Eiji Kanehira

Laparoscopic gastrectomies for cancer: The ACOI-IHTSC national guidelines

Abstract Guidelines for laparoscopy and cancer of stomach have been outlined by several scientific societies: The main recommendation being that laparoscopy should be used only by surgeons already highly skilled in gastric surgery. The laparoscopic approach to gastric cancer surgery has become more and more frequent in most Italian centers. On behalf of the Guideline Committee of the Italian Society of Hospital Surgeons and the Italian Hi-Tech Surgical Club, a panel of experts analyzed the highest evidence of all scientific papers focusing on laparoscopic gastrectomies for cancer and published from 2003 to 2011, and drew these national guidelines. Laparoscopic gastrectomy may be considered as a safe procedure with better short-term and comparable long-term results. compared to open gastrectomy (Grade A). There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as laparotomic gastrectomies (Grade B). Additional randomized controlled trials (RCT) that compare and investigate the long-term oncological outcomes of laparoscopic assisted gastrectomy are required.

The outburst age: How TEM ignited the MIS revolution

Once questioned on what best surgery was, Sir Alan Parks, the great British surgeon elected President of the Royal College of Surgeons in 1980 and in those years working at St. Marks Hospital in L...

Development of a novel multichannel port (x-Gate®) for reduced port surgery and its initial clinical results

Abstract Background: In order to reduce clashing between the instruments during single-incision endoscopic surgery or reduced port surgery we have developed a new multichannel port with wider distance between the channels. Material and methods: We used the newly developed multichannel port (x-Gate®) in 34 patients undergoing a variety of reduced port surgery procedures. The operation records of these patients were reviewed. Results: Overall performance of x-Gate® was sufficient in the clinical experience. There have been no complications attributed to x-Gate®. We found that with the x-Gate® the conflicts among the forceps have been drastically improved compared with other multi-channel ports we had used before, which had a shorter distance between the channels.

Long-term outcomes of percutaneous endoscopic intragastric surgery in the treatment of gastrointestinal stromal tumors at the esophagogastric junction.

BackgroundThe treatment options for gastrointestinal stromal tumors (GITSs) at the esophagogastric junction (EGJ) are controversial. There have been reports on enucleation for EGJ GISTs in order to avoid gastrectomy. But the number of patients is too small, or the follow-up period is too short to evaluate it. The purpose of this study was to review our experience of 59 patients with EGJ GISTs treated by enucleation by percutaneous endoscopic intragastric surgery (PEIGS) and assess the clinical outcomes.MethodsPEIGS is performed as described below. Access ports are placed through the abdominal wall and the anterior wall of the stomach. Through the access ports, an endoscope and surgical instruments are inserted into the gastric lumen and tumor enucleation and closure of the defect are carried out. In this study, 59 patients with EGJ GISTs treated by PEIGS between 2005 and 2013 were enrolled. Their hospital records were reviewed, and follow-up data for 8xa0years were collected to analyze the outcomes.ResultsEn-bloc enucleation was achieved without tumor rupture in all. Average operation time was 172.3xa0min. Postoperative complications occurred in 3 (one localized peritonitis, one bleeding, and one surgical site infection). Average tumor size was 35.6xa0mm. Pathological findings confirmed negative margin in all specimens. The maximum follow-up period was 101xa0months. Multiple liver metastases were detected in two patients (at 12 and 29xa0months). The survival rate was 100xa0%. The disease-free rate was 98.3xa0% at 12xa0months and 96.6xa0% at 29xa0months, respectively.ConclusionsAs far as the short- and long-term outcomes of our experience are reviewed, PEIGS seems as curative as other aggressive resection methods such as proximal gastrectomy. Tumor enucleation by PEIGS, offering a chance to preserve the stomach, can be a preferable option in carefully selected patients with EGJ GISTs, when performed by a skilled surgeon.

Transanal endoscopic microsurgery for surgical repair of rectovesical fistula following radical prostatectomy

AbstractBackgroundnRectovesical fistula is a rare complication following prostatectomy, associated with significant symptoms such as urinary drainage from anus or faecaluria. While several surgical procedures have been described to treat this condition, none of them has been accepted as the universal standard. Transanal endoscopic microsurgery (TEM) is a well-established endoluminal procedure for local excision of rectal tumors. But its application to the repair of rectovesical fistula has been almost unknown.MethodsWe performed TEM as a surgical repair for refractory rectovesical fistula developing after radical prostatectomy in 10 patients. Under the magnified three-dimensional view, through the stereoscope, the fistula and the surrounding rectal mucosa were precisely resected. The defect and the muscle layer of the rectum were closed by hand-sew technique in four layers.ResultsFistula was completely closed in 7 patients, who eventually underwent enterostomy closure, while in the other 3 patients the fistula recurred. In the three recurrent cases, the fistula was associated with wide, tough scar tissue due to previous irradiation, HIFU, or repeated surgical repair attempts.ConclusionsRectovesical fistulas associated with wide, tough scar tissue due to multi-time attempt of surgical repair or any type of energy ablation should not be indicated for repair by TEM. However, for simple fistulas without tough, fibrotic surroundings, TEM can be indicated as a minimally invasive surgical option with very low morbidity, without any incision in healthy tissue for approach.

