Tetsuro Nishikage

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.

IFN-γ Production from Liver Mononuclear Cells of Mice in Burn Injury As Well As in Postburn Bacterial Infection Models and the Therapeutic Effect of IL-18

Hosts after severe burn injury are known to have a defect in the Th1 immune response and are susceptible to bacterial infections. We herein show that liver NK cells are potent IFN-γ producers early after burn injury. However, when mice were injected with LPS 24 h after burn injury, IFN-γ production from liver mononuclear cells (MNC; which we previously showed to be NK cells) was suppressed, and the serum IFN-γ concentration did not increase, while serum IL-10 conversely increased compared with control mice. Interestingly, a single injection of IL-18 simultaneously with LPS greatly restored the serum IFN-γ concentration in mice with burn injury and also increased IFN-γ production from liver MNC. Nevertheless, a single IL-18 injection into mice simultaneously with LPS was no longer effective in the restoration of serum IFN-γ and IFN-γ production from the liver MNC at 7 days after burn injury, when mice were considered to be the most immunocompromised. However, IL-18 injections into mice on alternate days beginning 1 day after burn injury strongly up-regulated LPS-induced serum IFN-γ levels and IFN-γ production from liver and spleen MNC of mice 7 days after burn injury and down-regulated serum IL-10. Furthermore, similar IL-18 therapy up-regulated serum IFN-γ levels in mice with experimental bacterial peritonitis 7 days after burn injury and greatly decreased mouse mortality. Thus, IL-18 therapy restores the Th1 response and may decrease the susceptibility to bacterial infection in mice with burn injury.

Prevalence of Barrett's esophagus in Japan

Norman Barrett originally described two special conditions, namely, a congenital short esophagus with an intrathoracic gastric columnar lining and congenital gastric heterotropia in the esophagus with ulceration. Thereafter, these conditions began to be known as “Barretts esophagus.” It is an acquired condition of esophageal columnar metaplasia following chronic gastroesophageal reflux, and the classical Barretts esophagus has been defined as having a circumferential columnar metaplasia spreading minimally 3 cm or more upward from the esophagogastric junction, because the esophagogastric junction still tends to be difficult to recognize precisely. Recently, from the point of view of adenocarcinogenesis of the esophagus, the term and concept of short-segment Barretts esophagus (SSBE) as a developing condition of the classical Barretts esophagus and the confirmation of intestinal metaplasia has been required; however, the definition of Barretts esophagus still remains controversial. In Japan, although the prevalence of short-segment Barretts esophagus has been reported to vary considerably, from 1% to 52%, the prevalence of long-segment Barretts esophagus (LSBE) tends to range from 0% to 2%, which is a quite lower rate than that observed in Western countries. The great difference in the prevalence of SSBE is caused by the differences in the criteria of the esophagogastric junction and the definition concerning the necessity of intestinal metaplasia. A universally accepted definition of Barretts esophagus is thus needed to accurately determine its actual prevalence.

Subcutaneous reconstruction using ileocolon with preserved ileocolic vessels following esophagectomy or in esophageal bypass operation.

Background: When forming an esophageal substitute with an ileocolon in esophageal reconstruction with cervical anastomosis, the ileocolic vessels should be divided in many cases and this may be followed by the occurrence of poor blood circulation in the pulled-up substitute. Methods: Twenty-two consecutive esophageal reconstructions using an all-main-vessel-preserving ileocolon had been performed in the past 4 years and we evaluated the usefulness of this surgical modality. Results: In every case, the extension length of the ileocolon was sufficient for esophageal reconstruction. There were no serious surgical complications concerning the esophageal substitutes such as necrosis of the pulled-up ileocolon. Conclusions: Although it was thought that the surgical techniques shown here were possible only in selected patients, successful esophageal reconstructions were achieved with this new concept in 22 consecutive patients with various backgrounds. The procedures shown here are not new; however, the concept of using the all-main-vessel-preserving ileocolon as an esophageal substitute for every patient requiring esophageal reconstruction is new.

International collaboration between Japan and Chile to improve detection rates in colorectal cancer screening

In Chile, mortality from colorectal cancer (CRC) has increased rapidly. To help address this issue, the Prevention Project for Neoplasia of the Colon and Rectum (PRENEC) program was initiated in 2012 with intensive support from Tokyo Medical and Dental University (TMDU) in Tokyo, Japan, as part of an international collaboration.

A simple technique of using novel thread-holding and knot-pushing forceps for extracorporeal knot-tying

We designed some novel knot-pushing forceps for extracorporeal knot-tying and describe herein our simple technique of utilizing them. These forceps are modified only by a single 1-mm hole between their jaws, which hold a thread and push the knot toward the ligating tissue. The application of this simple device was handled well by surgeons beginning to perform advanced endoscopic surgery. The simple modification explained in this report seems applicable to most of the forceps currently used.

