Koichi Suda

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.

Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Amount of CD4+CD25+ regulatory T cells in autoimmune pancreatitis and pilonidal sinus.

Objectives Infiltration of many IgG4-positive plasma cells (G4-Ps) is seen in IgG4-related diseases and in several “non–IgG4-related diseases,” such as pilonidal sinus (PS) as well. The involvement of CD4+CD25+ regulatory T cells (CD4+CD25+ Tregs) in IgG4-related diseases has been reported. To see whether CD4+CD25+ Tregs are involved in autoimmune pancreatitis (AIP)/non–IgG4-related diseases with many G4-Ps, we investigated the amount of G4-Ps and CD4+CD25+ Tregs histologically in AIP/PS. Methods Four AIP and 10 PS were immunostained with IgG4/Foxp3, a specific marker for CD4+CD25+ Tregs. Double immunohistochemistry and dual fluorescent immunohistochemistry were conducted to see the amount of CD4+CD25+ Tregs. Results All AIP and 30% of PS showed abundant G4-Ps. G4-Ps infiltrated diffusely for all AIPs and in a patchy pattern for PS at the abscess/granulation foci. Foxp3 immunostaining/double immunohistochemistry showed moderate to abundant CD4+CD25+ Tregs in AIP and abscess of PS, but few to moderate in granulation of PS. Dual fluorescent immunohistochemistry also showed many CD4+CD25+ Tregs in AIP. Conclusions Many CD4+CD25+ Tregs were seen in AIP lesions, abscess of PS, but not in granulation of PS, suggesting that the amount of CD4+CD25+ Tregs sometimes do not synchronize with that of G4-Ps and might relate to the inflammatory activity of both AIP and PS.

Gastroenterological Surgery: Stomach.

Laparoscopic gastrectomy is recommended for cStage IA gastric cancer not indicated for endoscopic treatment and cStage IB gastric cancer according to the Japanese Classification of Gastric Carcinoma (version 14). Strength of recommendation: B These guidelines are applicable to the surgical techniques covered by health insurance, which, in terms of gastrectomy, include both laparoscopic gastrectomy and laparoscopic total gastrectomy. In other words, in medical care covered by health insurance, laparoscopic gastrectomy means laparoscopic distal gastrectomy in most cases. Thus, the statements on laparoscopic gastrectomy in the present guidelines are indicated mainly for laparoscopic distal gastrectomy.

Gastroenterological surgery: esophagus.

1-1 Which stages of thoracic esophageal cancer are indicated for thoracoscopic surgery? In many facilities, thoracoscopic surgery is indicated for cStages I, II, and III, except cT4, according to the TNM Classification of Malignant Tumours, seventh edition, or cStages I–IVa, except cT4, according to the Japanese Classification of Esophageal Cancer, 10th edition, edited by the Japan Esophageal Society.

Robotic surgery for the upper gastrointestinal tract: Current status and future perspectives: Robotic surgery for the upper GI tract

More than 4000 da Vinci Surgical Systems have been installed worldwide. Robotic surgery using the da Vinci Surgical System has been increasingly performed in the last decade, especially in urology and gynecology. The da Vinci Surgical System has not become standard in surgery of the upper gastrointestinal tract because of a lack of clear benefits in comparison with conventional minimally invasive surgery. We initiated robotic gastrectomy and esophagectomy for patients with upper gastrointestinal cancer in 2009, and we have demonstrated the potential advantages of the da Vinci Surgical System in reducing postoperative local complications after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. However, robotic surgery has the disadvantages of a longer operative time and higher costs than the conventional approach. In this review article, we present the current status of robotic surgery for gastric and esophageal cancer, as well as future perspectives on this approach, based on our experience and a review of the literature.

Delta-shaped anastomosis in totally robotic Billroth I gastrectomy: technical aspects and short-term outcomes.

Delta‐shaped anastomosis has been recognized as a method of intracorporeal Billroth I anastomosis in totally laparoscopic distal gastrectomy. However, the technical aspects and outcomes of the delta‐shaped anastomosis in totally robotic distal gastrectomy have never been reported.

Esophageal Cancer Surgery

Esophagectomy with total mediastinal lymphadenectomy with or without cervical lymphadenectomy remains the main option for the curative treatment of esophageal squamous cell carcinoma. However, meticulous mediastinal lymph node dissection frequently induces recurrent laryngeal nerve palsy (RLNP), leading to postoperative laryngopharyngeal dysfunction. Surgical robots have been developed to overcome some of the disadvantages of standard minimally invasive surgery and facilitate precise dissection in a confined surgical field with impressive dexterity. We have been using the surgical robot, da Vinci S HD Surgical System, in the thoracic phase of esophagectomy since 2009. To date, we have performed approximately 30 cases of robotic esophagectomy and have demonstrated the possibility that the use of the robotic system in thoracoscopic esophagectomy in the prone position might reduce postoperative laryngopharyngeal dysfunction related to RLNP. In this chapter, we present updates on the methods and short-term outcomes of robotic esophagectomy based on our experience and review of the literatures.

Replacement of laparoscopic total gastrectomy with laparoscopic proximal gastrectomy for upper early gastric cancer

In accordance with the increased incidence of proximal early gastric cancer (EGC), particularly in Asian countries (1,2), the demand for proximal gastrectomy (PG) as a function-preserving surgery continues to escalate.