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ABSTRACT: The aim of this study was to use the difficulty score for a laparoscopic cholecystectomy procedure to predict the surgical difficulty of single-port laparoscopic cholecystectomy. From January 2009 to April 2011, single-port laparoscopic cholecystectomy was performed in 30 patients at our institution. The patients were evaluated using the difficulty score and classified into 3 groups: low, intermediate, and high difficulty. All surgeries were successfully completed without conversion to conventional laparoscopic surgery. A strong relationship was observed between the increasing score and longer surgical time. The mean surgical time was longer and the amount of blood loss was greater in the intermediate-difficulty and high-difficulty groups than in the low-difficulty group. Moreover, the high-difficulty group had a higher rate of insertion of an additional trocar than the low-difficulty group. Thus, the difficulty of single-port laparoscopic cholecystectomy is well predicted using the difficulty score.
Surgical laparoscopy, endoscopy & percutaneous techniques 12/2012; 22(6):514-7. · 1.23 Impact Factor
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ABSTRACT: A patient with gastroduodenal obstruction caused by an unresectable gastroduodenal or periampullary cancer cannot ingest food and/or liquid. The patient's quality of life rapidly deteriorates, resulting in a dismal prognosis. Stomach-partitioning gastrojejunostomy has been previously reported, and here, we evaluate the laparoscopic procedure.
We performed laparoscopic stomach-partitioning gastrojejunostomy in 18 patients with unresectable gastroduodenal or periampullary cancers. Data on operation time, blood loss, complications, and postoperative course were retrospectively collected.
The mean operation time was 152 min, and conversion to open surgery was not required in any patients. Postoperative complications occurred in three patients (17%) and included cholangitis, anastomotic ulcer hemorrhage, and enterocolitis. The mean time to oral intake was 4.5 days, and the mean and median duration of oral intake were maintained for 133 and 88 days, respectively.
Laparoscopic stomach-partitioning gastrojejunostomy is a safe and effective procedure that allows patients with gastroduodenal outlet obstruction to eat again and improve the quality of their remaining life.
Asian Journal of Endoscopic Surgery 09/2012; 5(4):153-6.
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ABSTRACT: BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) procedures have been performed via transgastric, transvaginal, or transcolonic approaches. However, the transcolonic approach has potential disadvantages including intraperitoneal infection. To avoid such disadvantages, we applied the submucosal tunnel technique to transrectal peritoneal access in this study. Study aims are to clarify the technical feasibility of a submucosal tunnel method for transrectal abdominal access and to assess the healing process of the submucosal tunnel histopathologically. METHODS: The study comprised six female pigs. The following procedures were performed: (1) The mucosa was cut after injection of sodium hyaluronate into the submucosa at the upper rectum. (2) Submucosal tunneling was performed by endoscopic submucosal dissection technique. (3) A small incision was made at the end of the tunnel. (4) After transrectal peritoneoscopy, the mucosal incision site was closed with endoclips. RESULTS: Transrectal peritoneoscopy was successfully performed in all pigs. Necropsy revealed no findings of peritonitis. Histopathologic examination showed good healing of the submucosal tunnel. The wound healing process of the submucosal tunnel on postoperative day 7 was mainly in the inflammatory phase at the mucosal incision site, the proliferative phase at the submucosal tract, and the proliferative/remodeling phase at the seromuscular incision site. CONCLUSIONS: The submucosal tunnel technique appears to be useful and safe for transrectal peritoneal access because healing at the seromuscular incision site proceeded rapidly.
