Hirohisa Takeuchi

Recent developments in gastric endoscopic submucosal dissection: Towards the era of endoscopic resection of layers deeper than the submucosa

With technical advances in endoscopic submucosal dissection (ESD), several variations of endoscopic procedure derived from ESD and fusion procedures of endoscopy and laparoscopy for upper gastrointestinal submucosal tumor and cancer have recently been developed. The former includes endoscopic muscularis dissection (EMD), submucosal endoscopic tumor resection (SET), endoscopic submucosal tunnel dissection (ESTD) and endoscopic full‐thickness resection (EFTR), and the latter includes laparoscopic and endoscopic cooperative surgery (LECS), laparoscopy‐assisted endoscopic full‐thickness resection (LAEFR), and laparoscopic lymphadenectomy without gastrectomy following ESD. In the present article, recent developments in gastric ESD and advanced procedures derived from ESD are discussed.

Single-port endoscopic cholecystectomy: a bridge between laparoscopic and translumenal endoscopic surgery

BACKGROUND AND OBJECTIVE The intentional puncture of the normal viscera is likely the most important issue limiting the widespread use of natural orifice translumenal endoscopic surgery (NOTES). We developed a new procedure for cholecystectomy using a flexible endoscope via a single port placed in the abdominal wall without visceral puncture (single-port endoscopic cholecystectomy; SPEC) as a bridge between laparoscopic surgery and NOTES. This study aimed to evaluate the technical feasibility of SPEC. METHODS Five pigs were subjected to SPEC. An endoscope was inserted through a 12-mm port placed in the right upper abdomen. After grasping and retracting the gallbladder using a 2-mm retractor that was directly introduced into the peritoneal cavity, gallbladder excision with ligation of the cystic artery and duct using endoclips was carried out. RESULTS A complete gallbladder excision was carried out easily and safely in all cases. No major adverse events occurred. The mean operating time was 67 min (range 52-84 min). CONCLUSIONS SPEC is a technically feasible procedure. It is simpler, easier, and safer than NOTES cholecystectomy. SPEC could be a less invasive alternative to the conventional four-port laparoscopic cholecystectomy.

SURGICAL INDICATIONS AND PROCEDURES FOR BLEEDING PEPTIC ULCER

Recent important insights into the surgical treatment of bleeding peptic ulcer are reviewed in this article. Although the widespread use of endoscopic treatment and interventional radiology has reduced the number of surgical cases, surgery still plays a pivotal role in managing bleeding peptic ulcer. Failure to stop the bleeding by endoscopy and/or interventional radiology is the most important indication for emergency surgery. An early elective/planned surgery after the initial endoscopic control to prevent life‐threatening rebleeding seems justified in patients who have risk factors for rebleeding, although its true efficacy still remains controversial. The surgical procedures in emergency situations should be limited to safe hemostasis. The addition of acid‐reduction surgery may be unnecessary as a result of the increasing utilization of proton pump inhibitors. Angiographic embolization may be a less invasive alternative to surgery, and may further enhance endoscopic hemostasis.

Successful treatment of duodenal carcinoid tumor by laparoscopy‐assisted endoscopic full‐thickness resection with lymphadenectomy

Reports on endoscopic full‐thickness resection of the duodenum using the endoscopic submucosal dissection technique are rare. Here we present a case of a duodenal bulb carcinoid tumor successfully treated by laparoscopy‐assisted endoscopic full‐thickness resection (LAEFR). An asymptomatic 65‐year‐old woman had a 10‐mm, submucosal tumor on the anterior wall of the duodenal bulb. Abdominal CT revealed an enlarged lymph node adjacent to the duodenum and pancreas. Although we informed the patient of the need for pancreatoduodenectomy with a lymphadenectomy, the patient expressly requested LAEFR. After negative nodal metastasis was confirmed by an intraoperative frozen section of the enlarged nodes, LAEFR was performed using the endoscopic submucosal dissection technique under the laparoscopic assistance. The duodenal wall defect was closed by laparoscopy with an Albert anastomosis. The entire circumferential margin of the specimen was histopathologically negative for carcinoid tumor cells. In summary, LAEFR enables en bloc and whole‐layer excision of nonperiampullary duodenal lesions with a sufficient surgical margin, both vertically and laterally. LAEFR is a minimally invasive and effective treatment for selected patients with duodenal carcinoid tumor.

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

OBJECTIVE This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy. METHODS Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope. RESULTS A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1). CONCLUSION This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.

Microscopic cancer cell spread in gastric cancer: whole-section analysis of mesogastrium

PurposeCancer cells are often found in adipose connective tissue separate from the primary lesion and outside lymph nodes on routine pathologic examination of resected gastric cancer specimens. To identify the anatomical relationship between such cancer cell spread and lymph nodes, we investigated the microscopic cancer cell spread in the mesogastrium (CSM) by the whole-section analysis of the mesogastrium.MethodOne thousand five hundred fifty-two sections of the mesogastrium obtained from 37 patients with gastric cancer were subjected. CSM is defined as the existence of cancer cell spread in the mesogastrium separate from the primary lesion.ResultsCSM was detected in three (8%) of the 37 patients. CSM was classified into three types. CSM was found in three of the 12 patients with advanced cancer, but not in 25 patients with early cancer.ConclusionsCSM may occur in the mesogastrium separate from metastatic lymph nodes; therefore, we should pay particular attention to the potential existence of CSM in surgery for gastric cancer.

Laparoscopy-assisted transduodenal excision of superficial non-ampullary duodenal epithelial tumors

Transduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low‐grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy‐assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non‐ampullary duodenal epithelial tumors.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy.

A 54‐year‐old man had a 65‐mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ‐preserving laparoscopic surgery, we conducted laparoscopy‐assisted pancreas‐sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port‐site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.

Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor

A retrospective study was conducted to compare two resection methods, namely, endoscopic resection (ER) procedures (endoscopic submucosal dissection [ESD], endoscopic muscularis dissection [EMD], and endoscopic full‐thickness resection [EFTR]) and laparoscopic resections (LR) (laparoscopic endoscopic cooperative surgery [LECS] and laparoscopic wedge resection).

Laparoscopy-assisted full-thickness resection of the duodenum for patients with gastrointestinal stromal tumor with ulceration

Gastrointestinal stromal tumor (GIST) with ulceration may potentially disseminate into the peritoneal cavity after laparoscopic local wedge resection (full‐thickness resection) when the intestinal wall is opened under the aeroperitoneum. To prevent this intraoperative tumor seeding, we developed laparoscopy‐assisted full‐thickness resection (LAFTR) of the duodenum for GIST with ulceration. Here, we present the preliminary results of LAFTR.