Patent Publication Number: US-2009227866-A1

Title: Ultrasound endoscopic intraluminal organ treatment method

Description:
BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to an ultrasound endoscopic intraluminal organ treatment method, and, more particularly to an ultrasound endoscopic intraluminal organ treatment method for carrying out treatment by an ultrasound endoscope in luminal organs arranged through natural orifices in a body cavity. 
     2. Description of the Related Art 
     In recent years, researches concerning surgery called NOTES™ surgery (Natural Orifice Translumenal Endoscopic Surgery) for forming, while observing an image formed by an endoscope led into a luminal organ through a natural orifice, an opening on a wall surface of the luminal organ, leading the endoscope into an abdominal cavity from the opening, and performing observation and treatment for intra-abdominal organs have been actively performed. Various proposals concerning endoscopes and treatment instrument systems used for the surgery have been made by, for example, Japanese Patent Laid-Open No. 2004-267772. 
     On the other hand, it is disclosed that an opening or the like is temporarily held by using a T-bar unit such as “T-ANCHOR SUTURING DEVICE” described in, for example, U.S. Pat. No. 5,626,614 and a technique for making it possible to efficiently carrying out manipulation has been developed. 
     SUMMARY OF THE INVENTION 
     An ultrasound endoscopic intraluminal organ treatment method according to claim  1  of the present invention includes: 
     an endoscope inserting step of inserting an insertion portion of an ultrasound endoscope including one or more treatment instrument channels into a first object luminal organ from a natural orifice of a patient, the insertion portion having at a distal end thereof an optical observation portion for optically observing an observation region and an ultrasound observation portion that is capable of observing the observation region with ultrasound; 
     an adjacent organ confirming step of confirming a second object luminal organ adjacent to an outer wall surface of the first object luminal organ under an ultrasound observation of the ultrasound endoscope; 
     a capturing step of capturing the second object luminal organ under the ultrasound observation of the ultrasound endoscope; 
     an opening portion forming step of forming an opening portion in a luminal wall of the first object luminal organ; 
     a pulling-in step of pulling a part of the captured second object luminal organ into the inside of the first object luminal organ from the opening portion; and 
     a treatment step of applying treatment to the part of the second object luminal organ pulled into the inside of the first object luminal organ. 
     Other characteristics and advantages of the present invention will be sufficiently made apparent through the following explanation. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIGS. 1 to 5  relate to a first embodiment of the present invention.  FIG. 1  is a schematic diagram showing the entire structure of an ultrasound endoscope system.  FIG. 2  is an external view showing the structure of a distal end of the ultrasound endoscope shown in  FIG. 1 .  FIG. 3  is a diagram showing the structure of a T-bar portion of a T-bar unit inserted through the ultrasound endoscope shown in  FIG. 1  and used.  FIG. 4  is a diagram showing the structure of a T-bar injection portion of the T-bar unit inserted through the ultrasound endoscope shown in  FIG. 1  and used.  FIG. 5  is a diagram showing the structure of a guide wire with stopper inserted through a hollow portion of a piercing treatment instrument used via treatment instrument channels of the ultrasound endoscope shown in  FIG. 1 . 
         FIGS. 6 to 17  relate to the first embodiment of the present invention.  FIG. 6  is an overall diagram showing a system arrangement configuration for explaining actions of the ultrasound endoscope system shown in  FIG. 1 .  FIG. 7  is a flowchart for explaining a flow of intraluminal organ treatment method by an ultrasound endoscope shown in  FIG. 6 .  FIG. 8  is a first diagram for explaining the flowchart of  FIG. 7 .  FIG. 9  is a second diagram for explaining the flowchart of  FIG. 7 .  FIG. 10  is a third diagram for explaining the flowchart of  FIG. 7 .  FIG. 11  is a fourth diagram for explaining the flowchart of  FIG. 7 .  FIG. 12  is a fifth diagram for explaining the flowchart of  FIG. 7 .  FIG. 13  is a sixth diagram for explaining the flowchart of  FIG. 7 .  FIG. 14  is a seventh diagram for explaining the flowchart of  FIG. 7 .  FIG. 15  is an eighth diagram for explaining the flowchart of  FIG. 7 .  FIG. 16  is a ninth diagram for explaining the flowchart of  FIG. 7 .  FIG. 17  is a tenth diagram for explaining the flowchart of  FIG. 7 . 
