Kazuhito Minami

The triangulating stapling technique for cervical esophagogastric anastomosis after esophagectomy.

PurposeTo evaluate the safety and feasibility of the triangulating stapling technique (TST) for cervical esophagogastric anastomosis after esophagectomy (CEGA).MethodsThe subjects were 123 patients who underwent transthoracic esophagectomy with three-field lymph node dissection and reconstruction with a 3.5-cm wide gastric tube, for thoracic esophageal cancer. We performed the TST for CEGA in 33 patients operated on after December, 2006 (TST group) and hand-sewn anastomosis in 90 patients operated on between 2002 and 2006 (HSA group).ResultsIn the TST group, CEGA was performed in an end-to-end fashion using three linear staplers. The first anastomosis was applied to the posterior walls of the remnant esophagus and gastric tube in an inverted fashion. The second and the third anastomoses were done in an everted fashion to make the anterior wall. The end-to-end HSA was performed with interrupted sutures using 4-0 absorbable material. Anastomotic leakage occurred in only 1 (3.0%) of the 33 TST patients, but in 13 (14.4%) of the 90 HSA patients (P = 0.07). The frequency of anastomotic stenosis was 9.1% and 25.6% in the TST and HSA groups, respectively (P < 0.05).ConclusionsCervical esophagogastric anastomosis using TST may reduce the frequency of anastomotic leakage and stenosis. This technique is a safe and reliable alternative for CEGA after esophagectomy.

Follow-up and recurrence after a curative esophagectomy for patients with esophageal cancer: the first indicators for recurrence and their prognostic values

BackgroundNo standardized methods exist for the follow-up and treatment of recurrence after a curative esophagectomy for patients with thoracic esophageal cancers.MethodsOne hundred seventy-five patients with thoracic esophageal cancer underwent a curative resection and were followed up during a median period of 3.0 years (3 months-18 years). The time to recurrence, the first indicators (FIs) to suspect recurrence, and the factors predictive of prognosis after recurrence were investigated.ResultsRecurrence occurred in 72 (41.1%) of 175 patients. Forty (55.6%) and 22 (30.6%) of 72 cases presented with recurrences in the first and second year after the initial operation, respectively. Clinical visit (anamnesis and physical examination), tumor markers, and imaging were FIs in 39 (54.2%), 33 (45.8%), and 49 (68.1%) of 72 patients with recurrence, respectively. Imaging was the exclusive FI in 19 (26.4%) cases. A multivariate analysis showed the favorable prognostic factors after recurrence to be recurrence later than 1 year after the initial operation and a case in which the FI was only imaging.ConclusionsIntensive follow-up is required in the first 2 years after surgery, and early detection of recurrence is important. The accumulation of clinical data based on a fixed schedule with consensus is necessary to obtain more definite evidence for the diagnosis and treatment of recurrent esophageal cancer.

Locoregional immunotherapy of malignant effusion from colorectal cancer using the streptococcal preparation OK-432 plus Interleukin-2: Induction of autologous tumour-reactive CD4+ Th1 killer lymphocytes

In total, 16 patients with cytologically proven malignant effusion from colorectal cancer were treated by locoregional administration of the streptococcal preparation OK-432 alone or OK-432 plus the T-cell growth factor interleukin (IL)-2, and the action mechanism of the treatment was studied. A positive clinical response, showing a cytologic disappearance of cancer cells and decrease of effusion, was observed in nine of 11 (82%) patients treated with OK-432 alone and in all five patients treated with OK-432 plus IL-2. Flow cytometric analysis revealed that OK-432 plus IL-2 locally induced acute inflammation-like responses, including serial cellular infiltrations of granulocyte migration within a matter of hours, and activation of macrophages and T lymphocyte involvement within the following days, and that a predominant expansion of CD3+CD4+ lymphocytes (CD: cluster of differentiation) was induced by in vitro stimulation with IL-2 of locoregional cells after the OK-432 administration (OK/IL-2AK cells). The OK/IL-2AK cells produced tumour necrosis factor-α and interferon-γ, but these cells did not produce IL-4 and IL-6. The OK/IL-2AK cells expressed potent killing activity against autologous tumour cells. This activity was abrogated by treatment of the lymphocytes with anti-CD3, -CD4, -TCRαβ antibody, and by the treatment of target cells with anti-human leukocyte antigen (HLA)-DR antibody. The OK/IL-2AK cells expressed Fas-L gene, and flow cytometric analysis demonstrated HLA-DR expression in approximately 75% of CEA+ or cytokeratin+ effusion cells. TCRVβ gene analysis of the OK/IL-2AK cells showed an oligoclonal usage of TCRβ20, which was also involved in the cytotoxic mechanism of the OK/IL-2AK cells. Single-strand conformational polymorphism analysis demonstrated the clonotypes for the TCRVβ20 gene, and the CDR3s of the gene were sequenced. The clonotypic PCR using the TCRVβ20-CDR3 sequences could detect the CDR3-identical TCRs in effusion lymphocytes from the other patients. Taken together, it is suggested that locoregional administration of OK-432 plus IL-2 is highly effective for the management of malignant effusion from colorectal cancer. OK-432 plus IL-2 induces autologous tumour-reactive CD4+ Th1 killer lymphocytes, which recognise tumour antigen(s) presented with HLA class II molecules on effusion tumour cells by means of preferential usage of TCRVβ20. The clonotypic PCR using the TCRVβ20-CDR3 sequences may be informative for treating malignant effusion from colorectal cancer using OK-432 plus IL-2.

