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Endoscopic Submucosal Dissection (ESD) in Japan

Endoscopic Submucosal Dissection (ESD) is a minimally invasive treatment for early stage gastric / stomach / esophageal / colorectal cancer. It was pioneered in Japan in order to improve the malignant post-surgical health conditions such as loss of appetite, fevers, chills, pains and avoid the subsequent medications.

Since the first report of ERHSE by Dr. Masaki Hirao in 1983, an endoscopic treatment developed into EMR (Endoscopic Mucosal Resection), which removes the tumor with the inner lining of stomach, not the whole stomach removal required in Surgery causing the significant loss of quality in patient's life. EMR can resect the cancerous legions of the early stage Stomach, Esophageal, Colorectal Cancer, and is both the minimally invasive, and least costly procedure (about 10% cost of abdominal surgery) with better conditions than Surgery after the procedure.

ESD (Endoscopic Submucosal Dissection) was first introduced by Koichi Hosokawa, and Hiroyuki Ono at National Cancer Center Hospital in 1996. ESD extented the capacity of EMR to resect an area of mucosa larger than 2cm using the spcialized knife. Because of its ability to resect the area of tumor close to 15cm or bigger, ESD became the viable alternative to the surgery, and used to conserve the organs / tissues in GI tract, greatly enhancing the QoL of patients. 

ESD / EMR is available overseas, mostly in US, but the overwhelming number of procedures are carried out in Japan. Cost for ESD in Japan is about 30-50% of the cost for surgery and laparoscopy. Given the minimal invasion into the patient's body, ESD / EMR is recognized as the best clinical practices on the treatment of gastointestinal cancer, should it be applicable.

Cost (Stomach Cancer)

ESD (Endoscopic Submucosal Dissection) 400,000JPY (about 5000 USD)
Laparoscopy 1,000,000JPY (about 12000 USD)
Surgery 1,200,000JPY (about 14000 USD)

Cost (Colorectal Cancer)

EMR (Endoscopic Mucosal Resection) 100,000JPY (about 1,200 USD)
Laparoscopy 1,000,000JPY (about 12,000 USD)
Surgery 1,000,000JPY (about 12,000 USD)

Pioneering Surgeons

Operative procedure for ESD is known to be extremely precise and subtle, and there are a handful number of surgeons comfortable to undertake it.

  • Takuji Gotoda (National Cancer Center, moved to National Center for Global Medicine)
  • Tsuneo Koyama (Sasaki General Hospital)
  • Naohisa Yahagi (Toranomon Hospital)
  • Takashi Toyonaga (Kishiwada Tokushukai Hospital)
  • Hironori Yamamoto (Jichi Medical University)

Leading Hospital

  • National Cancer Center Hospital
  • Shizuoka Cancer Center
  • Cancer Institute Hospital of JFCR
  • Hiroshima University Hospital
  • Niigata University Medical and Dental Hospital
  • Toranomon Hospital
  • Kobe University Hospital
  • Tobata Kyoritsu Hospital
  • Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital
  • Keiyukai Sapporo Hospital

Device

Devices are of primary importance to the surgeons. All of the devices listed below were developed by Japanese ESD surgeons.

  • Needle Knife
  • Isulation Topped (IT) Knife (Olympus)
  • Hook Knife (Olympus)
  • Flush Knife (Fuji Film)
  • Flex Knife (Olympus)
  • Safe Knife
  • ClutchCutter (Fuji Film)

Regenerative Medicine

ESD is often the least invasive treatment for gastrointestinal cancer, but the resection of large area of the gastrointestinal tract leads to the inflammation, or stenosis. Cell sheets implantation can suppress the inflammation or stenosis after resection of tumor by ESD. In 2009, six patients were treated successfully using cell sheets implantation after ESD procedure, and the trials have been conducted since then. The cell sheet therapy with ESD may be the only available procedure to treat the patients without any noticeable post-surgical pains, and medication.

Reference:

  1.  R. Takagi, D. Murakami, M. Kondo, T. Ohki, R. Sasaki, M. Mizutani, M. Yamato, K. Nishida, H. Namiki, M. Yamamoto and T. Okano, "Fabrication of human oral mucosal epithelial cell sheets for treatment of esophageal ulceration by endoscopic submucosal dissection", Gastrointest Endosc., 2010 Oct 21. [Epub ahead of print]

hospital

National Cancer Center Hospital

Situated in Tsukiji, hospital recieves 1000 patients daily, and more than 4,000 operations are carried out yearly.

As a special hospital dedicated to cancer treatment, National Cancer Center Hospital consistently ranks top in any statistical measures, 5 year survival rates, surgery counts, etc in all types of cancers.

Cancer Institute Hospital of JFCR

Founded in 1908, Japanese Foundation  For Cancer Research was the first institution specializing in Cancer Research in Japan.

Often noted with National Cancer Center, Cancer Institute Hospital of JFCR is the center of excellence in Japanese cancer treatments.

