Moritsugu Tanaka

Evaluation of the delta-shaped anastomosis in laparoscopic distal gastrectomy: midterm results of a comparison with Roux-en-Y anastomosis

AbstractBackgroundnVarious methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and published, whereas only a limited number of reports are available on the utility of the delta-shaped anastomosis (Delta). This study compared Delta and Roux-en-Y anastomoses (RY), with the aim to clarify the utility of Delta.nMethodsStage 1 gastric cancer patients who had undergone LDG with Delta (group D, nxa0=xa068) and those who had undergone LDG with RY (group RY, nxa0=xa060) were compared in terms of operative outcomes, postoperative clinical symptoms, gastrointestinal fiberscopic findings, and changes in body weight.ResultsBoth the operative and anastomotic times were significantly shorter in group D (230 and 13xa0min, respectively) than in group RY (258 and 38xa0min, respectively) (pxa0<xa00.001). Among the complications observed at the anastomotic site, obstruction was seen in one group D patient and two group RY patients but was relieved with conservative management. Postoperative clinical symptoms were reported for 26.4xa0% of the group D patients but had decreased to 5.9xa0% 1xa0year later. Group RY yielded similar results. Upper gastrointestinal fiberscopy performed 1xa0year postoperatively showed no intergroup differences in the incidence of gastritis or residual retention and a significantly more frequent occurrence of bile reflux in group D. Postoperative weight changes did not differ between the two groups.ConclusionsDelta reconstruction after LDG is a safe and effective procedure that is totally laparoscopic, less time consuming, and associated with a favorable postoperative course and a better quality of life.

The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy

BackgroundLaparoscopic procedures are increasingly being applied to gastric cancer surgery, including total gastrectomy for tumors located in the upper gastric body. Even for expert surgeons, esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) can be technically challenging. We perform the overlap method of esophagojejunostomy after LATG for gastric cancer. However, technical questions remain. Is the overlap method safer and more useful than other anastomosis techniques, such as methods using a circular stapler? In addition, while we perform this overlap reconstruction after LATG in a deep and narrow operative field, can the overlap method be performed safely regardless of body habitus? This study aimed to evaluate these issues retrospectively and to review the literature.MethodsFrom October 2005 to August 2013, we performed LATG with lymph-node dissection and Roux-en-Y reconstruction using the overlap method in 77 patients with gastric cancer. This study examined pre-, intra- and postoperative data.ResultsMean operation time, time to perform anastomosis, and estimated blood loss were 391.4xa0min, 36.3xa0min, and 146.9xa0ml, respectively. There were no deaths, and morbidity rate was 13%, including one patient (1%) who developed anastomotic stenosis. Mean postoperative hospitalization was 13.4xa0days. Surgical outcomes did not differ significantly by body mass index.ConclusionsFirst, the overlap method for esophagojejunostomy after LATG is safe and useful. Second, this method can be performed irrespective of the body type of the patient. In particular, in a deep and narrow operative field, the overlap method is more versatile than other anastomosis methods. We believe that the overlap method can become a standard reconstruction technique for esophagojejunostomy after LATG.

Technique of Roux-en-Y reconstruction using overlap method after laparoscopic total gastrectomy for gastric cancer: 100 consecutively successful cases.

BackgroundWe have established a standard procedure for Roux-en-Y (RY) reconstruction in laparoscopic total gastrectomy (LTG) using esophagojejunostomy by the overlap method (OL). We report on our RY reconstruction technique and special approaches, and evaluate the usefulness of our reconstruction method based on the surgical results of 100 patients we have experienced to date.MethodsWe performed LTG in 100 patients with gastric cancer. After total gastrectomy using five ports, the resected stomach was extracted through a small laparotomy. Through that, we performed sacrifice of the jejunum, Y limb anastomosis, creation of the lifted jejunum. As the OL, a side-to-side anastomosis of the lifted jejunum to the esophageal stump was laparoscopically performed using a linear stapler in an isoperistaltic direction, and the entry hole was closed with full-thickness suturing. The lifted jejunum was fixed with suture to the duodenal stump at a location where the esophagojejunostomy site was made linear, and the duodenal stump was buried. The mesenteric gap was laparoscopically closed with suture.ResultsThe median operative time in 100 patients undergoing LTG was 385xa0min, the median blood loss was 65xa0mL, and the median time required for the OL was 32xa0min. The mean hospitalization period was 10xa0days, and postoperative complications included bleeding requiring reoperation in one patient; other complications such as pancreatic fistula in five patients (5xa0%) were treated conservatively. No complication associated with anastomosis occurred.ConclusionIn RY reconstruction using the OL, there were no complications associated with the anastomosis site in 100 consecutive patients, such as anastomotic leak or stenosis, indicating that it is a very useful and safe reconstruction method.

Laparoscopic-assisted total gastrectomy for early gastric cancer with situs inversus totalis: report of a first case

BackgroundSitus inversus totalis is a relatively rare condition and is an autosomal recessive congenital defect in which an abdominal and/or thoracic organ is positioned as a “mirror image” of the normal position in the sagittal plane. We report our experience of laparoscopic-assisted total gastrectomy with lymph node dissection performed for gastric cancer in a patient with situs inversus totalis.Case presentationA 58-year-old male was diagnosed with cT1bN0N0 gastric cancer. There were no vascular anomalies on abdominal angiographic computed tomography with three-dimensional reconstruction. laparoscopic-assisted total gastrectomy was performed with D1+ lymph node dissection, in accordance with the Japanese Gastric Cancer Treatment Guidelines. There were no intraoperative issues, and no postoperative complications.ConclusionsThis was the first report describing laparoscopic-assisted total gastrectomy with the standard typical lymph node dissection in the English literature. We emphasize that the position of trocars and the standing side of the primary surgeon during the lymph node dissection are critical.

