscopist. A considerably simplified technique is thus expected to be established only as a therapeutic measure

Ultra-high Magnification Endoscopic Observation of Carcinoma in situ of the Esophagus

Abstract: Super‐zooming observation of carcinoma in situ of the esophagus was achieved utilizing an ultra‐high magnification endoscope which has a 150X magnification capacity. Superficial flat and slightly depressed lesions (O‐llb and O‐llc according to the Japanese classification of esophageal cancer), usually observed as a well‐demarcated reddish patch, were revealed to be a composite of scattered red dots and a pinkish homogeneous background. Those red dots were disclosed to be intrapapillary capillary loop changes such as dilatation, meandering and caliber irregularities. These changes were never observed in normal mucosa or in the setting of esophagitis. These characteristic findings were confirmed histologically in the resected specimen.

Endoscopic esophageal mucosal resection using a transparent tube.

SummaryGenerally, it is considered technically impossible to perform an extensive mucosal resection of the esophagus using endoscopy. We have developed a new method of endoscopic esophageal mucosal resection using a transparent tube (EMRT). With this technique, any amout and any part of the esophageal mucosa can be safely and easily resected. After an experimental study, EMRT was performed in 11 patients and there were no major complications. Near-total circumferential resection of the mucosa was possible, and the surface of the esophageal muscle layer (non-bleeding resection layer) was left intact. We performed this technique on a patient with a mucosal cancer of the esophagus, and succeeded in resecting the lesion during a short course of treatment. We conclude that EMRT is of value in the endoscopic treatment of early-stage esophageal cancer.

Endoscopic mucosal resection for esophageal and gastric mucosal cancers

Accumulated data from surgically resected specimens reveal that mucosal cancers of the esophagus and stomach pose low risk of lymph node metastasis. The author used endoscopic mucosal resection (EMR) as curative treatment in 142 cases of esophageal cancer and 102 cases of stomach cancer. In absolutely indicated cases there has been no local or distant metastasis during the longest period of follow-up (nine years). One perforation and one post-treatment severe stenosis, which was resistant to dilation therapy in the esophagus, were encountered. Deeper layer resection (including partial proper muscle) occurred in the stomach in three cases where the lesions were positioned to the lesser curvature of the upper part of the stomach. Two cases of gastric mucosal resection leaving residual cancer were successfully treated by laser ablation. No case has required further surgery. Resected specimens were contributed to histological evaluation in all cases. In conclusion, EMR can be considered as the first-line treatment for selected cases of early stage esophageal and stomach cancer.

Endoscopic Mucosal Resection Using a Cap: Techniques for Use and Preventing Perforation

Endoscopic mucosal resection (EMR) is one of several local treatments that provide a specimen for histopathological analysis. The authors developed a technique of EMR using a transparent plastic cap (EMRC) in 1992. By using the EMRC procedure, any part of the gastrointestinal tract mucosa can be easily accessed. The technical details of EMRC are described. The authors have performed EMR in 380 cases of gastrointestinal lesions. The most serious complication may be perforation. Two perforations (one in the esophagus and one in the colon) have occurred. By evaluating recorded videotapes, it was determined that the lack of submucosal saline injection was the major cause. Therefore, large volume injection, which creates a large bleb and potentially reduces the risk of perforation, is recommended. Furthermore, target mucosa should be strangulated at the middle part of the created bleb (never strangulated at the base). Particularly in the colon, injecting a sufficient volume of saline and controlling the power of suction are extremely important, because the cap on the colonoscope is relatively large in size.

Ultra‐high Magnification Endoscopy of the Normal Esophageal Mucosa

Abstract: The normal esophageal mucosa was observed in detail using ultra‐high magnification endoscopy (UHM endoscopy). The UHM endoscope has a magnification capacity ranging from eight to 150x. High‐quality UHM endoscopic pictures can be continuously obtained by attaching a 2‐mm depth soft distal attachment to the tip of the UHM endoscope. The vascular architecture, which extends from the submucosal vessels through the proper mucosal layer, can be continuously visualized, thereby demonstrating the characteristic fine‐vascular network pattern, and the intrapapillary capillaries in the epithelium. With UHM endoscopy, intrapapillary capillaries can be clearly demonstrated as single loop vessels which we have termed “intrapapillary loops.” These structures cannot be observed with an ordinary magnifying endoscope which is capable of only 35x magnification. We conclude that a technique for obtaining high‐resolution endoscopic pictures has been established. The images obtained are useful for elucidating the microstructure of the esophageal mucosa, especially the fine‐vascular network and the newly recognized intrapapillary loop.

