Endoscopic submucosal dissection (ESD) is a new endoscopic treatment for early gastric cancer that enables complete resection of lesions in the lump. ESD has become widespread as a standard treatment because several devices, including high-frequency electro surgical units, injection solutions and endoscope with water jet, have been developed in Japan. Large lesions and lesions with an ulcer scar can be removed en bloc, and ESD has increased accordingly with the expanded indications. In addition, an accurate histopathological diagnosis can be made following en bloc resection. In this procedure, the circumferential mucosal incision around the lesion and the submucosa is dissected using an IT knife, hooking knife, electro-surgical snare (a thin type), flex knife or flush knife. In particular, the flush knife can emit a jet of water from the tip of a sheath that allows us to perform ESD efficiently. It is relatively safe for avoiding perforation and bleeding. However, ESD takes longer and requires advanced technical skill, and the incidence of major complications is higher in comparison with the standard EMR method. Therefore, it is desirable to learn all of the techniques and the characteristics of the devices and high-frequency units, as well as cutting, dissection and hemostasis in order to perform ESD safely.
Endoscopic breast surgery was developed originally in JAPAN. This minimally invasive technique for breast cancer has improved the cosmetic shape of breast conserving surgery by reducing the size and changing the position of surgical wounds. Each operative method is classified by the approach. At present, the transaxillary approach, periareola approach, lateral approach, and infra-mammary approach are performed. Complete endoscopic operation and endoscope-assisted surgery are performed with each approach. It is necessary to perform reconstruction in cases with a tumor diameter more than 2 cm. Recently, reconstruction using cellulose and collagen has been performed in our department, and these methods have improved the cosmetic shape after resection. Clinical results demonstrated that endoscopic breast conserving operation exhibited efficacy equivalent to the normal procedure. As a result, if the procedure is performed by an experienced endoscopic surgeon with strict regulations to protect from complications, endoscopic breast surgery can improve the cosmetic shape of breast surgery with keeping on radicality of operation. Furthermore, patients with early breast cancer will benefit by using this technique.
We used to utilize the Linton procedure by directly approaching the abnormal skin of lipodermatosclerosis and ligating the incompentent perforating veins at the subfascial space in patients suffering from stasis syndrome, such as pigmentation or ulcer. However we often experienced postoperative wound complications when approaching abnormal skin directly. We have utilized the SEPS procedure since 1999. During this time, we were able to reduce such complications and many patients have experienced improvements in their abnormal skin. We explain the SEPS procedure based upon a case that we experienced.
Laparoscopic surgery has been widely performed for various diseases around the world, ever since the first successful laparoscopic cholecystectomy in 1987. Initially, laparoscopic surgery was only indicated for benign disease; however, its application has now been expanded to malignancies, such as colon, esophageal and gastric cancer. In particular, laparoscopic surgery for gastric cancer is flourishing in Japan. Laparoscopic partial gastrectomy for gastric cancer was first reported in 1993 and laparoscopy-assisted distal gastrectomy with lymph node dissection was reported in 1994. However, this approach took some years to become popular even among the laparoscopic surgeons. We began using laparoscopy-assisted distal gastrectomy for gastric cancer in 1996 and have performed more than 200 cases by now. In this manuscript, we report our standardized procedure and the outcomes of laparoscopic gastrectomy with hand-assisted laparoscopic surgery (HALS).
This paper presents an overview of neuroendoscopic surgery. Innovations in optical engineering have raised the quality of the instrumentation for neuroendoscopy and have provided us with opportunities to perform therapeutic procedures through small, minimally invasive exposure with little disruption of neuronal structures in neurological surgery. As a result, various neuroendoscopic procedures, such as endoscopic third ventriculostomy (ETV), endoscopic transnasal-transsphenoidal surgery, etc., have been developed. For a patient to be considered a candidate for endoscopic third ventriculostomy (ETV), two criteria must be met. First, there must be a symptomatic noncommunicating hydrocephalus. Second, the subarachnoid space must be open and able to absorb cerebrospinal fluid (CSF). In the setting of noncommunicating hydrocephalus, there is absorption of CSF between the ventricles and the subarachnoid space to the circulation. In third ventriculostomy, a fenestration is established in the floor of the anterior third ventricle, allowing CSF to be shunted into the basal cistern, where it can then be absorbed into the venous system. Endoscopic transnasal-transsphenoidal surgery for pituitary tumor, especially pituitary adenoma, has permitted a direct transnasal approach to the sphenoidal sinus, without dissection of the septal mucosa, thus, reducing postoperative morbidity.
