[Show abstract][Hide abstract] ABSTRACT: Laparoscopic distal gastrectomy has become widespread as a treatment for early gastric cancer in eastern Asia, but a standard method for setting the stomach transection line has not been established. Here we report a novel method of setting this line based on anatomical landmarks. At the start of the operation, two anatomical landmarks along the greater curvature of the stomach were marked with ink: the proximal landmark at the avascular area between the last branch of the short gastric artery and the first branch of the left gastroepiploic artery, and the distal landmark at the point of communication between the right and left gastroepiploic arteries. Just before specimen retrieval, the stomach was transected from the center of these two landmarks toward the lesser curvature. Then, about two-third of the stomach was reproducibly resected, and gastroduodenostomy was successfully performed in 26 consecutive cases. This novel method could be used as a standard technique for setting the transection line in laparoscopic distal gastrectomy.
Preview · Article · Mar 2015 · Journal of Gastric Cancer
[Show abstract][Hide abstract] ABSTRACT: We report a case of a patient with internal hernia through a small hole which was made during an operation in the falciform ligament of the liver, after laparoscopic gastrectomy (LG) with Billroth-I reconstruction. A 67-year-old man underwent laparoscopic distal gastrectomy (LDG) with Billroth-I reconstruction for early gastric cancer. During the procedure whereby the lateral segment of the liver was lifted with a Penrose drain, the falciform ligament of the liver was opened because intraabdominal adhesion prevented access to the triangular ligament. The small hole in the falciform ligament was not closed during the operation. The patient started oral feeding on the 8th postoperative day (POD), but exhibited symptoms of ileus on POD 11. Internal hernia through the falciform ligament of the liver was diagnosed based on CT scan findings. The patient underwent re-operation laparoscopically. The small intestine was stuck in the falciform ligament from the left to right side, so the repositioning of the intestinal loop and the closure of the hole were performed. The intestine was viable. To the best of our knowledge, this is the first case of internal hernia through the falciform ligament of the liver after LG. Leaving the defect in the ligament or mesentery increases the potential risk of internal hernia, therefore proper closure of the defect is recommended.
[Show abstract][Hide abstract] ABSTRACT: Background
Laparoscopic distal gastrectomy (LDG) is a routinely performed procedure. However, clinical expertise in laparoscopic total gastrectomy (LTG) is insufficient, and it is only performed at specialized institutions. This study aimed to identify critical factors associated with complications after laparoscopic gastrectomy (LG), particularly LTG.
A large-scale database was used to identify critical factors influencing the early outcomes of LTG. Of 1248 patients with resectable gastric cancer who underwent LG, 259 underwent LTG. Predictive risk factors were determined by analyzing relationships between clinical characteristics and postoperative complications. Major complications after LTG were analyzed in detail.
Multivariate analysis of all LG procedures revealed LTG as a risk factor for complications. Morbidity in the LDG and LTG groups was 6.2 % (52 of 835 patients) and 22.4 % (58 of 259 patients), respectively. Major post-LTG complications included anastomotic leakages and pancreatic fistulae. The rate of anastomotic leakage was significantly higher in the LTG group (5.0 %) than in the LDG group (1.2 %); however, it showed a tendency to decrease in more recent cases. Pancreatic fistulae occurred frequently after LTG with D2 lymphadenectomy (LTG-D2), particularly in cases of concomitant pancreatosplenectomy. Obesity was also associated with pancreatic fistula formation after LTG with pancreatosplenectomy.
Compared with LDG, LTG is a developing procedure. Advances in the surgical techniques associated with the LTG procedure will improve the short-term outcomes of esophagojejunostomy. With regard to LTG-D2, establishing optimal and safe #10 node dissection is one of the most urgent issues. Pancreatic fistula after LTG with pancreatosplenectomy must be investigated in the future.
[Show abstract][Hide abstract] ABSTRACT: The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors.
Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis.
Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication.
This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.
