Masato Hoshino

Immunohistochemical study of the muscularis externa of the esophagus in achalasia patients.

The etiology of achalasia is believed to be the neuropathy associated with chronic inflammation of the nerve plexus, but the cause of plexus inflammation is unknown. The purpose of this study was to evaluate the pathophysiology of achalasia by examining the muscularis externa of the esophagus. We used the muscularis externa of the esophagus of 62 patients with achalasia (median 44 years, male : female 32:30) who underwent surgical treatment (achalasia group) and of 10 patients (median 65.5 years, male : female 9:1) who underwent esophagectomy for thoracic esophageal cancer (control group) to perform immunohistochemical staining with S-100, CD43, c-kit (CD117), n-NOS, vasoactive intestinal polypeptide (VIP), and ubiquitin. The cell counts that were positive for S-100, n-NOS, VIP, and ubiquitin were significantly lower in the achalasia group compared with the control group (P < 0.001, P= 0.001, P < 0.001, and P= 0.001, respectively). There were no statistically significant differences with respect to CD43 and c-kit staining (P= 0.586 and P= 0.209, respectively). In conclusion, the pathophysiology of achalasia is therefore considered to be an impaired production of NO and VIP, which both affect interstitial cell of Cajal and smooth muscles, and this impairment is therefore considered to play a role in the pathophysiology of achalasia.

Single-incision laparoscopic Heller myotomy and Dor fundoplication for achalasia : report of a case

A 31-year-old man, referred to our hospital for investigation of dysphagia, was found to have a spindle-shaped lower esophagus on a contrasted esophagram. The dysphagia was initially treated conservatively, but after 4xa0years of unsatisfactory control, he requested surgery. Our surgical team has been performing laparoscopic Heller–Dor fundoplication for achalasia since August, 1994, and 265 patients have undergone this procedure so far. Based on our experience, we decided to perform Heller–Dor fundoplication through a single incision for this patient. The operative time was 236xa0min with minimal blood loss and there were no perioperative complications. His postoperative course was uneventful and he was discharged on postoperative day 4, completing the clinical pathway used for conventional laparoscopic Heller–Dor fundoplication.

Short-term surgical outcomes of reduced port surgery for esophageal achalasia

PurposeTo clarify the feasibility and utility of reduced port surgery (RPS) for achalasia.MethodsBetween September 2005 and June 2013, 359 patients with esophageal achalasia, excluding cases of reoperation, underwent laparoscopic Heller myotomy and Dor fundoplication (LHD) according to our clinical pathway. Three-hundred and twenty-seven patients underwent LHD with five incisions (conventional approach), while the other 32 patients underwent RPS, including eight via SILS. The clinical data were collected in a prospective fashion and retrospectively reviewed. We selected 24 patients matched for gender, age and morphologic type with patients in the RPS group from among the 327 patients (C group). The surgical outcomes were compared between the C and RPS groups.ResultsThere were no significant differences between the two groups in the duration of symptoms, dysphagia score, chest pain score, shape of the distal esophagus and esophageal clearance. The operative time was significantly longer in the RPS group than in the C group (pxa0<xa00.001). There were no significant differences between the two groups in the length of postoperative hospital stay or rates of bleeding, mucosal injury of the esophagus and/or stomach and postoperative complications. The symptom scores significantly improved after surgery in both groups (pxa0<xa00.001). Furthermore, there were no significant differences between the C group and RPS group in terms of the postoperative symptom scores or satisfaction scores after surgery.ConclusionsThe surgical outcomes of RPS for achalasia are comparable to those obtained with the conventional method.

Effect of laparoscopic esophagomyotomy on chest pain associated with achalasia and prediction of therapeutic outcomes.

BackgroundThe effect of myotomy for achalasia on chest pain has not been clarified. The current study aimed to investigate the therapeutic effect of laparoscopic myotomy on chest pain associated with achalasia and to identify prognostic factors for outcomes.MethodBetween March 2005 and September 2008, 95 patients were available for detailed interviews and for assessment of clearance by timed barium esophagogram (TBE) before and after surgery. Of the 95 patients, 47 (24 men; mean age, 42.9xa0±xa013.5xa0years) who experienced chest pain before surgery were studied. The subjects were asked in detail about dysphagia and chest pain before surgery and 6xa0months after surgery. The frequency and severity of the symptoms were graded on a scale of 0 to 4. In addition, the values obtained by multiplying the grade for frequency by the grades for severity of the two symptoms were defined as the dysphagia score and the chest pain score, respectively. The patients with chest pain scores of 0 after surgery were defined as group A and those with scores smaller than their preoperative scores as group B. The remaining patients with other scores were defined as group C. The background factors and clinical conditions of the three groups were compared.ResultsThe mean chest pain score decreased from 5.0xa0±xa03.2 to 1.0xa0±xa01.6 (pxa0<xa00.001). The score after surgery was 0 for 27 patients and showed a decrease for 15 patients. Although the three groups did not differ in their characteristics, differences were noted in postoperative TBE factors (i.e., groups A and B had significantly shorter barium columns than group C at 1 and 5xa0min after surgery (pxa0=xa00.001).ConclusionLaparoscopic myotomy had a therapeutic effect on chest pain associated with achalasia, and improvement in postoperative esophageal clearance may influence the therapeutic effect.