A single surgeon's experience with transanal endoscopic microsurgery over 20 years with 153 early cancer cases.

Abstract Background: The first author performed transanal endoscopic surgery (TEM) in 302 patients in Japan for the last 20 years, 153 of which were early rectal cancer cases. The short- and long-term outcomes of the early rectal cancer cases are herein reported. Material and methods: The original technique of TEM developed by Gerhard Buess was performed in all cases. The hospital records were reviewed to assess the clinical outcomes. A questionnaire was sent to the patients to analyze the long-term outcomes. Results: One-hundred and fifty-three early cancer cases included 115 T0 and 38 T1 lesions. Full-thickness resection was performed in 36 patients, while 117 underwent submucosal dissection. Conversion to laparoscopic low anterior resection occurred in one case. Mortality was nil. Major operative complication was noted in only one patient, who developed stenosis. Seven patients underwent immediate salvage surgery. Six patients died of recurrence of rectal cancer. Disease-free survival rate at year 5 was 93.7%. Conclusions: Our study, one of the largest series in the world, confirms that TEM is a preferable option in the surgical treatment of T0 and T1a rectal carcinoma. As long as early cancer cases are treated, submucosal resection seems to be sufficient. When risk of recurrence is found by pathological examination, immediate salvage operation is mandatory to improve the prognosis.

Development of scar-less laparoscopic hernia repair (TAPP-252) facilitated by new 2mm instruments

Abstract Introduction: To minimize the invasiveness of laparoscopic transabdominal preperitoneal hernia repair (TAPP) for the treatment of adult inguinal hernia, we developed a new operative technique with the use of only one 5u2009mm port and two 2u2009mm punctures (TAPP-252). Material and methods: To facilitate TAPP-252, we developed seven kinds of new 2u2009mm instruments, including grasping forceps, hook shaped electrode, mesh pusher, needle driver, scissors, laparoscope and port. Results: TAPP-252 was stably performed in 35 patients with minimal abdominal wall destruction and excellent cosmetic result without any recurrence or morbidity. Conclusions: The newly developed 2u2009mm devices showed sufficient performance and durability in TAPP-252. Further investigation is necessary to assess durability and long-term outcomes.

25 years of SMIT: the past, the present, and the future of minimally invasive therapy.

Abstract A quarter of a century has passed since the Society of Minimally Invasive Therapy (SMIT) was founded in 1989 with the aim to provide a platform to promote the development of minimally invasive therapy and the new instruments and devices needed to carry out the new surgical techniques. Both the founder of the society, British urologist John EA Wickham, and the German surgeon Gerhard F Buess, who was one of the leading members from the beginning, conceived SMIT as an interdisciplinary forum to promote the cooperation between physicians from various surgical specialties, but also medical engineers, resp. medical device manufacturers, whose expertise was needed to build the instruments that had to be developed to carry out the new concept of surgery. In this paper we outline the history of SMIT over the past 25 years in order to highlight both the ideas behind the society and the dedication of the people who shaped it.

