Esophagocardiac Junction Research Articles

Minimally Invasive Surgery for Esophageal Atresia with Tracheoesophageal Fistula After Low Esophageal Banding in a Low-Birth Weight Infant

Background: Birth body weight has been recognized as a remarkable prognostic factor in esophageal atresia with tracheoesophageal fistula (EA/TEF). Surgical repair, either open or thoracoscopic, leads to inevitable lung manipulation and adversely affects lung functions. Low esophageal banding (LEB) has been recommended in high-risk patients as the initial operation, which temporarily occludes the esophagocardiac junction (ECJ) and prevents the communication between airway and stomach.1,2 The definitive surgical repair can be conducted in stable conditions of adequate body weight and better lung functions. We present a low-birth weight infant with EA/TEF who received minimally invasive surgery after LEB. Materials and Methods: A premature infant was born with birth weight of 1389 g. Nasal respirator support was required for respiratory distress soon after birth. Contrast study showed EA/TEF. The abdomen was progressively distended because of constant air pumping into the stomach. A decision was made to perform LEB on day 2 of life. Through an upper midline incision, a 12F G-tube was initially placed to decompress the pumping air from TEF and have a better surgical exposure. The ECJ was identified. A retroesophageal window was made. The low esophagus was wrapped doubly circumferentially with a vessel loop. Two clips were put on the vessel loop to tighten up the banding. Enteral feeding through the G-tube was initiated on postoperative day 3 after the contrast study confirmed no gastroesophageal reflux. At 45 days of age with the body weight of 2569 g, thoracoscopic repair was arranged. The patient was placed in the left semiprone position. Three ports of 5, 5, and 3 mm were made at 1 cm below the scapular tip, fourth, and sixth intercostal spaces along midaxillary line, respectively. Lung was collapsed with CO2 insufflation at pressure of 3 mm Hg. The azygos vein was cauterized and divided. TEF was clipped with a hemolock and left undivided at this time point. The proximal esophageal pouch was mobilized. After confirmation that the proximal esophagus has appropriate length, TEF was divided. An 8F feeding tube was inserted into the distal esophagus until resistance was encountered. Esophagoesophagostomy was accomplished with 5-0 polydioxanone interruptedly. A chest tube was placed. The patient was changed to supine position for laparoscopic banding removal. Severe adhesions were noted particularly between the anterior stomach wall and the liver. A loose space was found between pylorus and liver. Continuing dissection upward along the lesser curvature of the stomach, the vessel loop was discovered and removed. Under the direct vision of transgastrostomy endoscope, the nasogastric tube was placed into the stomach smoothly. Results and Conclusions: There was no leakage shown in the esophagogram on postoperative day 10. Oral feeding was restored. Minimally invasive EA/TEF repair is technically feasible after LEB. A long vessel loop should be left along the lesser curvature of the stomach to facilitate banding removal. No competing financial interests exist. Runtime of video: 6 mins 9 secs

Assessment of cricopharyngeal muscle aging with apoptotic markers.

The aims of this study were to evaluate histochemical markers of apoptosis in the cricopharyngeus muscle, which is the gatekeeper of the pharyngoesophageal region during the swallowing process; to investigate the effects of primary aging on this muscle; and to determine whether a relationship exists with gastroesophageal reflux disease. The study included 30 fresh cadavers with a time of death of 12 hours or less obtained from the Turkish Ministry of Justice Forensic Medicine Unit. All cadavers were dissected with routine postmortem skin incisions to extract specimens from the cricopharyngeus muscle and the esophagocardiac junction mucosa. Muscle degeneration and primary aging were demonstrated by immunodetection of Bax, Bcl-2, and Caspase-3 proteins as markers of the apoptosis. Esophageal specimens were examined for the presence of reflux esophagitis. The mean age was 41.5 (14-74) years, and the study included 18 male and 9 female cadavers. Three of them were excluded because of fixation artifacts. The mean Bax, Bcl-2, and Caspase scores showed no statistically significant relationship with age (P = 0.94). The right and left sides of the muscle were investigated separately, and the Bax scores of the right side of the cricopharyngeus muscle showed a statistically significant decrease with age (P = 0.026), whereas the Bax and Bcl-2 scores were increased with age (P = 0.035 and 0.049, respectively) on the left side. Evaluation of the 23 esophagus specimens revealed 10 cases of esophagitis. No relationship was found between the mean of each apoptotic marker and esophagitis. It is histopathologically not possible to demonstrate muscle death due to either primary aging or reflux. This might be attributable to the defensive capability of this unique muscle to maintain the feeding process.