Safe laparoscopic resection of a gastric gastrointestinal stromal tumor close to the esophagogastric junction

Laparoscopic gastrectomy is commonly performed for gastrointestinal stromal tumors (GISTs). Partial gastrectomy is usually achieved with a wedge resection to preserve gastric function; however, performing a wedge resection to excise a large tumor located close to the esophagogastric junction (EGJ) can result in deformation of the stomach and/or the stenosis of the EGJ if the gastric wall resection is excessive. We describe our procedure, in which the whole layer of the gastric wall was cut, maintaining a sufficient margin and confirming the distance between the tumor and the EGJ, by endoscopy and laparoscopy. The defect in the gastric wall was closed using linear staplers by hanging up the stay sutures. Five patients with GIST close to EGJ underwent this procedure, followed by a good postoperative course. Thus, we consider our procedure to be safe and effective for gastric GISTs close to the EGJ.

Surgical complications and the risk factors of totally laparoscopic distal gastrectomy

Purpose It has not yet been elucidated whether there are specific complications associated with totally laparoscopic distal gastrectomy (TLDG). We evaluated the complications and the risk factors associated with TLDG. Methods A retrospective analysis was performed on 138 consecutive patients who underwent TLDG. The clinical and operative data, which included the body mass index, respiratory function, hematological data, pathological data, and the experience of surgeon, were analyzed. Results Intraoperative and postoperative complications developed in 10 and 28 patients, respectively. A univariate analysis determined that the patient age, concurrent respiratory disease, and operation time were important risk factors. A multivariate analysis found no significant risk factors in this set, although the operation time was the most promising risk factor. Conclusions The present data suggest that TLDG can be performed with acceptable perioperative complication rates, although a longer operation time may cause a higher frequency of postoperative complications.

The impact of obesity on the use of a totally laparoscopic distal gastrectomy in patients with gastric cancer

Purpose Since a patients obesity can affect the mortality and morbidity of the surgery, less drastic surgeries may have a major benefit for obese individuals. This study evaluated the feasibility of performing a totally laparoscopic distal gastrectomy, with intracorporeal anastomosis, in obese patients suffering from gastric cancer. Materials and Methods This was a retrospective analysis of the 138 patients, who underwent a totally laparoscopic distal gastrectomy from April 2005 to March 2009, at the National Kyushu Cancer Center. The body mass index of 20 patients was ≥25, and in 118 patients, it was <25 kg/m2. Results The mean values of body mass index in the 2 groups were 27.3±2.2 and 21.4±2.3. Hypertension was significantly more frequent in the obese patients than in the non-obese patients. The intraoperative blood loss, duration of surgery, post-operative complication rate, post-operative hospital stay, and a number of retrieved lymph nodes were not significantly different between the two groups. Conclusions Intracorporeal anastomosis seemed to have a benefit for obese individuals. Totally laparoscopic gastrectomy is, therefore, considered to be a safe and an effective modality for obese patients.

Feasibility of delta-shaped anastomoses in totally laparoscopic distal gastrectomy.

