GASTRIC LIPOMA SUCCESSFULLY REMOVED BY LAPAROSCOPIC INTRAGASTRIC SURGERY

Lipomas are found very rarely in the stomach, where they account for only 3% of benign gastric tumors. Here, we report a case of large gastric lipoma removed successfully by laparoscopic intragastric surgery. A 45‐year‐old woman with no symptoms was incidentally diagnosed with a yellowish submucosal gastric tumor, about 3 cm in diameter, in the prepyloric antrum by upper gastrointestinal endoscopy. Pathological findings of biopsy specimens showed no evidence of malignancy. Computed tomography showed an ovoid and well‐circumscribed intramural mass, measuring 35 mm, which was of fat density. These findings suggested that the tumor was a lipoma that we felt should be treated, because large lipomas can give rise to gastrointestinal bleeding. We performed a laparoscopic intragastric enucleation for this tumor. Postoperatively, the tumor was confirmed pathologically to be a lipoma of the stomach. This laparoscopic procedure for benign non‐epithelial gastric tumors, such as lipomas, presented here is technically feasible, safe, and less stressful for the patient than gastrectomy.     

RECENT DEVELOPMENT AND USEFULNESS OF INFRARED ENDOSCOPIC SYSTEM FOR DIAGNOSIS OF GASTRIC CANCER

Background: Near‐infrared (IR) rays, because of their limited scattering characteristics and low absorption by water and hemoglobin, can penetrate deeply into tissue. Using infrared rays, we have developed an infrared electronic endoscope system and evaluated its usefulness for assessing the depth of involvement of gastric cancers. Recently, we developed a new infrared videoendoscopic system (dual wavelength system). With this system, we can recognize submucosal vessels of gastric cancers in a greater detail with higher resolution under IR light. Methods: A total of 30 patients with depressed gastric cancers underwent infrared endoscopy. Results: Twenty‐one (91%) of 23 intramucosal and submucosal cancers less than 1000 µm were observed as tumors with no stain or faint stain, whereas all (100%) of seven more invasive cancers were observed as tumors with dense stain or pooling of the dye. Thus, the overall accuracy was 93% (28 of 30 tumors). Moreover, 95% (18 of 19) of tumors with ulcerative changes were correctly diagnosed. Conclusions: New infrared electronic endoscopic system is useful for diagnosing the depth of involvement of early gastric cancer either with or without ulcerative changes. This system will bring us further development in the diagnosis of gastric cancer.     

ENDOSCOPIC RESECTION FOR EARLY GASTRIC CANCER AND FUTURE EXPECTATIONS

Considering the risks of surgery and the patient's poor quality of life after gastrectomy, it is sensible to offer endoscopic resection for the patients without risk of lymph node metastasis. Endoscopic resection (ER) of early gastric cancer (EGC) is now standard therapy in Japan and is increasingly becoming accepted and regularly used in other countries. The indications, techniques, and pathological assessment methods of ER in the treatment of EGC are demanding and require the endoscopist to follow them closely in order to ensure successful outcomes. New developments in ER techniques to dissect the submucosa directly, called ESD, allow resections of larger lesions in en‐bloc, although long‐term outcome data are currently still in progress. The purposes of the present review are to introduce ER methods for carrying out proper treatment and to describe future expectations.     

胃癌细胞凝集素受体变化与淋巴结转移的关系

本文采用ABC酶标技术，对63例胃癌组织及21例转移淋巴结进行菜豆凝集素（PHA）和花生凝集素（PNA）的亲和组化染色，观察胃癌原发灶与淋巴结转移灶的凝集素受体变化。结果示；（1）伴淋巴结转移的胃癌原发灶与PHA和PNA结合的阳性率(分别为90．3％和87．1％）高于以无淋巴结转移的胃癌原发灶（71．8％和65．6％）。（2）淋巴结转移组的PHA与PNA阳性强度以强阳性为主；无淋巴结转移组则以弱阳性和中等阳性为主。（3）淋巴结转移灶与胃癌原发灶的阳性强度基本一致，符合率为PHA57．1％，PNA71．4％。结果表明胃癌原发灶中凝集素受体的变化与淋巴结转移的状况密切相关，胃癌原发灶中带有PHA和（或）PNA受体的癌细胞具有转移的潜力。     