No preview · Article · Jan 2014 · Langenbeck s Archives of Surgery
[Show abstract][Hide abstract] ABSTRACT: We focused on the embryology and topographic anatomy of the infrapyloric lymph region, which is frequently involved in node metastases but technically complicated for dissection in gastric cancer surgery. Gastrointestinal organs possess their own mesenteries composed of double layers of peritoneum that enclose the intermediate adipose layer providing pathways for vessels, nerves, and lymphatic channels. The frontal layer of the mesoduodenum, in which no. 6 infrapyloric nodes lie, directly faces the pancreas and during gestation is overlain by the greater omentum and transverse mesocolon through the membranous connective tissue called the fusion fascia. Therefore, we performed no. 6 node dissection using the following process: (1) we traced out the mesoduodenum by detachment of the greater omentum and transverse mesocolon; (2) we transected the fusion fascia and (3) removed the adipose layer on the anterior face of the pancreas with its included lymph nodes together with the right gastroepiploic and infrapyloric vessels. The described technique is feasible and in keeping with the anatomical logic for oncologically reliable dissection of no. 6 infrapyloric nodes.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic gastrectomy has become widely used as a minimally invasive technique for the treatment of gastric cancer. When it was first introduced, most surgeons preferred a laparoscopic-assisted approach with a minilaparotomy rather than a totally laparoscopic procedure because of the technical challenges of achieving an intracorporeal anastomosis. Recently, with improved skills and instruments, several surgeons have reported the safety and feasibility of a totally laparoscopic gastrectomy with intracorporeal anastomosis. This review describes the recent technical advances in intracorporeal anastomoses using circular and linear staplers that allow for totally laparoscopic distal, total, and proximal gastrectomies. Data that demonstrate advantages in early surgical outcomes of a total laparoscopic method compared to laparoscopic-assisted operations are also discussed.
Preview · Article · Sep 2012 · Journal of Gastric Cancer
[Show abstract][Hide abstract] ABSTRACT: Background:
The oncologic safety and feasibility of laparoscopic D2 gastrectomy for advanced gastric cancer are still uncertain. The aim of this study is to compare our results for laparoscopic D2 gastrectomy with those for open D2 gastrectomy.
Between 1998 and 2008, a total of 336 patients with clinical T2, T3, or T4 tumors underwent laparoscopic (n = 186) or open (n = 150) gastrectomy involving D2 lymph node dissection with curative intent. To produce this study population, 123 patients in the open group who matched those of the laparoscopic group with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor location, and clinical tumor stage were retrospectively selected. The short- and long-term outcomes of these patients were examined.
Laparoscopic D2 gastrectomy was associated with significantly less operative blood loss and shorter hospital stay, but longer operative time, compared with open D2 gastrectomy. The mortality and morbidity rates of the laparoscopic group were comparable to those of the open group (1.1 % vs. 0, P = 0.519, and 24.2 % vs. 28.5 %, P = 0.402). The 5-year disease-free and overall survival rates were 65.8 and 68.1 % in the laparoscopic group and 62.0 and 63.7 % in the open group (P = 0.737 and P = 0.968). There were no differences in the patterns of recurrence between the two groups.
This study suggests that laparoscopic D2 gastrectomy provides reasonable oncologic outcomes with acceptable morbidity and low mortality rates. Although operation time is currently long, this approach is associated with several advantages of laparoscopic surgery, including quick recovery of bowel function and short hospital stay. Laparoscopic D2 gastrectomy may offer a favorable alternative to open D2 gastrectomy for patients with advanced gastric cancer.
No preview · Article · Jun 2012 · Surgical Endoscopy
[Show abstract][Hide abstract] ABSTRACT: Meticulous mediastinal lymphadenectomy frequently induces recurrent laryngeal nerve palsy (RLNP). Surgical robots with impressive dexterity and precise dissection skills have been developed to help surgeons perform operations. The objective of this study was to determine the impact on short-term outcomes of robot-assisted thoracoscopic radical esophagectomy performed on patients in the prone position for the treatment of esophageal squamous cell carcinoma, including its impact on RLNP.
A single-institution nonrandomized prospective study was performed. The patients (n = 36) with resectable esophageal squamous cell carcinoma were divided into two groups: patients who agreed to robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy performed in the prone position (n = 16, robot-assisted group) without insurance reimbursement, and those who agreed to undergo the same operation without robot assistance but with health insurance coverage (n = 20, control group). These patients were observed for 30 days following surgery to assess short-term surgical outcomes, including the incidence of vocal cord palsy, hoarseness, and aspiration.