Primary mesenteric neuroendocrine tumor that changed its internal composition from cystic to solid: a case report

Mesenteric neuroendocrine tumors are usually metastases originating from the small intestine; however, primary mesenteric cases are rare. We present an interesting case of a mesenteric neuroendocrine tumor that changed its internal composition from cystic to solid. A 72-year-old male visited our hospital because of epigastralgia 4xa0years earlier. A 25-mm tumor was recognized around the terminal duodenum on computed tomography and magnetic resonance imaging, and was diagnosed as a cystic lesion. Over the following 2xa0years, the tumor grew to 40xa0mm and its internal composition changed from cystic to solid. The lesion showed positive findings on fluorodeoxyglucose positron emission tomography. Upon laparotomy, a solid tumor was detected in the mesentery of the jejunum near the ligament of Treitz. The tumor was extracted without intestinal resection and was diagnosed as a low-grade neuroendocrine tumor after histopathological and immunohistochemical examination. One year has passed since the operation, and there has been no recurrence.

A rare case of secondary small bowel volvulus laparoscopically repositioned: literature review and classification

BackgroundSecondary small bowel volvulus is a rare condition caused by adhesions after laparotomy or tumors. There are no clear guidelines for indication of laparoscopic surgery.Case presentationA 69-year-old male visited our hospital complaining of epigastric pain. He had a history of hypopharyngeal carcinoma treated via pharyngolaryngoesophagectomy with restoration of esophageal continuity by harvesting a free jejunal autograft 6xa0years ago.Enhanced computed tomography revealed the whirl sign. An emergency laparoscopic operation was performed following a diagnosis of small bowel volvulus. This revealed rotation of the whole small bowel, involving the superior mesenteric artery as the center, and originating at the adhesion of the proximal and distal small bowel. Laparoscopic manipulation of volvulus and lysis of the adhesion were performed. The patient’s postoperative course was uneventful, and he was discharged on hospital day 5.ConclusionsLaparoscopic surgery may be useful for treating small bowel volvulus; however, the patient’s treatment indications should be judged carefully.

Two patients with spontaneous transomental hernia treated with laparoscopic surgery: a review

Abstract Here, we report two patients with transomental hernia who were successfully treated with laparoscopic surgery. The first patient was a 58-year-old female who presented to our hospital with abdominal pain and vomiting; she had no history of abdominal surgery. Enhanced computed tomography revealed strangulation ileus due to an internal hernia. The second patient was a 36-year-old male who presented to our hospital with abdominal pain and no history of abdominal surgery. Enhanced computed tomography indicated transomental hernia. Emergency laparoscopic surgery in both patients revealed incarcerated bowel loops through defects in the greater omentum. The bowel segments were laparoscopically released, and the patients were uneventfully discharged on postoperative Days 4 and 8. Laparoscopic surgery is useful for the diagnosis and treatment of small bowel obstruction due to transomental hernia through the greater omentum.

Sigmoid gallstone ileus: A case report and literature review in Japan

Highlights • We present a unique case of gallstone ileus with inguinal hernia.• A one-stage operation can be considered for patients with gallstone ileus associated with cholecystocolonic fistula.• A review of the literature pertaining to colonic gallstone ileus is presented.

A post operative complication of foramen of Winslow hernia with left to right herniation of the small intestine: An extremely rare case report

Highlights • A foramen of Winslow hernia is rare and difficult to diagnose.• We report a post operative complication of foramen of Winslow herniation from left to right.• There are no previous reports of a foramen of Winslow hernia with this presentation.• It has been thought that closure of the foramen is not necessary.• However, as there are no reports about the complications due to closing the Foramen of Winslow, the foramen should be closed, whenever possible.

A Giant Duodenal Leiomyoma Showing Increased Uptake on 18F-Fluorodeoxyglucose Positron Emission Tomography

Background Although 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) is now widely used in their differential diagnosis, it is sometimes difficult to distinguish between benign and malignant diseases. Case Presentation A 44-year-old woman was found to have abnormalities on health screening. Magnetic resonance imaging for detailed examination showed an intra-abdominal tumor measuring 12u2009cm in the major axis near the cranial end of the uterus. Upper gastrointestinal tract endoscopy showed a tumor with an ulcer in the third part of the duodenum, involving half the circumference. Heterogeneous uptake was observed within the tumor on FDG-PET/CT. Based on these findings, the patient underwent surgery for suspected primary malignant lymphoma of the duodenum or gastrointestinal stromal tumor. Laparotomy revealed a 12u2009cm tumor in the third part of the duodenum. Partial duodenectomy and end-to-end duodenojejunostomy were performed. Pathological findings showed a solid tumor growing from the muscle layer of the duodenum to outside the serous membrane; based on immunostaining, it was diagnosed as a leiomyoma. Conclusions Duodenal leiomyomas are originally benign; to date, there have been no reports of uptake in duodenal leiomyomas on FDG-PET/CT; therefore, our case is rare. Leiomyomas should be considered in the differential diagnosis of duodenal neoplastic diseases.