NODULAR GASTRITIS AND GASTRIC CANCER

Nodular gastritis is defined as antral gastritis usually characterized endoscopically by a miliary pattern resembling gooseflesh and pathologically by prominent lymphoid follicles and infiltration of mononuclear cells. This physiological phenomenon was once considered particular to young women. Recent studies have shown that nodular gastritis is strongly associated with Helicobacter pylori infection and may be associated with gastric cancer. Reported cases of gastric cancer with nodular gastritis showed some features in common: all gastric cancers were diagnosed histologically as the diffuse‐type, and all were located in the corpus with Helicobacter pylori infection. Because nodular gastritis may be a risk factor for diffuse‐type gastric cancer, Helicobacter pylori may need to be eradicated to prevent gastric cancer in patients with nodular gastritis.     

煌蓝色素内镜与胃癌

本文报告３６例胃癌患者普通胃镜和煌蓝色素内镜检查以及活检的结果。其中７例为早期胃癌，早期胃癌的检出率为１９．４％。普通胃镜仅发现１例早期癌，煌蓝色素内镜发现７例，差异有显著意义（Ｐ＜０．０５）。此外煌蓝色素内镜提高胃癌活检阳性率达９７．４％。也明显高于普通胃镜的活检阳性率（Ｐ＜０．０１）。作者认为在胃癌前病变的随访中应提倡使用煌蓝色素内镜。     

LONG‐TERM OUTCOME OF LAPAROSCOPIC SURGERY FOR COLORECTAL CANCERS

There are three types of laparoscopic surgery for colorectal disease, medial‐to‐lateral, lateral‐to‐medial and the retroperitoneal laparoscopic approach. The purpose of the present study is to evaluate the long‐term results of laparoscopic colectomy for colorectal cancer by the transabdominal and retroperitoneal laparoscopic approaches, to provide current status of clinical outcomes of laparoscopic surgery including acceptable ranges of complications, morbidity and survival rate. Many transabdominal operations have been reported the clinical outcomes either one surgical team or multiple center series in recent decades. However, only one journal reported retroperitoneal laparoscopic surgery, including data of 309 patients at Sakura National Hospital from June 1994 to March 2003. Ten cases (3.2%) were converted to open colectomy and nine of these were in the first 100 cases (1.9%) compared with only one within the other 209 patients (0.47%), this being within a reasonable range 0%?3.2%. There were no port site recurrences. Eight patients had lung and/or liver metastases and died of disease. The average survival time was 28.4 months. The 5‐year survival rates were 100%, 89.7%, 85.5% and 72.9% for stages I, II, IIIa and IIIb, respectively. In a literature review of journals for laparoscopic surgery for colorectal cancers, the conversion rate is variable from 0 to 17%, and the local recurrence rate is generally usually below 6.8%. The 5‐year survival rates are approximately 97‐89%, 88‐78% and 67‐59% for stages I, II and III, respectively.     

GASTRIC CANCER RETROSPECTIVELY INVESTIGATED FOR 9 YEARS AND 6 MONTHS: A CASE OF LINITIS PLASTICA

This report presents a rare case of a patient with gastric cancer whose clinical course with the development of tumor from early cancer type IIc to advanced cancer of linitis plastica was observed for 9.5 years. The cancer remained in early stage for 3 years and 8 months after the patient’s first endoscopy. At 5 years and 10 months after initial endoscopy, the lesion progressed to advanced cancer, and after 6 years and 7 months sclerotic changes in the gastric wall were detected at the lesion site. After 9 years, advanced gastric cancer of linitis plastica was present throughout the stomach. The initial stage of linitis plastica is considered to be early gastric cancer type IIc with histologically undifferentiated cancer cells. It is widely accepted that a period of 6–8 years is required for this type of cancer to develop from carcinogenesis to completion of lesions. The present case is valuable in that development from early gastric cancer type IIc to linitis plastica during approximately 10 years of follow up was clinically observed, and will contribute to knowledge of the natural history of gastric cancer.     

