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Department of Endoscopy

Kazuhiro Kaneko, Tomonori Yano, Hiroaki Ikematsu, Yasuhiro Oono

Introduction

The Department of Endoscopy covers the fields of the gastrointestinal (GI) tract and head and neck regions. In 2015, approximately 12,000 examinations and treatments were performed. This is the highest number to date. A narrow band imaging (NBI) system and/or Blue LASER imaging (BLI) system has been included for routine examination in six endoscopy rooms since September 2009. The BLI system was introduced in 2013. Furthermore, endoscopic treatments such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), percutaneous endoscopic gastrostomy (PEG), endoscopic balloon dilation (EBD), radial incision and cutting (RIC), and photodynamic therapy (PDT) have been performed.

In addition, research studies have been conducted in various fields: endoscopic diagnosis and treatment, or prevention for cancer patients in the GI tract and head and neck. Many of the research projects are conducted as prospective clinical studies either in a single institution or in collaboration with other institutions. The present research activities mainly focus on the development of new instruments for endoscopic diagnosis and new endoscopic treatment modalities. In addition, molecular biology research is also performed using blood and tissue samples of patients in order to examine strategies to enable the early detection, prevention, or prediction of prognosis for treatment. These projects are conducted in collaboration with not only commercial companies but also the faculties of Technology and Science in certain universities.

Routine activities

Routine endoscopic examinations including magnifying NBI and endoscopic ultrasound are presently used for head and neck, esophageal, gastric, and colorectal cancers, and the NBI or BLI systems have become essential in detecting very early cancers and precursor lesions in these areas. With the NBI or BLI systems, a differential diagnosis between neoplasia and non-neoplasia can be performed without the need for any dye solution. Double-balloon enteroscopy and capsule endoscopy are mainly performed for examinations of the small intestine. Follow-up examinations after endoscopic treatment and chemotherapy are also performed in many cases, in addition to routine examinations.

With the recent progress in instruments and techniques, the number of endoscopic treatments has been increasing. EMR is indicated routinely for early GI tract cancers, and ESD is basically used not only for gastric cancers but also for esophageal or colorectal cancers. For the colon and rectum, colonoscopic day surgeries such as polypectomy and EMR are currently performed in one-third of all examinations. Furthermore, EMR and PDT are sometimes indicated as salvage treatments for local residual/recurrent tumors after chemoradiotherapy for esophageal cancer. PEG and EBD are valuable supporting techniques during the treatment of patients with head and neck, and esophageal cancers.

Research activities

Furthermore, molecular biological analysis of cancers of the esophagus, head and neck, stomach, and colorectum is under way. Importantly, analysis of the genetic polymorphism in the genes coding for alcohol dehydrogenase (ADH 1B) and aldehyde dehydrogenase (ALDH 2) regarding alcohol metabolism is performed as a useful novel strategic approach in the prevention of upper aerodigestive tract cancers. In addition, the relationships between the production of acetaldehyde and oral microflora after consumption of alcohol are being investigated in our study group.

In contrast, developing research into novel endoscopy systems is being performed. Hypoxia imaging is detected for neoplastic lesions of the head and neck and alimentary tracts, with blue visualized images. The first in-human clinical trial of hypoxia imaging was finished, and we are preparing pharmaceutical approval. Another project is a new bioimaging system using near-infrared light with a wavelength of over 1,000 nm. This system is capable of penetrating through the gastrointestinal wall and obtaining images utilizing various spectrums. Furthermore, molecular imaging endoscopy with some agents such as small molecules, peptides, antibodies and nanoparticles has been developed in collaborate with some universities. With a low-temperature atmospheric pressure plasma system, endoscopic hemostasis and inactivation of bacteria are being investigated. A novel diagnosis system using photosensitizing agents, such as hypericin and 5ALA, has been constructed. Moreover, a new clinical trial of a biodegradable (BD) stent has been performed for patients with benign esophageal stricture after curative treatment, such as ESD, surgery, and chemoradiotherapy.