Modified Billroth-I reconstruction after distal gastrectomy

To the Editor: Although Billroth I (B-I) or Billroth II (B-II) has traditionally been the method for reconstruction after distal gastrectomy, Roux-en-Y (R-Y) is now being increasingly employed at many institutions, mainly to prevent duodenogastric refl ux and to ensure safe anastomosis. We do perform R-Y in our department, but only in limited cases in patients with special conditions, i.e., locally invasive tumors in the pylorus or the antrum in which the tumor may recur locally, or in patients having a subtotal distal gastrectomy for which a gastroduodenal anastomosis would result in excessive tension. The advantages of R-Y after distal gastrectomy include the absence of or a low incidence of refl ux gastritis and esophagitis [1] and a possible reduction in the future development of stump carcinoma [2]. On the other hand, with R-Y, stomal ulcer may develop [3, 4] and the incidence of cholelithiasis, for which endoscopic sphincterotomy is almost impossible, may increase [5, 6]. The notorious Roux stasis syndrome [7] may also develop in some cases. The advantages of B-I over R-Y include food passage through the physiological route, single anastomosis, low risk of stomal ulcer or cholelithiasis, and easy access to the duodenal papilla in case there is cholelithiasis or pancreatic disease. Thus, we select B-I reconstruction whenever possible. Because the main problem with B-I is duodenogastric refl ux, we recently developed a modifi ed B-I technique, in which the gastric mucosa is inverted like a checkvalve in the duodenum to prevent refl ux (Fig. 1). Since we fi rst reported the technique in 2007 [8], ten such patients have been followed up for a mean of 17.7 Fig. 1. Schematic view of the newly developed modifi ed Billroth I technique. With permission from the publishers of Surgery [8]

Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia

BackgroundMucosal injury during myotomy is the most frequent complication seen with the Heller–Dor procedure for achalasia. The present study aimed to examine risk factors for such mucosal injury during this procedure.MethodsThis was a retrospective analysis of patients who underwent the laparoscopic Heller–Dor procedure for achalasia at a single facility. Variables for evaluation included patient characteristics, preoperative pathophysiological findings, and surgeon’s operative experience. Logistic regression was used to identify risk factors. We also examined surgical outcomes and the degree of patient satisfaction in relation to intraoperative mucosal injury.ResultsFour hundred thirty-five patients satisfied study criteria. Intraoperative mucosal injury occurred in 67 patients (15.4xa0%). In univariate analysis, mucosal injury was significantly associated with the patient age ≥60xa0years, disease history ≥10xa0years, prior history of cardiac diseases, preoperative esophageal transverse diameter ≥80xa0mm, and surgeon’s operative experience with fewer than five cases. In multivariate analysis involving these factors, the following variables were identified as risk factors: age ≥60xa0years, esophageal transverse diameter ≥80xa0mm, and surgeon’s operative experience with fewer than five cases. The mucosal injury group had significant extension of the operative time and increased blood loss. However, there were no significant differences between the two groups in the incidence of reflux esophagitis or the degree of symptom alleviation postoperatively.ConclusionThe fragile esophagus caused by advanced patient age and/or dilatation were risk factor for mucosal injury during laparoscopic Heller–Dor procedure. And novice surgeon was also identified as an isolated risk factor for mucosal injury.

Laparoscopic Heller Myotomy and Dor Fundoplication Combined with Laparoscopic Diverticular Introversion Suturing for Achalasia Complicated by Epiphrenic Diverticulum : Report of a Case

A 41-year-old woman was admitted due to dysphagia and weight loss of 6 kg. An upper gastrointestinal radiographic contrast study demonstrated an S-shaped lower esophagus with a peak transverse diameter of 65 mm. Moreover, an epiphrenic diverticulum was also detected in the lower part of the esophagus (50 × 40 mm). The measurement of intraesophageal pressure showed a lower esophageal sphincter pressure of 80 mmHg and a lower esophageal sphincter length of 31 mm. Esophageal clearance assessment via a timed barium esophagogram demonstrated impaired contrast clearance, with a rate of 26% at 5 min. A laparoscopic Heller myotomy, Dor fundoplication, and diverticular introversion suturing were performed. The postoperative course was uneventful and the patient was discharged on day 4. At the 2-year follow-up, no dysphagia was present. This is the first report of a laparoscopic diverticuloplasty using an introversion buried suture with a Heller myotomy and Dor fundoplication for achalasia complicated by an epiphrenic diverticulum.

