[Show abstract][Hide abstract] ABSTRACT: Background: Which graft material is the optimal graft material for the treatment of infected aortic aneurysms and aortic graft infections is still a matter of controversy. Orthotopic aortic reconstruction with intraoperatively prepared xenopericardial roll grafts without omentopexy was performed as the "initial" operation to treat aortic infection or as a "rescue" operation to treat graft infection. Mid-term outcomes were evaluated. Methods: Between 2009 and 2013, orthotopic xenopericardial roll graft replacement was performed to treat eight patients (male/female: 6/2; mean age: 69.5 [55-80] yr). Graft material: equine/bovine pericardium: 2/6; type of operation: initial 4/rescue 4; omentopexy 0. Additional operation: esophagectomy 2. Mean follow-up period: 2.6 ± 1.6 (1.1-5.1) years. Results: Replacement: ascending 3, arch 1 (reconstruction of neck vessels with small xenopericardial roll grafts), descending 3, and thoracoabdominal 1. Pathogens: MRSA 2, MSSA 1, Candida 1, E. coli 1, oral bacillus 1, and culture negative 2. Postoperative local recurrence of infection: 0. Graft-related complications: stenosis 0, calcification 0, non-infectious pseudoaneurysm of anastomosis 2 (surgical repair: 1/TEVAR 1). In-hospital mortality: 2 (MOF: initial 1/rescue 1); Survival rate exclusive of in-hospital deaths (~3 y): 100 %, but one patient died of lung cancer (3.6 yr). Conclusions: Because xenopericardial roll grafts are not composed of synthetic material, the replacement procedure is simpler and less invasive than the standard procedure. Based on the favorable results obtained, this procedure may have the possibility to serve as an option for the treatment of aortic infections and aortic graft infections not only as a "rescue" treatment but as an "initial" treatment as well.
Journal of Cardiothoracic Surgery 12/2015; 10(1). DOI:10.1186/s13019-015-0343-5 · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: . Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity.
. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient’s postoperative course was uneventful and the patient was discharged on postoperative day 6.
. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT.
. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed.
[Show abstract][Hide abstract] ABSTRACT: IntroductionTransduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low-grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy-assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non-ampullary duodenal epithelial tumors.Methods
Three patients with superficial non-ampullary duodenal epithelial tumors (mucosal adenocarcinoma, n = 1; tubular adenoma, n = 2) underwent LATDE. LATDE consists of four major procedures: (i) laparoscopic wide Kocher maneuver (mobilization of the pancreaticoduodenum); (ii) extracorporeal approach to the fully mobilized duodenum through the upper median longitudinal incision (4 cm in length); (iii) tumor excision by submucosal dissection under direct vision through longitudinal duodenotomy (4 cm in length); and (iv) hand-sewn closure of the mucosal defect and duodenotomy.ResultsLATDE was successfully carried out without any intraoperative or postoperative adverse events. The mean operating time and estimated blood loss were 155 min and 17 mL, respectively. Contrast roentgenography on postoperative day 4 showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients.ConclusionsLATDE could eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracorporeally. The meticulously hand-sewn closures of the mucosal defect and duodenotomy can minimize the possibility of postoperative hemorrhage and/or anastomotic leakage. LATDE is a feasible, safe, and minimally invasive treatment for patients with superficial non-ampullary duodenal epithelial tumors that have no risk of lymph node metastasis in the first and second portions of the duodenum.
Asian Journal of Endoscopic Surgery 05/2015; 8(3). DOI:10.1111/ases.12191
[Show abstract][Hide abstract] ABSTRACT: IntroductionWe previously demonstrated the advantages of a short-type flexible endoscope as a working scope in laparoscopic surgery through single-incision procedures in animal experiments. In this report, we examined the outcomes of laparoscopic surgery through a single incision using a flexible endoscope in a clinical setting. Specifically, we performed cholecystectomy using single-incision multiport laparoendoscopic (SIMPLE) surgery.Methods
Thirteen patients with cholecystolithiasis or gallbladder polyp underwent SIMPLE cholecystectomy using a newly developed short-type flexible endoscope with a working length of 60 cm. Twenty-seven patients underwent standard single-incision laparoscopic cholecystectomy using a 5-mm rigid laparoscope. We retrospectively compared the surgical outcomes between the two groups.ResultsSIMPLE cholecystectomy using the short-type flexible endoscope was successfully carried out. No gallbladder perforation occurred, but perforation occurred in four cases in the standard laparoscopic cholecystectomy group; however, the difference was not statistically significant. Although no other surgical outcomes differed between the two groups, the flexible endoscope had several advantages over the standard laparoscope. The scope provided a flexible view of the operating field. The gallbladder dissection using the cutting device via the scope was easier and safer than that in standard single-incision laparoscopic cholecystectomy. The water-jet, suctioning, and self-cleaning lens functions of the scope served the surgery well.ConclusionsSIMPLE cholecystectomy using a short-type flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but this endoscope with multiple functions may make the surgical procedures less stressful and safer.