Comparison of Risk Factors and Disease Severity Between Old and Young Patients With Gastroesophageal Reflux Disease.

BackgroundGastroesophageal reflux disease (GERD) tends to relapse and develop complications. The aim of the study was to compare the risk factors and disease severity of GERD in young and old patients.MethodsData from patients with GERD were collected between January and November 2009. The enrolled cases were assigned to the younger group if they were below 65 years, or the elderly group if 65 years or older. The general demographic data, lifestyle characteristics and endoscopic findings of the two groups were compared.ResultsAmong all enrolled 111 patients, 78 and 33 patients were classified in the younger and elderly groups, respectively. The elderly group had significantly more men than the younger group did (72.7% vs 39.7%, P = 0.001). Lower rates of smoking (3% vs 6.4%, P = 0.029) and tea drinking (21.3% vs 34.6%, P = 0.001) were noted in the elderly patients, but similar rates of alcohol and coffee drinking. There were more severe esophagitis, esophagocardiac junction (ECJ) ulcers (21.2% vs. 2.6%, P = 0.003) and hiatal hernia (36.4% vs 16.9%, P = 0.025) in the elderly group.ConclusionElderly GERD patients were more likely to be male, and having severe esophagitis, but lower rates of cigarette smoking and tea drinking, than those of younger patients.

Laparoscopic Resection of Gastrointestinal Stromal Tumors: Safe, Efficient, and Comparable Oncologic Outcomes

Surgery of gastrointestinal stromal tumors (GISTs) has been modified, and laparoscopic resection of GIST has gained improvement and roles. We retrospectively reviewed clinical data and oncological outcomes of our GIST patients who underwent laparoscopic surgery and traditional open surgery. In total, 227 pathologically diagnosed GIST cases were retrospectively reviewed in Chang Gung Memorial Hospital at Linkou, Taipei, Taiwan, between 2005 and 2010. We excluded those with tumor size >5 cm, biopsy-only, combined other operation, endoscopic mucosal resection, tumor located in the duodenum, colon-rectum, esophagocardiac junction, omentum, pelvic area, or retroperitoneum, or metastasis when operated on and those diagnosed as other disease after immunohistologic examination of GIST. Fifty-eight cases were enrolled, including 16 patients in the laparoscopic surgery group (LSG) and 42 patients in the open surgery group (OSG). The patients' demography, perioperative, pathologic result, and oncology result were recorded and analyzed. Both groups showed no difference in clinical demography, tumor size, and locations. LSG patients showed fewer days to resume diet, shorter postoperative hospital stays, and less use of patient-controlled analgesia. The postoperative morbidity in LSG and OSG was 6.3% and 19%, respectively. The median follow-up time was 32.73 months in LSG and 39.75 months in OSG. Recurrence or metastasis was observed in 3 patients (1 in LSG and 2 in OSG). The recurrence rate between LSG and OSG showed no significant difference. Laparoscopic surgery was technically feasible for GIST of no more than 5 cm located at the stomach and small bowel. In the current study, we demonstrated that LSG patients benefited from fewer days to resume diet (5 versus 5.71 days), shorter postoperative stays (8 versus 9.07 days), and less patient-controlled analgesia use (6.7% versus 90.9%) during the perioperative period with the same short-term oncology result compared with OSG patients.

A pseudosarcomatous lesion resembling a malignant tumor of the esophagocardiac junction, diagnosed by a total biopsy with endoscopic surgery

A pseudosarcomatous lesion resembling a malignant tumor of the esophagocardiac junction, diagnosed by a total biopsy with endoscopic surgery

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases

Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. All of the procedures were performed successfully, with mean operation time of 62.6 +/- 8.9 min and mean intraoperative blood loss of 86.2 +/- 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7-2.5 cm, with a mean distance of 1.4 +/- 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 +/- 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection.

