Hiromichi Aoyama

Surgical advantages of gastric SMTs by laparoscopy and endoscopy cooperative surgery.

BACKGROUND/AIMS The treatment of gastric submucosal tumors (SMTs) is strictly surgical and enucleation of the tumor or wedge resection of the stomach is efficient to achieve R0 resection. Laparoscopic and endoscopic cooperative surgery (LECS) can be safely performed with adequate cutting lines. This study describes the initial 16 cases treated by LECS and evaluates the advantages by LECS for gastric SMTs retrospectively. METHODOLOGY Sixteen patients with gastric SMT underwent LECS from June 2007 to December 2010, their surgical data, clinical characteristics and surgical specimens of SMTs were compared. The surgical specimens of 9 gastric SMTs treated by laparoscopic wedge resection (LWR) were compared as a control. RESULTS The median (range) length of operation time, blood loss, hospital stay after surgery were minutes 172 (115- 220), <5mL (<5-115) and 10 days (6-17), respectively. The median (range) ratio of the longest diameter of the tumor divided by the longest diameter of the surgical specimen in LECS and LWR were 0.86 (0.625-1.0) and 0.69 (0.44-1.0), respectively (p=0.0189, Wilcoxon rank sum test). CONCLUSIONS LECS minimizes the surgical specimen while still providing sufficient surgical margins to successfully cure gastric SMTs.

Virtual Pancreatoscopy of Mucin-Producing Pancreatic Tumors

We used computer-based virtual endoscopy techniques as a novel approach to clarify the three-dimensional (3D) surgical anatomy of the pancreas and of mucin-producing pancreatic tumors. Thirteen cases (18 lesions) of mucin-producing pancreatic tumors were investigated by virtual pancreatoscopy. Virtual endoscopic images were generated with virtual endoscopy software application on UNIX workstations. We created surface-rendered virtual endoscopic images derived from a computer reconstruction of the cross-sectional magnetic resonance imaging data. Virtual endoscopy could visualize the surfaces of the pancreatic duct and the bile duct, and also demonstrated all cystic tumors. The surfaces of malignant mucin-producing pancreatic tumors were illustrated as being more irregular than those of benign lesions. The virtual endoscopic technique could demonstrate not only a surface-rendered endoscopic image of the tumors but also a 3D reconstructed image of the pancreas. The relationship to anatomic structures located outside the surfaces is continuously maintained and displayed at the same time. Virtual pancreatoscopy was useful for surgical planning of minimally invasive resection of the pancreas.

Focal segmental glomerular sclerosis recurrence with massive proteinuria and anuria immediately after kidney transplantation

Here, we report a case of focal segmental glomerular sclerosis (FSGS) recurrence immediately (47 minutes) after transplantation. A 1‐hour biopsy specimen showed large periodic acid‐Schiff–positive granules within the cells of the swollen proximal tubule, while electron microscopy revealed podocyte swelling and partial foot process effacement. These findings were worse on day 2 biopsy. Massive proteinuria and anuria were then observed. Two courses (2 × 2 times) of plasmapheresis and rituximab were administered, and the graft function gradually recovered. A day 22 biopsy specimen showed improvement in findings compared to those observed on day 2. One year after transplantation, no signs of FSGS recurrence are evident, and graft function remains good.

