Harushi Udagawa

Keio University, Edo, Tokyo, Japan

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Publications (152)232.77 Total impact

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    ABSTRACT: Background: Surgical risk assessment is becoming more important in the field of laparoscopic gastrectomy given the increasing complexity and technical demands of oncological procedures undertaken. However, no validated method for preoperative risk (PR) assessment has been reported. Methods: Two-hundred fourteen patients who underwent laparoscopic gastrectomy between October 2011 and August 2014 were reviewed. Independent risk factors were examined by multivariate analysis and a PR score model was established. Results: Thirty-six (16.8%) patients experienced postoperative complications. Multivariate analysis revealed that age ≥75 years, American Society of Anesthesiologists score ≥2, severe pulmonary disease, Brinkman index ≥600, history of upper abdominal surgery and body mass index (BMI) were independent factors. Among these, BMI was strongly correlated with postoperative morbidity rate (r = 0.960). To permit risk prediction using BMI and the remaining 5 factors, a new PR score was established using 5 categorical variables. The new score was significantly correlated with the postoperative complication rate (r = 0.948), and its predictive value was superior to conventional risk scores such as E-PASS and POSSUM. A contour map was then created using BMI and this new PR score to more accurately stratify patients according to surgical risk prior to laparoscopic gastrectomy. Conclusions: A 2-dimensional risk estimation model was created to better estimate surgical risk and is a promising new tool for adequate surgical management.
    No preview · Article · Dec 2015 · Digestive surgery
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    ABSTRACT: Spontaneous gastric perforation in the absence of chemotherapy is extremely rare. The authors encountered a case of spontaneous perforation of primary gastric lymphoma. A 58-year-old man visited the authors' hospital with acute severe epigastralgia. A large amount of free gas and a fluid collection around the stomach were noted on an abdominal computed tomography scan. The results of imaging studies indicated a perforated gastric ulcer, and a distal gastrectomy was performed. There was a large perforation about 50 mm in diameter in the anterior wall of the middle part of the stomach body. Microscopically, the full thickness of the gastric wall was diffusely infiltrated by a population of large atypical lymphoid cells. The lymphoid nature of these cells was indicated by the strongly positive immunohistochemical staining for CD20 and CD10. This confirmed the diagnosis of a germinal center B-cell-like type of diffuse large B cell lymphoma. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone were administered after the operation. Gastrectomy should be considered if a giant ulcer with necrotic matter on the ulcer floor is seen on upper gastrointestinal endoscopy because of the possibility of gastric perforation. If upper gastrointestinal endoscopy shows a finding similar to the abovementioned one during chemotherapy, dose reduction of chemotherapy or gastrectomy should be considered.
    Full-text · Article · Dec 2015 · World Journal of Surgical Oncology
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    ABSTRACT: Postoperative chylothorax is a rare but well-known complication of general thoracic surgery. Medical treatment of chylothorax was reported in the past, but there is still considerable controversy on the appropriate management strategies. Two patients with esophageal cancer underwent esophagectomy, 2-field lymph node dissection, and resection of thoracic duct together with ileocolic reconstruction via the retrosternal route at our hospital. Chylothorax developed on the 32nd postoperative day (POD) in 1 patient and the 12th POD in the other, manifesting as a change in the character of thoracic drainage to turbid white. Both were immediately started on octreotide (300 μg/ day) and etilefrine (120 mg/day). When the amount of pleural effusion decreased to <50 mL/day, we performed pleurodesis with Picibanil (OK432). Thereafter, the patients gradually made satisfactory progress and resumed oral food intake, and the thoracotomy tubes were eventually removed. They have remained recurrence-free at the time of writing. In this report, we demonstrated the clinical efficacy of etilefrine for the management of postesophagectomy chylothorax. New medical treatment options for this condition are now broad and the usefulness of combined therapy consisting of a sclerosing agent, etilefrine, and octreotide is underscored, regardless of the status of the thoracic duct.
    No preview · Article · Dec 2015 · Medicine
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    ABSTRACT: Objective: To evaluate the sites and frequencies of overall and initial lymph node (LN) metastases (LNMs) of clinical T1N0 esophageal cancer. Background: The sites and frequencies of initial LNMs and sentinel LNs (SLNs) of esophageal cancer remain unclear. Methods: The Japan Clinical Oncology Group JCOG0502 trial was a 4-arm prospective study that compared esophagectomy with chemoradiotherapy for clinical T1N0 esophageal cancer in both randomized and patient-preference arms. The preoperative diagnostic accuracy was evaluated for patients assigned to the surgery arm. Patients who withdrew consent and who were not treated were excluded. All patients underwent esophagectomy with D2 or greater LN dissection. From the pathologic findings, sites and frequencies of LNMs and SLNs were assessed and the frequency of skip LNMs was calculated. Results: In total, 211 patients underwent LNM and SLN analysis. Regarding N-factor accuracy, 57 (27.0%) of 211 clinical N0 cases had pathologic LNMs. The upper mediastinal and mediastinal/abdominal regions were frequent sites of LNMs in upper and lower thoracic cases, respectively. However, in middle thoracic cases, LNMs were observed in the neck, mediastinal, and abdominal regions, and pathologic SLN spread to all 3 fields. The frequency of skip LNMs was 36.7%. Conclusions: A clinical diagnosis of T1N0 is not sufficiently accurate, and therefore, it is unacceptable to omit LN dissection or minimize the prophylactic radiation field. SLNs, which are not location restricted, should be surveyed in all 3 fields. Copyright
