Mitsuhiro Asakuma

Impact of single-port cholecystectomy on postoperative pain.

This study compared postoperative pain following four‐port laparoscopic cholecystectomy (LC) and single‐port cholecystectomy (SPC).

Transgastric hybrid cholecystectomy

Clinical application of natural orifice transluminal endoscopic surgery is under investigation. Preliminary results of transvaginal cholecystectomy in women and associated technical issues have been described. The technique and initial results of hybrid transgastric cholecystectomy are now reported.

Clinicopathological analysis of recurrence patterns and prognostic factors for survival after hepatectomy for colorectal liver metastasis

BackgroundHepatectomy is recommended as the most effective therapy for liver metastasis from colorectal cancer (CRCLM). It is crucial to elucidate the prognostic clinicopathological factors.MethodsEighty-three patients undergoing initial hepatectomy for CRCLM were retrospectively analyzed with respect to characteristics of primary colorectal and metastatic hepatic tumors, operation details and prognosis.ResultsThe overall 5-year survival rate after initial hepatectomy for CRCLM was 57.5%, and the median survival time was 25 months. Univariate analysis clarified that the significant prognostic factors for poor survival were depth of primary colorectal cancer (≥ serosal invasion), hepatic resection margin (< 5 mm), presence of portal vein invasion of CRCLM, and the presence of intra- and extrahepatic recurrence. Multivariate analysis indicated the presence of intra- and extrahepatic recurrence as independent predictive factors for poor prognosis. Risk factors for intrahepatic recurrence were resection margin (< 5 mm) of CRCLM, while no risk factors for extrahepatic recurrence were noted. In the subgroup with synchronous CRCLM, the combination of surgery and adjuvant chemotherapy controlled intrahepatic recurrence and improved the prognosis significantly.ConclusionsOptimal surgical strategies in conjunction with effective chemotherapeutic regimens need to be established in patients with risk factors for recurrence and poor outcomes as listed above.

A novel method using the VIO soft-coagulation system for liver resection

BACKGROUND The VIO soft-coagulation system (SCS) is a new device for tissue coagulation. The current study evaluated the efficacy of the SCS when used for liver resection. METHODS The 252 patients were divided into 2 groups; in 155 patients (conventional group), liver transection was performed using an ultrasonic dissector and saline-coupled bipolar electrocautery for hemostasis. In 97 patients (SCS group), the SCS was used instead of bipolar electrocautery. RESULTS The median blood loss and surgical time were less in the SCS group than in the conventional group (350 vs 640 mL, P = .0028; 280 vs 398 min, P < .0001). No significant differences were found in postoperative complications between the SCS group (32.0%) and the conventional group (40.6%). The risk factors for bleeding were nonuse of the SCS (P = .0039), macroscopic vascular invasion of the hepatic tumors (P = .0088), and collagen type IV value in the sera >200 (P = .0250) on multivariate analysis. In a subgroup analysis, in the collagen type IV value >200 subgroup, the tumor diameter >5 cm subgroup, and the inflow nonocclusion subgroup, use of the SCS decreased surgical bleeding (P = .0120, P = .0126, and P = .0032, respectively) and surgical time (P = .0001, P < .0001, and P = .0036, respectively) compared with the conventional group. Furthermore, even in the major hepatectomy group, the SCS use decreased surgical time (P < .0001). CONCLUSION The SCS is an effective and safe device for decreasing surgical time and surgical bleeding without increasing the rate of bile leakage and causing other complications.

Robotics may overcome technical limitations of single-trocar surgery: an experimental prospective study of Nissen fundoplication.

OBJECTIVE To compare laparoscopic and robotic-assisted single-trocar access (STA) Nissen fundoplication in a porcine model. The STA procedure is an emerging concept in minimally invasive surgery that presents technical difficulties and challenges compared with traditional laparoscopy. Using multiple instruments inserted through a single trocar generates internal and external conflicts. Achieving triangulation requires the instruments and surgeons hands to cross over at the point of entry. Robotic-assisted surgery may overcome these difficulties owing to its capability of dissociating the hands of the surgeon from the instruments. DESIGN Prospective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance. SETTING A research institute. PARTICIPANTS Three surgeons with different experience. MAIN OUTCOME MEASURES Operative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons. RESULTS All of the procedures were successfully completed. Mean operative time (45.6 +/- 11.2 vs 65.4 +/- 10.7 minutes; P = .03) and number of conflicts (1.0 +/- 0.9 vs 3.8 +/- 1.2; P < .001) were significantly reduced in the robotic series. CONCLUSIONS Use of the robotic platform allows the surgeon to select which hand will move which instrument. Inverting the control allows crossing of the instruments without any consequences to the surgeon. Moreover, this system offers instruments with multiple degrees of freedom. These factors could explain the clear improvement demonstrated in this study. As a result, robotics may play an essential part in the diffusion of STA surgery.

Outcomes and predictors of microvascular invasion of solitary hepatocellular carcinoma

Microvascular invasion (MVI) is an important risk factor for early recurrence of hepatocellular carcinoma (HCC), but preoperative prediction of MVI is difficult.