EARLY GASTRIC CANCER WITH WIDESPREAD DUODENAL INVASION WITHIN THE MUCOSA

We report a rare case of early gastric cancer confined to the mucosal layer with extensive duodenal invasion, curatively removed with distal gastrectomy. An 84‐year‐old Japanese woman was referred to our hospital with gastric cancer. A barium meal examination and esophagogastroduodenoscopy revealed an irregular nodulated lesion measuring 6.5 x 5.5 cm in the gastric antrum and an aggregation of small nodules in the duodenal bulb. A biopsy specimen showed well‐differentiated adenocarcinoma. The patient underwent distal gastrectomy with partial resection of the duodenal region containing the tumor and regional lymph node dissection, with no complication. Histological examination of the resected tissue confirmed well‐differentiated adenocarcinoma limited to the mucosal layer and without lymph node metastasis. The cancer extended into the duodenum as far as 38 mm distant from the pyloric ring, and the resected margins were free of cancer cells. Gastric cancer located adjacent to the pyloric ring thus has the potential for duodenal invasion, even when tumor invasion is confined to the mucosal layer. In such cases, care should be taken during examinations to detect duodenal invasion, and the distal surgical margin must be negative given sufficient duodenal resection.     

CURRENT STATUS AND EVALUATION OF TRANSNASAL ESOPHAGOGASTRODUODENOSCOPY

We reviewed the current status of transnasal esophagogastroduodenoscopy (EGD) with regard to tolerance, safety, feasibility and accuracy. Comparison of standard and ultrathin scopes and recently reported endoscopic techniques with transnasal insertion are also described as well as the current status of transnasal EGD in European countries compared with Japan. As several studies concluded that transnasal EGD can facilitate comfortable endoscopy without the need for sedative drugs, it has been tried in countries in which a relatively high number of unsedated EGD are carried out in daily practice. Long‐tube intubation of the jejunum with the assistance of transnasal EGD will also be a part of the daily practice in the near future. However, its safety and accuracy should be further investigated. Even a standard scope whose charge‐coupled device (CCD) has the same resolution as an ultrathin scope is superior to an ultrathin scope in terms of luminosity and resolution. Given the small number of procedures reported to date, the absolute complication rate of unsedated transnasal EGD is unknown. Methods of nasal anesthesia, as well as informed consent, indications and contraindications for transnasal EGD are not standardized. A guideline of transnasal EGD is under discussion by the Japanese Gastroenterological Endoscopy Society.     

CLINICOPATHOLOGICAL STUDY OF UNSUSPECTED GALLBLADDER CANCER DIAGNOSED AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Background: Laparoscopic cholecystectomy (LC) has become a common treatment for benign gallbladder diseases. However, this method has not been established for gallbladder cancer. Methods: In the present study, we examined the clinicopathlogical features of gallbladder cancer that was diagnosed after LC. Results: The presence of unsuspected gallbladder cancer was found in five out of 498 patients (1.00%). Preoperative diagnoses were gallstone in two, gallstone with adenomyomatosis in one, adenomyomatosis in one and gallbladder polyp in one. During LC, there was no evidence of cancer, but bile leakage occurred in two patients. Histologically, the carcinoma had invaded into the subserosa in four patients and into the mucosa in one patient. An additional operation was performed in three patients. Histological examination revealed no cancer cells in the resected liver and lymph nodes. During the average follow‐up period of 47.5 months, no recurrences were observed. Although one patient died of liver metastasis 33 months later, the other three patients who underwent an additional radical operation, showed no recurrence. Conclusions: It is important to prevent port site recurrence or dissemination during LC, so a careful maneuver is required to avoid perforation of the gallbladder. At the time of bile leakage, it is best to wash around the liver bed fully to prevent recurrences of unsuspected gallbladder cancers. If gallbladder cancer has invaded the subserosa or deeper level histologically, a radical second operation should be performed as soon as possible.     

