Endoscopic mucosal resection of colorectal tumors

It has been possible to resect early colorectal cancer by endoscopy due to the progress of colonoscopic diagnosis and technology. Therefore, most cases of colorectal mucosal cancer and benign tumor have been resected by endoscopy only. We report some techniques for endoscopic resection of colorectal tumors. The technique of endoscopic resection: (i) The B‐Wave bipolar snare device: It is difficult to resect flat lesions that are not sufficiently elevated to be ligated by a usual snare. The snare of the B‐Wave bipolar snare device is coated to prevent slipping on the colorectal mucosa. (ii) ‘Sculpting down’ polypectomy: It is difficult to resect large sessile lesions because the bases of these lesions cannot be well observed endoscopically. ‘Sculpting down’ polypectomy is a useful method for safe resection of such tumors. (iii) Endoscopic resection through a retroflexed scope: Under retroverted colonoscopic observation, submucosal injection and partial resection is performed. Then, under ordinary observation, complete resection of the residual tumor is performed. (iv) Endoscopic mucosal resection using a cap‐fitted panendoscope (EMRC): EMRC is useful for lesions located in the lower rectum because there is no risk of free perforation. At first, submucosal injection is performed. The snare is set in the transparent cap and the lesion is aspirated into the cap. Then, it is snared and resected.     

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR RECURRENT GASTRIC TUMORS

Endoscopic resection has been accepted as the standard treatment for intramucosal gastric tumors of differentiated type. However, the indication was limited to small tumors to achieve en bloc resection and prevent local recurrence in cases of conventional endoscopic mucosal resection (EMR) such as the strip biopsy and the cap technique. To avoid multi‐fragmental resection, we have developed endoscopic submucosal dissection (ESD) as a new endoscopic resection technique. ESD is a remarkable technique, because we make it possible to remove the lesions en bloc regardless of size, shape, coexisting ulcer, and location. However, it is difficult or impossible to resect recurrent tumors en bloc in conventional EMR owing to hard fibrosis, and some patients need laparotomy. Using ESD, we can dissect the submucosal layer as we directly look at the submucosa, and remove the lesion safely and reliably even in cases of hard fibrosis. The key to treatment of recurrent tumors in ESD are as follows: (i) using enough submucosal injection solution (we use a mixture of Glyceol and 1% 1900 kDa hyaluronic acid preparation); (ii) incising the mucosa without fibrosis; (iii) understanding characteristics of various cutting devices, and changing other devices in difficult situations. In these ways we can remove the majority of the recurrent tumors en bloc. Hence, we consider that ESD is a very effective treatment which achieves excellent en bloc and complete resection rates and enables patients with intramucosal gastric tumors to a recurrent‐free survival even in recurrent tumors.     

Colorectal endoscopic submucosal dissection: present status and future perspective,including its differentiation from endoscopic mucosal resection

Endoscopic submucosal dissection (ESD) allows en bloc resection of a lesion, irrespective of the size of the lesion. ESD has been established as a standard method for the endoscopic ablation of malignant tumors in the upper gastrointestinal (GI) tract in Japan. Although the use of ESD for colorectal lesions has been studied via clinical research, ESD is not yet established as a standard therapeutic method for colorectal lesions because colorectal carcinoma has unique pathological, organ specific characteristics that differ radically from those of the esophagus and stomach, and scope handling and control is more difficult in the colorectum than in the upper GI tract. Depending on the efficacy of endoscopic mucosal resection (EMR) and the clinicopathological characteristics of the colorectal tumor, the proposed indications for colorectal ESD are as follows: (1) lesions difficult to remove en bloc with a snare EMR, such as nongranular laterally spreading tumors (particularly the pseudo depressed type), lesions showing a type VI: pit pattern, and large lesions of the protruded type suspected to be carcinoma; (2) lesions with fibrosis due to biopsy or peristasis; (3) sporadic localized lesions in chronic inflammation such as ulcerative colitis; and (4) local residual carcinoma after EMR. Colorectal ESD is currently in the development stage, and a standard protocol will be available in the near future. We hope that colorectal tumors will be efficiently treated by a treatment method appropriately selected from among EMR, ESD, and surgical resection after precise preoperative diagnosis based on techniques such as magnifying colonoscopy.     

