Masashi Takemura

A comparison of video-assisted thoracoscopic oesophagectomy and radical lymph node dissection for squamous cell cancer of the oesophagus with open operation.

An Erratum has been published for this article in British Journal of Surgery 90(6) 2003, 764.

Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results

Background: The efficacy of thoracoscopic radical esophagectomy for cancer of the thoracic esophagus and the learning curve required have yet to be clearly established. Methods: Eighty treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm minithoracotomy and four trocar ports. The outcomes in the first 34 patients (group 1) and the last 46 patients (group 2) were compared. Results: There were no differences in background or clinicopathologic factors between the two groups. The duration of the thoracoscopic procedure and blood loss were less (p <0.0001), the incidence of postoperative pulmonary infection was less (p = 0.0127), and the number of mediastinal nodes retrieved was greater (p = 0.0076) in group 2. Multivariate analysis demonstrated that surgical experience (number of cases performed) predicted the risk of pulmonary infection (p = 0.0331). Conclusion: Video-assisted thoracoscopic radical esophagectomy can be performed with safety and efficacy comparable to those of open esophagectomy. Morbidity decreases with the surgeons experience.

Laparoscopic gastrectomy for gastric cancer : experience with more than 600 cases

BackgroundAmong the less invasive operations noted in recent years, laparoscopic gastrectomy for gastric cancer has become popular because of advances in surgical techniques. The authors performed laparoscopic gastrectomy with regional lymph node dissection for 612 cases of gastric malignancies between March 1998 and August 2006. The technique and results of laparoscopic gastrectomy for gastric cancer are presented.MethodsOf the 612 gastric malignancy cases, distal gastrectomy was performed in 485 cases, proximal gastrectomy in 42 cases, and total gastrectomy in 85 cases. In all the cases, D1 or D2 lymph node dissection was performed according to the general rule of the Japanese Gastric Cancer Association.ResultsQuicker recovery was observed in the laparoscopic gastrectomy cases than in the open cases. The postoperative complications with this technique were within a permissible range. No statistical difference was seen in the survival curve after surgery between the laparoscopic group of advanced cases preoperatively diagnosed as surgical T2N1 or lower and the open group.ConclusionThe laparoscopic technique is not only less invasive, but also similarly safe and curative compared with open gastrectomy.

Reconstructive Procedure after Distal Gastrectomy for Gastric Cancer that Best Prevents Duodenogastroesophageal Reflux