Robot assistance significantly reduced the incidence of vocal cord palsy (p = 0.018) and hoarseness (p = 0.015) and the time on the ventilator (p = 0.025). There was no in-hospital mortality in either group. There were no significant differences between the two groups with respect to patient background, except for the use of preoperative therapy (robot-assisted group <control, p = 0.003). There were no significant differences in estimated blood loss, operating time, number of dissected lymph nodes, completeness of resection, or the incidence of the other complications, except for anastomotic leakage (p = 0.038).
Robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy is feasible and safe. This method shows promise in preventing RLNP.
No preview · Article · Mar 2012 · World Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Robotic surgery for the treatment of gastric cancer has been reported, but the technique is not yet established. The objective of this study was to assess the feasibility and safety of our novel integrated procedure for robotic suprapancreatic D2 nodal dissection during distal gastrectomy.
At our hospital from January 2009 to December 2010, a total of 25 consecutive cases of gastric cancer were treated by robotic distal gastrectomy with intracorporeal Billroth I reconstruction. These patients were enrolled in a prospective study to assess the safety and feasibility of robotic distal gastrectomy with nodal dissection by our novel integrated approach, which consists of three elements: arm formation, the surgical approach, a cutting device. To evaluate the learning curves involved in this approach, clinicopathologic features and surgical outcomes were compared between the initial (n = 12) and late (n = 13) phases.
All operations were completed without the need for open or conventional laparoscopic surgery. The mean operating time was 361 ± 58.1 min (range 258-419 min), and blood loss recorded was 51.8 ± 38.2 ml (range 4-123 ml). The median number of retrieved lymph nodes was 44.3 ± 18.4 (range 26-95). R0 resection was accomplished in all cases. There were no deaths or complications related to pancreatic damage. Operating time and surgeon console time for the late phase were significantly shorter than those for the initial phase.
Our novel robotic approach for D2 nodal dissection in gastric cancer is feasible and safe.
No preview · Article · Dec 2011 · World Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: The robot-assisted surgical system was developed for minimally invasive surgery and is thought to have the potential to overcome the shortcomings of laparoscopic surgery. We introduced this system for the treatment of gastric cancer in 2008. Here we report our initial experiences of robot-assisted surgery using the da Vinci system.
A retrospective review of robot-assisted gastrectomy for gastric cancer patients was performed in our institute. The clinicopathological features and surgical outcomes were analyzed. Whereas the procedures of the gastrectomy were similar to those of the usual laparoscopic surgery, several aspects such as the port placement and the role of the assistant were modified from those for conventional laparoscopic surgery.
From January 2008 to December 2010, 61 patients with gastric cancer underwent robot-assisted surgery. Gastrectomy was distal in 46 patients, total in 14, proximal in 1 and no operation was converted to the open procedure. D2 lymph node dissection was performed on 28 patients in the distal gastrectomy group and on 11 in the total gastrectomy group. Complications occurred in 2 cases (4%): these consisted of ruptured sutures and hemorrhage from the anastomotic site.
This study demonstrated that robot-assisted gastrectomy using the da Vinci system can be applied safely and effectively for patients with gastric cancer.
[Show abstract][Hide abstract] ABSTRACT: Suprapancreatic lymph node (LN) dissection is critical for gastric cancer surgery. Until currently, a number of laparoscopic gastrectomy procedures have been performed in the same manner as open surgery procedures [3, 4, 6]. Using the characteristic of laparoscopic surgery, the authors developed a new technique of suprapancreatic LN dissection.
After division of the duodenum, No. 8a LN is raised, and the surrounding tissue is dissected to identify the outmost layer of the nerves around the common hepatic artery. This layer can be dissected as the next step is headed for the root of the left gastric artery. Thin layers can be identified on the left and right sides of the artery. After this step, the LN dissection is performed toward both lateral sites, keeping the outmost layer of the nerves. At this stage, the surgeon should envision the "U" shape on the right side and the "V" shape on the left side for a superior performance. This technique was performed by the same surgeon for 20 consecutive patients with advanced gastric cancer.
All the patients successfully underwent laparoscopic distal gastrectomy with D2 LN dissection. The mean number of regional LNs retrieved was 45.1 ± 13.5. The mean number of only LNs around the celiac artery (No. 7, 8a, 9, 11p, and 12a) was 17.8 ± 5.5. This was not less than reported previously [1, 2, 5]. The mean blood loss was 91.1 ml, and the mean operative time was 296.0 min. At this writing, all the patients are disease free after a mean follow-up period of 15.4 months.