Asian Journal of Endoscopic Surgery 12/2014; 8(1). DOI:10.1111/ases.12148
[Show abstract][Hide abstract] ABSTRACT: The aims of the present study are to clarify the changes in clinicopathologic features, diagnosis and treatment for hepatolithiasis, and propose an appropriate management strategy in Japan. The research group conducted nationwide surveys seven times in the past over a period of 40 years. Furthermore, a cohort was followed up in 2010. We analyzed the clinical features, diagnosis tools, treatment procedures, outcomes, and predictive factors for cholangiocarcinoma. Surgery was the primary method for hepatolithiasis up to 1998, and the frequency of its use has decreased since then. In 2011, 66.7% of hepatolithiasis patients were treated using nonsurgical approaches. In addition, endoscopic retrograde cholangiography (ERC) with stone extraction was the most frequently performed procedure (22.7%). However, the incidences of residual stone and recurrent stone after ERC with stone extraction were higher than those after percutaneous transhepatic cholangioscopic lithotomy and surgery. Bile duct stricture and dilatation during follow up were significant risk factors for stone recurrences. In the cohort study, stone removal only and age >65 years were significant factors for the development of cholangiocarcinoma. In patients without a history of cholangioenterostomy, left-lobe-type stones were a risk factor, and hepatectomy reduced the risk of the development of cholangiocarcinoma significantly. Nonsurgical treatment may be performed as the first-line treatment for hepatolithiasis. Surgery should be performed on patients who were treated incompletely after nonsurgical treatment. However, hepatectomy may be recommended for patients with left-lobe-type stones and without a history of cholangioenterostomy.
[Show abstract][Hide abstract] ABSTRACT: An increasing number of laparoscopic pancreatic procedures are currently carried out worldwide. Laparoscopic distal pancreatectomy (LDP) appears to be technically and oncologically promising in selected patients with benign tumors and low-grade malignancies of the pancreatic body/tail, and is now widely adopted. Here, we described our standard procedures of LDP and some tips on LDP. Recent important insights into some variations/options of LDP including spleen preservation, hand-assisted procedure, and single-incision surgery are also reviewed in this article.
[Show abstract][Hide abstract] ABSTRACT: Background and AimWe present our experiences with the so-called ‘limited resections’ such as transduodenal excision and local full-thickness resection for superficial non-ampullary duodenal tumors (SNADT). The optimal surgical management for SNADT is also discussed.Methods
Six patients with SNADT (adenoma, n = 1; mucosal carcinomas, n = 2; submucosal carcinoma, n = 1; carcinoids, n = 2) were included in this study. Four patients underwent transduodenal excision, one local full-thickness resection, and one laparoscopy-assisted endoscopic full-thickness resection as a modification of local full-thickness resection.ResultsAll patients were successfully treated by these limited resections without any adverse events.Conclusions
Surgical resection is the treatment of choice for SNADT not amenable to endoscopic resection in terms of technical and/or oncological reasons. However, the optimal surgical management for SNADT remains controversial because of the complexity of the relevant anatomy of the duodenum, its rarity, the not well-known incidence of nodal metastasis, and the wide spectrum of pathologies that can be encountered.
[Show abstract][Hide abstract] ABSTRACT: The modified Glasgow prognostic score is an inflammation-based prognostic score. This study examined whether this score, measured before surgical procedures, could predict postoperative cancer-specific survival.