Billroth I and II reconstructions are commonly performed after distal gastrectomy. Both may cause duodenogastric and duodenogastro-esophageal reflux, conditions reported to have carcinogenetic potential. The aim of this study was to investigate which reconstructive procedure would most effectively prevent bile reflux into the gastric remnant and esophagus after distal gastrectomy. A group of 92 patients who underwent curative distal gastrectomy for gastric cancer were subjected and classified into three groups retrospectively by the reconstructive procedure undertaken: group A, Roux-en-Y (Roux-Y) reconstruction (n=29); group B, Billroth I reconstruction (n=41); group C, Billroth II reconstruction (n=22). The bile reflux periods (percent time) for the gastric remnant and esophagus were measured with the Bilitec 2000 under standardized conditions. The percent time for the gastric remnant was significantly less in group A than in group B or C. In 61% of all patients, bile reflux into the esophagus was found to be more than 5.0% of the time; it was less in group A than in group B or C (p=0.057). A questionnaire revealed a good correlation between the incidence of reflux symptoms and the percent time for the gastric remnant and esophagus. Roux-Y reconstruction is superior to either Billroth I or II reconstruction for preventing bile reflux into the gastric remnant and esophagus after distal gastrectomy.RésuméLe rétablissement de continuité après gastrectomie distale est habituellement selon Billroth I ou selon Billroth II. Cependant, les deux types de reconstruction peuvent être responsables de reflux duodénogastrique et de reflux duodénogastroesophagien, avec un risque plus élevé de développer un cancer. Le but de cette étude a été de déterminer quel type de rétablissement serait le plus efficient dans la prévention du reflux de bile dans le moignon gastrique et dans l’œsophage après gastrectomie distale. Quatre-vingt-deux patients qui ont eu une gastrectomie distale à visée curatrice pour cancer ont été inclus et classés rétrospectivement en trois groupes selon le type de reconstruction: groupe A, reconstruction par anse en Y (n=29); groupe B, rétablissement de continuité selon Billroth I (n=41); et groupe C, rétablissement selon Billroth II (n=22). La durée du reflux (en pourcentage de temps) au niveau du moignon gastrique et de l’œsophage a été mesurée dans des conditions standardisées Bilitec 2000. Le pourcentage de temps pour le moignon gastrique a été signifieativement plus bas dans le groupe A que dans les groupes B et C. La durée du reflux de bile dans l’œsophage a dépassé 5% chez 61% des patients: elle a été moins longue dans le groupe I que dans les groupes B et C (p=0.057). Grâce à un questionnaire on a pu trouver une bonne corrélation entre l’incidence des symptômes de reflux et la durée du temps de reflux dans le moignon gastrique et dans l’œsophage. Le rétablissement de continuité par anse en Y est supérieur aux rétablissements de types Billroth I et II en ce qui concerne la prévention de reflux de bile dans le moignon gastrique et dans l’œsophage après gastrectomie distale.ResumenLas reconstrucciones tipos Billroth I y II son las más comunes cuando se practica una gastrectomía. Sin embargo, ambas pueden causar reflujo duodenogástrico y duodeno gastroesofágico, fenómeno que se reconocen como de potencial efecto carcinogenético. El propósito del presente estudio fue investigar cuál procedimiento de reconstrucción podría prevenir el reflujo al remanente gástrico y al esófago luego de una gastrectomía distal. Noventa y dos pacientes sometidos a gastrectomía distal curativa por cáncer fueron clasificados retrospectivamente en 3 grupos: grupo A, reconstrucción de Roux-en-Y (n=29); grupo B, reconstrucción Billroth I (n=41); grupo C, reconstrucción Billroth II (n=22). El periodo de reflujo biliar (por ciento del tiempo) al estómago residual y al esófago fue determinado mediante Bilitec 2000 bajo condiciones estandarizadas. El porcentaje de tiempo para el estómago residual fue significativamente menor en el grupo A en comparación con los grupos B y C. En 61% de la totalidad de los pacientes se encontró reflujo al esófago por más del 5% del tiempo; fue menor en el grupo A que en los grupos B y C (p=0.057). La aplicación de un cuestionario reveló buena correlación entre la incidencia de los síntomas de reflujo y el porcentaje de tiempo del reflujo al remanente gástrico y al esófago. La reconstrucción de Roux-en-Y es superior a las reconstrucciones Billroth I y II en cuanto a la prevención del reflujo biliar al remanente gástrico y al esófago luego de una gastrectomía distal.

Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy.

Background: Thoracoscopic esophagectomy for esophageal cancer has been performed as an alternative to open surgery to reduce surgical trauma. However, its effect on pulmonary function, exercise tolerability, and quality of life is unknown. Methods: Fifty-one patients with esophageal cancer underwent thoracic esophagectomy with radical lymphadenectomy by posterolateral thoracotomy (29 cases) or thoracoscopic surgery (22 cases). Patients performed spirometry and exercise tolerance testing and completed a quality-of-life questionnaire before and 3 months after surgery. Results: Pre-to-postoperative change in vital capacity was 74.3 ± 10.6% in the thoracotomy group and 84.9 ± 10.4% in the thoracoscopy group (p = 0.021). Maximum oxygen uptake was similar, but dyspnea was the more common factor limiting exercise tolerance postoperatively in the thoracotomy group. Change in pre-to-postoperative performance status was 1.20 ± 0.62 in the thoracotomy group and 0.55 ± 0.51 in the thoracoscopy group (p = 0.0003). Conclusions: Thoracoscopic esophagectomy for esophageal cancer has better preservation of pulmonary function and quality-of-life.

