In bronchoesophagology, remarkable developments have been achieved in minimal invasive transoral endoscopic surgeries for laryngopharyngeal cancer, esophagological cancer, airway stenting and infant airway intervention. For laryngopharyngeal cancer, currently various novel transoral procedures are performed, namely: transoral videolaryngoscopic surgery (TOVS) and endoscopic laryngopharyngeal surgery (ELPS) both developed in Japan, and transoral robotic surgery (TORS) developed in the United States. In this article, the background and characteristics of, and differences between, these procedures are reviewed.

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For laryngeal and pharyngeal cancer, laryngeal preservation treatment consists of partial laryngopharyngectomy or (chemo) radiotherapy. As traditional open neck partial laryngopharyngectomy involves invasive surgery, transoral partial laryngopharyngectomy is gaining acceptance today as a minimally invasive surgery. We developed an original transoral surgical system, Transoral videolaryngoscopic surgery (TOVS), which is performed under distending laryngoscope and rigid laryngeal endoscope. This surgery can be performed by head and neck surgeons, and en bloc resection is feasible with direct laryngoscopic surgical technique. Indications of TOVS include Tis to selected T3 cases and salvage cases after (chemo) radiotherapy (rT1 and rT2). Regarding supraglottic and hypopharyngeal cancer, the 5-year overall survival, disease specific survival, local control rate, larynx preservation rate and recurrence-free survival were 82%, 98%, 95%, 95% and 81%, respectively. Regarding oropharyngeal cancer, the 5-year overall survival, disease specific survival, local control rate and recurrence-free survival were 89%, 94%, 91% and 76%, respectively. In the acute postoperative phase, bleeding and airway management are important. Postoperative dysphagia is rare but this complication should be informed to patients beforehand.

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Narrowband imaging (NBI) combined with magnifying endoscopy (ME-NBI) enables us to detect early superficial laryngo-pharyngeal cancers, which are difficult to detect by standard endoscopy. ELPS was developed to treat laryngo-pharyngeal superficial cancer and is performed by a head and neck surgeon using both hands. Primary indication of ELPS was initially limited to superficial cancers, but recently indications are expanding to include invasive cancer lesions. The advantages of ELPS include an excellent surgical field provided by ME-NBI and the curved laryngoscope, various forms of functional assistance enabled by the ME-NBI, subepithelial injection to preserve deeper structure, combined use of ESD if necessary. ELPS is cost effective, and even in the current era of transoral robotic surgery, it continues to be a good option as a treatment for laryngo-pharyngeal cancers.

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Transoral robotic surgery in the tracheoesophageal region is used as a minimally invasive treatment modality for oropharyngeal cancer, supraglottic cancer, and hypopharyngeal cancer. In comparison with tumor resection by external incision, transoral surgery is associated with a shorter operation time and hospitalization period, less blood loss, and greater preservation of postoperative swallowing function. Moreover, robotic surgery facilitates resection of tumors close to the anterior wall, which is difficult using conventional endoscopic surgery. Characteristically, various robotic functions facilitate quick and easy mastery of the surgical technique, ensuring uniformity of procedure. Various procedures, such as suturing, can be performed in the larynx within a narrow working space. There have been several overseas reports about the application of this technique, such as thyroidectomy, neck dissection, tongue base reduction for sleep apnea syndrome, removal of parapharyngeal space tumors, resection for skull base tumor and reconstruction surgery. Robotics technology is a rapidly developing, and advancements in this field are expected to give rise to novel transoral surgical techniques.

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Today, early detection and endoscopic treatment of esophageal cancer have become possible thanks to the development of endoscopes and related equipment. Endoscopic submucosal dissection (ESD) and Endoscopic mucosal resection (EMR) are the principal endoscopic treatments performed for early esophageal cancer. Thanks to advances in ESD technology, in the 2012 Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus the absolute indications of endoscopic treatment have been set at invasion depths of EP and LPM, and the relative indications at invasion depths of T1aMM and T1bSM1, without lymph node metastasis. Although it has thus now become possible to resect lesions of larger size, problems of postoperative scarring and stenosis have emerged. Additionally, problems remain with respect to intraoperative and postoperative bleeding, accidental perforation, intraoperative sedation, etc. It is only when management of all these issues becomes possible that endoscopic treatment can be stably performed. Here, we describe the current status of endoscopic treatment, especially ESD for esophageal cancer, including advances in equipment and procedures.