Warning for unprincipled colorectal endoscopic submucosal dissection: Accurate diagnosis and reasonable treatment strategy

Piecemeal endoscopic mucosal resection (EMR) is generally indicated for laterally spreading tumors (LST) >2 cm in diameter. However, the segmentation of adenomatous parts does not affect the histopathological diagnosis and completeness of cure. Thus, possible indications for piecemeal EMR are both adenomatous homogenous‐type granular‐type LST (LST‐G) and LST‐G as carcinoma in adenoma without segmentalizing the carcinomatous part. Diagnosis of the pit pattern using magnifying endoscopy is essential for determining the correct treatment and setting segmentation borders. In contrast, endoscopic submucosal dissection (ESD) is indicated for lesions requiring endoscopic en bloc excision, as it is difficult to use the snare technique for en bloc excisions such as in non‐granular‐type LST (LST‐NG), especially for the pseudodepressed type, tumors with a type V_I pit pattern, shallow invasive submucosal carcinoma, largedepressed tumors and large elevated lesions, which are often malignant (e.g. nodular mixed‐type LST‐G). Other lesions, such as intramucosal tumor accompanied by submucosal fibrosis, induced by biopsy or peristalsis of the lesion; sporadic localized tumors that occur due to chronic inflammation, including ulcerative colitis; and local residual early carcinoma after endoscopic treatment, are also indications for ESD. In clinical practice, an efficient endoscopic treatment with segregation of ESD from piecemeal EMR should be carried out after a comprehensive evaluation of the completeness of cure, safety, clinical simplicity, and cost–benefit, based on an accurate preoperative diagnosis.     

PRESENT STATUS and PERSPECTIVES OF SUBMUCOSAL DISSECTING METHOD OF ENDOSCOPIC MUCOSAL RESECTION IN THE COLORECTUM IN JAPAN

Endoscopic mucosal resection (EMR) is one of the endoscopic procedures for treatment of intramucosal cancer of the gastrointestinal tract. This method enables complete resection of a lesion, however, the size of lesions which can be resected en bloc has a limit. For lesions which can not be resected en bloc, endoscopic piecemeal mucosal resection (EPMR) are employed. However, it is often difficult to determine cancer invasion at holizontal and vertical cut end on pathological examination of resected specimens. Therefore, for the purpose of en bloc resection submucosal dissecting method of endoscopic mucosal resection (SDEMR) that is a method by which mucosa is dissected using some special devices after circumferential mucosal incision around the lesion was proposed. It enables us to resect large lesions which cannot be removed en bloc by EMR. Therefore, it is possible that this procedure is able to prevent residual cancer. Furthermore, sufficient pathological examination of resected specimens is possible, and it helps to determine a therapeutic plan after resection. It is now widely accepted as one of the endoscopic procedures for treatment of early gastric cancer, however, there have been few reports on its experience in the colorectum. Then, in order to consider the perspectives of SDEMR in the colorectum, the present status of it in Japan in August 2003 was analyzed and reviewed in this paper.     

Laparoscopic Gastrectomy for Early Gastric Cancer after Endoscopic Mucosal Resection

Abstract: In 1991, we first performed a simple technique of Iaparoscopy-assisted Bill-roth I gastrectomy for patients with mucosal gastric cancer. Endoscopic mucosal resection (EMR) sometimes fails to completely resect the early gastric cancer lesion, nor does it give full histopathology of the resected stomach. The aim of this study was to review the surgical and pathological findings of eight patients who underwent laparoscopic gastrectomy after EMR for early gastric cancer. Of 54 patients with early gastric cancer who were treated with laparoscopic gastrectomy between 1994 and 1998, eight patients underwent surgery after EMR. The resected margin of the EMR specimens was positive in three and suspicious in five; and three underwent laparoscopic wedge resection of the stomach, while five underwent Iaparoscopy-assisted distal gastrectomy with regional lymph node dissection. All but one resected stomach had residual cancer tissue in the mucosa or submucosa, and three patients had multiple gastric cancers. The results indicated that remnant cancer tissue might be present when the resected margin of the EMR specimen was positive or suspicious. Partial resection or distal gastrectomy under laparoscopy is useful for such patients who have undergone EMR for early gastric cancer. (Dig Endooc 1999; 11:132–136)     