We retrospectively studied 79 colorectal cancer patients who underwent a surgical procedure for incurable stage IV disease. The modified Glasgow prognostic score (0 to 2) comprises C-reactive protein (≤10 vs >10 mg/L) and albumin (<35 vs ≥35 g/L) measurements.
In terms of overall survival, univariate analysis revealed significant differences in the status of lung metastasis, peritoneal dissemination, distant metastasis, hemoglobin, C-reactive protein, albumin, tumor resection, adjuvant chemotherapy, and modified Glasgow prognostic score. Multivariate analysis revealed that hemoglobin (P = .019), adjuvant chemotherapy (P = .002), and modified Glasgow prognostic score (0 and 1, low; 2, high) (P = .0001) were significant predictive factors for postoperative mortality.
The modified Glasgow prognostic score is simple to obtain and useful in predicting survival in incurable stage IV colorectal cancer patients undergoing surgery.
American journal of surgery 07/2013; 206(2). DOI:10.1016/j.amjsurg.2012.07.051 · 2.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: With technical advances in endoscopic submucosal dissection (ESD), several variations of endoscopic procedure derived from ESD and fusion procedures of endoscopy and laparoscopy for upper gastrointestinal submucosal tumor and cancer have recently been developed. The former includes endoscopic muscularis dissection (EMD), submucosal endoscopic tumor resection (SET), endoscopic submucosal tunnel dissection (ESTD) and endoscopic full-thickness resection (EFTR), and the latter includes laparoscopic and endoscopic cooperative surgery (LECS), laparoscopy-assisted endoscopic full-thickness resection (LAEFR), and laparoscopic lymphadenectomy without gastrectomy following ESD. In the present article, recent developments in gastric ESD and advanced procedures derived from ESD are discussed.
[Show abstract][Hide abstract] ABSTRACT: Ectopic pancreas is a relatively rare condition that only occasionally causes the development of symptoms. This report presents a case of ectopic pancreas presenting as an inflammatory mass that formed in the gastric wall, which was successfully treated by surgical resection. A 32-year-old female was admitted due to a 3-year history of recurrent episodes of upper abdominal pain. Contrast-enhanced computed tomography showed an irregularly enhanced mass of heterogeneous density in the gastric antrum. Gastroscopy revealed a submucosally elevated mass with a central umbilication in the gastric antrum. These studies indicated the presence of a 3-cm ectopic pancreas associated with inflammatory changes. The patient underwent laparoscopic local resection of the stomach. Microscopic examination of the lesion revealed heterogenic pancreatic tissue containing islets, dilated pancreatic ducts, and massive fibrosis in the gastric wall, with acinar atrophy and inflammatory cell infiltration. These findings indicated the formation of an inflammatory mass in the ectopic pancreas.
Surgery Today 09/2012; 43(12). DOI:10.1007/s00595-012-0317-3 · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Reports on endoscopic full-thickness resection of the duodenum using the endoscopic submucosal dissection technique are rare. Here we present a case of a duodenal bulb carcinoid tumor successfully treated by laparoscopy-assisted endoscopic full-thickness resection (LAEFR). An asymptomatic 65-year-old woman had a 10-mm, submucosal tumor on the anterior wall of the duodenal bulb. Abdominal CT revealed an enlarged lymph node adjacent to the duodenum and pancreas. Although we informed the patient of the need for pancreatoduodenectomy with a lymphadenectomy, the patient expressly requested LAEFR. After negative nodal metastasis was confirmed by an intraoperative frozen section of the enlarged nodes, LAEFR was performed using the endoscopic submucosal dissection technique under the laparoscopic assistance. The duodenal wall defect was closed by laparoscopy with an Albert anastomosis. The entire circumferential margin of the specimen was histopathologically negative for carcinoid tumor cells. In summary, LAEFR enables en bloc and whole-layer excision of nonperiampullary duodenal lesions with a sufficient surgical margin, both vertically and laterally. LAEFR is a minimally invasive and effective treatment for selected patients with duodenal carcinoid tumor.