Endoscopic surgery is useful in Otorhinolaryngology and particularly epoch-making apparatus for improving sinus surgery has been developed since the 1980s. Recently, endoscopic surgery has been used for minimally invasive middle ear surgery, laryngeal surgery and skull base surgery. NBI (Narrow Band Imaging) has been used for operating in the early stages of pharyngeal malignancy. Neuroendoscopic Surgery.
We have routinely performed transurethral surgery, which shows unique urological peculiarity, for over a hundred years. The recent developments and technological advances in urological laparoscopic surgeries are also remarkable. Nowadays, endourology consists of 4 surgical approaches; including the transurethral, laparoscopic, retroperitoneal and percutaneus approach. Herein, we describe the recent advances of endoscopic surgeries in Urology.
Epiphora, or watering eye, is commonly caused by lacrimal duct stenosis or obstruction. Lacrimal endoscopy is useful not only for observation of the inner lumen of the lacrimal duct but also for direct endoscopic probing of obstructive lacrimal lesions. In this procedure, a fine endoscopic probe can be introduced from the upper or lower punctum of the lids to the orifice of nasolacrimal duct (NLD) into the inferior meatus. The endoscopy procedure usually requires local anesthesia, through infratrochlear nerve block and nasal instillation. The occurrence and distribution of the obstruction sites of NLD were studied using endoscopy. The most frequent obstruction site was the lower portion of NLD. By using endoscopy and silicone tube intubation for NLD obstruction, the success rate of the treatment was improved much greater than without endoscopy. The future and limitations of lacrimal endoscopy are discussed.
There are many women with fibroids or endometriosis. Since endoscopic surgery was approved for insurance coverage in Japan, these procedures have increased dramatically. Recently the incidence of laparoscopic surgery for benign disease has reached over 95 percent in our hospital, Nihon University Surugadai Hospital, and our institution is designated as a high performance level hospital in Japan. As there is the important problem of cost-benefit, e.g. because of the high cost of disposable instruments, we use reusable forceps in our hospital. It is clinically important to carefully evaluate benign tumors. After the preoperative status of uterine fibroids and ovarian tumors has been evaluated regarding tumor size, location and possibility of malignancy, we determine whether laparoscopic surgery or laparotomy is the best operation for the patient. The ultimate aim of infertility management is for women to go to term safely upon becoming pregnant. Although malignant tumors are contraindications for laparoscopic surgery at present, we believe that in the future malignant tumors are going to be treated laparoscopically following careful evaluation of each case. Difficult operations are more easily performed than previously, due to the increase of skills. Meanwhile, there have been various reports on several unexpected accidental complications. We must improve the management of emergencies and the prevention of accidental complications.