         FIGS. 18 to 21  relate to a modification of the first embodiment of the present invention.  FIG. 18  is a flowchart for explaining a modification of the processing shown in  FIG. 7 .  FIG. 19  is a first diagram for explaining an action in the flowchart of  FIG. 18 .  FIG. 20  is a second diagram for explaining the action in the flowchart of  FIG. 18 .  FIG. 21  is a third diagram for explaining the action in the flowchart of  FIG. 18 . 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     The present invention will be hereinafter explained with reference to embodiments shown in the figures. 
     First Embodiment 
     As shown in  FIG. 1 , an ultrasound endoscope system  1  according to the present embodiment mainly includes an ultrasound endoscope  2  that includes an endoscope observing unit having an endoscope observing function and an ultrasound observation unit having an ultrasound observation function, an endoscope observation device  3  that processes control of the endoscope observing unit and an output signal thereof, an ultrasound observation device  4  that processes control of the ultrasound observation unit and an output signal thereof, a display device  5  that receives the respective signals from the endoscope observation device  3  and the ultrasound observation device  4  and appropriately displays an endoscope image and an ultrasound tomographic image, a light source device  6  that is a light source of illumination light emitted from a front surface of a distal end of the endoscope observing unit, a video cable  7 , an ultrasound cable  8 , and a light source cable  9 . 
     The ultrasound endoscope  2  in the ultrasound endoscope system  1  is, as shown in  FIG. 2 , a convex-type ultrasound endoscope that has at a distal end thereof an ultrasound transducer unit  203  for scanning, for example, a surface parallel to a front side of an endoscope insertion axis. A direct-vision convex-type ultrasound endoscope device or the like is applied as the ultrasound endoscope  2 . In the ultrasound endoscope  2 , two treatment instrument channels (not shown) are arranged such that, on a distal end surface, an observation direction of an observation window  201  for guiding an observation image to an image pickup device (not shown) in the distal end and a direction in which distal end opening portions  202   a  and  202   b  of the treatment instrument channels (not shown), which are inserted through the insertion portion  11  of the ultrasound endoscope  2 , face are substantially parallel to the endoscope insertion axis. The distal end opening portion  202   a  is arranged to be placed on an ultrasound scanning surface. 
     In the distal end surface of the ultrasound endoscope  2 , an illumination window  204  for emitting illumination light from the light source device  6  is provided adjacent to the observation window  201 . The illumination light emitted from the illumination window  204  is transmitted through an optical fiber bundle (not shown) inserted through the insertion portion  11  from the light source device  6 . 
     Referring back to  FIG. 1 , the ultrasound endoscope  2  mainly includes the slim insertion portion  11  inserted into a body cavity, an operation portion  12  continuously provided on a proximal end side of the insertion portion  11  and used for operating the insertion portion  11 , a universal cable  13  extending from a side of the operation portion  12 , and a connector portion  14  provided at one end of the universal cable  13 . 
     The insertion portion  11  mainly includes, in order from a distal end side thereof, a distal end rigid portion  16  formed of a rigid member, a bending portion  17  continuously provided on a proximal end side of the distal end rigid portion  16  and formed to freely bend, and a flexible tube portion  18 , one end of which is continuously provided on a proximal end side of the bending portion  17  and the other end of which is continuously provided on a distal end side of the operation portion  12 , and that is formed thin and long with flexibility. In the insertion portion  11 , plural, for example, two treatment instrument channels (not specifically shown in the figure) inserted through between the proximal end and the distal end thereof are formed. 
     In the inside of the distal end side of the distal end rigid portion  16 , although not shown in the figure, an endoscope observing unit and an ultrasound observation unit are disposed. In the ultrasound observation unit, plural ultrasound transducers that transmit and receive ultrasounds are arrayed to form an ultrasound scanning surface. The ultrasound observation unit can acquire an ultrasound signal that contributes to creation of a tomographic image further in the inside than a body cavity wall (an ultrasound tomographic image). The endoscope observing unit has an observation optical member, an illumination optical member, an image pickup device, and the like. The endoscope observing unit can obtain an image pickup signal that contributes to generation of an image signal for optically picking up an image of the surface of the body cavity wall and displaying an endoscope image for observation. 
     The operation portion  12  includes operation members for performing various kinds of operation of the ultrasound endoscope  2  such as an angle knob  12   a  that is an operation member for freely carrying out bending operation on the bending portion  17  of the insertion portion  11  in up, down, left and right directions, a suction button  12   b  for performing suction operation, an air-supply and water-supply button  12   c  for performing air supply and water supply operation, and plural operation members  12   d  for performing various kinds of operation such as display switching for the display device  5  and freeze instruction and release instruction for a display image. 