H.I.H Prince Hitachi is nominated as the Honorary President of the institute.

treatments

Elimination of Barrett's Esophagus (BE) Dysplasia - Early Esophageal Cancer

Barrett's Esophagus (BE) refers to an abnormal change (metaplasia) in the cells of the lower esophagus. When damaged by the chronic stomach acid exposure, the cells turn from squamous epithelium (normal state) to columnar epithelium (metaplasia). Barrett's Esophagus patients may face the increased risk of esophageal cancer.

Progression of Barrett Esophagus into cancer is described as below:

Radiofrequency Ablation (RFA) on Liver cancer (Hepatocellular carcinoma)

Radiofrequency ablation is a promising medical procedure to remove liver or hepatocellular tumors using high frequency alternating current. A procedure is performed under image guidance, and considered to be highly technical field due to the underlying difficulty in spotting the tumors surrounded with neighboring organs, requiring the intervetionists well experienced with various types of tumors for both effective ablation and safety.

International Hospital Ranking

Cancer Adoptive Cell Immunotherapy in Japan

Cell based Immunotherapy (Autologous immune enhancement therapy) has been more frequently practised in Japan.Techniques to harvest the cells are extremely intricate and delicate processes. For the treatments to be rountinely available to the cancer patients apart from the clinical trials, advanced engineering cell reprocessing center must be available with good corroboration with the hospitals.

Since Japan made the Immuno-Cell Therapy to be a part of health care systems, the cell processing centers (CPCs) rapidly increased in the past decades. For the therapy of high complexity such as dendritic cell / autologous enhancement immunotherapy to be regularly practiced in the hospital, those CPCs were essential, and this explains why much of innovations in cell based cancer immunotherapy took place in Japan. 

Endoscopic Submucosal Dissection (ESD) \ Endoscopic Mucosal Resection (EMR) in Japan

Both EMR and ESD was originally developed in Japan. EMR / ESD (endoscopic biopsy or polyp resection procedure on gastrointestinal tract) is the area that Japanese surgeons are leading the research at forefront. It is the minimally invasive endoscopic procedure that conserves organs / tissues, and patients can be discharged from the hospital in the same day or a week after the operations. It is usually applicable to early stage cancer / tumor, and improves the post-surgical health conditions such as loss of appetite, fever, chills, pains and life-long medication.

Proton Beam Therapy

Currently there are about 31 proton (or carbon ion) therapy facilities in the world, 8 of which is built in Japan. Proton Beam Therapy is much less invasive than other radiotherapy treatments, and can treat the cancer without incision of the body, and with much less side effects than X-ray treatments. Japan has invested in Proton beam therapy (PBT) / Carbon Ion Therapy infrastructure for a long time, and clinical level studies are numerous and thus well experienced with all kinds of localized tumors.

Radiofrequency Ablation (RFA) on Liver cancer (Hepatocellular carcinoma)

Japan has been leading the RFA intervention technology for a long time, and the yearly number of RFA interventions in Japan currently exceeds that of United States and China. (See the Table below.) Survival rates for the patients undergoing the RFA are not different from those of surgery. But the surgery is harder to be operated multiple times, whereas the RFA is not restricted by the number of interventions or by the presence of Hepatitis.  For this reason, RFA becomes a standard treatment in Japan.

Yearly volume of RFA on Liver Cancer
Japan 34,000
US 14,000
China 9,500

Table: Yearly number of Radiofrequency ablation of Liver or hepatic tumors by country.

Regenerative Medicine on Dilated Cardiomyopathy, or Myocardial Infarction

Recent technological advances in cell sheets engineering extended to the pre-clinical trial of the treatment of heart disease patients often in need for the heart transplant.

Micro-Catheter treatments on varicose veins (including the veins below the knee)

In japan, complex operations towards varicose veins below the knee are established with safey and high response rates. Various catheter and micro-catheter devices are extensively used, and some of them are only available in Japan.

Cancer and Heart Disease Treatment in Japan  

Medical technology in Japan for cancer screening and gastrointestinal diseases are known to be very strong, supported by good clinical statistics, i.e., high five year survival rate after the surgery (or radiology / chemotherapy) among the colon, rectal, stomach, and esophageal cancer patients as well as liver, lung, and larynx cancer (See Table below). 

Since Japanese health agency is notoriously slow and counter-productive when it comes to the approval of new drugs, Japan's hospitals and patients suffered for so long by the technology lag from the rest of the world. Ironically, these regulatory problems lead physicians to the innovations in the fields other than drug discoveries, i.e., in the surgical / laparoscopic, endoscopic, micro-catheter procedures, cell based immunotherapy / vaccinations, radiation (carbon ion and proton beam), and regenerative medicine (iPS cells, cell sheets).

Since the Japanese physicians had less options in chemotherapy, they had more opportunities in experiencing difficult surgeries, and tried the new treatments due to the low availability of new drugs. Thus, many exotic and unique medical technologies emerged out of the isolations casued by the incompetence of Japanese health agency.

Site (Survival Rate:  %)

7 Cancer Registrates in Japan

 US SEER Program Eurocare-3
Esophagus 25 14 10
Stomach 58 22 23
Colon 66 62 51
Rectum 63 63 48
Liver 17 7 7
Gallbladder 18 16 12
Pancreas 6 4 4
Larynx 77 65 62
Lung, bronchus 20 15 11