Clinical trials

A wide range of many prospective clinical trials is ongoing into the endoscopic treatment of cancers of the esophagus, stomach, and colorectum, as follows: clinical trial of hypoxia imaging for neoplasia of the alimentary tract in a single unit; a phase II clinical trial for BD stent implantation for benign esophageal stricture; a clinical trial for photodynamic diagnosis using 5ALA; multicenter clinical trials of a follow-up study after EMR of m1-3 esophageal cancers; a phase I/II study of PDT using Laserphyrin in residual/recurrent cases followed by chemoradiation for esophageal cancers; a multicenter clinical study for enrollment of early gastric cancer following endoscopic treatment for an enrollment system using the Web; a multicenter clinical trial of ESD for undifferentiated gastric cancer (JCOG1009); a randomized controlled phase II/III study comparing EBD combined with steroid versus RIC combined with steroid for refractory anastomotic stricture after esophagectomy (JCOG1207); a multicenter clinical study of a learning curve trial using NBI; a multicenter clinical study regarding residual/recurrent rates and observation periods of endoscopic piecemeal mucosal resection (EPMR) for colorectal neoplastic lesions; and the Japan Polyp Study (JPS) for determination of observation periods after endoscopic treatment for colorectal polyps.

Education

The aim is cultivation of human resources in specializing in endoscopic diagnosis and treatment for alimentary tract cancer. Staff supervise individual residents. The importance of positiveness is highlighted in periodic case conferences and joint conferences among internal medicine, surgery and radiology staff. Staff supervise academic congress presentations and writing manuscripts after deciding upon individual themes, and detailed discussion is undertaken in the department conference. For residents interested in development research, opportunities to study are supported after graduation.

Future prospects

Existing endoscopic diagnosis for neoplasia of the alimentary tract is performed on the basis of the morphological features of the tumor. Molecular imaging endoscopy is a novel system to visualize cancer using a specific laser source under phosphor combined with cancer-specific agents. We can obtain new imaging, since the function or metabolic state in cancer cells is visualized. In additional modalities, there are hypoxia imaging endoscopy, photodynamic diagnosis and endomicroscopy. These modalities, especially including near infrared light, are anticipated to be next generation endoscopy, and we will undertake innovative development to produce new endoscopy.