Single-port laparoscopy assisted appendectomy under local pneumoperitoneum condition

We describe herein a novel, simplified technique of laparoscope-assisted appendectomy under local pneumoperitoneum condition. A 12-mm-outer-diameter laparoscope fitted with a transparent plastic cap is inserted through a single, small, open laparotomy incision. This scope has a 5-mm working channel for insertion of the multifunctional metallic catheter which maintains the local pneumoperitoneum condition.When we have located the inflamed appendix by tracing the tenia of cecum, we use the grasping forceps protruding from the working channel of this laparoscope to grasp its tip or root on the cecum. This allows us to pull the appendix up and out through the small incision and to resect it in the conventional surgical way. This procedure permits the surgeon to perform appendectomy by making only one small incision under spinal anesthesia, and also eliminates development of the intracavitary concomitant diseases.

Multiple Primary Cancers Associated with Esophageal Carcinoma

Abstract This study was conducted to examine the characteristics of esophageal cancers with primary synchronous or metachronous cancer in another organ. We retrospectively evaluated 744 patients who underwent esophagectomy for esophageal cancers between 1985 and 1998. The patients were divided into two groups according to whether they had multiple primary cancer (MPC) or nonmultiple primary cancer (NPC). Stage I cancer was significantly more frequent among patients with MPC than among those with NPC (P < 0.0001). Among patients with MPC, another primary cancer was found in the head and neck region in 70 (42.4%), in the stomach in 51 (30.9%), and in the colon, lung, breast, and other locations in the remaining patients. Of the 70 patients with another primary cancer in the head and neck region, 32 (45.7%) had pharyngeal cancer. Furthermore, the incidence of intraesophageal multiple cancer in the patients with primary cancer in the head and neck region was significantly higher than that in those whose other primary cancers were gastric cancer or in those with NPC (P = 0.0135, P < 0.0001). The 5-year survival rate of the patients with MPC was 51.28%, which was significantly higher than that of those with NPC (P = 0.019). In conclusion, a better knowledge of the relationships between esophageal carcinoma and cancers in other organs may lead to earlier detection of other primary cancers and improved therapeutic results.

Endoscopic resection of early-stage esophageal cancer

SummaryEarly-stage esophageal cancerous lesions in four clinical cases were endoscopically resected via a newly developed procedure, endoscopic esophageal mucosal resection using a transparent tube (EMRT). In the complete resection of cancer-bearing mucosa, more than half of the circumferential mucosal resections did not involve major complications such as perforation or massive bleeding. Large ulcers artificially induced by this procedure disappeared within 3 weeks, exhibiting no stenotic changes. Resected specimens contributed well to microscopic examination for histological classification and determination of the depth of cancer invasion and possible vascular involvement. No signs of recurrence were observed during the 15-month follow-up period. We conclude that EMRT is a safe and minimally invasive local treatment for early-stage esophageal cancer that also provides specimens that are suitable for accurate histopathological diagnosis.

High‐Magnification Endoscopic Diagnosis of the Superficial Esophageal Cancer

The character of the esophageal mucosa can be classified into five types, ranging from normal to squamous cell carcinoma. The type is categorized by endoscopic findings consisting of two criteria. One criteria is the staining pattern with iodine dye. Type I and II lesions are iodine-staining positive. Type III, IV and V lesions are iodine-staining negative. Iodine staining can detect a complete flat lesion, and can demonstrate the extent of the lesion clearly. The other criteria is IPCL changes detected using high-magnification endoscopic imaging. This classification is summarized in Fig. 3.