Standard values of 24-h multichannel intraluminal impedance–pH monitoring for the Japanese

BackgroundCombined multichannel intraluminal impedance and pH monitoring (MII–pH) is the gold standard for diagnosing gastroesophageal reflux (GER), but there are no concrete data for a Japanese population. The aim of this study is to determine the standard values of MII–pH for a Japanese population.MethodsTwenty healthy Japanese volunteers without symptoms of GER were recruited through the homepage of the Department of Surgery at The Jikei University School of Medicine. Their mean age was 29.0xa0±xa03.0xa0years (range 24–36) and three of the volunteers were women (15xa0% of the total number of volunteers). The volunteers underwent MII–pH measurements at 6 sites. These sites were centered at 3, 5, 7, 9, 15, and 17xa0cm higher than the lower esophageal sphincter (LES) and a pH-monitoring device was placed 5xa0cm above the upper border of the LES. GER events were detected and divided into acid or non-acid reflux by pH and liquid acid or liquid non-acid reflux by impedance.ResultsThe normal values of MII–pH for the Japanese population were as follows: a pH below 4 holding time of less than 2.5xa0%, less than 2.1 total number of reflux events longer than 5xa0min, duration of the longest reflux event less than 12.7, and DeMeester Score less than 11.0. The total number of liquid reflux events was less than 80. The total number of liquid acid reflux events and liquid non-acid reflux events was less than 49 and 58, respectively.ConclusionsWe provided the standard values of MII–pH for a Japanese population.

Backflow prevention mechanism of laparoscopic Toupet fundoplication using high-resolution manometry.

AbstractBackgroundThe use of multichannel intraluminal impedance pH (MII-pH) and high-resolution manometry (HRM), which are new devices used to examine the esophageal function, has recently become common in Europe and the USA, thus garnering much attention. There have not been enough studies as of yet, however, on the esophageal motor function and the benefits of treatment after these devices have been used in laparoscopic fundoplication.ObjectiveTo use MII-pH and HRM to study the treatment effectiveness of laparoscopic fundoplication and consider a backflow prevention mechanism for laparoscopic Toupet fundoplication.nMaterials and methodsThe study looked at 27 of a total of 60 patients undergoing laparoscopic fundoplication due to reasons of either gastroesophageal reflux disease or esophageal hiatal hernia between October 2012 and February 2014, who underwent a postsurgical HRM examination. Of these, 25 patients whose symptoms disappeared following surgery and who were not orally administered gastric secretion inhibitor (of whom nine were male, average age 55.9xa0±xa014.9xa0years, and of whom 76xa0% underwent MII-pH) were taken as the subjects of the study. The postsurgical evaluation was conducted 3xa0months after the operation.ResultsUsing HRM, although no change was noted in the lower esophageal sphincter pressure (LESP) (pxa0=xa00.943), an increase in lower esophageal sphincter pressure integral (pxa0=xa00.024) and extensions in both overall length and abdominal length were noted (both pxa0<xa00.001), while a significant improvement was noted in the lower esophageal sphincter (LES). Furthermore, the cases subjected to MII-pH demonstrated a reduced gastroesophageal reflux time, total number of liquid reflux episodes, and total number of reflux episodes (pxa0<xa00.001, pxa0=xa00.008, pxa0=xa00.009).ConclusionsBackflow prevention mechanism of laparoscopic Toupet fundoplication is thus considered to improve the overall LES function without elevating LESP.

Usefulness of pyloric reconstruction without compromising curative resection in gastric cancer treatment.

IntroductionWe herein report the short-term results of the newly developed modified technique of Billroth I (modified B-I; pylorus reconstruction) that prevents duodenogastric reflux (DGR) and remnant gastritis after distal gastrectomy.Patients and MethodsDistal gastrectomy with this technique was performed in 20 patients (age, 41 to 86xa0years [mean, 68.5u2009±u200911.8xa0years], male/femaleu2009=u200912:8) with gastric cancer from June 2006 through December 2009. These patients were compared with another 20 patients who underwent conventional B-I after distal gastrectomy (age, 41 to 85xa0years [mean, 69.3u2009±u20098.69xa0years], male/femaleu2009=u200911:9). The side effects of gastric surgery evaluated in this study were the degree of remnant gastritis, the presence of dumping syndrome, and the degree of weight loss.ResultsBy gastrografin contrast imaging on the fifth day after pylorus reconstruction, the remnant stomach was not dilated and gastrografin flowed physiologically to the duodenum without backward reflux into the remnant stomach. By gastroscopy at 6xa0months after the operation, DGR and the degree of remnant gastritis after pylorus reconstruction was lower than those of conventional B-I (Pu2009=u20090.00068). The bile acid concentration of remnant gastric juice of pylorus reconstruction was lower than that of conventional B-I (55.5u2009±u200993.5 vs. 1,369.5u2009±u20092,502.1xa0μmol/L, Pu2009=u20090.0415). Weight loss at 1xa0year after distal gastrectomy was less in pylorus reconstruction compared with conventional B-I (6.2u2009±u20095.2% vs. 9.8u2009±u20098.7%, Pu2009=u20090.0725).ConclusionPylorus reconstruction is a simple and safe anastomotic technique that reduces the side effects of B-I reconstruction.