A STUDY OF PHYSICAL EFFICACY OF DIFFERENT SNARES FOR ENDOSCOPIC MUCOSAL RESECTION

There are various types of snares for endoscopic mucosal resection (EMR). Some endoscopists may choose the snare according to their feeling, but we supposed that there were some physical reasons behind each choice. In this paper, we raise the questions, ‘What is the best snare chosen for EMR?’, and ‘Why do we have to do it?’. From the theory of dynamics, we thought that the most important element was vertical force, which we could add against mucosa through the snare. First, we made two situations; one was keeping horizontal faced position of loop of snare (we defined it as HPW; horizontal faced position weight), and the other was rising up position of it (we defined it as RPW). We inspected these forces for the representative and different seven snares, and calculated the ‘Effective Range’, which was a RPW minus a HPW in average. The results demonstrated that both the spiral snare and the smaller ‘Snare Master’ showed higher than other snares in HPW, RPW, and the Effective Range. Based on our study, we judged them as the most adequate snares for EMR in physics and logicality.     

Multiband mucosectomy for advanced dysplastic lesions in the upper digestive tract

Endoscopic resection(ER) is at present an accepted treatment for superficial gastrointestinal neoplasia. ER provides similar efficacy to surgery; however, it is minimally invasive and less expensive. Endoscopic mucosal resection(EMR) is superior to biopsy for diagnosing advanced dysplasia and can change the diagnostic grade and the management. Several EMR techniques have been described that are alternatively used dependent upon the endoscopist personal experience, the anatomic conditions and the endoscopic appearance of the lesion to be resected. The literature suggests that EMR offers comparable outcomes to surgery for selected indications. EMR techniques using a cap fitted endoscope and EMR using a ligation device [multiband mucosectomy(MBM)] are the most frequently use. MBM technique does not require submucosal injection as with the endoscopic resectioncap technique, multiple resections can be performed with the same snare, pre-looping the endoscopic resection-snare in the ridge of the cap is not necessary, MBM does not require withdrawal of the endoscope between resections and up to six consecutive resections can be performed. This reduces the time and cost required for the procedure, while also reducing patient discomfort. Despite the increasing popularity of MBM, data on the safety and efficacy of this technique in upper gastrointestinal lesions with advanced dysplasia, defined as those lesions that have high-grade dysplasia or early cancer, is limited.     

Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type)

Background: Although the strip biopsy method and aspiration method are popular endoscopic mucosal resection techniques for its convenience and reliability, they have limitations in resectable tumor size and location. Endoscopic submucosal dissection techniques using the diathermic needle knife or the insulated‐tip diathermic knife have been introduced to overcome this disadvantage, but they have high risks for bleeding and perforation. Therefore, we have developed a new endoscopic submucosal dissection technique using the tip of an electrosurgical snare (thin type) and assessed its efficacy. Methods: Fifty‐nine lesions with differentiated‐type gastric cancer without ulceration were treated with our technique at the University Hospital. The tip of an electrosurgical snare (thin type) was used for mucosal incision and submucosal dissection as a flexible diathermic knife. Results: The size of tumor was 5–85 mm in diameter (mean size: 29 mm) and the location varied from cardia to antrum. Among 59 lesions, 56 lesions (56/59, 95%) were resected completely in an en‐bloc fashion with much less perforation (2/59, 3.4%) and bleeding (1/59, 1.7%) regardless of their size and location. Conclusion: New endoscopic submucosal dissection technique using the tip of an electrosurgical snare (thin type) is safe and reliable. We were able to resect early gastric cancer with a much higher en‐bloc resection rate and fewer complications using this technique.     

Pathological evaluation of gastrointestinal endoscopic submucosal dissection materials based on Japanese guidelines

Endoscopic surgery first started as snare polypectomy and then progressed to endoscopic mucosal resection (EMR). In order to resect a lesion that is more than 2 cm, endoscopic submucosal dissection (ESD) was developed. ESD therapy has now been established and is being used for early stage neoplastic lesions in the stomach, colon, esophagus, larynx and pharynx. In ESD specimens, we deal with relatively small lesions; therefore, more meticulous and precise pathological diagnosis is required compared to that in surgically resected specimens. In addition, we should be expert in the eligibility criteria of the different organs for ESD therapy. Here, we explain the biopsy diagnosis, including the Japanese group classification as well as the Vienna classification, handling the specimen, including fixation, photography, cutting and paraffin embedding, histological type, depth, vascular invasion and evaluation of the surgical margins, based on the latest Japanese guidelines. Japanese histopathology diagnostic criteria for the stomach, colon and esophagus are also described. We also demonstrate some examples of those mentioned above.     