Surgical Endoscopy 06/2012; · 4.01 Impact Factor
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ABSTRACT: Introduction. Usefulness of submucosal tunneling for transgastric approach with clip closure of the mucosal incision in natural orifice translumenal endoscopic surgery (NOTES) has been described. Although the narrow longitudinal submucosal tunnel itself is considered good for wound approximation and healing, no reports have evaluated the sealing effect in this technique. This study was aimed at evaluating the technical feasibility of a submucosal tunnel technique for transgastric peritoneal access without mucosal closure. Methods. Transgastric peritoneoscopy using submucosal tunneling with endoscopic submucosal dissection without mucosal closure was performed on six 40- to 45-kg female pigs. Measures included (a) evaluation of technical feasibility, (b) clinical monitoring for 7 days, (c) necropsy findings, and (d) pathological examination. Results. NOTES transgastric peritoneoscopy was successfully performed in all pigs, and all recovered well clinically. Necropsy findings revealed no peritonitis, confirming completeness of gastric closure in 5 of the 6 pigs. One pig in which the submucosal layer of the tunnel was injured during dissection from the muscular layer showed local peritonitis. Pathological examination at the submucosal site tunnel showed wound healing with focal transmural fibrosis and inflammatory cell infiltration in 5 pigs, whereas the pig with peritonitis had a large mucosal defect with necrotic tissue, abscess formation, and focal transmural fibrosis. Conclusions. The submucosal tunnel technique without mucosal closure is safe and effective for transgastric peritoneal access and subsequent closure, when the endoscopists' learning curve is accomplished and the submucosal tunnel is produced without damaging of mucosa. It is necessary to use devices such as mucosal clips or tissue anchors in order to achieve adequate healing of mucosal defect.
Surgical Innovation 02/2012; · 2.13 Impact Factor
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ABSTRACT: Although the laparoscopic approach is accepted for the treatment of colon cancer, its value for low rectal cancer is unknown. We sought to evaluate the technical feasibility of laparoscopic low anterior resection (Lap-AR) by determining short-term clinical outcomes and identifying the corresponding predictive factors.
A retrospective single-institution study was carried out on 82 patients in whom Lap-AR had been attempted for rectal cancer during the period spanning April 2001 to December 2009. Patient characteristics, operative outcomes, and postoperative morbidities and mortalities were analyzed.
The median operative time and the intraoperative blood loss were 300 minutes and 72.5 g, respectively. Overall morbidity and mortality rates were 11.0% and 0%, respectively. Complications included wound infection (6.1%, n=5), anastomotic leakage (1.2%, n=1), ileus (1.2%, n=1), and pneumonia (2.4%, n=2). A multivariate analysis indicated that the important risk factor associated with an operative time of >300 minutes was the T factor, and the risk factor associated with intraoperative blood loss was a body mass index (BMI) of >25 kg/m(2).
Lap-AR is a technically feasible, safe, and effective method for treating patients with rectal cancer. A BMI>25 kg/m(2) and the T factor related to operative blood loss and operative time, respectively. Assessment of high BMI and, in particular, advanced tumor depth, should alert surgeons to the increased technical difficulty of Lap-AR.
Surgical laparoscopy, endoscopy & percutaneous techniques 02/2012; 22(1):52-7. · 1.23 Impact Factor
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ABSTRACT: Sodium alginate is used clinically in the treatment of peptic ulcer disease. Because of its viscosity, sodium alginate could possibly become a new submucosal injection material for use in endoscopic resection.
We evaluated the feasibility of endoscopic submucosal dissection (ESD) using sodium alginate.
The lesion-lifting properties of sodium alginate were examined in porcine stomachs and were compared with those of normal saline solution and sodium hyaluronate solution. After confirming the proper concentration of sodium alginate, ESD using sodium alginate was performed in 11 patients with gastric mucosal cancer or adenoma.
The lesion-lifting properties of sodium alginate and clinical outcomes were assessed.
The thickness of the submucosal elevation created by 3% sodium alginate in porcine stomach was equivalent to that of sodium hyaluronate. ESD using sodium alginate was completed successfully in all patients without adverse effects except in 1 patient in whom transient shrinkage of the gastric wall disappeared spontaneously after approximately 30 minutes. The mean tumor size was 15.3 mm. En bloc resection and a negative resection margin were obtained in all. Histopathologic examination revealed that all tumors were confined to the mucosal layer except for 1 that was confined to the submucosal layer without lymphovascular invasion, and there were no adverse effects such as tissue damage. No patient required additional treatment, and none showed recurrence during a median follow-up period of 28 months.
Small sample size.
This preliminary study suggests that sodium alginate might be a novel, safe submucosal injection material for use in endoscopic resection. Further investigation of the properties of sodium alginate is warranted.