NOTES retroperitoneal transvaginal distal pancreatectomy

BackgroundThe retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.MethodsWith the pig supine, under general anesthesia, a 10-mm posterior colpotomy was performed with a needle-knife operated through a flexible 12-mm, double-channel endoscope (Karl Storz®). A retroperitoneal tunnel was created with blunt dissection up to the left kidney with progressive visualization of the left iliac vessels, ureter, and abdominal aorta. To reach the posterior aspect of the pancreas, a space was opened medial to the upper renal pole dividing the Gerota’s fascia. The tail of pancreas was mobilized with blunt and sharp dissection, using monopolar cautery. Once the distal pancreas was dissected free, it was secured using a polypropylene endoscopic loop and then resected with an endoscopic snare (Olympus®).ResultsThe procedure was successfully accomplished by a totally NOTES approach in five pigs, with a mean operative time of 118 (range, 105–185) minutes with no intraoperative complications and no injury to any retroperitoneal structure.ConclusionsThe pancreas is accessible by a transvaginal retroperitoneal NOTES approach. Human cadavers studies are necessary to confirm the validity of this model and to explore the need for specific technological developments, such as flexible stapling devices, to improve the safety of pancreatic resection.

Intraperitoneal Virtual Biopsy by Fibered Optical Coherence Tomography (OCT) at Natural Orifice Transluminal Endoscopic Surgery (NOTES)

IntroductionFibered optical coherence tomography (OCT) in conjunction with natural orifice transluminal endoscopic surgery (NOTES) could provide a facility for rapid, in situ pathological diagnosis of intraperitoneal tissues in a truly minimally invasive fashion.Materials and MethodsA large porcine model was established to test this hypothesis. A standard double channel gastroscope (Olympus) was used to achieve a transgastric access to the peritoneum and initiate the pneumoperitoneum. Magnetic retraction was used to display the sigmoid colon along with its mesentery. A commercially available fibered OCT probe (NIRIS system, Imalux) was inserted via a working channel of the gastroscope and used to assess intraperitoneal tissues. Separately, OCT images of human tissue specimens ex vivo were contrasted with representative standard histopathological slides.ResultsIntraperitoneal OCT provided clear real-time images of both the serosal and muscularis propria mural layers as well as the submuscosal–muscularis interface. Examination of mesenteric lymph nodes (including sentinel nodes) allowed visualization of their subcapsular sinus. Comparison of representative cross-sections however failed to evince sufficient resolution for confident diagnosis.ConclusionThis approach is technically feasible and, if the technology is advanced and proven accurate in human patients, could potentially be used to individualize operative extent prior to definitive resection.

Risk factors and patterns of early recurrence after curative hepatectomy for hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma (HCC) often recurs after curative hepatectomy; and early recurrence after hepatectomy (ERAH) is associated with poor prognosis. This study aimed to clarify risk factors and disease patterns for ERAH. METHODS We retrospectively analyzed clinicopathological factors of 232 patients who underwent initial curative hepatectomies for HCC between April 2000 and March 2013, and examined associated risk factors and early recurrence patterns by liver function status (as indicated by indocyanine green retention rate at 15 min [ICGR15]). RESULTS Patients who experienced recurrence within 6 months after hepatectomy (i.e., ERAH) had significantly shorter survival than those with longer disease-free intervals (P < 0.001). In multivariate analysis, microvascular invasion (mVI; P = 0.034) and ICGR15 ≥ 16% (P = 0.010) were independent risk factors for ERAH. In the ICGR1<16% subgroup, positive L3-AFP (P = 0.04), tumor size ≥ 5 cm (P = 0.011), surgical margin = 0 (P = 0.0103), mVI (P = 0.034), and extrahepatic recurrence were significant predictors of ERAH; in the ICGR15 ≥ 16%, subgroup, multiple tumors (P = 0.046) were identified as a risk factor for ERAH; however, this group did not experience much extrahepatic recurrence. CONCLUSIONS ERAH was associated with mVI and ICGR15 ≥ 16%. Recurrence patterns and risk factors vary by liver function status, which should be considered in forming management strategies for early recurrence of HCC after curative hepatectomy.

An operative case of hepatic pseudolymphoma difficult to differentiate from primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue

Hepatic pseudolymphoma (HPL) and primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) are rare diseases and the differential diagnosis between these two entities is sometimes difficult. We herein report a 56-year-old Japanese woman who was pointed out to have a space occupying lesion in the left lateral segment of the liver. Hepatitis viral-associated antigen/antibody was negative and liver function tests including lactic dehydrogenase, peripheral blood count, tumor markers and soluble interleukin-2 receptor were all within normal limit. Imaging study using computed tomography and magnetic resonance imaging were not typical for hepatocellular carcinoma, cholangiocarcinoma, or other metastatic cancer. Fluorodeoxyglucose-positron emission tomography examination integrated with computed tomography scanning showed high standardized uptake value in the solitary lesion in the liver. Under a diagnosis of primary liver neoplasm, laparoscopic-assisted lateral segmentectomy was performed. Liver tumor of maximal 1.0 cm in diameter was consisted of aggregation of lymphocytes of predominantly B-cell, containing multiple lymphocyte follicles positive for CD10 and bcl-2, consistent with a diagnosis of HPL rather than MALT lymphoma, although a definitive differentiation was pending. The background liver showed non-alcoholic fatty liver disease/early non-alcoholic steatohepatitis. The patient is currently doing well with no sign of relapse 13 months after the surgery. Since the accurate diagnosis is difficult, laparoscopic approach would provide a reasonable procedure of diagnostic and therapeutic advantage with minimal invasiveness for patients. Considering that the real nature of this entity remains unclear, vigilant follow-up of patient is essential.