Extraluminal Laparoscopic Wedge-Resection of Submucosal Tumors on the Posterior Wall of the Gastric Fundus Close to the Esophagocardiac Junction

Laparoscopic resection of submucosal tumors in the gastric fundus, especially in the posterior wall near the esophagocardiac junction (ECJ), is difficult and time consuming and is and likely to cause esophageal stenosis and splenic injury. In this article, we report an extraluminal laparoscopic wedge-resection (ELWR) that minimizes these problems. Thirty-seven patients with submucosal tumors in the posterior wall of the gastric fundus received ELWR. The operation consisted of four steps: 1) localization of the tumor, 2) dissection of the omentum, 3) mobilization of the gastric fundus/upper pole of the spleen and exposure of the ECJ, and 4) resection of the gastric fundus with a linear endoscopic gastrointestinal anastomosis stapler. None of the cases needed conversion to open surgery. Mean postoperative hospital stay was 5.5 +/- 1.0 days. The distance between the tumor and the incision margin ranged from 0.7 to 2.5 cm toward the ECJ. Pathologic examination revealed 7 cases of leiomyomas, 29 cases of stromal tumors (4 were low-grade malignant tumors), and 1 case of neurofibroma. There was no recurrence, metastasis, esophageal stenosis, or any other severe adverse event during the follow-up period (52 +/- 3.1 months). ELWR is a safe, effective treatment for submucosal tumors in the posterior wall of the gastric fundus.

Application of Laparoscopic Techniques for Resection of Individual Gastric Submucosal Tumors

Large gastric submucosal tumors should be excised to prevent ischemic mucosal ulceration of the overlying surface and central necrosis of the neoplasm, which may in turn lead to massive hemorrhage. Large tumors near the esophagocardiac junction or on the posterior wall are usually resected by an open procedure. We describe 2 cases of upper gastrointestinal tract bleeding owing to huge submucosal tumors in the posterior gastric high body treated by laparoscopic resection of the gastric tumors. These 2 patients recovered smoothly without major or minor complications. We emphasize that design of specific strategies for individual tumors is essential for the successful laparoscopic resection of tumors adjacent to the esophagocardiac junction and large tumors on the posterior wall.

Interobserver agreement in endoscopic evaluation of reflux esophagitis using a modified Los Angeles classification incorporating grades N and M: A validation study in a cohort of Japanese endoscopists

The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.

Robotic intragastric surgery: A new surgical approach for the gastric lesion

Intragastric surgery is accepted as a minimally invasive procedure for mucosal or submucosal lesions. Robotic surgery promises to extend the capabilities of the minimally invasive surgeon and many surgical specialties are applying this new technology. However, there is no report of robotic intragastric surgery. We describe the use of the da Vinci Surgical System for intraluminal mucosal resection of the stomach. We developed our porcine intragastric surgery model using the Tuebingen MIS Trainer. We set a tentative lesion on the posterior wall near the esophagocardiac junction (ECJ) of the stomach and performed mucosal resection of the lesion using the da Vinci Surgical System. We also performed closure of the defect after mucosal resection and subsequent closure of the intentional gastric perforation. Using our porcine intragastric surgery model, we successfully performed mucosal resection of the tentative lesion. We also smoothly completed closure of the defect and closure of the perforation without any complications. The mean size of the mucosa was 6 cm and the mean duration of the procedure was only 12 min. The safety and efficacy of robotic intragastric surgery was preliminarily established in this study. However, further studies are needed to prove its practical feasibility in humans using the da Vinci Surgical System to make it an effective operation.

