Takeshi Nagahama

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.

Thoracoscopically managed parathyroid adenoma in the upper anterior mediastinum.

We thoracoscopically managed parathyroid adenoma of the upper anterior mediastinum in a 29-year-old man. He had a backache and was found to have bilateral ureteric stones, hypercalcemia, and extremely increased parathyroid hormone levels. 99mTc-methoxyisobutyl isonitrile scintigraphy showed an accumulation area projected onto the right thyroid lobe and the upper mediastinum. A diagnosis of primary hyperparathyroidism secondary to double adenomas was made. The patient then underwent surgical intervention. With the patient under general anesthesia with one-lung ventilation, a reddish brown adenoma of an upper mediastinum was removed thoracoscopically with three trocars, whereas the right superior parathyroid adenoma was excised by a standard open cervical procedure. Conventionally, the mediastinal parathyroid adenoma was removed by an open approach and was associated with perioperative distress to the patient. If the exact location of the mediastinal lesion is established, thoracoscopic excision of these lesions is feasible and is strongly recommended.

Enhanced Anticancer Effect of Vincristine with Methionine Infusion after Methionine-depleting Total Parenteral Nutrition in Tumor-bearing Rats

Methionine‐depleting total parenteral nutrition (Met(−) TPN), in which an amino acid solution devoid of L‐methionine and L‐cysteine is infused, is thought to reduce tumor cell growth through acting as a partial late S‐G2 (i.e., late‐S and G2 phases) blocker. The antitumor effect of vincristine (VCR), which acts on mitotic phase cells, was examined with methionine infusion immediately after Met(−) TPN in Yoshida sarcoma (YS)‐bearing rats. Rats were given Met(−) TPN for 8 days immediately after inoculation with YS cells (days 0 to 8), which was followed by methionine‐containing (Met(+)) regular TPN for 3 days (days 9 to 11) along with intraperitoneal administration of 0.05 mg/kg/day VCR. All rats were then fed solid food and water ad libitum until they died, with 0.1 mg/kg VCR administration on days 12 and 13. As controls, a Met(−) TPN only group, Met(+) TPN groups with and without VCR, and freely fed groups with and without VCR were studied. The progression of YS was markedly suppressed by Met(−) TPN with VCR. The median survival time in days was 25 days, significantly longer (P<0.001) (generalized Wilcoxons tests) by 11 to 14 days than that of any of the other groups. In conclusion, VCR appears to have greater efficacy as an anticancer agent when administered together with methionine after Met(−) TPN.

CASE OF A SEVERE AND LONG BENIGN STRICTURE OF THE ESOPHAGUS

A unique case of a severe and long benign stricture of the esophagus was experienced by the authors. A 50‐year‐old alcoholic man was admitted to our hospital complaining of dysphagia as well as severe and continuous retrosternal burning pain of acute onset after abrupt vomiting. His previous medical history included alcoholic liver dysfunction, renal dysfunction, Klinefelter’s syndrome and a surgically treated duodenal ulcer. Ingestion of foreign body or acid/alkali substances was excluded. Although histopathologic examination of the endoscopic biopsy specimen was reported to be an esophageal squamous cell carcinoma, endoscopic findings and a barium esophagogram were not typical for a malignant disease. Since this study demonstrated a smooth surface of the lumen in spite of it being approximately 10 cm long, severe stricture of the esophagus was diagnosed. Because the stricture was very long and severe, and was not conservatively treatable, it was decided, after obtaining informed consent, that surgical resection of the esophagus would be performed. Subtotal esophagectomy with lymph node dissection and colonic interposition was carried out. During surgery, the patient was diagnosed as having liver cirrhosis. Histopathologic examination of the surgically resected specimen revealed a 10 cm‐long narrowing of the middle and lower thoracic esophagus with thick walls, particularly in the inner circular muscle layer, without malignancy. Unfortunately, the patient’s postoperative course was followed by cervical leakage. He subsequently died of multiple organ failure on the sixteenth postoperative day. It is worth keeping in mind that esophageal benign stricture with longitudinal ulceration can be induced by esophageal submucosal dissection, as seen in the present case.

Endoscopically treated esophageal lipoma presenting with recurrent dysphagia after esophagectomy for esophageal carcinoma

We have reported a case of endoscopically treated lipoma of the cervical esophagus. The patient was referred to our hospital with a chief complaint of dysphagia and underwent an esophagectomy through right thoracotomy, followed by esophagogastrostomy for superficial esophageal cancer 31/2 months before. However, this benign lesion was not revealed by preoperative check‐up. He again complained of dysphagia after esophagectomy and lipoma of the cervical esophagus was confirmed. Esophageal lipomas are relatively rare in the digestive tract; however, lipoma of the cervical esophagus can cause upper airway obstruction in the case of regurgitation of the tumor. Therefore, this disease must be considered in the examination of the patient with dysphagia.

5 Cases of Gastric Cancers with Extraordinary Liver Metastasis.

初診時に胃癌の著しい肝転移による肝腫大および肝機能異常を認める初発症例の胃癌を「超肝転移胃癌」と定義し検討した.「超肝転移胃癌」は253例中5例 (1.9%) であった. 年齢平均67歳で, 男女比4/1であった. 生検では5例全例por1であり, 組織学的に2例が神経内分泌細胞に分化を示す腫瘍で, 残り3例はAFP 産生胃癌であった. 腫瘍マーカーとしてNSE, AFP が重要であった. 肝動注および静脈内化学療法 (CDDP+5FU) を施行し, 全例に肝転移に対して著しい効果を得, 肝臓は正常大に復し, 肝機能も正常化した. 化学療法による肝臓体積の縮小率は43～67%(平均56%) であった. 3例は癌再燃し, 平均14か月で死亡し, 生存2例は8および18か月観察中である.「超肝転移胃癌」は生物学的および臨床, 治療の観点から, 胃癌の中で特異的な単位であると考えられた.