    No preview · Article · Dec 2015 · Annals of Surgery
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    ABSTRACT: Background The extent of node dissection in esophageal cancer surgery is usually estimated by the number of resected nodes, irrespective of the area of dissection. The efficacy of lymph node dissection by area was evaluated according to the location of the primary tumor. Methods The study group comprised the 3827 patients who underwent R0 esophagectomy with three-field lymph node dissection for squamous cell carcinoma, registered in a nationwide registry in Japan. The areas of lymph node were classified into zones according to AJCC Staging Manual. The Efficacy Index (EI) calculating the frequency and patient survival of metastases to each zone was investigated according to tumor location. Results The EI was high in supraclavicular and upper mediastinal zones in patients with upper esophageal tumors, highest in upper mediastinal zone followed by supraclavicular and perigastric zones in patients with middle esophageal tumors, and highest in perigastric zone followed by upper and lower mediastinal zones in patients with lower esophageal tumors. In patients with middle and lower esophageal cT1 tumors, the EIs of upper mediastinal and perigastric zones were higher than middle and lower mediastinal zones. Conclusion The EIs of each zone were differed by tumor location. The extent of lymph node dissection should be estimated by the dissected zones and modified by the tumor location. Supraclavicular dissection is indispensable for patients with upper esophageal tumors, and recommended for patients with middle esophageal tumors. Upper mediastinal dissection is recommended for all patients with thoracic esophageal squamous cell carcinoma, irrespective of the location.
    Full-text · Article · Nov 2015 · Esophagus
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    ABSTRACT: Esophageal adenocarcinoma arising from ectopic gastric mucosa (EGM) is extremely rare. We describe here two Japanese patients with adenocarcinoma of the cervical esophagus arising from EGM. Case 1 is a 62-year-old man who had slightly red EGM in the cervical esophagus on upper gastrointestinal endoscopy (UGE). Because the biopsy showed atypical glands that were suspicious for adenocarcinoma, endoscopic submucosal dissection was performed. Histopathological examination revealed that the lesion was a well-differentiated adenocarcinoma (pT1a MM). Lymphovascular invasion was absent, and the margins were free from carcinoma. Case 2 is a 57-year-old man who had an elevated lesion with a bleeding tendency in an area of EGM in the cervical esophagus on UGE. Adenocarcinoma was diagnosed in the biopsy. Because of the presence of enlarged lymph nodes (#106recL), preoperative chemoradiotherapy was performed to reduce the size of the adenocarcinoma and lymph nodes prior to resection of the cervical esophagus and reconstruction with free jejunal grafts. Histopathological examination revealed moderately differentiated adenocarcinoma (0-I, pT2N1M0, pStage II). In both cases, adenocarcinoma was surrounded by EGM, which led to the diagnosis of EGM-derived esophageal adenocarcinoma. Here, we report its immunohistochemical characteristics in the present cases and discuss the histogenesis.
    No preview · Article · Oct 2015 · Clinical Journal of Gastroenterology
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    ABSTRACT: Background The area of nodal dissection should be modified by the location of the primary tumor in an individual patient. The purpose of this study was to evaluate the efficacy of lymph node dissection based on station by the location of the primary tumor based on a multi-institutional nationwide registry of esophageal cancer. Methods The study group comprised 1295 patients who underwent R0 resection and three-field esophagectomy. The Efficacy Index (EI) was calculated by multiplying the incidence of metastases to a station and the 5-year survival rate of patients with metastases to that station, by tumor location. Results There were 550 patients without nodal metastases and 745 patients with them. In patients with upper tumors, the EIs of recurrent nerve nodes, cervical paraesophageal nodes and supraclavicular nodes were highest. In patients with middle tumors, the EIs of recurrent nerve nodes, cardiac nodes and lesser curvature nodes were highest, and the EIs of supraclavicular nodes and cervical paraesophageal nodes were not negligible. In patients with lower tumors, the EIs of cardiac nodes, lesser curvature nodes and left gastric artery nodes were highest, and the EIs of recurrent nerve nodes were also high. Conclusion The EIs of certain node stations were different by location of the primary tumor. Node stations for dissection should be modified by the location of the primary tumor. For upper and middle esophageal tumors, the three-field approach is recommended. Dissection of the upper mediastinum is recommended for patients with lower esophageal tumors.
    Full-text · Article · Jul 2015 · Esophagus
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    ABSTRACT: A consensus has almost been reached in favor of hepatic resection for colorectal cancer metastases. It remains unclear whether resection of gastric cancer metastases in the liver is justified. The purpose of this study was to assess the survival benefit of surgical resection for gastric cancer metastases confined to the liver. We reviewed the clinicopathological features and outcome of 107 patients with liver metastases without other non-curative factors from the case records of 5437 gastric cancer patients. These subjects included 34 synchronous cases with tumors present at the time of gastrectomy and 73 metachronous cases with new lesions that appeared after radical gastrectomy. Hepatectomies were performed in nine synchronous and four metachronous cases that had ≤3 tumors with diameters <3 cm. The overall survival rates after hepatectomy were significantly higher than those in eligible candidates who did not receive hepatectomy despite having comparable metastatic status (synchronous, n = 8, p = 0.009; metachronous, n = 24, p = 0.016). The survival rate of patients who underwent hepatectomy for synchronous metastases was not inferior to that of patients who underwent hepatectomy for metachronous metastases. The median disease-free interval in metachronous cases was significantly shorter in patients who did not undergo resection than those who underwent resection. However, multivariate analyses revealed that hepatectomy was the only significant (p = 0.001) prognostic factor whereas DFI was not. Hepatectomy for ≤3 metastatic tumors with diameters <3 cm offered superior survival compared with non-surgical treatment even for metastases detected synchronously or within a short period after radical gastrectomy.