A novel endoscopic suturing technique using a specially designed so-called "8-ring" in combination with resolution clips (with videos)

BACKGROUND: Although EMR has been proven to be a safe procedure, the risk of hemorrhage and perforation increases with the size of the resected lesion. To overcome such complications, we previously reported a technique using an endoloop and metal clips to close large mucosal defects after EMR. This procedure, however, requires a 2-channel colonoscope, which is not always available. OBJECTIVES: Our purpose was to demonstrate the feasibility of mucosal defect closure by using a conventional single-channel colonoscope, a specially designed figure-of-8-shaped stainless steel ring (8-ring) and resolution clips. DESIGN: Pilot study. SETTING: Private outpatient clinic. PATIENTS: A total of 10 patients with 10 lesions underwent this procedure for closure after EMR. INTERVENTION: After EMR, a Resolution clip (Boston Scientific, Natick, Mass) was placed through 1 hole of the 8-ring and then attached to normal mucosa near 1 side of the resection site. Another resolution clip was inserted through the remaining hole of the device and clipped in the normal mucosa on the other side, thus providing complete closure. To strengthen the closure, conventional endoclips were also placed. MAIN OUTCOME MEASUREMENTS: Technical feasibility of endoscopic closure of the mucosal defect after EMR and complications associated with endoscopic procedures. RESULTS: Mean size of resected lesion was 16.3 mm. All the defects were successfully closed without any complication such as delayed bleeding or perforation. LIMITATIONS: Further study is needed to examine the maximum size of defects that can be closed with this method. CONCLUSIONS: Defects after EMR can be treated successfully with this simple technique.     

Modification of endoscopic mucosal resection to collect plural polypectomied specimens with clip connected with string using a one‐channel colonoscope

Background: Multiple colon polyps and early cancers are often detected at colonoscopy, but we could not collect all polypectomied specimens in one insertion of a colonoscope. Endoscopic mucosal resection (EMR) may often be very difficult for the collection of the size, type, form, or location of the polyps. Methods: We performed EMR to collect plural polypectomied specimens by a modified new technique using a clip connected with a string in 40 patients (25 male, 15 female) who visited Saiseikai Nakatsu Hospital and Mitsubishi Kobe Hospital for colonoscopic treatment. The method was as follows: (i) insert a colonoscope; (ii) check polyps by indigocarmine pigmentation and endoscopic ultrasonography (EUS); (iii) check the lift‐up sign by submucosal injection of 2.5% hypersaline‐epinephrine containing indigocarmine; (iv) make a clip connected with string (Tegusu‐3 go) and insert the clip kit through the channel of the colonoscope; (v) clip the polyp; (vi) insert snare in the channel of an endoscope, passing the string through the center of the snare; (vii) snare the polyp with counter traction of string and cutting by bipolar electric power; (viii) check for bleeding. If there is bleeding from the polypectomied site, another clip is necessary; and (ix) collect polyp. If there are many polyps, flags connecting the string are required. Results and Conclusion: All polyps were treated and collected in all patients by one insertion of the colonoscope without complications. Our modified EMR method was useful in the collection of multiple polypectomied polyps.     

NEW ENDOSCOPIC TECHNIQUE TO CLOSE LARGE MUCOSAL DEFECTS AFTER ENDOSCOPIC MUCOSAL RESECTION IN PATIENTS WITH GASTRIC MUCOSAL TUMORS

Endoscopic mucosal resection has been recognized as a standard method for treating mucosal tumors of the stomach in Japan. In our department, we have treated mucosal defects after this procedure by using metallic clips to prevent and manage complications related to endoscopic mucosal resection. In the present study, we explain the new technique, the ‘loop‐and‐clips’ method, which uses clips and a detachable snare to close large mucosal defects after endoscopic mucosal resection.     