A Novel Method for Real-Time Audio Recording With Intraoperative Video

OBJECTIVE Although laparoscopic surgery has become widespread, effective and efficient education in laparoscopic surgery is difficult. Instructive laparoscopy videos with appropriate annotations are ideal for initial training in laparoscopic surgery; however, the method we use at our institution for creating laparoscopy videos with audio is not generalized, and there have been no detailed explanations of any such method. Our objectives were to demonstrate the feasibility of low-cost simple methods for recording surgical videos with audio and to perform a preliminary safety evaluation when obtaining these recordings during operations. DESIGN We devised a method for the synchronous recording of surgical video with real-time audio in which we connected an amplifier and a wireless microphone to an existing endoscopy system and its equipped video-recording device. We tested this system in 209 cases of laparoscopic surgery in operating rooms between August 2010 and July 2011 and prospectively investigated the results of the audiovisual recording method and examined intraoperative problems. SETTING Numazu City Hospital in Numazu city, Japan. PARTICIPANTS Surgeons, instrument nurses, and medical engineers. RESULTS In all cases, the synchronous input of audio and video was possible. The recording system did not cause any inconvenience to the surgeon, assistants, instrument nurse, sterilized equipment, or electrical medical equipment. Statistically significant differences were not observed between the audiovisual group and control group regarding the operating time, which had been divided into 2 slots-performed by the instructors or by trainees (p > 0.05). CONCLUSIONS This recording method is feasible and considerably safe while posing minimal difficulty in terms of technology, time, and expense. We recommend this method for both surgical trainees who wish to acquire surgical skills effectively and medical instructors who wish to teach surgical skills effectively.

Effectivity of Hypothermic Machine Perfusion Preservation for Non-Heart-Beating Donor Kidney Transplantation in Japan

Background In Japan, brain-dead donors have been increased by revised Act of Organ Transplantation, however, insufficiency of deceased donors is still serious problem. In kidney transplantation, it is important to use marginal donors such as non-heart-beating donors for solving this problem. Static cold storage (SCS) is the most widely used organ preservation method for deceased donor, and in Japan it is now the only technique for kidney preservation, however, hypothermic machine perfusion preservation (HMP) technique may improve better outcomes than SCS. HMP technology has had a major impact in circumventing ischemic injury in kidney transplantation in western countries. In this presentation, we report efficiency of HMP method for preservation of long ischemic kidney grafts in beagle and case reports of clinical usage to kidney transplantation of non-heat-beating donor in Japan. Methods Young beagles were used as autonomic HMP transplantation model. After general anesthesia of beagles, left renal artery and vein were made ligation, after 30 min warm ischemia time (WIT) in situ, the left kidney was harvested. Each harvested kidney was assigned to one of two preservation treatment groups; SCS group (storage in UW solution at 2-4°C for 24h, n=5); HMP group (storage on LifePort® (Organ Recovery Systems), at 4-6°C on 30 mmHg pressure for 24h with KPS-1 solution, n=5). After the storage, wedge biopsies were taken for histological evaluation. The preserved graft was transplanted to the same beagle in left iliac fossa and removed right kidney. After the operation, recipient survival and graft qualities (urine output, serum creatinine, sodium and potassium) were checked as the clinical outcomes. Results All recipients of HMP group survived, however, three recipients of SCS group were dead with uremia. Serum creatinine level of HMP group was under 4mg/dL in all post-operation period and reduced under 1.5mg/dL after 11days of post-operation. The other hands, those of SCS group went up over 5mg/dL and did not reduce under 3mg/dL. In histological findings, HE staining revealed that a little bit interstitial edema was exist with HMP groups, and remarkable interstitial edema and vaculolation were exist with SCS group. Clinical Cases We performed three cases of renal transplant with HMP graft from non-heart-beating donor. The all three recipients were discharged hospital without any complications with achieved withdrawal of hemodialysis. HMP reduced the duration of delayed graft function and graft function with HMP was same as that with SCS. Conclusion In this experiment, we indicate that HMP would be better for long term WIT kidney model compared with SCS method in beagles. We experienced three clinical cases of non-heart-beating donor kidney transplantation with LifePort® preserved graft in Japan. It suggests that with marginal donor that is non-heart-beating and is with long agony, HMP should be paid more tribute to than SCS technique.

Impact of primary diabetic nephropathy on arteriolar hyalinosis lesions in patients following kidney transplantation: Allograft arteriolar hyalinosis with diabetes

Arteriolar hyalinosis (AH) is a common lesion in allograft biopsies taken following kidney transplantation. Recent studies have shown that severe AH may predict transplant outcomes and provide information about previous exposure to certain drugs, such as calcineurin inhibitors (CNI). However, the incidence of AH as a direct result of diabetic nephropathy (DN) after kidney transplantation has not been fully evaluated. This study aimed to assess the impact of primary DN on the development of AH lesions in patients who underwent kidney transplantation.