Proposal of a novel method to evaluate anastomotic tension in esophageal atresia with a distal tracheoesophageal fistula

Anastomotic tension with the potential to lead to post-operative complication is usually evaluated using gap length before anastomosis in patients with esophageal atresia and a distal tracheoesophageal fistula (EA with a TEF). However a uniform, accurate measurement of gap length is not possible and estimation of the length the delicate distal esophageal stump is stretched by the anastomosis may have greater utility. The aim of this paper was to propose a novel method to evaluate the anastomotic tension in EA with a TEF. Forty consecutive patients having EA with a TEF were studied. Primary anastomosis without gastrostomy was performed in all cases. When the TEF was cut off, the most proximal site of the tracheal side was marked using a tiny metallic clip. When anastomosis was completed, the distance from the clip to the anastomotic site was measured as the stretched length. On the esophagram taken subsequently, the same distance was measured, together with the distance from the clip to the esophago-cardiac junction as the original distal esophageal length. The stretching ratio was calculated by dividing the former by the latter. The stretched length on esophagram (median: 3.0 mm, range: -12 to 21) was significantly correlated with that measured during surgery (median: 2.3 mm, range; -14 to 15) (r = 0.96, P < 0.0001). The median of original distal esophageal lengths was 60.0 mm (range: 35-80). The stretching ratio was significantly correlated with the stretched length, and the number of the stretching ratio as a percentage corresponded to about double the number of the stretched length on esophagram in millimeters (y = 1.91x + 0.58, r = 0.98, P<0.0001). Anastomotic leakage and recurrence of TEF were not experienced. In patients complicated with gastroesophageal reflux (GER), the site of TEF was significantly more distal as compared with the other cases [median (range): 5.0th (4.0-6.0) vs 3.5th (1.5-5.0) thoracic vertebral level, P<0.009]. The stretched length and the stretching ratio were also longer and larger, respectively [median (range): 10.0 mm (6-21) vs 2.0 (-12 to 14) mm, P<0.008, 17.3% (12.7-47.7) vs 2.9% (-16.4 to 29.8)%, P<0.018). Similar tendencies were observed for patients complicated with stricture. Estimation of the stretched length of the distal esophageal stump is useful to evaluate the anastomotic tension. If the stretched length is more than 10 mm, it will be necessary to consider the possibility that stricture or GER may arise afterwards.

Laparoscopic intragastric resection of gastric stromal tumor located at the esophago-cardiac junction.

We performed laparoscopic intragastric surgery (LIGS) for gastric stromal tumors located at the esophago-cardiac junction (ECJ) in 7 patients. The tumors measured 27 to 75 mm in diameters. Histologically, there were 4 cases of gastrointestinal stromal tumors, 2 leiomyomas, and 1 schwannoma. LIGS was performed with 1 camera port (10 mm) inserted by the open method and two 5-mm working ports inserted by puncturing the stomach. Tumors were enucleated or resected with appropriate margins confirming the muscle layer of the stomach wall and retrieved orally by gastrofiberscope. The mean surgical duration was 141.4 minutes. Recent patients took their first meal on day 3 postoperatively and were discharged within a week. There were no complications including stenosis or gastroesophageal reflux in any patient to date. LIGS is a feasible surgical option for gastric stromal tumors located at ECJ.

Laparoscopic resection of submucosal tumor on posterior wall of gastric fundus.

Laparoscopic resection of tumors on the posterior wall of gastric fundus, especially when they are next to the esophagocardiac junction (ECJ), is both difficult and time-consuming. Furthermore, it can lead to inadvertent esophagus stenosis and injury to the spleen. In order to overcome these difficulties, laparoscopically extraluminal resection of gastric fundus was designed to manage submucosal tumors located on the posterior wall of gastric fundus and next to ECJ. From January 2001 to September 2003, laparoscopically extraluminal resection of gastric fundus was successfully carried out on 15 patients. There were 11 males and 4 females with an average age of 58 years (range, 38 to 78 years). The mean diameter of the tumors was 4.8 cm. The distance of the tumor border from ECJ was about 1.5-2.5 cm. The four-portal operation procedures were as follows: localization of the tumor, dissection of the omentum, mobilization of the gastric fundus and the upper polar of spleen, exposure of ECJ, and resection of the gastric fundus with Endo GIA. The laparoscopic operation time averaged (66.2+/-10.4) min, the average amount of bleeding was (89.4+/-21.7) mL. The mean post-operative hospital stay was (5.3+/-1.1) d. Within 36 h post-operation, 73.3% of all the patients recovered their gastrointestinal function and began to eat something and to walk. In all the operations, no apparent tumor focus was left and no complication or conversion to open surgery occurred. Our newly designed procedure, laparoscopically extraluminal resection of the gastric fundus, can avoid contamination of the abdominal cavity, injury to the spleen and esophageal stenosis. The procedure seems to be both safe and effective.