Gerhard Buess, a Great Maverick Passes Away at 62

Professor Dr. Gerhard Fritz Buess, the Editor in Chief of Minimally Invasive Therapy and Allied Technologies (MITAT), passed away on 30th October 2010 at a hospital in Herrsching, a small town near Munich, Germany. He was 62. The cause was a septic condition as a complication of the brain tumor that was first detected in 2006. In 1983 the world’s first endoscopic operation on the gastrointestinal tract by a surgeon was performed by Gerhard Buess at Koeln University, Germany. In 1980 Gerhard Buess, a general surgeon and innovator, began to develop an endoluminal surgical device for transanal resection of rectal tumors. He introduced his original device into clinical use three years later. Today this operation is well known as transanal endoscopic microsurgery (TEM). It is remarkable that the first case of TEM predated the first laparoscopic cholecystectomy in 1985 by Muehe. Moreover TEM can even be regarded as a prototype of natural orifice transluminal surgery (NOTES) and of single incision endoscopic surgery, which are ranked among the most advanced forms of endoscopic surgery today. Gerhard Buess was a maverick. Initially his innovative work was not well understood and sometimes even ridiculed in the medical societies – a fate he shared with many pioneers before him. But as endoscopic operations in general spread to the world and became standard operations people appreciated what Gerhard Buess had done before. He became a professor at Eberhard-Karls University Tuebingen, Germany, in 1989 and established the division of Minimally Invasive Surgery. His professional activities sped up. He became the Editor in Chief of MITAT in 1992, together with John Wickham, a British urologist and the founder of the society for Minimally Invasive Therapy (SMIT). Gerhard Buess became the president of SMIT in 1996 and hosted its international conference in Berlin. He was then elected as the president of the society of European Association for Endoscopic Surgery (EAES) in 2005 and organized the 10 World Congress of Endoscopic Surgery in Berlin in 2006. Just after the great success of the World Congress he organized in 2006 he was hospitalized when his physician diagnosed a brain tumor. He underwent an operation in October 2006. Surprisingly he resumed his activities very quickly after the operation. Regrettably the tumor recurred in November 2009. But he continued to go abroad for invited operations and lectures. Disregarding the disease he went to Japan, Cuba, China, India, Turkey, and other countries. In June 2010 he was still able to attend the EAES meeting in Geneva, where we could listen to his very last lecture. Despite his fame and the importance in the medical societies, Gerhard Buess never became arrogant. He loved to teach young surgeons. A lot of young people came to Tuebingen to learn endoscopic surgery. He welcomed young surgeons not only from theWest but also from many other countries such as Japan, India,

Who assesses your surgical skill? How?

In such fields as sports and some sorts of technical professions, assessment and qualification of the skills have been commonly performed for long time. On the contrary, in the field of surgery, which should highly demand the same work, we have not seen it intensely done in the past, probably partially due to the fact that surgery directly treats human beings and operations have been performed in a rather closed situation. Although there are societies or organizations who try to qualify the surgeons by the attendance of hands-on courses, seminars, or paper examination, these are not necessarily assessing the surgeon’s practical skills. In the reality of most hospitals the surgeon’s skills seems to be assessed by senior surgeons according to their experiences. Then young surgeons are allowed to start operating under the direction of seniors after this “personal” assessment and qualification. Recently a movement is seen that is trying to make this work more objective, scientific, and global. The spread of endoscopic surgery, in which surgical procedures can be easily recorded and preserved, must have promoted this movement. So has the development of sophisticated simulators driven by a high-tech computer program. It is extraordinarily interesting to see the development of skills assessment programs by computer, which seem perfectly objective. When the surgeon’s skill is analyzed and resolved to the final particles, we should know that skill is an assembly of the elements of most basic skills. And these final elements of basic skill must be the ideal targets of computer-aided assessment systems. From the clinical point of view, however, the outcome of surgery should not be determined only by these elements. It must be determined not only by the surgeon’s pure technical dexterity, but also by many other factors that also belong to the surgeon, such as experience and knowledge of the anatomy, ability to decide, ability to concentrate, ability to command to the assistants, ability to conduct the entire team, and so on. In addition there are other factors, which don’t belong to the surgeon, such as abilities of assistants and comedicals, quality of the facilities, performance of the devices, and so on. To make things more complicated, there may be another factor, the fact that many of the above mentioned factors can be affected by the mental condition of the surgeon(s). This fact has been well recognized among the OR staffs, although it has not been focused on, and the relationship with the clinical outcomes has not been analyzed in a scientific way, so far. In contrast to the purely scientific assessment of each basic element of surgical skills, the Japan society for endoscopic surgery (JSES) started an interesting trial five years ago. It is a “video assessment”, in which two or three judges, who are selected by the society as “experts”, see a non-edited video submitted by each candidate and assess the skills. In terms of assessment of total ability of a surgeon, which should reflect more practically on clinical situations, the JSES trial can cover the possible drawbacks of the computer-aided assessment of skill elements, although it must also have a risk not to be as perfectly objective as in the computer assessment. In Japan there is an interesting old saying “A priestling in front of the gate chants a sutra nobody taught”. It means that even if nobody teaches a young boy a sutra, he will be able to recite it when he listens to it every day. It may be the same thing with “A saint’s maid quotes Latin” in English. Conventionally learning method in surgery has been something like this saying. “Just keep on seeing it and learn it!” But how to teach in surgery might be changed from “analog” to scientific or digital when the methods of analysis and assessment of surgical skills are developed and matured. Such an era seems to be just around the corner.