Video-assisted thoracoscopic esophagectomy and radical lymph node dissection for esophageal cancer: A series of 75 cases

AbstractsBackground: The efficacy of thoracoscopic radical esophagectomy for cancer has yet to be established, mainly because previous reports have not included a sufficient number of cases. Methods: Seventy-five treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm mini-thoracotomy and four trocar ports. Results: Video-assisted thoracoscopic surgery was performed without major intraoperative complications or emergency conversion to open surgery. We retrieved 34.1±13.0 mediastinal nodes, including 11.5±3.8 tracheobronchial nodes and 6.2±3.0 recurrent laryngeal nodes. Mean time of operation and blood loss were less in the last 39 patients than the first 36 (186.7±25.3 min and 165.4±101.8 g vs 270. 2±96.0 min and 421.5±31.2 g, respectively: p <0.0001 and p <0.001). Pulmonary morbidity was 5% in the later 39 patients. Survival was 90%, 80%, and 57% at 1, 2, and 5 years after surgery. Conclusion: Thoracoscopic radical esophagectomy has less morbidity and comparable survival to conventional surgery, after a moderate amount of experience. Mini-thoracotomy is essential to perform the procedure safely and effectively.

Primary volvulus of the small intestine in an adult, and review of 15 other cases from the Japanese literature.

Abstract: We report case of primary volvulus of the small intestine and review 15 cases from the Japanese literature. A 56-year-old woman, with a history of appendectomy 30 years previously, was admitted with abdominal distension and signs of peritonitis. Abdominal computed tomography (CT) demonstrated a whirl-like pattern of the mesentery, showing the tightly twisted mesentery around the point of torsion. An emergency laparotomy revealed strangulation of the small intestine, from 200 cm anal to the Treitz ligament to 5 cm oral to the terminal ileum, caused by 360° clockwise torsion. There was no adhesion caused by the previous operation nor were there any congenital anomalies. The strangulated intestine was removed and jejuno-colonostomy was performed. The patient was discharged from hospital on day 39 after the operation. Primary volvulus of the small intestine was reported to be rare in Japan, but the mortality was 26%. Immediate diagnosis and surgical intervention is essential to achieve a good outcome. A whirl-like pattern of the mesentery is a typical sign of this condition on CT.

Usefulness of self-expandable metallic stent with an antireflux mechanism as a palliation for malignant strictures at the gastroesophageal junction.

BACKGROUND: Patients with unresectable malignant gastroesophageal strictures often are troubled with reflux esophagitis after stent placement. METHODS: A self-expandable metallic stent (SEMS) without an antireflux mechanism was placed in seven patients with unresectable malignant gastroesophageal strictures (group A), and SEMS with an antireflux mechanism was placed in five patients (group B). After we obtained monitoring systems, two patients in group A and all the patients in group B underwent measurement of bilirubin and pH in the esophagus using a 24-h bilirubin and pH monitor. RESULTS: The mean percentage of total time less than 0.14 for use of the bilirubin absorbance unit was 12.4% in group B and 64.0% in group A. The mean percentage of total time for a pH less than 4 was 2.9% in group B and 37.8% in group A. CONCLUSION: The placement of SEMS with the antireflux mechanism can be effective not only for palliation of gastroesophageal stricture, but also for prevention of reflux.

Intracorporeal Billroth 1 reconstruction by triangulating stapling technique after laparoscopic distal gastrectomy for gastric cancer.

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patients figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The “triangulating stapling technique” (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patients figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

Quantitative Determinations of Duodenogastric Reflux, Prevalence of Helicobacter pylori Infection, and Concentrations of Interleukin-8

Billroth I or II reconstruction after distal gastrectomy often is associated with inflammation in the gastric remnant. We sought to determine which reconstructive procedure was most effective in preventing such remnant gastritis. Patients undergoing curative distal gastrectomy for cancer (n = 82) were classified as group A (Roux-en-Y, n = 22); group B (Billroth I, n = 40); or group C (Billroth II, n = 20). Interleukin (IL)-8 concentrations in gastric mucosa were measured 3 months after surgery. In the absence of Helicobacter pylori infection, IL-8 concentrations were 13, 56, and 87 pg/mg protein in groups A, B, and C, respectively (p < 0.05). In the presence of H. pylori infection, IL-8 concentrations were 61, 161, and 234 pg/mg protein in groups A, B, and C (p < 0.01). Roux-en-Y reconstruction is better able to prevent remnant gastritis than either the Billroth I or II procedure as judged from IL-8 concentrations in gastric remnant mucosa.