ADENOCARCINOMA IN SITU ARISING FROM THE ECTOPIC SUBMUCOSAL CARDIAC GLANDS OF SHORT‐SEGMENT BARRETT's EPITHELIUM

Adenocarcinoma of the esophagocardiac junction is a condition difficult to define. It is often necessary to differentiate between esophagocardiac junctional adenocarcinoma and carcinoma in Barrett's esophagus. We herein report a case of an 83‐year‐old Japanese man with adenocarcinoma in situ arising from ectopic submucosal cardiac glands in short‐segment Barrett's epithelium, associated with squamous cell carcinoma. Despite the visualization of a nodule in short‐segment Barrett's epithelium, we diagnosed the present case as one of esophagocardiac junctional cancer arising from ectopic submucosal cardiac glands, using Alcian‐blue staining.

Familial gastrointestinal stromal tumors associated with dysphagia and novel type germline mutation of KIT gene

A family with multiple gastrointestinal stromal tumors (GISTs), a new type of germline mutation of KIT gene, and dysphagia is reported. The mutation was observed at Asp-820 in tyrosine kinase (TK) II domain. Mutations in TK II domain have been found in mast cell and germ cell tumors but not in GISTs, and the present family members are the first reported cases of GISTs with TK II domain mutations, including sporadic GISTs. Because interleukin 3-dependent Ba/F3 murine lymphoid cells transfected with the mutant KIT complementary DNA grew autonomously without any growth factors and formed tumors in nude mice, the mutation was considered to be gain-of-function type. Family members with the germline KIT mutation reported dysphagia, but those without the mutation did not. The mechanism of dysphagia was examined with gastrointestinal fiberscopy, endoscopic ultrasonography, and esophageal manometry. No mechanical obstruction was found, and the esophagus was not remarkably dilated. In the family members with dysphagia, endoscopic ultrasonography at the esophagocardiac junction showed a thickened hyperechoic layer between the circular and longitudinal muscle layers, suggesting hyperplasia of interstitial cells of Cajal at the myenteric plexus layer. Manometry showed low resting lower esophageal sphincter pressure and abnormal simultaneous contractions of the esophagus without normal peristalsis. These findings indicate that the dysphagia of the present family is different from typical achalasia. This is the first report of familial dysphagia caused by germline gain-of-function mutation of the KIT gene at the TK II domain.

Collision carcinoma at the esophagogastric junction.

Atrue collision carcinoma at the esophagogastric junction is rare. In this article, we report colliding double primary cancers of the esophagus and the stomach in a 68-year-old man and discuss this entity. Pathological analysis after total gastrectomy and partial esophagectomy showed the following findings. Areas of squamous differentiation were found on the esophageal side of the tumor and were adjacent to normal mucosa, and areas of glandular differentiation were found to the gastric side of the tumor and adjacent to normal mucosa. These two tumors collided at the esophago-cardiac junction, but there was no intermingling. In one lymph node, an independent non-intermingled metastatic adenocarcinoma and squamous cell carcinoma were observed. The pathological findings of this case satisfy rigorous criteria for collision carcinoma.

肉塊食道内かん入を契機に発見された表層拡大型早期食道癌の１例

A 64-year-old male was admitted to our hospital because a piece of meat had become stuck in his esophago-cardiac junction (ECJ). We removed the piece of meat in the ECJ using endoscopy. A subsequent endoscopy revealed a superficially-spreading early esophageal carcinoma in the lower part of the esophagus and an esophagitis-like lesion in the intrathoracic middle esophagus. Right thoracotomy and esophagectomy were carried out. The two chief lesions were a superficially-spreading early esophageal carcinoma in the lower esophagus, and a similar tumor occupying an area extending from the upper to the middle esophagus. Histopathologically, the squamous cell carcinoma of the lower esophagus was of the total layer type, but the tumor in the middle esophagus was of the basal layer type. The histological difference in the tumor proliferation between the two lesions may be associated with the exfoliation of the intraepithelial carcinoma in the former case, and natural proliferation in the latter. The exfoliation of the intraepithelial carcinoma was thought to have been induced by the endoscopic removal of the meat lump. Furthermore, six solitary neoplastic lesions were noted independently. Histological findings in the present case support the concept of a“field carcinogenesis”and/or“lateral involvement”of esophageal carcinoma.

