Kazuyuki Kawamoto

Correlation of Tensile Strength with Bursting Pressure in the Evaluation of Intestinal Anastomosis

Background: Although bursting pressure and tensile strength have long been measured to evaluate anastomotic techniques, it has yet to be clarified whether or not they are correlated, what implications they have, and which should be used as a gold standard. Material and Methods: Using an experimental model to estimate pressure and tension in the same colonic anastomosis, the following variables were measured in 48 rats between days 0 and 14: bursting pressure (BP); minimal tensile strength (MITS) necessary to break a part of the anastomosis, and maximal tensile strength (MATS) needed to disrupt the whole anastomosis. Also, circulatory wall tension (CWT) was derived from BP and the anastomotic circumference (AC), and longitudinal wall tension (LWT) from MITS and AC. These variables were compared using correlation and regression analysis. Results: During the lag phase (days ≤4) there was poor correlation between pressure-related and tension-related variables whereas highly significant correlations were noted in the subsequent fibroplastic phase (day ≥5). It was shown by regression lines that positive MITS and MATS were expected when BP was zero. Conclusion: Contrary to the previous assumption, no correlation was found between BP and tensile strength in the critical postoperative period. Based on our present and previous studies, measurement of MITS is recommended to evaluate the healing of colonic anastomosis.

Expression of Insulin-Like Growth Factor-2 Can Predict the Prognosis of Human Colorectal Cancer Patients: Correlation with Tumor Progression, Proliferative Activity and Survival

Expression of insulin-like growth factor-2 (IGF-2) has been reported in tissue specimens and cell lines of human colorectal cancers. However, the effects of IGF-2 in colorectal cancer patients are not well known. In this study, IGF-2 staining was performed on tissue samples from 92 patients with colorectal cancer, and the relationship of IGF-2 staining to clinicopathological variables, proliferating cell nuclear antigen (PCNA) staining and patient survival was analyzed. IGF-2 staining was correlated with tumor progression, PCNA staining and patient survival. Our results suggest that IGF-2 plays an important role in tumor progression and that IGF-2 staining is useful as a prognostic factor in colorectal cancer patients.

Pathologic significance of tumor progression in locally recurrent rectal cancer: different nature from primary cancer.

PURPOSE: It has recently been demonstrated that the tumor growth rate is a stronger determinant of survival than the extent of the growth in local recurrence of rectal cancer. We studied which factors controlled the tumor growth rate using modern immunohistochemical methods. METHODS: In 51 patients who underwent extended resection for this condition, paraffin-embedded specimens were examined for 1) tumor angiogenesis by CD31 staining and microvessel counting, 2) apoptosis by terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling staining, and 3) cellular proliferative activity using anti-proliferative cell nuclear antigen antibody. The results were compared with carcinoembryonic antigen doubling time and survival. RESULTS: The five-year survival rate was 20 percent. The postoperative carcinoembryonic antigen doubling time, which was the strongest predictor of survival, correlated highly with proliferative cell nuclear antigen labeling index, but did not correlate with the apoptotic index or microvessel counts. CONCLUSION: Our study shows that cancer cell proliferation rather than apoptosis or angiogenesis is a major determinant of tumor growth rate and survival in patients with locally recurrent rectal cancer.

Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma

AIM To evaluate a laparoscopic approach to gallbladder lesions including polyps, wall-thickening lesions, and suspected T1 and T2 gallbladder cancer (GBC). METHODS We performed 50 cases of laparoscopic whole-layer cholecystectomy (LCWL) and 13 cases of laparoscopic gallbladder bed resection (LCGB) for those gallbladder lesions from April 2010 to November 2016. We analyzed the short-term and long-term results of our laparoscopic approach. RESULTS The median operation time was 108 min for LCWL and 211 min for LCGB. The median blood loss was minimal for LCWL and 28 ml for LCGB. No severe morbidity occurred in either procedure. Nine patients who underwent LCWL and 7 who underwent LCGB were postoperatively diagnosed with GBC. One of these patients had undergone LCGB for pathologically diagnosed T2 GBC after LCWL. All of the final surgical margins were negative. Three of these 15 patients underwent additional open surgery. The mean follow-up period was 26 mo, and only one patient developed recurrence. CONCLUSION LCWL and LCGB are safe and useful procedures that allow complete resection of highly suspected or early-stage cancer and achieve good short-term and long-term results.

Two-stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) in treating liver metastases of rectal cancer: a case report.

IntroductionAn innovative approach, called associated liver partition and portal vein ligation for staged hepatectomy(ALPPS), has made possible a marked increase in future liver remnant (FLR) volume over a short period of time, thus permitting extended hepatectomy.Case descriptionThis report describes ALPPS in a 63-year-old male patient with rectal cancer and synchronous multiple liver metastases. The primary lesion was resected, followed by chemotherapy. We had planned to completely resect the metastases in both liver lobes, but CT volumetry revealed a very small FLR (364 ml, 29% of the total liver volume, 0.61% of total body weight). His indocyanine green retention rate at 15 minutes was 12.7%. Because of the risk of tumor progression in the interim, we performed ALPPS. During the first stage, the tumor in segment 3 was resected, the right lobe was mobilized, the liver was partitioned, and the right portal vein was ligated. The right hepatic artery, duct and vein were secured with vessel loops. CT on postoperative day 6 showed sufficient FLR increase (from 364 ml to 573 ml, or from 0.61% to 0.96% of total body weight) and ICGR15 improvement to 3.4%. The second stage of ALPPS was on postoperative day 7, completing resection of the metastases. The patient recovered well and was discharged 21 days after the second step.Discussion and evaluationThe ALPPS approach has many advantages, but it lacks evidence of long-term results. Considering the high mortality and morbidity rates of ALPPS, it is essential to evaluate its risks and benefits in individual patients and determine the strict criteria for this surgical method.ConclusionsALPPS procedure rapidly increases FLR, permitting extended hepatectomy for patients with initially insufficient FLR.

