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Takuji Gotoda

Publications and source records attributed to Takuji Gotoda.

At least 19 recordsLinked to original sources
PubMed2006

Endoscopic submucosal dissection of early gastric cancer.

The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.

Endoscopy, Gastrointestinal↗
PubMed2006

Metachronous gastric cancers after endoscopic resection: how effective is annual endoscopic surveillance?

BACKGROUND: Endoscopic resection (ER) has been widely accepted in Japan as a less invasive treatment for early gastric cancer, but the incidence of subsequent metachronous gastric cancer (MGC) and the appropriate endoscopic follow-up interval after ER have not been determined as yet. In this study, we investigated the incidence of MGC after ER and assessed our annual endoscopic surveillance program after ER. METHODS: We studied the clinicopathological features of 633 consecutive ER patients (575 with a single lesion and 58 with synchronous multiple lesions) treated at our institution from 1987 through 2002, after excluding 158 patients who underwent additional surgery due to noncurative ERs, 180 patients whose surveillance periods were less than 1 year, 1 patient with hereditary non-polyposis colorectal cancer, and 1 patient with gastric tube cancer. We defined a second cancer found within 1 year after ER as "synchronous" and a second cancer found after 1 year as "metachronous." RESULTS: First MGCs had an overall incidence of 8.2% (52 out of 633 patients); the annual incidence was constant, and the cumulative 3-year incidence was 5.9%. The average time to the discovery of a first MGC after the initial ER was 3.1 +/- 1.7 years (range, 1-8.6 years). Almost all first MGCs (96.2%, 50 out of 52 lesions) were treated curatively with repeat ER. CONCLUSION: In order to detect MGC at a stage early enough for a curative repeat ER, an annual endoscopic surveillance program is both practical and effective for post-ER patients.

Adult↗
PubMed2006

Detection and treatment of early cancer in high-risk populations.

In this paper we describe how to more efficiently detect and treat early gastric cancer (EGC) in high-risk populations. For detection, we first assess the value of known risk factors from the viewpoint of availability for cancer screening. Serum pepsinogen appears to be the most useful and realistic of the factors examined, although its adequacy needs to be assessed in high-risk populations other than those in Japan. Helicobacter pylori infection is known to be a universal risk factor (or gastric carcinogen), and several interventional studies have recently shown positive results. However, H. pylori infection can be eradicated from at-risk populations, thereby decreasing its availability for cancer screening. Smokers are thought to be at risk epidemiologically, but the efficacy of screening in this population has yet to be elucidated, and further studies are warranted. Gender and aging can be risk factors in Japanese populations; male gender and old age are predominant in the intestinal type of carcinoma which is dominant in Japan, although this is not the case in the West. As for early diagnosis of cancer, only endoscopy can be commonly used for the detection of gastritis-like EGC, seen as a faint mucosal irregularity or discoloration. To make early diagnosis more accurate, it is indispensable to carry out detailed endoscopy together with careful scrutiny of the mucosa using dye-spraying techniques. The remarkable progress of early diagnosis in Japan prompted the endoscopic treatment for less invasive EGCs. The first success was with endoscopic mucosal resection (EMR). Although convenient, its therapeutic efficacy is inadequate, particularly for larger lesions. Endoscopic submucosal dissection (ESD) has no limitation on resection size and is expected to replace surgery, although it needs a high level of skill and there are several technical problems to be solved.

Endoscopy, Gastrointestinal↗
PubMed2006

Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video).

BACKGROUND: When gastric perforation occurs during endoscopic resection for early gastric cancer, a surgical treatment generally is performed. Considering the increasing number of EMRs and the possibility of perforation, our research sought to investigate whether endoscopic treatment for gastric perforation is possible. METHODS: From 1987 to 2004, 121 of 2460 patients who underwent gastric EMR at the National Cancer Center Hospital had gastric perforation during EMR (4.9%). The initial 4 patients were treated with emergent surgery. The subsequent 117 patients who were treated with endoclips formed our study population. RESULTS: Endoscopic closure with endoclips in 115 patients (98.3%) was successful. Two patients with unsuccessful endoscopic closure underwent emergent surgery. In the past 6 years, patients with perforation during gastric EMR treated with endoscopic closure had a recovery rate similar to that of the nonperforation cases. CONCLUSIONS: Gastric perforation during endoscopic resection can be conservatively treated by complete endoscopic closure with endoclips.

Adult↗
PubMed2006

Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection.

