Kyoichi Mizutani

The diagnosis and treatment of esophageal perforations resulting from nonmalignant causes

Esophageal perforations are extremely difficult to diagnose and treat. We report herein our results of a review of 26 patients with esophageal perforation which were spontaneous in 11, iatrogenic in 11, and caused by a foreign body in 4. Surgical treatment was performed in 7 of the patients with spontaneous rupture, but the remaining 19 patients were treated conservatively. The abnormality was found by plain radiography (X-ray) in 22 (85%) of the 26 patients, and by computed tomography (CT) in all 13 patients who underwent this procedure. The detection rates by esophagography and esophagoscopy were 100%, or all of 25 patients examined, and 60%, or 9 of 15 patients examined, respectively. Of 12 patients with underlying diseases, 4 (33%) died after the perforation, whereas only 1 (7%) of 14 patients without any underlying disease died. Postoperative empyema developed in all of 3 patients treated by intraoperative unfixed intrathoracic drainage (UID), but in none of the 4 treated by fixed intrathoracic drainage (FID). Conservative treatment achieved satisfactory results for spontaneous esophageal ruptures confined to the mediastinum, and for iatrogenic perforations and esophageal perforations caused by foreign bodies, provided there was no serious underlying disease such as advanced cirrhosis. Moreover, intraoperative FID proved useful in helping to prevent postoperative empyema.

Endoscopic Criteria for Invasive Depth of Superficial Esophageal Cancer

Abstract: The therapeutic strategy for superficial esophageal cancer should be determined by the depth of invasion. Therefore, we endeavored to develop reliable criteria for endoscopic evaluation of the invasive depth of superficial esophageal cancer. Two hundred and fifty nine superficial squamous cell carcinoma cases were enrolled in this study, designed to investigate the relationship between endoscopic classification and the depth of invasion, and also between lesion size and depth of invasion. Almost all 0‐1, 0‐1+0‐llc, O‐llc+0‐lla and 0‐111 lesions invaded the submucosal layer, although 0‐lla and O‐llb lesions were limited to the mucosal layer. The 0‐llc type of lesion showed a wide range of invasive depths from M1 to SM3; in M1 cases with minimal depression the surface appears entirely smooth; in M2 cases the depressed surface is uniformly granular; and M3 cases have slightly larger granules. With submucosal cancer, the depressed surface showed some irregularity and variability in granule size. In the 0‐llc type, 100% of lesions under 10 mm and 80% of those under 30 mm in greatest dimension were mucosal cancer. The accuracy of our criteria for endo‐scopically evaluating the depth of invasion was 80.2%. The accuracy rate, in terms of assignment to group Ml and M2, M3 and SM1, or SM2 and SM3, was 90.6%.

Clinical Pathological Analysis of Surgically Resected Superficial Esophageal Carcinoma to Determine Criteria for Deciding on Treatment Strategy

We performed a clinical pathological study of conventionally resected superficial esophageal carcinomas since this type of lesion has been increasing, in order to develop criteria of determination for therapeutic strategies. Pathological studies were performed on specimens obtained by radical surgical resection in 133 cases of superficial esophageal cancer. Evaluation was performed in terms of the gross classification of the lesion type, depth of invasion, lymph node metastasis, vascular invasion, size of the lesion, outcome, etc. In 0-I, 0-IIc+0-IIa, and 0-III type submucosal cancer lesions the rate of metastasis to lymph nodes was more than 40%, but in 0-IIa and 0-IIb mucosal cancer cases no lymph node metastasis was observed. 0-IIc type lesions showed a wide range of invasiveness, ranging from m1 to sm3. In cases with m1 or m2 invasion, no lymph node or lymph-vessel invasion was recognized, but in m3, sm1, sm2, and sm3 cases lymph node metastasis was recognized in 12.5%, 22.2%, 44.0% and 47.4%, respectively. In 47% of lesions with a greatest dimension of less than 30 mm invasion was limited to the mucosa. Seventy-two percent of m1 and m2 cases were 30 mm in size or less. Lymph node metastasis was recognized in only 16.7% of cases less than 30 mm in size, but in cases of lesions 30 mm or more the rate of lymph node metastasis was 35.8%. 0-IIb and 0-IIa type lesions are indications for endoscopic esophageal mucosal resection (EEMR), while 0-I, 0-IIc+0-IIa, and 0-III lesions should be candidates for radical surgical resection. In the 0-IIc category, lesions in which the depression is relatively flat and with a finely granular surface are indications for EEMR, but those cases in which the surface of depression shows granules of varying sizes should be treated with radical surgical resection. Cases of 0-IIa type 30 mm or larger in greatest dimension which have a gently sloping protruding margin shoulder or reddening should be treated with caution, but EEMR can be performed first and subsequent therapeutic strategy decided on, based on the pathological findings of the specimen.

Endoscopic Mucosal Resection for Early Carcinomas of the Esophagus

Recently, the rate of detection of early and superficial esophageal cancer has increased particularly with the development of panendoscopy and endoscopic staining techniques in Japan. The intra-epithelial and intra-mucosal carcinomas not extending to the muscularis mucosae did not have vascular invasion or lymph node metastases. Thus we have employed endoscopic mucosal resection for these patients. In this paper, we explained the technique of endoscopic mucosal resection in detail, focusing on the endoscopic mucosal resection tube(EEMR-tube) method which we devised originally. This method was employed in more than 85 cases and 107 lesions of early esophageal cancers.