Gastrointestinal endoscopy 11/2011; 74(5):1026-32. · 6.71 Impact Factor
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ABSTRACT: Few long-term results of laparoscopic resection for gastrointestinal stromal tumors (GISTs) of the stomach have been established to evaluate technical safety and oncologic feasibility.
Between April, 1998 and October, 2008, data of 18 patients who underwent laparoscopic resection of GISTs of <5 cm in diameter were reviewed.
There were 10 men and 8 women with average age of 66.5 years. Estimated blood loss was minimal, and average operation time was 99.2 ± 30.5 minutes. There were no major intraoperative complications or conversions to open approach. Oral feeding started 2 to 4 days after operation, and the mean hospital stay was 10.1 ± 5.5 days. There were no major postoperative complications except for 1 patient who suffered from aspiration pneumonia. Tumor size was 3.7 ± 1.1 cm (range, 1.5 to 7.0 cm), and all patients had free surgical margins. During long-term follow-up (average 54.6 mo), no complications occurred except for liver metastasis in only 1 patient who was responding well to imatinib therapy.
Laparoscopic wedge resection of GISTs of <5 cm in diameter is a safe and oncologically feasible technique offering good long-term outcomes.
Surgical laparoscopy, endoscopy & percutaneous techniques 08/2011; 21(4):260-3. · 1.23 Impact Factor
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ABSTRACT: Issues surroundings the safety and efficacy of palliative laparoscopic resections for patients with stage IV colorectal cancer have not been explicitly examined in the literature. We describe our experience with laparoscopic procedures for patients with stage IV incurable symptomatic colorectal cancer and compare perioperative outcomes with a contemporaneous group of patients who underwent conventional open procedures.
We retrospectively reviewed data from laparoscopic resections performed in patients for symptomatic stage IV colorectal cancer between 1999 and 2009. Data regarding patient demographics, perioperative morbidity and mortality, intraoperative blood loss, operative time, length of postoperative hospital stay, and time from surgery to chemotherapy were assessed.
A total of 29 patients were identified and of these patients, 11 (38%) underwent palliative laparoscopic resections and 18 (62%) underwent conventional open resection for stage IV colorectal cancer. In comparing laparoscopic to conventional procedures, the length of postoperative hospital stay in the laparoscopic resection group was significantly shorter than that in the open resection group (median, 17 vs. 20 d, P<0.05). Significant differences were present between the 2 groups when following features were compared: leukocyte on day 1 (median, 7.87 vs. 8.70 × 10/L) and day 3 (median, 6.40 vs. 7.80 × 10/L), albumin level on day 7 (median, 38.0 vs. 29.8 g/L), and C-reactive protein level on day 7 (median, 0.6 vs. 2.8 mg/dL). There were no significance differences between the 2 groups in intraoperative blood loss (median, 105 vs. 155 mL), operative time (median, 271.5 vs. 187.5 min), time to intake of solid food (median, 4 vs. 4 d), the rate of postoperative complications, perioperative mortality, or a duration from surgery to chemotherapy (median, 22 vs. 28 d).
Palliative laparoscopic resection is a safe and feasible option with acceptable morbidity and mortality in patients with stage IV colorectal cancer. Importantly, in this group of difficult-to-treat patients, our results compare favorably with those from previously published reports on open procedures.
Surgical laparoscopy, endoscopy & percutaneous techniques 06/2011; 21(3):184-7. · 1.23 Impact Factor
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ABSTRACT: Pre-operative chemoradiotherapy (CRT) is an important neoadjuvant therapy for locally advanced rectal cancer. In the present study, we investigated the factors that influence the efficacy of pre-operative CRT in locally advanced rectal cancer. We divided 50 patients with locally advanced rectal carcinoma treated with pre-operative CRT into two groups according to the grade of tumor response to pre-operative CRT: low-sensitivity group and high-sensitivity group. As candidates for the prediction of sensitivity to pre-operative CRT, clinicopathological factors and 12 biomarkers, including factors related to tumor growth, cell cycle, apoptosis, tumor stroma and cancer stem cells, were examined immunohistochemically in 48 resected specimens. Thirty-one tumors showed high sensitivity and 19 showed low sensitivity to pre-operative CRT. The status of stem cell-related factors, CD133 and CD24, was significantly associated respectively with sensitivity to pre-operative CRT (P=0.003, P=0.029). In 10 tumors positive for both CD133 and CD24, low sensitivity to CRT was found in 9 (90%), whereas in 16 tumors negative for both CD133 and CD24, low sensitivity was found in 3 (19%). Other pathological parameters were not associated with tumor response to pre-operative CRT. In conclusion, overexpression of cancer stem cell-related factors, CD133 and CD24, is associated with the sensitivity of locally advanced rectal cancer to pre-operative CRT.