    No preview · Article · Jul 2015 · World Journal of Surgery
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    ABSTRACT: Although laparoscopic radical gastrectomy has several advantages over conventional surgery, postoperative liver dysfunction is an unwanted complication. The major cause is considered to be use of mechanical liver retraction. To prevent liver damage after laparoscopic gastrectomy, we modified the liver retraction method: the retractor was used only after lymph node dissection along the greater curvature had been completed, and it was released before reconstruction and intermittent repositioning to avoid discoloration of the liver parenchyma. This study sought to determine whether postoperative liver dysfunction could be prevented by making these simple modifications. In this retrospective study involving 114 laparoscopic gastrectomy patients, postoperative serum aspartate aminotransferase, alanine aminotransferase (ALT), and total bilirubin levels were compared between laparoscopic gastrectomy patients who had undergone the modified procedure and those who had not. Discoloration of the liver was classified into three groups just before the retractor was released at the end of surgery. Aspartate aminotransferase and ALT levels on postoperative days 1 and 2 and the proportion of patients with elevated aspartate aminotransferase or ALT levels on postoperative day 1 were significantly lower after the modifications. ALT level on postoperative day 1 was significantly higher in the subgroup with broad liver discoloration. Reducing the duration of liver retraction and moving the position of the retractor or releasing it intermittently before discoloration of the liver parenchyma may be effective for preventing postoperative liver damage. © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
    Full-text · Article · Jun 2015 · Asian Journal of Endoscopic Surgery
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    ABSTRACT: Inguinal hernias account for 75 % of abdominal wall hernias, with a lifetime risk of 27 % in men and 3 % in women. Major complications are recurrence, chronic pain, and surgical site infection, but their frequency is low. Few studies have reported a calcified mesh causing neuropathy by chronic compression of the femoral nerve after mesh & plug inguinal hernia repair. This is the first report of laparoscopic plug removal for femoral colic due to femoral nerve irritation cause by a calcified plug after mesh & plug inguinal hernia repair. In July 2013, a 53-year-old man presented to our hospital with a chief complaint of colic pain in the left lower limb while walking. The patient had undergone left inguinal hernia repair about 10 years earlier and reported no chronic pain after the operation. Physical examination revealed a colic pain exacerbated by left thigh movement, especially during flexion, but the patient was pain-free at rest and had no sensory loss. Axial computed tomography and magnetic resonance imaging showed that the inward-projecting plug was extremely close to the femoral nerve. Because of the radicular symptoms and the absence of orthopedic and urological disease, we strongly suspected that the neuralgia was associated with the previous hernia operation and advised exploratory laparotomy, which revealed the plug bulging inward into the abdominal cavity. Moreover, the tip of the plug was firmly calcified and compressing the femoral nerve, which lay just beneath the plug, especially during hip flexion. We explanted the plug and his pain resolved after the operation. The patient remains pain free after 20 months of follow up. In this study, laparoscopic hernioplasty proved useful for plug removal because laparoscopic instruments can easily grasp perilesional tissue, and laparoscopic approach has the benefit of isolating the plug for removal while preserving the onlay patch, and helpful for restoring peritoneal defects. Laparoscopic plug removal effectively resolved colic pain in the left thigh due to compression of the femoral nerve by a calcified plug.
    Preview · Article · May 2015 · BMC Surgery
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    Full-text · Article · May 2015 · Asian Journal of Endoscopic Surgery
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    ABSTRACT: We herein report a case of bronchial bleeding after radical esophagectomy that was treated with lobectomy. A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis. After the esophagectomy, bilateral vocal cord paralysis was observed, and the patient suffered from repeated episodes of aspiration pneumonia. Bronchoscopy revealed hemosputum in the right middle lobe bronchus, and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus. Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis, the procedures were unsuccessful. Right middle lobectomy was therefore performed via video-assisted thoracic surgery. Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen. The patient recovered uneventfully and was discharged on postoperative day 14.
    Full-text · Article · Mar 2015
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    ABSTRACT: We herein report a case of bronchial bleeding after radical esophagectomy that was treated with lobectomy. A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis. After the esophagectomy, bilateral vocal cord paralysis was observed, and the patient suffered from repeated episodes of aspiration pneumonia. Bronchoscopy revealed hemosputum in the right middle lobe bronchus, and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus. Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis, the procedures were unsuccessful. Right middle lobectomy was therefore performed via video-assisted thoracic surgery. Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen. The patient recovered uneventfully and was discharged on postoperative day 14.
    Full-text · Article · Mar 2015 · World Journal of Gastroenterology