Efficacy and safety of three different endoscopic methods in treatment of 6–20 mm colorectal polyps

Abstract

Objective: Endoscopic resection of colorectal polyps is widely established as the optimal method to manage precancerous lesions. But the optimal technique for removal of the polyps is uncertain. The aim of this study was to compare the efficacy and safety of three methods for the management of 6–20mm colorectal polyps.

Methods: A prospective, randomised controlled trial was conducted at the 900TH Hospital of Joint Logistics Support Force in Fujian, China. Endoscopically diagnosed colorectal polyps, 6–20 mm in size, were randomly assigned to the cold snare polypectomy (CSP), cold snare endoscopic mucosal resection (CS-EMR) or endoscopic mucosal resection (EMR) group. After polypectomy, additional 3–5 forceps biopsies by leading narrow-band imaging (NBI) were performed at the base and margins of polypectomy sites to assess the presence of residual polyp tissue and all samples were sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval and complications were recorded at the time of the procedure.

Results: A total of 781 polyps in 404 patients were assessed and randomly assigned to each group. Of these, 763 polyps were finally analyzed based on the pathology results. The complete resection rates with CSP, CS-EMR and EMR were 81.6%, 94.1% and 95.5%, respectively (p?<?.001). The intraprocedural bleeding rate, immediately after polypectomy, was significantly higher in the CSP group than in the CS-EMR and EMR group (9.4% vs. 4.4% vs. 1.9%; p?<?.001). However,delayed bleeding was higher in the EMR group than in the CSP and CS-EMR group (2.6% vs. 1.2% vs. 0.8%, respectively; p?=?.215). In the multivariate analysis showed that the operation method, lesion size, morphology and the number of resection were independent risk factors for complete resection rate (CRR) (p < .05), but the location and pathological classification of polyps had no significant influence on CRR.

Conclusions: CS-EMR is safe and effective in the treatment of 6–20?mm colorectal polyps. Especially for 6–15?mm non-pedunculated polyps, CS-EMR has a high histological complete resection rate comparable to EMR, and retains the low risk of delayed complications after polypectomy with cold snare. CS-EMR is expected to become a more valuable new cold-cutting technique after cold snare polypectomy.     

SYNCHRONOUS MULTICENTRIC SIGNET‐RING CELL CARCINOMA OF THE STOMACH

A case of simultaneous multicentric signet‐ring cell carcinoma (SRC) of stomach is presented. Initially, an early gastric cancer (IIc) was diagnosed and this was cured with distal gastrectomy. Thirty‐eight months after the operation, follow‐up endoscopy revealed a tiny mucosal discoloration lesion, which was diagnosed as a minute SRC focus with biopsy. This was successfully treated with endoscopic mucosal resection (EMR). Nine months later, gastroscopy discovered another small mucosal lesion and it was again diagnosed as a tiny SRC lesion, which was also successfully treated with EMR. After a further 2 months, endoscopy showed three small mucosal lesions (discoloration) similar to previous lesions, two of which proved to be SRC with biopsy. As these lesions distributed widely over the remnant stomach, total gastrectomy of the residual stomach was performed. Pathological examination demonstrated a total of 22 simultaneous multifocal SRC lesions, which were all very small mucosal cancer. These cancers, including previously EMR‐treated ones, seemed to develop in a multicentric manner, as they were diagnosed within 11 months. This case also indicated that even subtle endoscopic findings should vigorously be sought and, if in doubt, be biopsied in order to locate gastric cancer early enough for minimal invasive curative treatment to be feasible.     

ENDOSCOPIC SUBMUCOSAL DISSECTION OF COLORECTAL LESION

Endoscopic submucosal dissection (ESD) has been developed for en‐bloc resection of mucosal lesions of the gastrointestinal tract. It enables us to resect almost all mucosal and slightly submucosal invasive tumors, regardless of size and shape, even in the colon. Therefore, preoperative diagnosis, especially for the depth of invasion, is very important to determine the treatment strategy. The shape of the lesion, its pit pattern and also EUS findings are very useful in estimating the depth of invasion. We use an EndoEcho system with ultrasonic probe, which gives us both radial and linear image of the lesions. Remodeled three‐dimensional (3D) images are also very useful in evaluating the size and the expansion of the lesion when it is located on a fold. Although the large intestine involves structural and technical difficulties, we conduct en‐bloc resection by ESD while exercising various ingeunities in preparation, endoscopes, use of instruments and local injections. ESD is the reliable technique, which allows en‐bloc resection of gastrointestinal mucosal lesions, and has a excellent chance of success in the treatment of early stage colorectal cancer.     

