Esophageal achalasia is a benign esophageal motility disorder resulting from an impaired relaxation of the lower esophageal sphincter. The principles of treatment involve disruption of the sphincter ...at the esophagogastric junction. Treatment techniques include balloon dilatation, botulinum toxin injection, and surgical myotomy. In 2008, per-oral endoscopic myotomy (POEM) was introduced by Inoue et al. as an endoscopic myotomy with no skin incision. The procedure has been well accepted and widely applied owing to its minimal invasiveness and high cure rates. Moreover, there have been discussions on wider indications for POEM and new technical developments have been reported. The present article reviews the historical background and present status of POEM, as well as future prospects for its application in the treatment of esophageal achalasia.
Endocytoscopy is ultrahigh magnifying endoscopy which enables in vivo cellular imaging of gastrointestinal mucosa. Double staining using both 0.05% crystal violet and 0.1% methylene blue (CM double ...staining) was developed as this was anticipated to produce similar results to conventional haematoxylin-eosin staining in histology. Endocytoscopy with CM staining enables us to evaluate tissue atypia by approximating the tip of the endoscope onto the mucosal surface. Our initial clinical experience of 152 patients who underwent endocytoscopic examination did not identify any patients with clinically evident side effects. The safety of staining methods has recently been questioned in the literature and in order to clarify this further, a literature review was undertaken. There are only a few reports warning against the use of dye, due to toxicity. This was particularly apparent in animal studies with increased risk of carcinogenesis after one year of daily dye administration. Single administration of dye, however, does not seem to cause severe side effects especially at the low concentrations used during endoscopy. Olliver et al. described one case of genetic injury secondary to dye administration, but carcinogenesis after routine chromoendoscopy has not been verified. Although there is not sufficient evidence to support that genetic injury results in carcinogenesis, we advocate measures during endoscopy to reduce the volume and concentration of dye solution in contact with the gastrointestinal mucosa. Therefore, regularly suctioning and irrigation should be routinely performed as a precautionary measure.
Recently, endoscopic submucosal dissection (ESD) has been widely accepted as a curative, less-invasive treatment for early-stage gastric cancer. Laparoscopic gastrectomy is generally indicated in ...cases in which ESD could not be completed. When severe scar formation occurs in intramucosal cancer, it is often difficult to complete ESD and laparoscopic surgery must be performed. However, laparoscopic gastrecctomy for intramucosal cancer with deep ulcer scars may be overtreatment. Therefore, we developed a combined endoscopic and laparoscopic technique to perform full-thickness resection of the gastric wall. Laparoscopic and endoscopic cooperative surgery (LECS) has recently been highlighted by Hiki et al. LECS has been performed in various clinical situations, and the lesion-lifting method reported by Ohgami et al. is a beneficial application of the LECS technique. CLEAN-NET is a combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique. CLEAN-NET allows us to perform full-thickness gastric wall resection without any leakage of gastric contents into the abdominal cavity. We have so far performed CLEAN-NET in 39 consecutive patients. The results were clinically satisfactory, indicating that CLEAN-NET may have the potential to become a standard treatment option for T1N0 gastric cancer.
We assessed the clinicopathological characteristics of patients with serrated polyposis syndrome (SPS) and the incidence of advanced adenoma/colorectal cancer (CRC). We prospectively enrolled 249 ...consecutive patients who underwent colonoscopy at the National Cancer Center Hospital over a 6-month period. All the polyps were diagnosed using magnification colonoscopy and resection/biopsy. The enrolled patients were divided into two groups, i) those with ≥5 histologically diagnosed hyperplastic polyps (HPs) proximal to the sigmoid colon, with at least 2 polyps >10 mm in diameter and ii) those with ≥20 HPs distributed throughout the colon. The clinical characteristics of the two groups were compared, including lifestyle, family history of CRC and colonoscopic findings. HPs were identified in 228 patients, of whom 21 (8.4%) had SPS. All 21 patients had ≥20 HPs distributed throughout the colon, with none having >2 HPs ≥1 cm in diameter in the right colon. Synchronous advanced adenoma/CRC was diagnosed in 76/249 (30.5%) patients. The prevalence of advanced adenoma/CRC was higher among patients with compared to those without SPS (P=0.075). SPS was also associated with older age and higher body mass index (BMI). Our results suggested that older age and higher BMI are independent risk factors for SPS. Advanced adenoma/CRC tended to occur more frequently among patients with compared to those without SPS, although the difference was not statistically significant.
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