  • No preview · Article · Mar 2015 · Journal of the American College of Surgeons
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    ABSTRACT: Thoracoscopic esophagectomy is rapidly and increasingly being used worldwide because it is a less invasive alternative to open esophagectomy. However, few prospective multicenter studies have evaluated its safety profile. This study aimed to evaluate the safety profile of thoracoscopic esophagectomy using perioperative data from the Japan Clinical Oncology Group Study (JCOG0502). JCOG0502 is a four-arm prospective study comparing esophagectomy with chemoradiotherapy for esophageal cancer, with randomized and patient preference arms. Patients with clinical stage T1bN0M0 esophageal cancer were enrolled until patient accrual was completed. Open or thoracoscopic esophagectomy was selected at the surgeon's discretion. Perioperative complications were defined as adverse events of ≥grade 2 as per Common Terminology Criteria for Adverse Events ver. 3.0. A total of 379 patients were enrolled between December 2006 and February 2013. Of the 210 patients who underwent surgery, 109 patients underwent open esophagectomy, and 101 patients underwent thoracoscopic esophagectomy. Although thoracoscopic esophagectomy decreased the incidence of postoperative atelectasis (open: 22.0 %, thoracoscopy: 10.9 %; P = 0.041), reoperation was more frequent in the thoracoscopy group (open: 1.8 %, thoracoscopy: 9.9 %; P = 0.016). The incidence of overall complications did not differ between the two groups (open: 44.0 %, thoracoscopy: 44.6 %; P = 1.00). There was one in-hospital death in each group (open: 0.9 %, thoracoscopy: 1.0 %; P = 1.00). Thoracoscopic esophagectomy is a safe procedure with morbidity and mortality comparable with those of open esophagectomy. However, it is associated with a higher frequency of reoperation.
    Full-text · Article · Feb 2015 · Surgical Endoscopy