Background: Delta-shaped (DS) anastomosis is a new reconstruction method for totally laparoscopic distal gastrectomy (TLDG) using a linear stapler. We evaluated the feasibility of using this method for TLDG. Methods: A retrospective analysis was performed in 114 patients who underwent TLDG with DS anastomosis. Twenty-four patients reconstructed with a Roux-en-Y (RY) anastomosis during the same period were analyzed as control subjects. Results: The patient characteristics of DS and RY anastomoses were slightly different in terms of tumor location and extent of lymph node dissection, since this was not a prospective comparative study. Blood loss, postoperative complication rate and postoperative hospital stay were not different between the two groups. There was only 1 case of anastomotic leakage, and no case of anastomotic stricture after DS anastomosis. The length of the operation using DS anastomosis was significantly shorter than for RY anastomosis. The rates of body weight loss were not significantly different at 1 year after the operation. Conclusions: Although this was a small retrospective analysis, DS anastomosis was feasible, required a shorter operation time, and had no associated complications. This method can therefore be recommended as a standard procedure for TLDG.

Risk factors for early recurrence after curative hepatectomy for colorectal liver metastases.

PurposeWith the broadening indications for hepatectomy to treat colorectal liver metastases (CRLM), early recurrence is a major problem. The aim of this study is to identify risk factors of early recurrence, defined as recurrence within 1 year after surgery.MethodsA retrospective analysis was performed on 121 consecutive patients who underwent hepatectomy for CRLM.ResultsAmong 121 patients, 52 (43.0%) developed early recurrence. The independent risk factor for early recurrence was “number of liver metastases ≥3” (odds ratio 2.65). There were significantly more patients with liver recurrence (51.9%) and recurrence beyond curative surgical resection (63.5%) in those with early recurrence. In addition, patients with three or more liver metastases had significantly more liver recurrence (66.7%; P = 0.02) and recurrence beyond curative surgical resection (70.8%; P = 0.04). The overall survival rates of both patients with early recurrence (5-year survival rate 20%) and those with three or more liver metastases (5-year survival rate 24%) were significantly worse.ConclusionsThe independent risk factor for early recurrence is the “number of liver metastases ≥3.” Patients with three or more liver metastases have a significantly higher risk of liver recurrence and a higher rate of recurrence beyond curative surgical resection, and these are correlated with a poor prognosis.

Neuroendocrine carcinoma of the esophagus: Clinicopathological and immunohistochemical features of 14 cases

Background Neuroendocrine carcinoma (NEC) of the esophagus is a rare and highly aggressive disease but the biological features are poorly understood. The objective of this study was to analyze the clinicopathological and immunohistochemical features of NEC of the esophagus. Methods Fourteen patients diagnosed with NEC of the esophagus from 1998 to 2013 were included in this study. Clinicopathologic features, therapeutic outcomes and immunohistochemical results were analyzed. Results Eleven out of 14 cases showed protruding or localized type with or without ulceration. Only three patients were negative for both lymph node and organ metastasis and seven cases were positive for metastases to distant organs and/or distant lymph nodes. Of the six patients with limited disease (LD), three patients were treated by surgery. Three patients with LD and seven patients with extensive disease (ED) were initially treated with chemotherapy, except for one who underwent concurrent chemo-radiotherapy due to passage disturbance. The median survival of patients with LD was 8.5 months, whereas that of patients with LD was 17 months. Among the 14 cases, 12 cases (83.3%), 13 cases (91.7%) and 12 cases (83.3%) showed positive immunostaining for choromogranin A, synaptophysin and CD56, respectively. Nine of 14 cases (64.2%) presented positive staining for c-kit and most (8/9, 88%) simultaneously showed p53 protein abnormality. Two cases were negative for c-kit and p53, and positive for CK20. Conclusion Consistent with previous reports, the prognosis of NEC of esophagus is dismal. From the results of immunohistochemical study, NEC of esophagus might be divided into two categories due to the staining positivity of c-kit and p53. This study provides new insight into the biology of NEC of the esophagus.

Totally Laparoscopic Gastrectomy for Gastric Cancer Associated with Recklinghausen's Disease.

This paper documents the first case of gastric cancer associated with Recklinghausens disease, which was successfully treated by a totally laparoscopic operation. A 67-year-old woman with Recklinghausens disease was referred to this department to undergo surgical treatment for early gastric cancer. The physical examination showed multiple cutaneous neurofibromas throughout the body surface, which made an upper abdominal incision impossible. Laparoscopic surgery requiring only small incisions was well indicated, and a totally laparoscopic distal gastrectomy with lymph node dissection was performed. Billroth I reconstruction was done intra-abdominally using a delta-shaped anastomosis. The patient followed a satisfactory postoperative course with no complications. Since the totally laparoscopic gastrectomy has many advantages over open surgery, it should therefore be preferentially used as a less invasive treatment in the field of gastric cancer.