The nerves are thick and sturdy around the root of the left gastric artery. Additionally, the magnified and horizontal laparoscope view provides a straightforward approach and visibility to the layer. The authors believe that the "medial approach" is a straightforward method of suprapancreatic LN dissection in laparoscopic gastric cancer surgery.
No preview · Article · Jun 2011 · Surgical Endoscopy
[Show abstract][Hide abstract] ABSTRACT: Retraction of the liver is necessary to ensure an adequate working space in laparoscopic surgery, but the retraction force applied may cause transient liver dysfunction. We have introduced the technique using a Penrose drain to suspend the liver with the performance of laparoscopic gastrectomy for gastric adenocarcinoma.
111 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy using either a Penrose drain (n = 47) or a Nathanson's retractor (n = 64) for displacement of the liver. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, alkaline phosphatase (ALP) and albumin were compared among the groups at baseline, immediately after operation, and on postoperative days (POD) 1, 2, 3, 5, and 7.
The levels of ALT on POD 2, 3, and 5 were significant higher in the Nathanson's retractor group than in the Penrose drain group. Levels of AST on POD 2 and 3 were also higher in the Nathanson's retractor group than in the Penrose drain group. There was no significant difference in total bilirubin, ALP, and serum albumin levels between groups.
The use of the Penrose drain for retraction of the liver appears to attenuate postoperative liver dysfunction during laparoscopic gastrectomy for gastric adenocarcinoma.
Full-text · Article · Jun 2011 · Journal of Gastrointestinal Surgery
[Show abstract][Hide abstract] ABSTRACT: We developed a new method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis, in which only endoscopic linear staplers are used. In this report, we present the short- and long-term outcomes of our initial experience with this procedure.
We retrospectively analyzed 100 consecutive gastric cancer patients who underwent the delta-shaped anastomosis procedure from May 2001 to November 2006. All of them underwent a laparoscopic distal gastrectomy with regional lymph node dissection. Quality of life was assessed with a questionnaire 6 months or more postoperatively, and the gastric remnant was evaluated by endoscopy one year following the surgery.
Eight surgeons successfully performed the delta-shaped anastomosis without any conversion to laparotomy. The learning curve for all surgeons was steep and the mean time for the anastomosis was 13 min. Only one patient developed an anastomotic leak, and the leak was minor. Sixty-five patients tolerated a 1500 kcal/day soft diet at the time of discharge. The mean follow-up period was 54.9 months. Only one patient reported symptoms indicative of dumping. Two patients were diagnosed with reflux esophagitis, and approximately 70% had evidence of bile reflux, but severe gastritis of the remnant stomach on endoscopy was uncommon.
The wide lumen of the delta-shaped anastomosis led to early, adequate postoperative oral intake without a significant incidence of dumping syndrome. The delta-shaped anastomosis is safe and simple and provides satisfactory postoperative results.
[Show abstract][Hide abstract] ABSTRACT: Although laparoscopic gastrectomy has been recognized as a treatment of early gastric cancer, the indication for laparoscopic gastrectomy with D2 lymph node dissection has remained controversial. D2 lymph node dissection is considered to be feasible for advanced gastric cancer in some high-volume institutions specifically trained for the laparoscopic procedure. This study was undertaken to determine the clinical outcome and clinicopathological characteristics of patients who showed recurrence following laparoscopic gastrectomy for advanced gastric cancer.
From August 1999 through February 2009, among 805 patients who underwent laparoscopic gastrectomy associated with regional lymph node dissection, a total of 209 patients undergoing gastrectomy associated with lymph node dissection who consequently obtained complete resection for advanced gastric cancer were subjected to the retrospective analysis to evaluate clinical outcome.
The mean period of postoperative observation was 1,068 days. The final stages of the 209 cases were as follows: 83 in IB, 56 in II, 46 in IIIA, and 24 in IIIB. The 5-year survival rate was 89.1% in stage IB, 93.1% in stage II, 52.5% in stage IIIA, and 46.5% in stage IIIB, respectively. A total of 27 patients (12.9%) had recurrence. Postoperative recurrence of gastric carcinoma occurred in peritoneal dissemination in 13 patients, liver in 7, distant lymph nodes in 6, ovary in 3, lung in 2, skin in 1, and meninges in 1 patient. There were neither port-site metastases nor locoregional recurrence.