BACKGROUND: Repeat endoscopic mucosal resection (EMR) to cure locally recurrent early gastric cancer (EGC) is difficult to perform because the initial EMR causes submucosal fibrosis; however, ESD allows submucosal dissection through the fibrosis and provides an en bloc specimen. OBJECTIVE: The objective was to determine the safety and efficacy of ESD and compare the results to historical controls. DESIGN: This was a retrospective, case-control study. PATIENTS: We used our prospectively entered database (1993-2003) to identify 64 patients who had locally recurrent EGC after EMR. MAIN OUTCOME MEASUREMENTS: We defined the resections as curative when the lateral and vertical margins were free of cancer and repeat endoscopy showed no recurrent disease. RESULTS: Among 46 patients who underwent ESD, 41 (89.1%) en bloc resections were achieved compared to none in 18 conventional procedures (P < .0001). The specimen of 1 lesion (2.4%) out of 41 en bloc resections was histologically nonevaluable, compared with 10 lesions (43.4%) in 23 piecemeal resections (P < .0001). Three residual tumors (27.3%) were found in the 11 nonevaluable specimens. Three perforations occurred during ESD; all were successfully treated endoscopically with endoclips. LIMITATIONS: The limitation of the study was retrospective design. CONCLUSIONS: ESD provides high en bloc resection rate for locally recurrent EGC after previous EMR. In turn, en bloc resections allow precise histological staging to be assessed and prevent residual disease and recurrence.

Aged↗
PubMed2006

Endoscopic resection of early gastric cancer: the Japanese perspective.

PURPOSE OF REVIEW: To examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer. RECENT FINDINGS: Endoscopic mucosal resection of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. Though this minimally invasive technique is a safe, convenient and efficacious method, it is insufficient for larger lesions. Difficulties in correctly assessing the depth of tumour invasion and increases in local recurrence by standard endoscopic mucosal resection have been reported in lesions larger than 15 mm. This is because such lesions are often resected piecemeal due to the technical limitation of standard endoscopic mucosal resection. New developments in endoscopic resection techniques to dissect the submucosa directly, called endoscopic submucosal dissection, allows resections of larger lesions en bloc. There are no limitations in resection size in endoscopic submucosal dissection, which is expected to replace surgery. This technique, however, still has higher complications rates than standard endoscopic mucosal resection and requires highly skilled endoscopists. SUMMARY: The techniques, indications, and pathological assessment methods of endoscopic resection of early gastric cancer are described so that proper treatment guidelines can be established and long-term outcome data can be assessed.

Adenocarcinoma↗
PubMed2006

Higher methylation levels in gastric mucosae significantly correlate with higher risk of gastric cancers.

BACKGROUND: Helicobacter pylori infection potently induces methylation of CpG islands in gastric mucosae, which is considered to decrease to a certain level after active H. pylori infection discontinues. Noncancerous gastric mucosae of H. pylori-negative cases with a gastric cancer had higher methylation levels than those of H. pylori-negative healthy individuals. Here, using cases with multiple gastric cancers, we analyzed whether the higher methylation levels correlated with the higher risk of gastric cancers. METHODS: Twenty-six healthy volunteers (HV), 30 cases with a single well-differentiated gastric cancer (S cases), and 32 cases with multiple well-differentiated gastric cancers (M cases) were recruited. H. pylori infection status was analyzed by the culture method. Methylation levels were quantified by real-time methylation-specific PCR of seven CpG islands. RESULTS: In H. pylori-negative individuals, significant increasing trends were present in the order of HV, S cases, and M cases for FLNc and HAND1 methylation levels (P < 0.01, Spearman's rank-order test). Furthermore, the FLNc methylation level of M cases was significantly higher than that of S cases (P < 0.01, t test). Even adjusted by the extent of gastric atrophy, the FLNc methylation level retained a significant increasing trend (P = 0.03). In contrast, methylation levels in H. pylori-positive individuals were increased to various degrees in all the three groups. CONCLUSIONS: In H. pylori-negative individuals, methylation levels in gastric mucosae significantly increased in cases with a single gastric cancer and more in cases with multiple gastric cancers. Quantitative analysis of methylation levels is a promising risk marker for gastric cancers.

Aged↗
PubMed2005

A flexible endoscopic surgical system: first report on a conceptual design of the system validated by experiments.

BACKGROUND: Surgery is a standard diagnostic and therapeutic procedure. However, its technical difficulty and invasiveness pose problems that are yet to be solved even by current surgical robots. Flexible endoscopes can access regions deep inside the body with less invasiveness than surgical approaches. Conceptually, this ability can be a solution to some of the surgical problems. METHODS: A flexible (surgical) endoscopic surgical system was developed consisting of an outer and two inner endoscopes introduced through two larger working channels of the outer endoscope. The concept of the system as a surgical instrument was assessed by animal experiments. RESULTS: Gastric mucosa of the swine could be successfully resected using the flexible endoscopic surgical system, thereby showing us the prospect and directions for further development of the system. CONCLUSION: The concept of a flexible endoscopic surgical system is considered to offer some solutions for problems in surgery.