Experimental and therapeutic medicine 01/2011; 2(3):465-470.
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ABSTRACT: A few studies have addressed the physiology related to a basic natural-orifice transluminal endoscopy surgery (NOTES) procedure, such as transgastric peritoneoscopy, but the physiologic impact of more complex NOTES procedures has not been previously examined.
To evaluate the cardiopulmonary and immunologic effects of transvaginal NOTES cholecystectomy compared with laparoscopic cholecystectomy.
Survival experiments in 10 40-kg female pigs assigned to transvaginal cholecystectomy and laparoscopic cholecystectomy groups.
Transvaginal cholecystectomy was performed with the assistance of a needlescopic device, and laparoscopic cholecystectomy was performed in the standard manner.
Cardiopulmonary and immunologic parameters in the transvaginal cholecystectomy group were compared with those in the laparoscopic cholecystectomy group. Cardiopulmonary parameters included heart rate, blood pressure, saturation pulse oximetry, intratracheal pressure, and arterial blood gases. Immunologic parameters included white blood cell count, tumor necrosis factor-α, interleukin-1β, and interleukin-6.
All procedures were performed successfully without complications. Although operation times were longer for transvaginal cholecystectomy than for laparoscopic surgery, cardiopulmonary changes were similar and stable in both groups. White blood cell count, interleukin-1β, and interleukin-6 did not differ between the 2 groups, and the increase in tumor necrosis factor α after transvaginal cholecystectomy was significantly smaller on postoperative day 1 than after laparoscopic cholecystectomy (133.4 pg/mL vs 200.4 pg/mL; P < .05).
Animal model and small sample size.
Transvaginal cholecystectomy resulted in cardiopulmonary stability and well preserved immune function similar to those of laparoscopic cholecystectomy, suggesting that NOTES may be less invasive than laparoscopic surgery.
Gastrointestinal endoscopy 12/2010; 72(6):1241-8. · 6.71 Impact Factor
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ABSTRACT: The advent of natural orifice transluminal endoscopic surgery (NOTES) has accelerated the development of new technology in the field of GI endoscopy. Various suturing devices or multitasking platforms are expected to be valuable for endoluminal surgery as well as for NOTES.
To evaluate a new multitasking platform in performing endoscopic full-thickness resection (EFTR).
Bench-top comparison study.
Research laboratory study of 10 ex vivo porcine models.
Ten EFTRs (5 with a double-channel endoscope vs 5 with a new multitasking platform) assisted with percutaneous gastric lifting. Each group was given the task of resecting a full-thickness specimen of the gastric wall including a pseudolesion 10 mm in diameter with an effective margin.
Outcome measurements included time to perform the procedure, accuracy of the resection, and efficiency for the task. Accuracy was assessed according to variability of the surgical margin and misalignment between the mucosal layer and the seromuscular layer. Efficiency was assessed according to the duty ratio, which is the percentage of time spent for the main purposes compared with the total procedure time.
Mean diameter of the specimen was not significantly different between the groups. All other assessment items were significantly superior in group B to those in group A (P < .05).
Ex vivo animal model study.
We were able to perform EFTR procedures precisely and effectively by using a new multitasking platform compared with use of a conventional endoscope in a porcine model. A multitasking platform developed for NOTES procedures would be useful for advanced endoluminal surgery such as endoscopic submucosal dissection or EFTR as well as NOTES.
