Masayuki Tori

A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy

In laparoscopy-assisted total gastrectomy, esophagojejunostomy is technically difficult. We describe a safe and simple technique for circular-stapled esophagojejunostomy. After mobilization of the stomach and the esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An anvil of a circular stapling device, secured with a Prolene suture (Ethicon, Inc, Somerville, NJ), is introduced via the esophagotomy. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is staple transected at this point. The circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed in 10 patients with gastric cancers. All patients were completed laparoscopically without any complications. The time of anvil placement was 9 minutes in median. Although a wound infection occurred in 1 patient, there were no major complications. There was no mortality in this series. Esophagojejunostomy using this technique is safe and simple. Its practical value is the elimination of the need for pursestring suture placement.

Initial T-cell activation required for transplant vasculopathy in retransplanted rat cardiac allografts.

Background. A precise understanding of immunological mechanisms is needed to prevent transplant vasculopathy. Methods. The developing process of transplant vasculopathy was investigated by retransplanting rat cardiac allografts and measuring the expressions of 21 different genes inside the retransplanted allografts under nonimmunosuppressive conditions. Results. Significant transplant vasculopathy developed if WKY hearts were grafted to LEW and retransplanted to WKY 5 days after the initial grafting, but it did not in allografts retransplanted 3 days after the initial grafting. The disease did not progress in retransplanted isografts or if nude rats were used as the initial recipients. However, the development of transplant vasculopathy was not affected by changing the second recipients to the F1 progeny of donor × recipient or to nude animals. Among the expressions of 21 different genes observed in allografts at 1, 14, 30, or 60 days after retransplantation, those of T-cell activation-related genes, such as interferon-&ggr; and Fas ligand, showed the earliest and the most dramatic difference between 3- and 5-day-retransplanted allografts whereas macrophage/monocyte activation-related genes showed little difference. Furthermore, reverse transcription-polymerase chain reaction analyses of allografts retransplanted to nude animal indicated that T cells of the initial recipient origin survive and remain activated even 60 days after retransplantation. Conclusions. The T-cell response occurring between 3 and 5 days after grafting was identified as the critical parameter to the disease progression. Once alloreactive T cells enter a graft, they may be able to survive a long period and promote chronic rejection.

Intraductal tubulopapillary neoplasm of pancreas with stromal osseous and cartilaginous metaplasia; a case report

Recently, a surgically resected case of intraductal tubulopapillary neoplasm (ITPN) with stromal osseous and cartilaginous metaplasia was encountered. A CT scan showed calcification at the tail of the pancreas two years before the operation. In the resected specimen, macroscopically, the main pancreatic duct was dilated and filled with a whitish solid mass without mucinous material. The tumor showed mainly a solid and papillary growth pattern. The tumor cells had no evidence of acinar differentiation. The tumor cells, at the tail of the pancreas, invaded focally to surrounding pancreatic parenchyma with stromal desmoplastic and fibrosclerotic reaction and also formed nodular stromal osseous and cartilaginous metaplasia. The tumor did not invade extrapancreatic tissue and showed no lymph node metastasis. As there were no signs of chronic calcifying pancreatitis, it is hypothesized that the metaplastic stroma was formed by a stromal reaction due to the tumor growth. It is thought, therefore, that the intraducal component of the tumor had existed at least for two years. This case suggests that ITPN is a relatively indolent tumor with a better prognosis than that of other types of invasive ductal adenocarcinoma of the pancreas.

Active cell migration in retransplanted rat cardiac allografts during the course of chronic rejection

BACKGROUND Chronic allograft vasculopathy (CAV) is caused by the infiltration of host immune cells to a graft, but it has been technically difficult to monitor the movements of the cells in graft rejection. METHODS We used a male-specific gene, SRY, as a marker to investigate the dynamics of host cells in a model of CAV in which immunosuppression was unnecessary and anti-male responses were practically negligible. Fluorescent-based real-time quantitative polymerase chain reaction (PCR) was adapted to estimate the fraction of host cells in a graft by the ratio of SRY to IL-2 gene. Using this technique, we studied the turnover and migration of host cells during the course of CAV progression by retransplanting female allografts from male to female or from female to male rats. RESULTS We detected histologic CAV 60 days after retransplantation in allografts retransplanted to the F(1) progeny of donor x recipient on the 5th day, but not in those retransplanted on the 3rd day, regardless of the mismatches in the genders. Most of the initial infiltrating cells disappeared rapidly in both cases. The fraction of migrating cells from the second recipient, however, continuously increased in allografts developing CAV, and 60 days after retransplantation exceeded 50%, whereas it stayed at 5% to 15% in those not developing CAV. ED-1-positive macrophages/monocytes were likely candidates for the migrated cells. CONCLUSION We have developed a simple method to measure the migration of host cells into a graft. This technique was useful, at least in certain rat strains, to investigate the cellular mechanisms of chronic cardiac allograft rejection.

Totally laparoscopic low anterior resection for lower rectal cancer: combination of a new technique for intracorporeal anastomosis with prolapsing technique.