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Aim : To assess the effectiveness of argon plasma coagulation (APC) in the treatment of early esophageal squamous cell carcinoma (EESCC). Patients and Methods : We studied 61 patients (male, n=47; female, n=14) with EESCC who underwent treatment with APC-subepithelial ablation between April 2008 and April 2014. The reasons for their treatment were as follows : occurrence of other primary cancers after endoscopic resection (n=12), maintenance of iodine unstained areas (n=12), treatment of primary esophageal cancer (or other primary advanced cancers) in an elderly patient (n=9), two-stage endoscopic treatment for superficial esophageal cancer requiring circumferential resection (n=9), treatment of a local recurrence of endoscopic resection (n=8), treatment of a local recurrence of residual lesions of chemo-radiotherapy (n=7), and treatment of cancer within the esophageal diverticulum (n=4). The iodine unstained area was treated with APC ablation. After the initial ablation, the epithelium was exfoliated, and a secondary ablation was performed until the color changed from red to golden brown. Results : All of the tumors were macroscopically classified as mucosal lesions. The median treatment time was 17 min. The median number of treatment sessions per site was 2 (range : 1-12). Fifty-eight of the 110 sessions (62.5%) were performed for outpatients. There were no severe complications related to treatment (such as bleeding or perforation). Ten of the 61 patients were undergoing treatment for another primary EESCC, and were cured by an additional endoscopic resection. Conclusion : APC ablation is considered to be a safe and effective method for the management of EESCCs, especially in high-risk patients.

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Patients with significant central airway obstruction are frequently within hours or days of death from suffocation. For inoperable patients due to either physiological or oncological criteria, therapeutic interventional pulmonology provide rapid palliation that can be lifesaving and improve quality of life (QOL). This retrospective study reports our experience with the placement of an airway stent in patients with inoperable malignant disease or postoperative tracheobronchial stenosis, as well as high feasibility of simulating airway stent placement using a three-dimensional (3D) printed airway model. The medical records of 50 patients who had undergone placement of airway stents at our institution between April 2005 and December 2014 were reviewed. Recently, we used a 3D printed airway model for planning of stent placement before intervention. Primary diagnosis was malignant disease in 47 cases, and postoperative bronchial anastomotic stenosis after bronchoplasty in 3 cases. The airway stents included 45 silicon stents (Y stent, n=30; straight stent, n=15), 4 double stents with silicon and metallic stent, and 1 metallic stent. Extracorporeal membrane oxygenation (ECMO) was used during stent placement in 5 cases to prevent critical hypoxic complication. Improvements in respiratory status after stenting were recognized in 42 of the 50 patients (84%). Median survival and 1 year survival rate in the 47 patients with malignant disease were 152 days (range 11-1,417 days) and 23.8%, respectively. Significantly longer survival was observed in 26 patients who received post-procedural chemotherapy and/or radiotherapy compared with 21 patients who did not receive additional therapy (median survival : 259 days vs 47 days, p=0.008). Interventional pulmonology including airway stenting for central airway obstruction can provide relief of dyspnea and improve survival in patients with additional treatment after stent placement. Also, a 3D printed airway model is a useful simulation tool for understanding anatomy before a procedure and determination of placement of an airway stent.

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Airway intervention treatment is a “non-invasive” surgical procedure carried out for benign and malignant airway stenosis using rigid or flexible endoscopic procedures. Generally airway intervention procedures are achieved by endoscopic balloon dilatation or a core-out procedure to remove the intraluminal tumor in order to achieve adequate airway caliber. The established airway lumen is usually maintained by insertion of an airway stent. When treating infants, however, removal of the airway foreign body is the most frequently performed airway intervention technique. Airway boogie dilatation is seldom performed for tracheal stenosis caused by congenital tracheal stenosis. A neoplastic lesion of the respiratory tract that requires airway intervention treatment is extremely rare in infants. In Japan, beans are the most common substance that causes airway foreign body in infants. The problem appears most frequently after 1 year of age, when children are shifted from baby food to regular meals. The characteristics of the airway intervention procedure for infants are : ①the airway is too small and narrow for available intervention equipment usually designed for adults ; ②the patient's co-operation in the treatment is limited. Also, special consideration is needed with respect to the anesthesia used during the procedure. How to safely use intervention tools designed for adults when treating an infant is an issue of great importance. This report introduces precautions and procedures devised specially for airway intervention treatment mainly focused on airway foreign bodies in infants.

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