Asian Journal of Endoscopic Surgery 05/2012; 5(2):81-5. DOI:10.1111/j.1758-5910.2011.00120.x
[Show abstract][Hide abstract] ABSTRACT: IPMN is a slow-growing tumor and has a good prognosis, but is very often associated with a high incidence of pancreatic ductalcarcinoma(DC). Unlike IPMN, DC progresses rapidly, and has a poor prognosis. However, DC concomitant with IPMN has a better prognosis than DC without IPMN. The reason for the good prognosis of the former is undetermined, but perhaps it is the early detection of DC or its not so malignant behavior. It is important to thoroughly examine the entire pancreas for the potentialco -occurrence of DC in patients with IPMN.
Gan to kagaku ryoho. Cancer & chemotherapy 03/2012; 39(3):347-50.
[Show abstract][Hide abstract] ABSTRACT: Aim: The aim of this study was to delineate predictive factors for cholangiocarcinoma in patients with hepatolithiasis, and to establish optimal management for hepatolithiasis from the viewpoint of carcinogenesis on the basis of a Japanese nationwide survey for hepatolithiasis.
Methods: The Hepatolithiasis Research Group was organized in 2006 by the Ministry of Health, Labour and Welfare of Japan, and conducted a nationwide survey. The research group collected data on 336 cases of hepatolithiasis in 2006, in a cross-sectional survey involving 2592 institutions in Japan. Predictive factors for cholangiocarcinoma associated with hepatolithiasis were analyzed by univariate and multivariate analyses of clinicopathological and therapeutic factors.
Results: Twenty-three patients had cholangiocarcinoma. Histories of choledocoenterostomy and liver atrophy were found to be significantly predictive factors by multivariate analysis. In 87.5% of cases of cholangiocarcinoma with liver atrophy, cholangiocarcinoma was located in the atrophic lobes. The method of reconstruction did not affect the incidence of cholangiocarcinoma (choledochojejunostomy vs. choledochoduodenostomy; side-to-end vs. side-to-side anastomosis).
Conclusions: Choledocoenterostomy and liver atrophy may increase the risk of developing cholangiocarcinoma. Choledocoenterostomy is thus contraindicated in patients with hepatolithiasis. An aggressive resection strategy is recommended for an atrophic segment.
Hepatology Research 12/2011; 42(2):166-70. DOI:10.1111/j.1872-034X.2011.00908.x · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Our recently developed procedure, a combination of endoscopic submucosal dissection (ESD) and laparoscopic lymph node dissection (LLND), may lead to the elimination of unnecessary gastrectomy in early gastric cancer (EGC) patients having a potential risk of lymph node metastasis (LNM).
To examine the long-term outcomes of the combination of ESD and LLND.
A retrospective study using consecutive data.
Single academic center.
Twenty-one EGC patients having a potential risk of LNM were treated by ESD followed by LLND.
Long-term outcomes of the combination of ESD and LLND.
The histopathological examination of the dissected lymph nodes confirmed the absence of LNM in 19 of the 21 patients. Two patients who had LNM were followed without any additional surgery in accordance with the patients' wishes. During the median follow-up of 61 months, all of the patients were alive without any recurrent disease. Two patients (10%) had symptoms such as abdominal distention and belching, which were associated with disturbed gastric emptying between meals. Endoscopic examination 2 years postoperatively revealed food residue problems in 3 patients (15%). However, the preoperative quality of life was restored with no dietary restrictions, and body weight was well maintained in all of the patients.
A retrospective study with a small number of patients.
The combination of ESD and LLND can be an effective, minimally invasive treatment that maintains long-term quality of life for selected EGC patients having a potential risk of LNM.
[Show abstract][Hide abstract] ABSTRACT: We hypothesized that using a flexible endoscope as a working scope in laparoscopic surgery through a single incision might provide many benefits. To this end, a short-type flexible endoscope with a working length of 600 mm was newly developed. In this animal experimental study, we aimed to evaluate the technical feasibility of our new approach, single-incision multiport laparoendoscopic (SIMPLE) cholecystectomy, using this endoscope.
Eight pigs were subjected to SIMPLE cholecystectomy using the short-type flexible endoscope. The endoscope was inserted through a 12-mm trocar in an SILS Port followed by the insertion of two additional 5-mm trocars in the SILS Port. Encirculation and ligation of the pedicle of the cystic artery and duct were carried out using laparoscopic instruments through the 5-mm trocars, while the dissection of the gallbladder from the intrahepatic fossa was predominantly performed using a cutting device through the endoscope.