NEWLY DEVELOPED OPTIMAL BAND IMAGING SYSTEM FOR THE DIAGNOSIS OF EARLY GASTRIC CANCER

Background: Magnifying narrow band imaging system is useful for the diagnosis of early gastric cancer. However, it is difficult for the operator of the scope to maintain the correct distance between the tip of the endoscope and the gastric mucosa for appropriate visualization. The newly developed optimal band imaging system can reconstruct good spectral images derived from ordinary endoscopic images and enhance the mucosal surface without magnification as well as with low magnification. This imaging technique is based on narrowing the bandwidth of the conventional image arithmetically, using spectral estimation technology. Methods: We evaluated endoscopic features of 30 lesions with elevated‐type, 32 lesions with depressed‐type and two lesions with flat‐type early gastric cancer using this new system. Results: We found the best images in all cases of early gastric cancers by using a specific combination of the following three wavelengths available in this system: 470 nm for blue, 500 nm for green and 550 nm for red. The optimal band images showed the depressed‐type early gastric cancer as reddish lesions distinct from the surrounding yellowish non‐cancerous area, leading to a clear demarcation line between the cancerous and non‐cancerous mucosa without magnification. Moreover, 30–40‐fold magnified optimal band images showed a clearly irregular microvascular pattern or a microstructure pattern of the mucosal surface in all types of gastric cancers. Conclusion: This new system can provide useful information for diagnosing various types of early gastric cancers without and with low magnification.     

胃癌术前分期超声诊断的临床应用价值

通过对47例胃癌患者术前超声与术后病理分期的对比研究，结果表明超声对胃癌分期准确率为72．3％。其中对Ⅳ期胃癌诊断准确率为89．4％，灵敏度71．4％，特异度97．0％，提示超声对胃癌术前分期，特别是对Ⅳ期胃癌的检出，有重要的临床实用价值。     

双胃镜粘膜切除法切除早期胃癌及其癌前病变

自１９９１年３月至１９９２年１２月，我院应用双胃镜对６例粘膜层早期胃癌及其癌前病变进行了内镜下粘膜切除术，其中Ⅱｃ型早期胃癌１例，Ⅱａ型早期胃癌２例，扁平隆起型重度异型增生２例，山田１型腺瘤１例，所有病变直径均小于２ｃｍ。一次操作病变完全切除３例，经第二次操作又完全切除２例，残留切除１例，后又补充外科手术切除。经追踪３～２１个月，尚未见复发征象。文中对本法适应症、完全切除的标准等也进行了讨论     

COMPARISON OF ENDOSCOPIC DETECTION RATE OF EARLY GASTRIC CANCER AND GASTRIC ADENOMA USING TRANSNASAL EGD WITH THAT OF TRANSORAL EGD

Background: To investigate the influence of the reduced image quality of transnasal esophagogastroduodenoscopy (EGD) with the ultrathin endoscope (transnasal EGD) on endoscopic diagnoses, we compared the detection rate (DR) of early gastric cancer and gastric adenoma by transnasal EGD with that of transoral EGD using a standard endoscope. Methods: Transnasal EGD was carried out in 2791 examinations for the purposes of screening or other reasons. Controls were examined by transoral EGD and numbered 3591 examinations. The transnasal endoscope used was an EG530N. Lesions graded C‐3 or higher by Kimura‐Takemoto's classification were regarded as endoscopic atrophy. Results: (i) DR in all subjects and those with atrophy were not different between transnasal and transoral EGD. (ii) Multivariate analysis of DR in subjects with atrophy was carried out using five variables: gender, age, purposes of endoscopy, endoscopic insertion route and the four endoscopists. DR was significantly higher in males or subjects ≥60 years. No difference was noted between the endoscopic insertion routes (transnasal vs transoral). (iii) The subjects analyzed in (ii) were divided into the transnasal and transoral groups, and multivariate analysis of DR was carried out using four variables. DR was not different among the endoscopists in the transoral group. However, in the transnasal group, DR increased as the years of endoscopic experience was prolonged. Conclusions: Multivariate analysis detected no significant difference in DR between transnasal and transoral EGD. However, a significant difference in DR by transnasal EGD among the endoscopists is detected. Transnasal EGD should be carefully carried out by experienced endoscopists.     