     Further, in the operation portion  12 , plural treatment instrument insertion openings  21  (only one treatment instrument insertion opening is shown in the figure) serving as insertion openings for inserting, in using the ultrasound endoscope  2 , the ultrasound endoscope  2  through treatment instrument channels (not shown) in the insertion portion  11  and leading various treatment instruments  22  into the body cavity are provided near the distal end side in a state projecting from the operation portion  12 . 
     The universal cable  13  is a cable that is disposed to extend from the side of the operation portion  12  as described above and through which various plural signal lines and the like for transmitting electric signals and the like and an optical fiber cable bundle and the like for illumination light are inserted. A connector portion  14  for securing connection of the respective devices of the endoscope observation device  3 , the ultrasound observation device  4 , and the light source device  6  to the ultrasound endoscope  2  are disposed at a distal end portion of the universal cable  13 . 
     The endoscope observation device  3  is an optical image processing device that controls to drive the image pickup device of the endoscope observing unit of the ultrasound endoscope  2  to receive an image pickup signal transmitted from the image pickup device, perform various kinds of signal processing, and generate a video signal for an endoscope optical observation image. 
     The ultrasound observation device  4  is an ultrasound image processing device that controls to drive an ultrasound transducer of an ultrasound transducer unit  203  of the ultrasound endoscope  2  to transmit ultrasound of a predetermined frequency to an observation object and receive, from the ultrasound transducer, an electric signal obtained by receiving the ultrasound reflected by the observation object. The ultrasound observation device  4  performs various kinds of signal processing to thereby generate a video signal for an ultrasound tomographic image. 
     The display device  5  is a device that receives the various video signals generated by the ultrasound observation device  4  and the endoscope observation device  3  to display observation images corresponding to the video signals, respectively, i.e., the ultrasound tomographic image and the optical observation image by appropriately switching the images or simultaneously display the images. 
     The light source device  6  is a device that supplies illumination light for illuminating the front of the ultrasound endoscope  2  through an illumination window  204  provided on a front portion at the distal end of the endoscope observing unit of the ultrasound endoscope  2 . 
     The ultrasound cable  8  is a connection cable that electrically connects the ultrasound observation device  4  and the ultrasound endoscope  2 . 
     The video cable  7  is a connection cable that electrically connects the endoscope observation device  3  and the ultrasound endoscope  2 . 
     The light source cable  9  is an optical fiber cable made of an optical fiber bundle that connects the light source device  6  and the ultrasound endoscope  2  and guides the illumination light from the light source device  6  to the illumination window  204  of the endoscope observing unit in the ultrasound endoscope  2 . 
     The plural (two in the present embodiment) treatment instrument insertion openings  21  (only one treatment instrument insertion opening is shown in the figure) provided in the operation portion  12  of the ultrasound endoscope  2  communicate with the treatment instrument channels (not shown) formed to be inserted through to the distal end opening portions  202   a  and  202   b  (see  FIG. 2 ) provided on the front side of the distal end rigid portion  16  from the inside of the operation portion  12  via the inside of the insertion portion  11 . Therefore, the various treatment instruments  22  inserted from the treatment instrument insertion openings  21  can be inserted through the treatment instrument channels and projected from and retracted into the distal end opening portions  202   a  and  202   b  of the insertion portion  11 . 
     Examples of the treatment instruments  22  inserted from the plural treatment instrument insertion openings  21  include a high-frequency treatment instrument such as a needle knife as an opening forming treatment instrument that is a surgical treatment instrument (an opening treatment instrument for an endoscope) that is used for dissection of a desired region of the luminal organs to form an opening portion under observation by the ultrasound endoscope  2 , a balloon treatment instrument as an expansion treatment instrument for expanding the opening portion, and a T-bar unit as a holding treatment instrument that performs treatment for holding an opening state of the opening portion. 
     In the present embodiment, as described above, the surgical treatment instrument  22  for performing a surgical operation of the intra-abdominal organs under the observation by the ultrasound endoscope  2 , a suturing treatment instrument for suturing the opening portion opened under the observation by the ultrasound endoscope  2 , and the like are inserted into the treatment instrument channels from the plural treatment instrument insertion openings  21 . This makes it possible to perform various kinds of treatment such as the surgical operation of the intra-abdominal organs under the observation by the ultrasound endoscope  2 . 