  • Table 1. Number of patients
  • Table 2. Endoscopic procedures in 2015

List of papers published in 2015

Journal

  1. Osera S, Ikematsu H, Odagaki T, Oono Y, Yano T, Kobayashi A, Ito M, Saito N, Kaneko K. Efficacy and safety of endoscopic radial incision and cutting for benign severe anastomotic stricture after surgery for lower rectal cancer (with video). Gastrointest Endosc, 81:770-773, 2015
  2. Zako T, Yoshimoto M, Hyodo H, Kishimoto H, Ito M, Kaneko K, Soga K, Maeda M. Cancer-targeted near infrared imaging using rare earth ion-doped ceramic nanoparticles. Biomater Sci, 3:59-64, 2015
  3. Satake H, Yano T, Yoda Y, Fujii S, Zenda S, Tomioka T, Shinozaki T, Miyazaki M, Kaneko K, Hayashi R. Feasibility of salvage endoscopic resection for patients with locoregional failure after definitive radiotherapy for pharyngeal cancer. Endosc Int Open, 3:E274-E280, 2015
  4. Zako T, Ito M, Hyodo H, Yoshimoto M, Watanabe M, Takemura H, Kishimoto H, Kaneko K, Soga K, Maeda M. Extra-luminal detection of assumed colonic tumor site by near-infrared laparoscopy. Surg Endosc, 2015
  5. Takizawa K, Ono H, Yamamoto Y, Katai H, Hori S, Yano T, Umegaki E, Sasaki S, Iizuka T, Kawagoe K, Shimoda T, Muto M, Sasako M. Incidence of lymph node metastasis in intramucosal gastric cancer measuring 30 mm or less, with ulceration; mixed, predominantly differentiated-type histology; and no lymphovascular invasion: a multicenter retrospective study. Gastric Cancer, 2015
  6. Ikematsu H, Matsuda T, Osera S, Imajoh M, Kadota T, Morimoto H, Sakamoto T, Oono Y, Kaneko K, Saito Y. Usefulness of narrow-band imaging with dual-focus magnification for differential diagnosis of small colorectal polyps. Surg Endosc, 29:844-850, 2015
  7. Wada Y, Kudo SE, Tanaka S, Saito Y, Iishii H, Ikematsu H, Igarashi M, Saitoh Y, Inoue Y, Kobayashi K, Hisabe T, Tsuruta O, Kashida H, Ishikawa H, Sugihara K. Predictive factors for complications in endoscopic resection of large colorectal lesions: a multicenter prospective study. Surg Endosc, 29:1216-1222, 2015
  8. Oka S, Tanaka S, Saito Y, Iishi H, Kudo SE, Ikematsu H, Igarashi M, Saitoh Y, Inoue Y, Kobayashi K, Hisabe T, Tsuruta O, Sano Y, Yamano H, Shimizu S, Yahagi N, Watanabe T, Nakamura H, Fujii T, Ishikawa H, Sugihara K, Colorectal Endoscopic Resection Standardization Implementation Working Group of the Japanese Society for Cancer of the Colon and Rectum, Tokyo, Japan. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol, 110:697-707, 2015
  9. Kanesaka T, Uedo N, Yao K, Ezoe Y, Doyama H, Oda I, Kaneko K, Kawahara Y, Yokoi C, Sugiura Y, Ishikawa H, Kato M, Takeuchi Y, Muto M, Saito Y. A significant feature of microvessels in magnifying narrow-band imaging for diagnosis of early gastric cancer. Endosc Int Open, 3:E590-E596, 2015
  10. Mochizuki S, Uedo N, Oda I, Kaneko K, Yamamoto Y, Yamashina T, Suzuki H, Kodashima S, Yano T, Yamamichi N, Goto O, Shimamoto T, Fujishiro M, Koike K, SAFE Trial Study Group. Scheduled second-look endoscopy is not recommended after endoscopic submucosal dissection for gastric neoplasms (the SAFE trial): a multicentre prospective randomised controlled non-inferiority trial. Gut, 64:397-405, 2015
  11. Daiko H, Fujita T, Ohgara T, Yamazaki N, Fujii S, Ohno Y, Yano T. Minimally invasive hybrid surgery combined with endoscopic and thoracoscopic approaches for submucosal tumor originating from thoracic esophagus. World J Surg Oncol, 13:40, 2015
  12. Satake H, Yano T, Muto M, Minashi K, Yoda Y, Kojima T, Oono Y, Ikematsu H, Aoyama I, Morita S, Miyamoto S, Fujii S, Yoshizawa A, Ochiai A, Hayashi R, Kaneko K. Clinical outcome after endoscopic resection for superficial pharyngeal squamous cell carcinoma invading the subepithelial layer. Endoscopy, 47:11-18, 2015
  13. Osera S, Yano T, Odagaki T, Oono Y, Ikematsu H, Ohtsu A, Kaneko K. Peritonitis related to percutaneous endoscopic gastrostomy using the direct method for cancer patients. Surg Endosc, 29:2941-2946, 2015
  14. Sasaki T, Fuse N, Kuwata T, Nomura S, Kaneko K, Doi T, Yoshino T, Asano H, Ochiai A, Komatsu Y, Sakamoto N, Ohtsu A. Serum HER2 levels and HER2 status in tumor cells in advanced gastric cancer patients. Jpn J Clin Oncol, 45:43-48, 2015
  15. Oka S, Tamai N, Ikematsu H, Kawamura T, Sawaya M, Takeuchi Y, Uraoka T, Moriyama T, Kawano H, Matsuda T. Improved visibility of colorectal flat tumors using image-enhanced endoscopy. Dig Endosc, 271:35-39, 2015

Book

  1. Muto M, Inoue H, Morita S, Monma K, Yano T, Katada C, Goda K, Tajiri H, Fujiwara J. Atlas of neoplastic lesions. In: Muto M, Yao K, Sano Y (eds), Atlas of Endoscopy with Narrow Band Imaging, Japan, Springer Japan, pp 79-129, 2015