Animals↗
PubMed2005

Distribution of the deepest penetrating point of minute submucosal gastric cancer.

BACKGROUND: Accurate assessment of depth of invasion is critical in decision-making for additional surgery after endoscopic resection of early gastric cancer (EGC). Although this depth of invasion is determined at the deepest point of submucosal invasion (DPSI), there is no literature describing the distribution of deepest invasion point. OBJECTIVE: To describe the location of the DPSI, and to determine whether it is possible to predict this point by clinicopathological features before treatment. METHODS: One hundred and ninety-five lesions of EGC with minute submucosal invasion, which had been resected en bloc between 1991 and 2003, were reviewed. For each lesion, we recorded the location of the DPSI as being in one of three areas demarcated by three concentric equal distance rings. We also examined the correlation between the location of the deepest penetration and the clinicopathological characteristics. RESULTS: The DPSI was located most often (53%) in the central, less often (31%) in the middle and least often (16%) in the outermost area. There was no significant correlation between the distribution of the deepest point and any clinicopathological features. CONCLUSIONS: The DPSI was not always in the central area, and it was impossible to predict its location by clinicopathological features alone. To obtain an accurate measure of depth of tumor invasion, we must histologically assess the entire lesion by thin sections.

Adenocarcinoma↗
PubMed2005

Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract.

The purpose of this literature review is to examine recent advances in technique and technology of endoscopic mucosal resection of superficial early cancers of the upper gastrointestinal tract. Endoscopic mucosal resection (EMR) of superficial early cancers of the upper gastrointestinal tract is standard technique in Japan and is increasingly used in Western countries. Newer techniques of EMR allow removal of larger lesions en-bloc. These minimally invasive techniques, when applied correctly, allow safe and efficacious treatment in situations that would otherwise require major surgery. Through the establishment of long-term outcomes data, standardization of endoscopic and pathologic reporting, and newer EMR technology and techniques, the future treatment of early cancers in the upper gastrointestinal tract may be achieved primarily through the endoscope.

Endoscopy, Gastrointestinal↗
PubMed2005

Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan.

BACKGROUND: The Japanese population is rapidly aging, and the actual number of elderly patients with gastric cancer, including early cancer, has been increasing, even though the standardized incidence of gastric cancer in the population is decreasing. The optimal treatment for these patients remains a challenge to the surgeon. The aim of this retrospective analysis was to describe the results of gastrectomy and EMR for early gastric cancer in elderly patients (80 years of age and over). METHODS: This is a retrospective review of 93 elderly patients who had undergone gastrectomy or EMR at the National Cancer Center Hospital for early gastric cancer. EMR was performed aiming en bloc local resection with a clear curative margin (R0). The clinicopathologic characteristics, comorbidity, postoperative mortality, and outcome were recorded. RESULTS: Gastrectomy was performed in 44 patients (surgery group) and EMR in 49 patients (EMR group). There were significant differences in mean tumor size (p < 0.05), histologic type (p < 0.05), and depth of tumor invasion (p < 0.05) between the two groups. There was no significant difference in comorbidity between the two groups. No operative death was reported in either group. In the EMR group, 7 patients were reported to have recurrence of local disease and two patients died of advanced disease. There were no significant differences in the overall 3-year survival rate or the 5-year survival rate between the surgery group and EMR group (73.5% vs. 82.5% and 55.0% vs. 62.5%, respectively). CONCLUSIONS: EMR (R0) resection was performed safely in the elderly, and the overall results were excellent, the same as the results with gastrectomy. Gastrectomy can still be performed if EMR is unsuccessful.

Aged↗
PubMed2005

A new sinker-assisted endoscopic submucosal dissection for colorectal cancer.

BACKGROUND: Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, but it is not widely used to treat the colorectum because of its degree of technical difficulty. Thus, a noninvasive tool that facilitates the direct visualization of the submucosal layer is needed. METHODS: Traction-assisted dissection was performed on 4 superficial lesions. The system consisted of a metallic clip attached by a nylon line to a sinker 6 x 4 x 4 mm in size and weighing 1 g. After partially dissecting the submucosa, the clip was attached to the edge of the exfoliated mucosa and the weight of the sinker pulled down the partly resected lesion. OBSERVATIONS: In all 4 cases, the sinker allowed direct visualization of the cutting line, and en bloc resection was successfully accomplished. CONCLUSIONS: These preliminary results suggest that sinker-assisted ESD is effective for the complete removal of selected superficial early colorectal cancer.

Aged↗
PubMed2005

A large endoscopic resection by endoscopic submucosal dissection procedure for early gastric cancer.