     The T-bar unit includes a T-bar portion  300  shown in  FIG. 3  and a T-bar injection portion  310  shown in  FIG. 4 . The T-bar portion  300  includes a bar-like distal end bar member  301 , a thread-like member  302  that is connected to the center of the distal end bar member  301  and has the distal end bar member  301  at a distal end thereof, and a center bar member  303 , to the center of which the thread-like member  302  is connected. By moving the center bar member  303  along the thread-like member  302 , it is possible to hold an organism tissue with the distal end bar member  301  and the center bar member  303 . The T-bar injection portion  310  includes a needle-like member  311  having a hollow path through which the T-bar portion  300  is inserted and a T-bar push-pull portion  312  (e.g., equivalent to a syringe of an injector) that can push out the T-bar portion  300  in the hollow path of the needle-like member  311  to a distal end side of the needle-like member  311 . The needle-like member  311  can be inserted through the treatment instrument channels. 
     In the T-bar injection portion  310 , a guide wire  290  having a stopper  291  at a distal end thereof (hereinafter referred to as G. W. with stopper) shown in  FIG. 5  can be inserted through the hollow path of the needle-like member  311 . Like the T-bar portion  300 , the G. W. with stopper  290  in the hollow path of the needle-like member  311  can be pushed out to the distal end side. The length of a thread-like wire portion  292  of the G. W. with stopper  290  is sufficiently longer than the length of the insertion portion  11  such that, even in a state in which the stopper  291  is retained in the front at the distal end of the insertion portion  11 , predetermined length from the treatment instrument insertion openings  21  remains at a proximal end of the wire portion  292 . 
     An example of manipulation in the prior art same as that in the present embodiment is explained. For example, a bypass method such as gastrojejunostomy has been conventionally carried out by celiotomy or under a laparoscope in the past. However, since invasiveness against a patient is high, less invasive treatment is demanded. 
     Therefore, as an example of low invasive manipulation in the prior art, for example, there are those disclosed in documents of (1) to (3) described below.
     (1) GASTROINTESTINAL ENDOSCOPY: 2005, Volume 62, No. 2, P. 287 to P. 292   (2) GASTROINTESTINAL ENDOSCOPY: 2006, Volume 63, No. 2, P. 307 to P. 312   (3) GASTROINTESTINAL ENDOSCOPY: 2006, Volume 63, No. 2, P. 302 to P. 306   

     The document (1) discloses manipulation for performing treatment by taking out an endoscope inserted into a luminal organ through a natural orifice to the outside of a lumen from the luminal organ. However, since such manipulation is manipulation performed in an abdominal cavity outside the lumen, it is necessary to secure, for example, a space for performing the manipulation. There are problems in which the treatment is complicated and in which likelihood of causing complication is nonnegligible because surgical treatment is performed in the abdominal cavity outside the lumen. 
     The document (2) discloses manipulation for pulling a second luminal organ into a first luminal organ and dissecting and suturing the second luminal organ. However, in the dissecting and suturing manipulation, means for checking a projecting state of a treatment instrument for performing treatment is neither disclosed nor indicated. Therefore, there is a problem in that a risk to other organs during the treatment is high. 
     The document (3) discloses manipulation for pulling a lymph node into a lumen and endoscopically excising the lymph node. However, in the lymph node excising manipulation, a lymph node is identified under an ultrasound observation using an ultrasound endoscope having one treatment instrument channel, means for pulling the lymph node into a lumen is retained, and, thereafter, the ultrasound endoscope is removed and replaced with an optical endoscope having plural channels, and the remaining treatment is carried out by the optical endoscope. In such manipulation, for example, when an ultrasound observation is necessary during the manipulation, endoscopes have to be frequently replaced, for example, it is necessary to replace the optical endoscope with the ultrasound endoscope. Therefore, there is a problem in that the manipulation is not only complicated but also takes time to deteriorate manipulation efficiency. 
     Therefore, it is an object of an ultrasound endoscopic intraluminal organ treatment method according to the present embodiment to, in order to solve these problems, make it possible to carry out less invasive, safer, and more efficient endoscope treatment while checking regions around a lumen under an optical observation and an ultrasound observation. 
     Manipulation performed by using the ultrasound endoscope system  1  according to the present embodiment is explained below with reference to  FIGS. 6 to 17 .  FIGS. 6 to 17  are diagrams for explaining a procedure and the like of the manipulation and conceptually show, for example, an arrangement relation of various organs and the like in the body cavity. 