RETROSPECTIVE STUDY OF ENDOSCOPIC FINDINGS: 250 CASES OF GASTRIC CANCER

Background : The accuracy of endoscopy for detecting gastric cancer is high but failures may occur if the cancer is not visualized or recognized with gastroscopy. The aim of this study was to understand the reasons why gastroscopy may not detect gastric cancer. Methods : Patients with gastric cancer (n = 4053) diagnosed between 1979 and 1996 were studied by linking gastroscopic examinations (n = 111 094). Endoscopic records were reviewed in 250 patients who were diagnosed with gastric cancer but had not been diagnosed as such on the examination within the previous 3 years. Results : In 33 patients (13.2%) gastric cancer was detected at the advanced stage. The percentage of advanced cancer was significantly higher on the cardia and the gastric body than it was on the angulus and the antrum. In 107 patients (42.8%) no lesion was identified after reviewing endoscopic records. In 102 patients (40.8%) marked lesions were present but had not been diagnosed as such. In 41 patients (16.4%) gastric cancer may have been overlooked but due to a lack of photographic documentation in the specific areas, these findings were not confirmed. The percentage of the indeterminate examinations was significantly higher in lesions on the remnant stomach and the cardia than in other areas. Conclusion : In order to reduce the proportion of the advanced gastric cancer to under 20%, repeated endoscopic examinations were recommended within 2 years even if any suspicious lesions could not be detected by the initial examination.     

CHARACTERISTICS AND ROLE OF ENDOSCOPIC MUCOSAL RESECTION USING CAP‐FITTED PANENDOSCOPE FOR EARLY GASTRIC CANCER

Background: It is accepted in Japan and in the gastric cancer treatment guidelines that small gastric mucosal cancers without lymph node metastasis can be curatively treated by endoscopic mucosal resection (EMR). Various techniques of EMR for early gastric cancer have been reported, and in the present study, the results of EMR using cap‐fitted panendoscope (EMRC) for early gastric neoplastic lesions are examined, and the characteristics and the role of EMRC procedure are discussed. Methods: From August 1992 to March 2003, 181 gastric neoplastic lesions in 155 patients were treated by EMRC at the Department of Surgery, Esophagogastric Division, Tokyo Medical and Dental University. The frequency of residue and the cause of residue following EMRC for 181 gastric neoplastic lesions were examined. Five‐year survival rates were calculated and compared according to the 49 patients who underwent en bloc resection and the 49 patients who underwent planned fractionated resection by EMRC for early gastric cancer. Results: There was residue in nine (5%) of 181 lesions treated by EMRC. Residues from four elevated lesions resulted from muscular resection and insufficient additional resection; residues from five depressed lesions resulted from incorrect diagnosis of the spread of the lesions prior to resection and insufficient additional resection. In the EMRC patients, the survival rates for 49 patients treated by en bloc resection (93%) and 49 patients by planned fractionated resection (91%) were not significantly different. Conclusion: The EMRC technique, that is en bloc and planned fractionated resection by EMRC procedure, has an important role as an easy and curative EMR method for almost all of the indicated early gastric cancers by the gastric cancer treatment guidelines with no limitations from the lesion sites.     

胃癌浆膜侵犯与腹腔内游离癌细胞的相互关系

采用上腹腔冲洗法，对６６例例胃癌患者进行了腹腔内游离癌细胞检查，其游离癌细胞阳性率与肿瘤浸润受度呈正相关，Ｓ２及Ｓ３组性率分别为３３．３％和６５．２％，并与浆膜受侵面积密切相关，受侵浆膜面积大于２０ｃｍ＾２组阳性率高达７３．３％。本文将癌底浆膜外观分为Ⅰ、Ⅱ、Ⅲ型，其阳性率分别为４７．３％，１６．７％，０％。本文结果认为：腹腔内游离癌细胞与胃癌侵润深度，受浸浆膜面积及癌底浆膜外观密切相关。