Gastrectomy with lymph node dissection has provided an excellent therapeutic outcome for patients with early gastric cancer, with a 5-year survival rate of 96%. The prevalence of lymph node metastasis of intramucosal- and submucosal-invading cancer was reported as approximately 3% and 20%, respectively, which means surgery may have been excessive for many patients with these diseases. The endoscopic distinction between mucosal and submucosal invasion is made correctly in only approximately 80% of tumors. However, this means that the pretreatment diagnosis is incorrect for 20% of those tumors otherwise identified as candidates for local treatment. Furthermore, the evaluation of lymphatic-vascular involvement associated with lymph node metastasis is available only through accurate histologic examination. It is essential to evaluate accurately the endoscopically resected specimen and then decide whether or not an additional surgical procedure is warranted. There are several techniques for endoscopic mucosal resection. It is difficult to correctly assess the depth of tumor invasion from resected materials by conventional endoscopic procedures in lesions larger than 15 mm. This is because such lesions often are resected piecemeal because of the size limitation of a resectable specimen. A new endoscopic procedure, endoscopic submucosal dissection, using an insulation-tipped needle knife specifically designed at the National Cancer Center Hospital, Japan, is superior to other endoscopic methods in the treatment of early gastric cancer, and provides an en bloc specimen. En bloc resections allow precise histologic staging and have the potential to prevent recurrent disease.

Equipment Design↗
PubMed2004

Percutaneous traction-assisted EMR by using an insulation-tipped electrosurgical knife for early stage gastric cancer.

BACKGROUND: EMR now is accepted as a minimally invasive treatment for early stage gastric cancer. However, the endoscopic approach sometimes is limited by the size and location of the tumor. The technique and early results of percutaneous, traction-assisted EMR for resection of larger early stage gastric cancers is described. METHODS: EMR, by using an insulation-tipped electrosurgical knife, was performed with the simultaneous assistance of laparoscopy devices. A small snare was introduced into the gastric lumen through a gastric port (2-mm diameter) to grasp and pull the EGC away from the muscularis propria to facilitate resection. RESULTS: The technique was performed successfully in our endoscopic suite in the first patient under general anesthesia and the remaining seven under conscious sedation. Tumors situated in any part of the stomach could be reached with percutaneous assistance, and this facilitated en bloc resection of large specimens (mean size 50 mm). The procedure was performed in about 60 minutes. Seven patients (88%) resumed eating 1 or 2 days after surgery. All patients were discharged after 1 week without complication. CONCLUSIONS: Percutaneous, traction-assisted EMR is useful for resection of large lesions en bloc and can be performed easily and safely under direct vision.

Adult↗
PubMed2004

High-grade dysplasia associated with fundic gland polyposis in a familial adenomatous polyposis patient, with special reference to APC mutation profiles.

We report a patient with familial adenomatous polyposis who developed high-grade dysplasia against a background of fundic gland polyposis. Two large high-grade dysplasia lesions were found in the gastric body, where numerous fundic gland polyps were present. In both lesions, the dysplastic epithelium covered non-neoplastic oxyntic glands that occasionally exhibit cystic changes. A genetic analysis for APC (adenomatous polyposis coli) revealed a somatic 50-bp deletion involving codons 1502-1517 and 2-bp deletion at codon 1465 in each lesion of high-grade dysplasia. In contrast, six of the 18 fundic gland polyps were found to harbor an identical mutation: 1-bp insertion at codon 1556. Both lesions of high-grade dysplasia and the fundic gland polyps were similarly located in the fundic gland area and were caused by the inactivation of APC; however, their mutation profiles of APC were different. These results imply that fundic gland polyps and high-grade dysplasia of the stomach have distinct preferences for APC genotypes in their development.

Adenomatous Polyposis Coli↗
PubMed2003

Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy.

BACKGROUND: Placemet of self-expandable metallic stents in patients with advance esophageal cancer improves dysphagia and occludes tracheoesophageal fistulas. However, the safety of self-expandable metallic stents for patients who have undergone chemoradiotherapy is controversial. This study evaluated the morbidity and modality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy. METHODS: A total of 22 patients in whom self-expandable metallic stents were placed because of progressive or recurrent esophageal cancer after chemoradiotherapy were studied. RESULTS: All 22 patients had dysphagia, and 13 had a tracheoesophageal fistula. After self-expandable metallic stent placement, the mean dysphagia grade improved from 3.5 to 0.9, and tracheoesophageal fistula was successfully managed in all cases. Seventeen patients had T4 stage disease, and among 8 of them with invasion to the aorta, 6 (75%) died of sudden massive hemorrhage. Median survival for these 6 patients was 31 days (range 13-63 days) compared with 67 days (range 4-262 days) for all patients after self-expandable metallic stent placement. CONCLUSION: Self-expandable metallic stent placement improved dysphagia and was useful for treatment of tracheoesophageal fistula. However, for patients with T4 lesions that invade to the aorta, self-expandable metallic stent placement after chemoradiotherapy should be considered carefully.

Aged↗