Major hepatectomy using the glissonean approach in cases of right umbilical portion

Right umbilical portion (RUP) is a rare congenital anomaly associated with anomalous ramifications of the hepatic vessels and biliary system. As such, major hepatectomy requires a careful approach. We describe the usefulness of the Glissonean approach in two patients with vessel anomalies, such as RUP. The first patient underwent a right anterior sectionectomy for intrahepatic cholangiocarcinoma. We encircled several Glissonean pedicles that entered the right anterior section along the right side of the RUP. We temporarily clamped each pedicle, confirmed the demarcation area, and finally cut them. The operation was performed safely and was successful. The second patient underwent a left trisectionectomy for perihilar cholangiocarcinoma. We secured the right posterior Glissonean pedicle. The vessels in the pedicle were preserved, and the other vessels and contents were resected. Identifying the vessels for preservation facilitated the safe lymphadenectomy and dissection of the vessels to be resected. We successfully performed the operation.

Laparoscopic vs Open Radical Antegrade Modular Pancreatosplenectomy for Left-Sided Pancreatic Cancer Using the Ligament of Treitz Approach

Background Laparoscopic distal pancreatectomy (Lap-DP) for benign lesions or those with low malignant potential has been proven safe and effective, and its performance is now widespread [1, 2, 3]. Lap-DP for left-sided pancreatic cancer (PC) is also being increasingly performed. According to some reports, Lap-DP has superior short-term outcomes (blood loss, postoperative hospital stay) and comparable oncological outcomes and overall survival with those of open distal pancreatectomy (Op-DP) [4, 5, 6]. PC has highly malignant potential; thus, complete resection and sufficient regional lymphadenectomy with tumor-free margins are very important. Radical antegrade modular pancreatosplenectomy (RAMPS) is an accepted standard Op-DP technique for PC and is reportedly useful for achieving R0 resection and radical lymphadenectomy [7, 8, 9, 10]. However, laparoscopic RAMPS (Lap-RAMPS) is not yet popular because of its technical difficulty and lack of adequate evidence. Few reports have described the detailed surgical technique of Lap-RAMPS [11, 12, 13]. We employ Lap-RAMPS using the ligament of Treitz approach with the benefit of a laparoscopic view and herein describe the usability of this laparoscopic procedure with a video.

Feasibility of a novel tacking method of securing mesh in transabdominal preperitoneal inguinal hernia repair: Secure tacking against recurrence: Novel tacking method in TAPP

Postoperative chronic pain is an important outcome of hernia surgery. In laparoscopic hernia surgery, either fixation outside the trapezoid of disaster or no fixation is recommended to avoid postoperative pain. To avoid recurrence are transabdominal preperitoneal (TAPP) hernia repair, the myopectineal orifice must be covered with mesh during TAPP, but lifting or shrinking of the mesh can lead to recurrence. The aim of this study was to evaluate the feasibility of a novel technique for mesh fixation to prevent the mesh from lifting off.

The safety and efficacy of laparoscopic hepatectomy in obese patients

BACKGROUND Obesity is generally reported to increase the risk of surgical complications. There have been few reports of laparoscopic hepatectomy (LH) in obese patients. The purpose of this study was to compare the safety and efficacy of (1) LH versus open hepatectomy (OH) in obese patients and (2) LH in obese patients versus LH in non-obese patients. METHODS We introduced LH at our institution in April 2014. LH was performed in 63 obese patients and 108 non-obese patients from April 2014 to May 2017. OH was performed in 79 obese patients from January 2010 to May 2017. This study retrospectively compared the short-term outcomes of the LH obese group with those of the OH obese group and the LH non-obese group. RESULTS In patient characteristics, the LH obese group included a significantly higher percentage of patients with liver cirrhosis than the OH obese group. The LH obese group had fewer patients with a history of abdominal surgery but more with liver cirrhosis than the LH non-obese group. For short-term outcomes, the LH obese group had significantly less blood loss, fewer intraoperative transfusions, fewer positive surgical margins, and shorter postoperative hospital stays than the OH obese group. In contrast, only operation time was significantly different (longer) in the LH obese group than in the LH non-obese group. There were no significant differences in morbidity or mortality between the LH obese group and either the OH obese or the LH non-obese groups. CONCLUSION LH in obese patients is safe and effective.

Inflammatory polyp in the common bile duct with pancreaticobiliary maljunction.

A 63-year-old woman was admitted because of epigastric pain and obstructive jaundice. Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography revealed a 25-mm papillary nodule in the middle to inferior portion of the common bile duct (CBD). Pancreaticobiliary maljunction (PBM) was also identified. Contrast-enhanced computed tomography also showed an enhanced nodule in the CBD, and we suspected intraductal papillary neoplasm of the bile duct. We performed pylorus-preserving pancreatoduodenectomy. Postoperative pathological examination revealed an inflammatory polyp in the middle CBD. Inflammatory polyp in the bile duct is rare and there are no previous reports accompanied by PBM. PBM is a major risk factor for biliary tract cancer. Preoperative diagnosis of a benign disorder was difficult in this case.