Gastrointestinal endoscopy 11/2010; 73(1):117-22. · 6.71 Impact Factor
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ABSTRACT: Minimally invasive surgery for gastric cancer has been an important treatment modality since its introduction in 1991 from Japan. The practice of surgical techniques in laparoscopic gastrectomy with lymph node dissection is improving and evolving. Furthermore, advanced techniques including total gastrectomy, proximal gastrectomy, extended lymph node dissection and robot-assisted gastrectomy, have been safely carried out. A retrospective multicenter study in Japan has shown that the short-term outcomes of laparoscopic gastrectomy are beneficial, and the long-term outcomes are the same as those for open surgery. Recently, prospective multicenter randomized controlled trials have been conducted in Japan and Korea to evaluate the safety and oncological feasibility of laparoscopic gastrectomy for clinical stage I gastric cancer or advanced gastric cancer. In the future, laparoscopic surgeons will need to design and implement education and training systems for standard laparoscopic procedures based on the clinical outcomes of multicenter randomized controlled trials.
Surgical technology international 10/2010; 20:153-7.
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ABSTRACT: As endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) increases, increasing numbers of patients require additional gastrectomy with lymph node dissection after noncurative ESD. ESD may cause intra-abdominal adhesions, making additional laparoscopic gastrectomy technically difficult.
To assess the relation of the presence of intra-abdominal adhesions and ESD treatment to allow safe laparoscopic gastrectomy.
Case series from a retrospective review of additional gastrectomy after noncurative ESD.
Tertiary care center.
Eight of 333 patients receiving ESD at Oita University Faculty of Medicine from 1999 to 2008 underwent additional laparoscopic gastrectomy because of noncurative ESD.
Intra-abdominal adhesions were evaluated by using an adhesion scoring system (0-3 points) and clinicopathologic findings, including artificial ulcerations after ESD.
All patients successfully underwent laparoscopic gastrectomy within 1 to 2 months after ESD. Three patients with large artificial ulceration (>25 mm) after ESD treatment had severe intra-abdominal adhesions (adhesion score > or =2). These patients tended to have a large blood loss and long operation times during laparoscopic gastrectomy. Despite the 2-month interval from ESD to laparoscopic gastrectomy, ulcerations in these patients were at healing stage with inflammatory cells infiltrating the muscular deep layer.
A retrospective study.
After ESD with large artificial ulceration (>25 mm), the presence of intra-abdominal adhesions complicating additional laparoscopic gastrectomy was often observed.
Gastrointestinal endoscopy 08/2010; 72(2):438-43. · 6.71 Impact Factor
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ABSTRACT: The present patient was a 53-year-old female diagnosed as gastric cancer with peritoneal dissemination by staging laparoscopy. She was treated with chemotherapy using S-1 (80 mg/body/day) and CDDP (80 mg/body/day, day 8) administered for 3 weeks followed by a drug-free 2 weeks, in five-week courses. Stable disease (SD) was obtained after six courses, and then she underwent second-staging laparoscopy. Because of disappearing peritoneal disseminated nodules both macroscopically and histologically, she underwent curative total gastrectomy with D2 lymph node dissection and reconstruction by the Roux-en Y method. The postoperative pathological findings showed T2 (se) N1M0, stage IIIa and chemotherapy effective evaluation demonstrated Grade 1b. Postoperatively, S-1/CDDP therapy was carried out, after two cycles she suffered from anorexia, and then S-1 only was given. Fourteen months later, peritoneal dissemination developed. Despite changes in the regimen such as docetaxel or CPT-11, she died 23 months after the initial gastrectomy.
Gan to kagaku ryoho. Cancer & chemotherapy 08/2010; 37(8):1573-7.
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ABSTRACT: Lymph node navigation and accurate staging of liver or peritoneal metastasis leads to better selection of the optimal treatment for patients with pancreatic and biliary malignancy. Less invasive techniques of detecting lymph node metastasis and distant metastasis would be valuable. Natural orifice translumenal endoscopic surgery (NOTES) is a new, evolving concept of minimally invasive surgery that may be useful for the staging of intraabdominal cancers.
Review of the literature regarding peritoneoscopy and lymph node mapping and biopsy by NOTES.