Background: Laparoscopically assisted low anterior resection is difficult even for experienced surgeons because of difficulties in selecting the appropriate transection line and completing anastomosis in the narrow pelvic space. The prolapsing technique resolves these problems. We combined our new technique for intracorporeal anastomosis with this prolapsing technique and achieved a totally laparoscopic low anterior resection. Methods: After the total mesorectal excision, a semi-circumferential colotomy is made at the anterior colonic wall just proximal to the proximal transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the anvil penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. The distal rectum is everted and pulled transanally outside the body using a grasping forceps inserted from the anus. Staple-closure and transection of the distal rectum is performed under direct vision. Anastomosis is established using the double-stapling technique. Results: Totally laparoscopic low anterior resections using this technique were performed for 7 patients with rectal cancer. There was no anastomotic leakage/stenosis. Conclusions: Our procedure can be performed easily, which enables surgeons to achieve minimal invasiveness compared with hybrid NOTES.

A Simple and Safe Method for Gastrojejunostomy in Laparoscopic Distal Gastrectomy Using the Hemidouble-Stapling Technique: Efficient Purse-String Stapling Technique

Aim: To describe a simple technique for intracorporeal circular-stapled gastrojejunostomy in laparoscopic distal gastrectomy with Roux-en-Y reconstruction. Methods: After the stomach and duodenum were mobilized, gastrotomy was established in the anterior gastric wall. An anvil, which was secured with a suture needle, was inserted completely through the gastrotomy. The needle was advanced to the greater curvature of the gastric wall to enable penetration of the central rod into the gastric wall. Subsequently, the stomach was cut using a linear stapler to secure the anvil on the stomach and was sequentially transected using another linear stapler to achieve distal gastrectomy. Circular-stapled gastrojejunostomy was then performed intracorporeally using the hemidouble-stapling technique, while handling the shaft of the instrument via the umbilical incision. The jejunal stump was closed using a linear stapler. Results: Gastrojejunostomies were successfully performed in 20 gastric cancer patients using this technique. None of the patients showed anastomotic leakage and/or stenosis. There were no mortalities in this series. Conclusions: Gastrojejunostomy performed using the above-mentioned technique was safe and simple. The most important feature of the technique was the elimination of the need for purse-string suture placement, as well as the achievement of better cosmesis using the transumbilical approach.

Multiple benign metastasizing leiomyomas in the pelvic lymph nodes and biceps muscle: Report of a case

A 47-year-old woman with an earlier history of uterine leiomyoma suffered from multiple recurrent tumors in the retroperitoneal lymph nodes and biceps muscle of the right upper arm. The woman with a right lower abdominal tumor was referred to our hospital. An abdominal computed tomography scan revealed two round nodules with well-defined margins in the retroperitoneum in the pelvis, and echography revealed a similar nodule in the biceps of the right upper arm. A biopsy of the abdominal retroperitoneal tumor demonstrated benign metastasizing leiomyoma (BML). An extirpation of the abdominal tumors was therefore performed. After the operation, false climacteric medical treatment was performed for 3 years and no recurrence has since been observed. This is the first reported case of multiple BML in the lymph nodes and muscle occurring simultaneously.

Thyroid carcinoma with extensive tumor thrombus in the atrium.

To our knowledge, only a few cases of thyroid carcinoma with an extensive tumor thrombus in the atrium have been reported in literature. We describe a unique case of papillary carcinoma of the thyroid with extensive tumor thrombus in the atrium. A 74-year-old man consulted our hospital because of thyroid carcinoma with an extensive tumor thrombus in the atrium. Computed tomography (CT) revealed a 2-cm tumor with extensive continuous tumor thrombus in the left jugular vein, innominate vein, superior vena cava, and atrium. The tumor was resected to reduce the risk of sudden death from tumor embolism into the pulmonary arteries. Histologically, the diagnosis was papillary carcinoma of the thyroid. Thyroid carcinoma, especially papillary carcinoma, rarely develops a macroscopic tumor thrombus. Patients with an extensive tumor thrombus generally have poor prognoses and high mortality. This patient has been followed for 7 months after successful operation without recurrence.

Short-term outcome of single-incision laparoscopic totally extra-peritoneal inguinal hernia repair.

We performed single‐incision laparoscopic surgery for totally extra‐peritoneal (SILS‐TEP) repair using a lightweight mesh fixed by absorbable tacks and without balloon dilation. Thirty‐four patients (mean age, 66.5 years) underwent SILS‐TEP repair in our hospital between September 2011 and April 2012; 30 patients had unilateral hernia and 4 had bilateral hernias. Mean operative time was 85.6 min for unilateral hernia and 137.7 min for bilateral hernias. All patients underwent successful SILS‐TEP repair. Mean hospital stay was 3.4 days. Mean duration of follow‐up was 7.1 months. Four seromas were observed, but no recurrences or major complications occurred. SILS‐TEP is an economical and useful method for decreasing postoperative complications, such as neuralgia and recurrence, and it could be an attractive approach for inguinal hernia.

Model of mouse pancreaticoduodenal transplantation

Our technical procedure for mouse pancreaticoduodenal transplantation is described. A number of methods were attempted. Among them, a modification of S. Lees method was thought to be the most successful procedure, which was performed with end‐to‐side anastomosis of the donor portal vein to the inferior vena cava and that of the donor aortic patch to the aorta. Even with this method, however, arterial thrombosis or venous stenosis of the anastomoses was inevitable without the use of some devices as well as special skills in microsurgery.