The Japan Orthopedic Association has led the way with endoscopic surgery for the spine and has developed its own training course and technical authorization system. Endoscopic surgery can be classified roughly as an anterior procedure from the pleural or peritoneal cavity or as a posterior procedure from the posterior interlaminar space in spine endoscopic surgeries. A representative technique of the endoscopic posterior spine surgery, which uses the posterior method, is microendoscopic discectomy (MED). While MED was initially utilized for lumbar herniotomy, it has recently been used for lumbar spinal canal stenosis and cervical spine disease. Therefore, all the posterior operative procedures are generally used with an MED system and they are referred to as MED. Thus, MED accounts for 98.7% of spine endoscopic operations performed in Japan (2006). There is little soft tissue damage with this approach and the lamina can be reached between the muscles for lumbar disc herniation. In the MED, radiographic control is indispensable for localization of the tube retractor, and it is necessary to resect the yellow ligament little by little to divide the superficial layer and the deep layer. MED is superior in visual safety for retraction of the nerve root to herniotomy. As for issues with MED, there is a substantial learning curve, the operation requires a long time, expensive instrumentation, there is the lack of haploscopic vision, the visual field to operate is limited, there is a tendency to become disoriented, and the lack of sensation of palpating an organ. Additional approaches include video-assisted thoracoscopic spine surgery (VATS) and endoscopic anterior lumbar spine surgery via the peritoneal or retroperitoneal cavity, but they do not lead to global operations.
The parietal association cortex has been considered to play important roles in the integration of a variety of sensory information. Recent studies have revealed that this cortical area also participates in motor control. Since there are no direct neuronal connections between the parietal association cortex and the primary motor cortex that controls somatic movements, the parietal information could be sent to the primary motor cortex indirectly via two or more synapses. However, the existence of such multisynaptic pathways has not yet been demonstrated experimentally. Rabies virus selectively infects neuronal cells and moves across synapses in a retrograde direction. Therefore, the use of this virus as a neuronal tracer enables us to visualize the entire organization of a specific neural circuit. In the present study, we injected the virus into the hindlimb, proximal forelimb, and distal forelimb representations of the primary motor cortex in macaque monkeys and analyzed the distribution patterns of second-order neurons (labeled disynaptically) in the parietal association cortex. We found that such parietal projections to the primary motor cortex are organized in a somatotopic fashion.
Acute interstitial pneumonia (AIP) is a rapidly progressive lung disease that is clinically characterized as acute lung injury. Chest radiographs and computed tomography of AIP reveal diffuse or patchy infiltrates in bilateral lung fields. Case 1 exhibited bilateral ground-glass opacities at the onset. Case 2 exhibited patchy air space consolidations in the bilateral lung fields. Both cases died due to progressive respiratory failure, and their pathologic findings revealed diffuse alveolar damage (DAD) pattern. In particular, case 2 exhibited the histological features of acute and organizing phase of DAD that indicated disease progression.
A 58-year-old man visited our hospital for follow-up of colonic polyps. Three years ago, colonoscopy demonstrated small erosions at the sigmoid colon and polyps at the descending colon. He has received an a-glucosidase inhibitor for diabetes mellitus for 3 years. Control of his diabetes was poor. Colonoscopy showed multiple elevated lesions similar to submucosal tumors in the rectum and sigmoid colon. Barium-enema study demonstrated the same findings. He was diagnosed with pneumatosis cystoides intestinalis. The α -glucosidase inhibitor was withdrawn because it was suspected to be related to the disorder.
We report a case of an aneurysm of the gastroduodenal artery. An 86-year-old woman was admitted to our hospital for treatment of an aneurysm that was found incidentally by abdominal contrast enhancement computed tomography (CECT). Angiography demonstrated a saccular aneurysm of the gastroduodenal artery that was 28 mm in diameter and stenosis of the superior mesenteric artery. Transcatheter embolization was performed using micro-coil. One month after the embolization, the aneurysm had disappeared on abdominal CECT.
It is generally accepted that steroid therapy is effective for minimal change nephrotic syndrome. The prognosis of this disease is generally good, although the decrease of blood plasma volume caused by hypoproteinemia and renal blood flow may cause reversible acute renal failure. Herein we report a case of nephrotic syndrome that was diagnosed as minimal change nephrotic syndrome by renal biopsy one year ago. The patient visited the outpatient clinic routinely for steroid treatment, but after an infection and excessive exercise his nephrotic syndrome recurred and he developed acute renal failure. He recovered after steroid pulse therapy and hemocatharsis treatment. It appears to be important to diagnose minimal change nephrotic syndrome early and not to miss the timing of hemocatharsis for the maintenance of renal function because of the good prognosis of this disease.