NOTES peritoneoscopy for accurate diagnosis and staging of intraabdominal cancers is already in clinical use, and two case reports have shown the safety and feasibility of this technique. Previous experimental studies have also shown that lymph node mapping by NOTES is technically feasible with the currently available devices.
With the continued development of the techniques and technology of NOTES, peritoneoscopy and lymph node mapping by NOTES may become an alternative method for preoperative staging for patients with pancreatic and biliary malignancy.
Journal of hepato-biliary-pancreatic sciences. 09/2009; 17(5):617-21.
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Gan to kagaku ryoho. Cancer & chemotherapy 09/2009; 36(9):1447-50.
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ABSTRACT: This review summarizes the published data regarding single port surgery (SPS) in order to evaluate the current status of SPS. SPS is a rapidly evolving technique in minimally invasive surgery. A wide variety of SPS have been performed since 1992, including appendectomy, cholecystectomy, colectomy, inguinal hernia repair, liver cyst fenestration, and bariatric surgery, and the technical feasibility has been demonstrated. Further advancements in technology and technique may allow the broad acceptance of this new method. Prospective randomized trials comparing SPS to laparoscopic surgery are essential to further determine the advantages and disadvantages of SPS.
Asian Journal of Endoscopic Surgery 08/2009; 2(2):29 - 35.
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ABSTRACT: Laparoscopic surgery has widely spread in the treatment of colorectal cancer. In Japan, a nation-wide survey has shown that a rate of advanced colorectal cancer has increased gradually and reached 65% of the total cases for colorectal cancer in 2007. For colon cancer, many randomized controlled trials regarding short-term outcome demonstrate that laparoscopic surgery is feasible, safe and has many benefits including reduction in a peri-operative mortality. In terms of long-term outcome, four randomized controlled trials insist that there are no differences in both laparoscopic and open surgeries. However, there are still more important issues including long-term oncological outcome for advanced colon cancer, cost effectiveness and the impact on quality of life of patients. Meanwhile, for rectal cancer, a controversy persists with regard to the appropriateness of laparoscopic surgery because of concerns over the safety of the procedure and a necessity of lateral lymph node dissection for lower rectal cancer. At present, laparoscopic surgery is acceptable for Stage I colon cancer, whereas there are controversies for Stage II/III colon cancer and each staged rectal cancer because of inadequate clinical evidences. Whether laparoscopic surgery further spreads to be applied for colorectal cancer or not, it would be confirmed by Japanese large-scale phase III trial (JCOG0404) estimating oncological outcome for Stage II/III colon cancer and a Phase II trial estimating the feasibility for Stage 0/I rectal cancer in near future.
Japanese Journal of Clinical Oncology 07/2009; 39(8):471-7. · 1.78 Impact Factor
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ABSTRACT: Gastric cancer is one of the leading causes of cancer-related deaths worldwide (Roder, 2002; Brennan, 2005). In Asian countries,
up to 60% of all gastric cancers are now diagnosed as early gastric cancers because of widespread mass screening and improved
diagnostic instruments (Tsubono and Hisamichi, 2000; Japanese Gastric Cancer Association Registration Committee, 2006). Most
early gastric cancers are cured by surgery, and it is important to improve the short-term quality of life of these patients
after surgery.
12/2008: pages 163-170;
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ABSTRACT: Background: Many experimental studies have shown the technical feasibility of natural orifice translumenal endoscopic surgery (NOTES). We report the first clinical application of natural orifice transgastric endoscopic peritoneoscopy in Japan for preoperative staging in a patient with pancreatic cancer.Methods: A submucosal tunnel was created for safe peritoneal access and secure closure of the gastric-incision site.Results: Transgastric peritoneoscopy provided an excellent view and allowed approach to various areas of the abdominal cavity. After confirmation of operative curability, the patient underwent an open standard operation without complication.Conclusions: Natural orifice transgastric endoscopic peritoneoscopy for cancer staging using the submucosal tunnel technique appears to be feasible and safe.
Digestive Endoscopy 09/2008; 20(4):198 - 202. · 1.19 Impact Factor