     Endoscope manipulation performed by using the ultrasound endoscope system  1  according to the present embodiment explained below is a kind of an ultrasound endoscopic intraluminal organ treatment method for observing and treating luminal organs of a patient. 
     In the ultrasound endoscopic intraluminal organ treatment method according to the present embodiment, conceptually, a surgeon forms an opening portion in a wall of a first luminal organ while observing optical and ultrasound images formed by an ultrasound endoscope inserted into the first luminal organ through a natural orifice. The surgeon pulls a part of a desired second luminal organ, which is adjacent to the first luminal organ, from the opening portion into the inside of the first luminal organ through an abdominal cavity and applies treatment to the second luminal organ in the inside of the first luminal organ. 
     First, in  FIG. 6 , the surgeon energizes the various devices in the ultrasound endoscope system  1  to bring the system into a usable state. 
     In the state, the surgeon inserts the insertion portion  11  of the ultrasound endoscope  2  into, for example, the inside of a stomach  401 , which is a first luminal organ in a tube wall of which an opening is formed, from a natural orifice, for example, a mouth cavity  101  of a patient  100  or the like while observing an optically-acquired endoscope image displayed on the display device  5 . Here, the first luminal organ refers to an organ into which an (ultrasound) endoscope can be inserted from the natural orifice in a normal procedure. Therefore, operation for inserting the ultrasound endoscope  2  according to the present embodiment up to this stage is operation same as a flexible endoscope test normally carried out in general. 
     Specifically, using the ultrasound endoscope system  1 , the surgeon starts, as shown in  FIG. 7 , as the endoscope inserting step, in step S 1 , insertion of the insertion portion  11  of the ultrasound endoscope  2  into the natural orifice, for example, the mouth cavity  101  of the patient  100  or the like (see  FIG. 6 ). Using the ultrasound endoscope system  1 , the surgeon checks, with an optical observation of the ultrasound endoscope  2 , the insertion of the insertion portion  11  into, for example, the stomach  401 , which is the first object luminal organ in the tube wall of which an opening is formed, from an esophagus  400  (see  FIG. 8 ). 
     Next, using the ultrasound endoscope system  1 , the surgeon sets, as an adjacent organ confirming step, in step S 2 , as shown in  FIG. 8 , the ultrasound transducer unit  203  of the ultrasound endoscope  2  adjacent to an inner wall surface of the stomach  401 , transmits and receives ultrasound using the ultrasound transducer unit  203 , and confirms, with an ultrasound observation, that a luminal wall of a jejunum  402  is present on the outside of the stomach  401 . 
     Moreover, using the ultrasound endoscope system  1 , the surgeon confirms, as a safe area confirming step, in step S 3 , a pierceable area, which is a safe area without other luminal organs (including blood vessels and the like)  411 , between the luminal wall of the stomach  401  and the luminal wall of the jejunum  402  in an observation range  410  of the ultrasound observation. 
     Using the ultrasound endoscope system  1 , the surgeon pierces, as a capturing step, in step S 4 , a piercing treatment instrument  313  into the luminal wall of the stomach  401  and the luminal wall of the jejunum  402  through a first treatment instrument channel of the ultrasound endoscope  2  and inserts the G. W. with stopper  290  through a hollow path of the piercing treatment instrument  313 . As shown in  FIG. 9 , using the ultrasound endoscope system  1 , the surgeon retains the stopper  291  of the G. W. with stopper  290  from a distal end of the piercing treatment instrument  313  in the jejunum  402  and removes the piercing treatment instrument  313  from the treatment instrument channel of the ultrasound endoscope  2 . 
     Subsequently, using the ultrasound endoscope system  1 , the surgeon brings, as an opening portion forming step, in step S 5 , as shown in  FIG. 10 , instead of the piercing treatment instrument  313 , a needle knife  420 , through a hollow path of which the G. W. with stopper  290  is inserted, into contact with the luminal wall of the stomach  401  via the first treatment instrument channel of the ultrasound endoscope  2  to form an opening portion  430  in the luminal wall of the stomach  402 . Using the ultrasound endoscope system  1 , the surgeon pushes, as an opening portion expanding step, in step S 6 , as shown in  FIG. 11 , instead of the needle knife  420 , a balloon dilator  421 , through a hollow path of which the G. W. with stopper  290  is inserted, into the opening portion  430  via the first treatment instrument channel of the ultrasound endoscope  2  and inflates a balloon of the balloon dilator  421  to expand the opening portion  430 . 