The characteristics and the rate of postoperative recurrence after laparoscopic gastrectomy for advanced gastric cancer were not greatly different from those of the open conventional procedure. Although further observation is required to finally conclude long-term survival, laparoscopic radical gastrectomy may possibly be indicated for patients with advanced gastric cancer.
[Show abstract][Hide abstract] ABSTRACT: Although bronchogenic cysts (BCs) are benign congenital malformations usually occur in thoracic cavity, retroperitoneal location is extremely uncommon. We reported a case of BC occurred in the retroperitoneum, which was excised laparoscopically. A 64-year-old Japanese woman was admitted to the hospital because of submucosal tumor in the upper part of the stomach. An upper gastrointestinal endoscopy revealed a submucosal tumor located just distal to the esophagogastric junction. The abdominal computed tomography scan revealed a cystic mass located in contact with lesser curvature of the stomach and the dorsal surface of the liver. As the cystic mass was well-circumscribed and showed no positive findings suggestive of malignancy, the laparoscopic excision of the cystic mass was performed. The cystic tumor was completely excised with a laparoscopic procedure. The histologic findings indicated that the cyst was surfaced by the ciliated pseudostratified epithelium without the presence of the cartilage, which was compatible with the BC of the retroperitoneum. This case highlights the safety and the feasibility of complete laparoscopic excision of retroperitoneal BC. Laparoscopic excision of retroperitoneal BC definitely provides all advantages of minimally invasive procedure, which improves postoperative patient discomfort and pain and shortens hospital stay. Laparoscopic procedure may definitely be a standard approach for the excision of retroperitoneal BC.
No preview · Article · Dec 2010 · Surgical laparoscopy, endoscopy & percutaneous techniques
[Show abstract][Hide abstract] ABSTRACT: Although neoadjuvant chemotherapy has been recognized as an important option to improve the clinical outcome of patients with advanced gastric carcinoma, the precise histological effects of neoadjuvant chemotherapy on the primary and metastatic foci have not well been documented. The aim of the present study was thus to evaluate histological effects of S-1-based neoadjuvant chemotherapy on the resected specimens of gastric carcinoma and regional lymph nodes, and primarily to focus on the histology of the cases showing complete regression of the primary cancer cells. A total of 164 patients received neoadjuvant chemotherapy with the combination of S-1 (80 to 120 mg/body/day for 3 weeks) and cisplatin (35 to 60 mg/m2 on day 8). One course of the regimen was completed in 5 weeks and the next course was started after 2 weeks. A total of 9 patients who showed complete regression of the primary gastric cancer were subjects of the study. A total of 77 cases (46.9%) responded to the neoadjuvant chemotherapy and 9 cases (5.5%) showed a complete regression of the primary gastric carcinoma. Three out of 9 cases had remnant cancer cells in the metastatic foci; 1 in the liver and 2 in the regional lymph nodes. Five of 9 cases were solid-type poorly-differentiated adenocarcinoma (por1), and the incidence of responders was the highest in patients with por1. A total of 8 cases were alive and the mean postoperative survival was 612±192 days. One patient died 518 days after gastrectomy associated with hepatic resection. S-1-based neoadjuvant chemotherapy has significant histological effects on gastric carcinoma and metastatic foci, which may further improve long-term clinical outcome in patients with advanced gastric carcinoma.
No preview · Article · Nov 2010 · Gan to kagaku ryoho. Cancer & chemotherapy
[Show abstract][Hide abstract] ABSTRACT: The aim of this paper is to share our first experience of a novel procedure with da Vinci surgical system® for colorectal cancer here in Japan and provide the current status of robot surgery. A 77-year-old male was transferred to our department for curative surgery of sigmoid colon cancer (T1N0M0). The patient was placed in Trendelenburg position and 5 ports were inserted into the abdominal cavity. After that, patient cart with 4 arms was docked on the left caudal side. Superior rectal artery and vein were divided, sigmoid colon was mobilized and rectum was dissected in robotic surgery. The outcomes of this case were comparable to those in the literature in terms of blood loss, morbidity and length of hospital stay, apart from operative duration due to being unfamiliar with robot. Robotic surgery might be feasible and safe procedure for colorectal cancer.