A complete gallbladder excision, with complete encirculation and ligation of the pedicle, was completed in all cases. The mean operating time was 58 min (range 34-78 min). The endoscope provided a good view of the operating field, and it allowed some degree of freedom to the working laparoscopic instruments without compromising the field of view. Dissection of the gallbladder using the cutting device through the endoscope was much easier than that using the laparoscopic device, because the articulating instruments together with the endoscope enabled operation with triangulation. Furthermore, the water-jet and suctioning functions and the self-cleaning lens capability of the endoscope served the surgery well.
SIMPLE cholecystectomy using the newly developed short-type flexible endoscope is a technically feasible procedure. Using this flexible endoscope for various tasks, such as resection, suctioning, and smoke evacuation, can make the surgical procedures easier.
[Show abstract][Hide abstract] ABSTRACT: Little information is available on the long-term outcomes of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in patients of advanced age (≥80 years).
A multicenter study was conducted at 10 Japanese institutions concerning their results for ESD. Data on 440 patients of advanced age (≥80 years) with EGC (470 lesions) were collected and reviewed. Early and long-term outcomes of ESD were assessed. We compared the overall survival rates between 3 patient groups, those with curative ESD, additional surgery after noncurative ESD, and nonsurgical follow-up after noncurative ESD.
Bleeding and perforation rates were 3.2 and 2.8%, respectively. Curative ESD was achieved in 366 of the 470 lesions (77.9%). Of the 104 patients with noncurative ESD, 12 patients (11.5%) underwent additional surgery and 91 patients (87.5%) were followed without surgery. The 5-year survival rate in the patients with nonsurgical follow-up after noncurative ESD (66.7%) was significantly lower than that in the patients with curative ESD (80.3%, p = 0.0001). There was no significant difference in the 5-year survival rates between the patients with curative ESD and those with surgery after noncurative ESD (100%, p = 0.21), nor was there a difference in these rates between the patients with surgery after noncurative ESD and those with nonsurgical follow-up after noncurative ESD (p = 0.061). None of the patients developed cancer recurrence after curative ESD, and none developed cancer recurrence following the additional surgery after noncurative ESD. In the patients with curative ESD and in those with surgery after noncurative ESD, the cumulative observed survival was better than the expected survival for the general population of similar age and gender.
ESD is safe for the treatment of EGC in patients 80 years of age or older. Both curative ESD and additional surgery after noncurative ESD may contribute to the extension of life expectancy.
Gastric Cancer 06/2011; 15(1):70-5. DOI:10.1007/s10120-011-0067-8 · 3.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous studies revealed that the incidence of cancer cell involvement along the pelvic autonomic nerves ranged from 4 to 14%. However, patients' profiles and methodologies differed among the studies. This study was conducted to clarify the incidence of cancer cell involvement in and around the pelvic autonomic nerves immunohistochemically.
Immunohistochemical staining was performed on pelvic autonomic nerve specimens resected from 17 patients with p-Stage I-III lower rectal cancers. Antibodies used were pan-cytokeratin (AE1/AE3) for staining cancer cells, S-100 for autonomic nerves, and D2-40 for lymphatic vessels. Lymphatic permeation around the pelvic autonomic nerves was defined as present when AE1/AE3-positive cells were detected in D2-40-stained lymphatic vessels. The presence of metastasis to the interstitial tissue or contaminants was also recorded.
TNM staging was stage I in 1, stage II in 5, and stage III in 11 cases, respectively. No cases had lymphatic permeation or metastasis to the interstitial tissue in and around the pelvic autonomic nerves. Cancer cell contaminants were seen in four cases (23%). In three cases (18%), metastatic nodes were located at the root of the middle rectal artery, very close to the pelvic autonomic nerves.
Cancer cell involvement was not seen in and around the pelvic autonomic nerves, suggesting that complete pelvic autonomic nerve preservation may be feasible, unless nerves are invaded by the tumor. In some cases, however, metastatic nodes were seen very close to the nerves. Meticulous lymph node dissection along the pelvic autonomic nerves is mandatory.
International Journal of Clinical Oncology 10/2010; 15(5):462-7. DOI:10.1007/s10147-010-0091-4 · 2.13 Impact Factor