     The needle knife  420  has the hollow path for inserting the G. W. with stopper  290 . However, the needle knife  420  is not limited to this and does not have to have the hollow path as long as the surgeon can insert the G. W. with stopper  290  as a guide after confirming safety with ultrasound scanning. 
     Next, using the ultrasound endoscope system  1 , the surgeon draws out, as a pulling-in step, in step S 7 , as shown in  FIG. 12 , the wire portion  292  from the treatment instrument insertion openings  21  and pulls the G. W. with stopper  290  to thereby pull the jejunum  402  retained in the inside by the stopper  291  into the inside of the stomach  401  via the opening portion  430 . In this step, in order to remove the G. W. with stopper  290 , a caught portion of the stopper  291  is slightly dissected. 
     Subsequently, using the ultrasound endoscope system  1 , the surgeon carries out, in treatment in a post step, a provisional fixing step for preventing the jejunum  402  from being drawn in. Using the ultrasound endoscope system  1 , the surgeon holds, as the provisional fixing step, in step S 8 , as shown in  FIG. 13 , an organism tissue between the distal end bar members  301  and the center bar members  303  of the T-bar portions  300  using the T-bar portions  300  of the T-bar unit inserted through the first treatment instrument channel of the ultrasound endoscope  2  and using a grasping treatment instrument (not shown) inserted through the second treatment instrument channel of the ultrasound endoscope  2  and provisionally fixes an outer wail of the pulled-in jejunum  402  to the opening portion  430 . The provisional fixing step may be carried out by using clips or the like instead of the T-bars. 
     Using the ultrasound endoscope system  1 , the surgeon inserts, as a treatment step, in step S 9 , as shown in  FIG. 14 , the needle knife  420  through the first treatment instrument channel of the ultrasound endoscope  2  again and, as shown in  FIG. 15 , forms an opening portion  450  in the outer wall of the pulled-in jejunum  850 . Moreover, using the ultrasound endoscope system  1 , the surgeon sutures, in step S 10 , as shown in  FIGS. 16 and 17 , the opening portion  450  of the jejunum  402  and the opening portion  430  of the stomach  401  using the T-bar portion  300  of the T-bar unit inserted through the first treatment instrument channel and using a grasping treatment instrument  470  inserted through the second treatment instrument channel and bypasses the jejunum  430  to the stomach  401 . Using the ultrasound endoscope system  1 , the surgeon removes, in step S 11 , the ultrasound endoscope  2  from the inside of the body cavity and finishes the processing. 
     As described above, according to the present embodiment, it is possible to obtain the following effects:
     (1) since it is unnecessary to replace an endoscope, efficient manipulation can be carried out;   (2) since the surgeon can perform manipulation while checking the respective portions under the ultrasound observation, processing with less risk can be carried out; and   (3) since surgical manipulation is performed in a lumen, likelihood of complication can be reduced.   

     Modification 
     A modification of the present embodiment is explained below. In the first embodiment described above, the bypass treatment of the stomach  401  and the jejunum  402  is explained as the example. In this modification, an example of lesion region excision treatment performed when a lesion region such as a tumor is present in the jejunum  402  is explained. 
     In this modification, instead of steps S 9  and S 10  explained with reference to  FIG. 7 , steps S 21  to S 24  are carried out as shown in  FIG. 18 . 
     Using the ultrasound endoscope system  1 , the surgeon specifies, after the step of step S 8  explained with reference to  FIG. 7 , as a treatment step, in step S 21 , as shown in  FIG. 19 , a lesion region  500  of the jejunum  402  pulled into the inside of the stomach  401  and excises the lesion region  500  with the needle knife  420  (not shown). Using the ultrasound endoscope system  1 , the surgeon sutures, in step S 22 , as shown in  FIG. 20 , an excision region  510  formed by excising the lesion region  500  using a suturing treatment instrument  505 . Next, using the ultrasound endoscope system  1 , the surgeon pushes out, in step S 23 , the pulled-in jejunum  402  to the outside of the stomach  401  from the opening portion  430 . Using the ultrasound endoscope system  1 , the surgeon sutures, in step S 24 , as shown in  FIG. 21 , the opening portion  430  using the suturing treatment instrument  505  and proceeds to step S 11  explained with reference to  FIG. 7 . 
     In such a modification, it is possible to obtain effects same as those in the first embodiment. 
     In the present invention, it is evident that different embodiments can be implemented in a broad range on the basis of the present invention without departing from the spirit and the scope of the invention. The present invention is not limited by specific embodiments thereof except that the invention is limited by the appended claims.