Clinicopathological and Endoscopic Studies on Gastric Cancer Located; the Cardia

Abstract: In this study the definition of cardiac cancer (histologically adenocarcinoma) was taken to be a cancerous lesion, the size of which is less than 4 cm and the center of which is located within 2 cm from the esophagocardiac junction. 42 patients (0.8%) fit the above definition of cardiac cancer out of 4,958 patients with solitary gastric cancer operated on at the National Cancer Center Hospital daring the period between 1962 and 1988. The clinicopathological and endoscopic findings of these 42 patients were compared with those of 132 patients with gastric cancer located in the upper third of the stomach other than in the cardia (cancer in the other C‐area). In the group with cardiac cancer, the male patients (M/F ratio: 3.7), the elderly patients (mean age: 61.3 years), a differentiated type of adenocarcinoma (90%), lesions located at the lesser curvature (62%) and the elevated type of lesion were found to predominate. The incidence of early cancer (60%) and the incidence of small lesions less than 2 cm (32%) in diameter were lower than in the patients with cancers in the other C‐area. In the group with cardiac cancer, however, the incidence of such types of early cancer as the depressed lesion, a small lesion less than 2 cm in diameter and lesions difficult to diagnose endoscopically, have been increasing. In recent years, cardicac cancers have been found not only on the lesser curvature, but also in different areas of the cardia.These results suggest an improvement in endoscopic diagnosis for cardiac cancer. To make early detection more precise, it will be indispensable not to overlook even faint or indistinct mucosal abnormalities at the area adjacent to the esophagocardiac junction.

A CASE OF GIANT ESOPHAGEAL LEIOMYOMA IN THE ESOPHAGOCARDIAC JUNCTION

We report a case of giant leiomyoma in the esophagocardiac junction which was succesfully treated by the excision of the tumor nucleus. A 35-year-old female without any symptoms was pointed out a torose lesion in the lower esophagus by mass screening examination. The patient was diagnosed as having an esophageal leiomyoma by esophagogastric transillumination, endoscopy, ulrasonoscopy and biopsy. Laparotomy and excision of the tumor nucleus were undertaken. The excised tumor was 11.5×5.0×2.0 cm in size. The histopathological findings indicated benign leiomyoma.By view of the literature, lower esophagectomy and upper gastrectomy have been frequently undertaken to the leiomoyma in the esophagocardiac junction, but to keep the function of esophagocardiac junction excision of the tumor nucleus should be positively performed.

内視鏡的 Nd:YAG レーザー治療とその問題点にっいて

Endoscopic laser irradiation therapy was performed on 81 patients. The chief diseases of the patients were as follows; 20 cases of early gastric carcinoma, 7 cases of advanced gastric carcinoma, 5 cases of esophageal carcinoma and 24 cases of postoperative anastomotic stenosis. Most of these cancer patients were in old age, and had severe complications. In case of early gastric carcinoma, the prognosis of depressed type was worse than that of elevated one. About the size of the lesion, the most suitable case for laser therapy was that the area of the carcinoma in the mucous layer was less than 1cm in diameter. In most of these cases, carcinoma was disapeared after laser irradiation. On the other hand, in case that the area of carcinoma was more than 2cm in diameter, remaining of carcinoma was often recognized after laser therapy. In case of advanced gastric carcinoma, laser therapy for the stenosis of esophagocardiac junction was effective for oral food intakes. In case of postoperative anastomotic stenosis, laser therapy was very effective, particularly for relief of the stenosis of membranous one. In these cases, we usually use the contact type quartz fiber with cone shaped top end attachment. The fiber attachment of this type was called for cutting probe. In these cases, the combined use with the balloon dilator or bougie increase the improving effect for a long time.