Osteoplastic bone metastasis in esophageal squamous cell cancer : report of a case

This report presents a case of esophageal squamous cell cancer with osteoplastic bone metastasis. A 58-year-old male patient underwent multimodality treatment for esophageal cancer. Sclerotic changes resembling bone metastasis from prostate cancer were detected in the 4th thoracic and the 5th lumber vertebral body soon after the adjuvant chemoradiotherapy. Systemic examinations revealed no primary cancer as a cause of osteoplastic bone metastasis and no esophageal cancer recurrence. A needle biopsy revealed metastases of esophageal squamous cell cancer with osteoplastic changes. Multiple sclerotic changes were detected in the systemic bones at that time, and new carcinomatous bilateral pleural effusion developed. The drastic systemic progression of the cancer caused the rapid deterioration of the patient’s general condition.

Argon plasma coagulation for local recurrence of squamous cell carcinoma of the esophagus after endoscopic mucosal resection: technique and outcome

BackgroundIt is difficult to undergo a second endoscopic mucosal resection (EMR) for local cancer recurrence because ulcer scars caused by the previous EMR are frequently located near the tumor. The main objective of this study was to evaluate whether argon plasma coagulation (APC) is an effective and safe modality for treating early esophageal cancer recurrence untreatable by EMR.MethodsWe reviewed the experience of this clinic in the administration of EMR for the treatment of mucosal esophageal cancer in 249 patients with 276 lesions (142, m1; 98, m2; 36, m3) between December 1989 and March 2005. A local recurrence of the disease after the EMR was detected in 24 cases (9.6%). Seventeen patients were treated with APC. An argon gas flow of 2 l/min was used at a power setting of 60 W. The follow-up period of the 17 patients ranged from 13 to 87 months (median, 68 months).ResultsThe depth of tumor invasion, estimated by endoscopy, was mucosal in all patients. Seventy-three sessions (mean, 4.3 sessions/person; range, 1–12 sessions) were performed. All lesions were easily irradiated. No serious complications such as bleeding, perforation, or stenosis occurred. Complete local control was achieved in 16 of the 17 patients, but the remaining patient required further surgery. Death occurred in 3 cases. Two patients died as a result of other disease, and 1 patient died of other carcinomas, but no patient died of esophageal carcinoma.ConclusionAPC is a safe and effective method for the treatment of local recurrence of squamous cell carcinoma of the esophagus after an EMR.

A Prospective Study of Nutritional Supplementation for Preventing Oral Mucositis in Cancer Patients Receiving Chemotherapy

BACKGROUND AND OBJECTIVES Patients undergoing chemotherapy often develop distressing adverse effects such as oral mucositis and diarrhea. Nutritional support with elemental diet is effective against various gastrointestinal complications and may exert protective effects against adverse effects induced by chemotherapy. To evaluate the influence of elemental diet on chemotherapy-induced oral mucositis and diarrhea, we conducted a randomized control trial in patients with esophageal cancer undergoing chemotherapy. METHODS AND STUDY DESIGN Twenty esophageal cancer patients receiving chemotherapy with 5-fluorouracil plus cisplatin were assigned randomly to one of the following two groups: (1) receiving elemental diet with Elental (one pack per day) for 14 days and (2) not receiving Elental during chemotherapy. The severity of oral mucositis and diarrhea was graded using clinical examination by doctors and a standard questionnaireon days 1-14. RESULTS Based on the analysis of the standard questionnaire, the distribution of the maximum severity of oral mucositis showed a statistically significant reduction in the Elental group (p=0.020), while clinical examination showed insignificant reduction but shift toward lower grade. In the Elental group, the incidence of oral mucositis (grade >=2) reduced consistently and the median grade was lower at all-time points. Regarding diarrhea, no difference was observed between the two groups based on the analysis of the standard questionnaire and clinical examination results. CONCLUSIONS This study illustrates the effectiveness of oral elemental diet in preventing oral mucositis during chemotherapy. This is a preliminary report and further study with larger patients groups should be devoted to optimization of efficacy.

Ultrasonic Tactile Sensor: An Experimental Study to Evaluate the Depth of Invasion in Esophageal Squamous Cell Carcinomas

Abstract: To date, an objective scale for evaluation of tissue stiffness has been lacking. A new instrument, the “ultrasonic tactile sensor (UTS)”, allows objective evaluation of stiffness. For the purpose of evaluating cancer stiffness, we first introduce an experimental study on tissue stiffness using surgically resected specimens of esophageal squamous cell carcinomas with no special preoperative treatment. From November 1995 to January 1996, the authors examined 11 esophageal cancer specimens. Although this experiment revealed no differences between normal mucosa and mucosal cancer in the esophagus, significant differences between mucosal and submucosal cancers in terms of tissue stiffness were clearly demonstrated. Therefore, UTS examination is useful for assessing malignant invasion, thereby providing valuable information for determining appropriate indications for endoscopic mucosal resection. We currently perform this UTS examination using a miniature probe during preoperative endoscopy. We anticipate that this new method will become an essential tool for evaluating the depth of invasion in esophageal cancer preoperatively.