Endoscopic mucosal resection using a partial transparent hood for lesions located tangentially to the endoscope

BACKGROUND: Numerous methods have been developed to resect early-stage gastric and esophageal cancers, but it is difficult to resect lesions viewed tangentially with the endoscope. METHODS: We have designed and developed an original method of endoscopic mucosal resection using a partial transparent hood to treat difficult cases in which the lesions are located tangentially to the endoscope. The hood was attached on the right side of the endoscope and, after insertion into the stomach or the esophagus, was lightly pressed on the orad side of the lesion. Then the lesion was resected using grasping forceps and electrosurgical current snare. RESULTS: The average diameter of specimens was 26 +/- 8 mm in gastric lesions and 20 +/- 3 mm in esophageal lesions, both 6 mm larger than those obtained by previous methods. CONCLUSION: This device and technique were extremely useful for mucosal resection of lesions located tangentially to the endoscope.     

Gastric vascular ectasia treated by endoscopic mucosal resection

An 80‐year‐old woman consulted our hospital complaining of general weakness. She had iron deficiency anemia, and upper gastrointestinal endoscopy revealed a small lesion accompanying a small amount of fresh bleeding in the stomach. Close observation of the lesion revealed that it was composed of a local assembly of dilated microvessels. The diagnosis of this patient was gastric vascular ectasia causing anemia. Endoscopic ultrasonography demonstrated that the lesion involved the mucosal and submucosal layers of the stomach, and that there were no large vessels inflowing to or outflowing from the lesion. In the present case, we attempted endoscopic mucosal resection (EMR). The lesion was completely resected by only one procedure of EMR without complications such as bleeding. After the endoscopic treatment, iron deficiency anemia improved. Follow‐up endoscopy performed 1 year later revealed that there was no residual or recurrent lesion. Although there have not been any published reports describing the use of EMR for gastric vascular ectasia, EMR may be a useful endoscopic treatment for this condition.     

Endoscopic Mucosal Resection of Adenocarcinoma at the Minor Duodenal Papilla: A Case Report and Suggestions for the Optimal Treatment Strategy

We herein report an extremely rare case of adenocarcinoma of the minor duodenal papilla (MiDP) which was successfully treated by endoscopic mucosal resection (EMR). An asymptomatic 84-year-old man underwent upper gastrointestinal endoscopy, which revealed a slightly elevated lesion at the MiDP. The biopsy findings were suggestive of adenocarcinoma. Computed tomography, magnetic resonance images and endoscopic ultrasonography did not reveal pancreatic tumor infiltration nor any apparent distant metastases. Therefore, we treated the lesion using EMR with complete resection. No recurrence or metastasis has been detected at 13 months after EMR. Total resection of the MiDP can thus serve as a relatively safe and simple treatment.     

RISK MANAGEMENT OF THERAPEUTIC COLONOSCOPY (HOT BIOPSY,POLYPECTOMY, ENDOSCOPIC MUCOSAL RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION)

The concept of an adenoma–carcinoma sequence has been widely accepted in the colon and rectum, contrary to that in gastric cancer. Consequently, most target lesions for endoscopic resection using these newly developed techniques are histologically assessed as adenoma or intramucosal carcinoma in adenoma. Based on results in conventional endoscopic mucosal resection (EMR), almost all remnant or recurrent tumors can be successfully managed by salvage EMR, and all materials resected by salvage EMR also showed adenoma or intramucosal cancer. These results suggest that en bloc resection is not always clinically necessary to obtain complete cure for all colorectal neoplasia. However, larger lesions tend to be resected in a piecemeal fashion; it is difficult to confirm whether EMR has been completed or not. For precise histopathological assessment of the resected specimen, endoscopic submucosal dissection (ESD) for en bloc resection is desirable, although further experience is needed to establish its safety and efficacy. The present review contains a summary of the risk management of therapeutic colonoscopy including ESD for large colorectal mucosal neoplasia, debated at the Endoscopic Forum Japan 2006, Hakone, and discussion of the problems and future prospects of these procedures.