Fumihiro Yoshimura

A Protective Technique for Retraction of the Liver During Laparoscopic Gastrectomy for Gastric Adenocarcinoma: Using a Penrose Drain

BackgroundRetraction 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.Methods111 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 phoshatase (ALP) and albumin were compared among the groups at baseline, immediately after operation, and on postoperative days (POD) 1, 2, 3, 5, and 7.ResultsThe 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.ConclusionsThe use of the Penrose drain for retraction of the liver appears to attenuate postoperative liver dysfunction during laparoscopic gastrectomy for gastric adenocarcinoma.

Clinical Outcome and Clinicopathological Characteristics of Recurrence after Laparoscopic Gastrectomy for Advanced Gastric Cancer

Background: 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. Methods: 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. Results: 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. Conclusion: 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.

Robot-assisted surgery for gastric cancer: experience at our institute.

Objective: 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. Methods: 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. Results: 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. Conclusions: This study demonstrated that robot-assisted gastrectomy using the da Vinci system can be applied safely and effectively for patients with gastric cancer.

Lymph node dissection with cervical approach as a salvage surgery for locoregional failure after definitive chemoradiotherapy in a patient with recurrent esophageal carcinoma: report of a case

Salvage surgery is one important therapeutic option after locoregional failure of definitive chemoradiotherapy (dCRT) in patients with advanced or recurrent esophageal carcinoma. We have performed cervical lymph node dissection as a salvage surgery after chemoradiotherapy in a patient with recurrent esophageal carcinoma. A 54-year-old Japanese man was admitted to our hospital because of multiple lymph node metastases after endoscopic submucosal dissection (ESD) for early-stage esophageal carcinoma. The patient underwent a circumferential ESD of early-stage esophageal carcinoma in another hospital. The esophageal carcinoma, measuring 75 × 60 mm in size, was a superficial spreading type located in the middle portion of the thoracic esophagus. Histology of the resected specimen revealed a moderately to poorly differentiated squamous cell carcinoma, and the depth of invasion was limited within the mucosal layer associated with a small area being attached to the muscularis mucosae. Five months after ESD, lymph node metastases in the regions of right recurrent nerve and the left tracheobronchus were found, for which dCRT was performed. These metastatic lymph nodes disappeared in the chest CT scan images. Lymph node metastasis in the region of the right recurrent nerve then reappeared 8 months after the completion of CRT. Considering the solitary lymph node metastasis and surgical invasiveness, lymph node dissection using a cervical approach was selected as a salvage surgery. Cervical approach for the lymph node dissection in the region of right recurrent nerve may be one feasible option as a minimally invasive salvage surgery for patients with recurrent esophageal carcinoma after dCRT.

Successful management of esophageal necrosis after thoracic endovascular aortic repair for ruptured traumatic aortic aneurysm

A 65-year-old man reported nausea and anorexia after falling down a flight of stairs. Computed tomography (CT) showed a ruptured descending thoracic aortic aneurysm, and emergency thoracic endovascular aortic repair (TEVAR) was performed. However, after resuming food intake, the patient developed a fever. CT scan showed severe pneumomediastinum and a mediastinal abscess, and the patient was diagnosed with esophageal perforation. Emergency esophagectomy was performed, with an esophageal fistula made at the cervix. Jejunostomy was then performed to enable enteral nutrition. Histological examination showed substantial necrosis at the middle intrathoracic esophagus, and the patient was diagnosed with esophageal necrosis leading to perforation. Five months after the esophagectomy, gastric conduit reconstruction through the retrosternal route was performed. The patient was able to resume food intake, and survived more than 1 year after this surgery. Here, we describe the successful management of this rare case of esophageal necrosis after TEVAR for ruptured traumatic aortic aneurysm.

Multidisciplinary therapeutic approach for maintaining long-term nutritional status for patient with advanced esophageal carcinoma confounded by dermatomyositis

We report a patient with advanced esophageal carcinoma associated with dermatomyositis who successfully maintained long-term good nutritional status by chemoradiation therapy and continuous enteral nutrition. A 64-year-old Japanese man was admitted to our hospital because of dysphagia and systemic edema. Because of debilitated status and malnutrition, intravenous corticosteroid infusion was first performed. Continuous enteral nutrition was performed through percutaneous endoscopic gastrostomy, and chemoradiation therapy was then performed. Although the endoscopic examination revealed complete regression of esophageal carcinoma, an esophagobronchial fistula was formed. The patient was periodically followed up by a multidisciplinary team for appropriate nutritional management; as a result, nutritional status was markedly improved and well maintained. A covered, selfexpandable metallic stent was placed in the esophagus to conceal the esophagobronchial fistula. This case highlights the importance of multidisciplinary therapeutic approach for maintaining good nutritional status and quality of life in patients with advanced esophageal carcinoma confounded by debilitating disorders.