  • No preview · Conference Paper · Jan 2015

  • No preview · Conference Paper · Jan 2015
  • I. Okuda · S. Nawano · Y. Nakajima · K. Hirata · H. Udagawa
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    ABSTRACT: We describe the optimal magnetic resonance-thoracic ductography (MRTD) procedures and provide examples of the thoracic duct (TD) anatomy. The MRTD protocol included a long echo time and was based on enhancement of signals from the liquid fraction and suppression of other signals, based on the principle that lymph flow through the TD appears hyperintense on T2-weighted images. MRTD allows non-invasive evaluation of TD and can be used to identify TD configuration. TD configuration was analyzed based on embryological considerations, was classified into nine types in terms of location (right and/or left side/s of the descending aorta) and outflow (right and/or left venous angle/s). The majority of cases had a right-side TD that flew into the left venous angle. Minor configuration variations were noted in 14% of cases.
    No preview · Article · Jan 2015
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    ABSTRACT: Background/Aims: The current literature wound suggest that patients with gastric cancer who have a previous history of ligation of the splenic artery undergo total gastrectomy. However, an analysis of the risk factors for postoperative complications in elderly patients showed a higher rate of morbidities for total gastrectomy compared to subtotal gastrectomy. Case Report: We herein report a rare case of successful distal gastrectomy in a 78-year-old female diagnosed with gastric cancer with a previous history of distal pancreatectomy combined with splenectomy, because an adequate blood flow was provided by the fundic branches from the left inferior phrenic artery (LIPA). Preoperative computed tomography demonstrated a ligated splenic artery and left gastric artery with developed fundic branches from the left inferior phrenic artery. The intraoperative findings showed a sufficient blood flow to the proximal stomach after ligation of all main gastric arteries, thus suggesting that the gastric remnant could be supplied by the fundic branches from the LIPA. The patient’s postoperative course was un-eventful. Conclusion: This case suggests that a distal gastrectomy is a possible treatment modality even after distal pancreatectomy combined with splenectomy.
    Full-text · Article · Nov 2014 · Hepato-gastroenterology
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    ABSTRACT: Background/Aims: The current literature would suggest that patients with gastric cancer who have a previous history of ligation of the splenic artery undergo total gastrectomy. However, an analysis of the risk factors for postoperative complications in elderly patients showed a higher rate of morbidities for total gastrectomy compared to subtotal gastrectomy. Case Report: We herein report a rare case of successful distal gastrectomy in a 78-year-old female diagnosed with gastric cancer with a previous history of distal pancreatectomy combined with splenectomy, because an adequate blood flow was provided by the fundic branches from the left inferior phrenic artery (LIPA). Preoperative computed tomography demonstrated a ligated splenic artery and left gastric artery with developed fundic branches from the LIPA. The intraoperative findings showed a sufficient blood flow to the proximal stomach after ligation of all main gastric arteries, thus suggesting that the gastric remnant could be supplied by the fundic branches from the LIPA. The patient’s postoperative course was un- eventful. Conclusion: This case suggests that a distal gastrectomy is a possible treatment modality even after distal pancreatectomy combined with splenectomy.
    No preview · Article · Nov 2014 · Hepato-gastroenterology

Publication Stats

2k Citations
232.77 Total Impact Points

Institutions

  • 2015
    • Keio University
      • Department of Surgery
      Edo, Tokyo, Japan
  • 1984-2015
    • Toranomon Hospital
      Edo, Tokyo, Japan
  • 2007
    • Kurume University
      • Department of Surgery
      Куруме, Fukuoka, Japan
  • 2002
    • Juntendo University
      • Department of Medicine
      Edo, Tōkyō, Japan