Nobumi Tagaya

Experience with ultrasonographically guided vacuum-assisted resection of benign breast tumors

AIM To evaluate the feasibility and safety of vacuum-assisted resection of benign breast tumours using an 8 G handheld device. MATERIALS AND METHODS Over a 2-year period, 22 patients with 26 breast tumours diagnosed as benign using aspiration biopsy cytology were enrolled. The mean patient age was 38 years, and the mean maximal diameter of the tumour was 13 mm. A handheld Aloka SSD 6500 ultrasonography device with a linear-type 7.5 MHz transducer was inserted into the posterior aspect of the tumour with the patient under local anaesthesia, and the tumour was resected under ultrasonographic guidance. RESULTS This method was employed successfully in all patients, and the mean operation time was 33 min. Post-procedure complications included subcutaneous bleeding in 12 cases and haematoma in one. The pathological diagnoses were fibroadenoma in 16 cases, mastopathy in six, and tubular adenoma and pseudoangiomatous stromal hyperplasia in two cases each, respectively. Follow-up ultrasonography revealed residual tumours in four cases (15.4%). CONCLUSIONS Although this method is feasible and safe without severe complications, it is necessary to select appropriate patients, and to obtain informed consent regarding the possibility of recurrence or residual tumour.

Reevaluation of needlescopic surgery

BackgroundAlthough the use of single-incision laparoscopic surgery (SILS) has spread rapidly, most procedures employ additional needlescopic instruments to ensure safety and shorten the operation time. Therefore, on the basis of results obtained in our department, the present study was conducted to reevaluate the current state of needlescopic surgery (NS) to improve the cosmetic results and postoperative quality of life of patients and to reduce cost and degree of stress on surgeons.MethodsBetween May 1998 and February 2011, we performed NS in 202 patients. The diagnoses included gallbladder diseases in 151 patients, spontaneous pneumothorax in 11, thyroid tumor and axillary lymph node metastases in 10 patients each, splenic cyst and appendicitis in 4 patients each, idiopathic thrombocytopenic purpura and postoperative abdominal wall hernia in 3 patients each, primary aldosteronism and hepatic cyst in 2 patients each, and adhesional bowel obstruction and gastric stromal tumor in 1 patient each. Under general anesthesia, one 12-mm and tow or three 2- or 3-mm ports were introduced into the operative field. The specimen was retrieved via the 12-mm wound using a plastic bag.ResultsThe operations were completed in all patients without the need to convert to an open procedure. In 8 (5.3%) of the 151 cholecystectomies, a change to 5-mm instruments was required. There were no perioperative complications. Pertinent technical points included avoidance of direct organ mobilization to minimize injury, rotation of the operating table and utilization of organ gravity to create a better operative field, minimum use of needlescope to ensure safe maneuvering, and improvement of the bi-hand technique.ConclusionsNS is a safe and feasible procedure that allows experienced surgeons to achieve minimally invasive surgery with low morbidity, without the need to convert to a conventional or open procedure.

NOTES: approach to the liver and spleen

BACKGROUND Minimally invasive abdominal surgery means minimal trauma to the abdominal wall, thus reducing postoperative pain and wound complications, and facilitating earlier mobilization and shorter hospitalization in comparison with conventional surgery. Natural orifice translumenal endoscopic surgery (NOTES) has the potential to further reduce the invasiveness of surgery in human patients. Here we report an experimental study of NOTES to access the liver and spleen, discuss its current status, and review the related literature. METHODS The utility of transgastric peritoneoscopy was evaluated using one 15-kg pig and four 8-kg dogs on the basis of acute experiments. Under general anesthesia with endotracheal intubation, a forward-viewing, double-channel endoscope was advanced into the peritoneal cavity through a gastric hole. Liver biopsy from the edge of the liver was performed using routine biopsy forceps. Splenectomy was performed using a laparoscopically assisted procedure, and then the spleen was pulled into the stomach using an endoscopic polypectomy snare after enlargement of the gastric orifice. The animals were then sacrificed and necropsy was performed. RESULTS There were no complications during incision of the gastric wall and entry into the peritoneal cavity. Peritoneoscopy gave satisfactory visualization of the abdominal cavity in all directions. Liver biopsy was performed successfully without any bleeding and adequate samples were obtained in all cases. Splenectomies were also accomplished uneventfully, except for injury of the splenic parenchyma due to excessive force during pulling into the stomach. Necropsy revealed no particular damage to other intraperitoneal organs related to this transgastric procedure. CONCLUSION Although NOTES is a feasible procedure and offers several advantages to patients, surgeons and endoscopists need to resolve several key issues before its clinical introduction for routine surgical work and to establish a training system for NOTES in order to avoid critical complications.

Triple-negative breast cancer: Histological subtypes and immunohistochemical and clinicopathological features

To reveal heterogeneous properties of triple‐negative (TN) breast cancers (estrogen receptor negative, progesterone receptor negative and HER2 negative) and to clarify whether the developmental pathways to TN breast cancer are single or multiple, we conducted clinicopathological and immunohistochemical studies on TN breast cancers, with special reference to comparison of the invasive component (iIC) and the ductal component (dcIC) of invasive TN breast cancer and pure TN ductal carcinoma in situ (TNDCIS). Tumor tissues were obtained from 97 patients with TN invasive carcinoma and 10 patients with TNDCIS. Two histological subclassifications, “atypical” medullary carcinoma (type A, n = 16) and carcinoma with a central acellular zone (type B, n = 11), were distinguished from conventional ductal carcinoma. Other invasive ductal carcinomas were classified as type C (n = 64) and special types were classified as type D (n = 5). The follow‐up period for the 96 patients ranged from 5 to 147.8 months (mean, 47.6 months). Out of 97 cases, dcIC was present in 29 (30%) cases and type A and B had significantly few ductal components, 0% and 18%, respectively. There were only six (6%) cases with non‐TN cells in dcIC and TN cells in iIC and five of them were type C. In 13 (13%) cases, epidermal growth factor receptor (EGFR) expression existed only in iIC. Therefore, most of the TN carcinoma develops originally and rapidly invades at the early stage, especially in types A and B. The relapse rate of type B was the highest (36.4%) and the overall survival of patients with type B was the shortest (P = 0.02), which indicates that the prognosis of type B is significantly worse than the other types. (Cancer Sci 2011; 102: 656–662)

Laparoscopic resection of a retroperitoneal pelvic schwannoma

Schwannomas are rarely located in the pelvis. A 54-year-old woman was found incidentally to have a tumor in the abdomen. Abdominal computed tomography and magnetic resonance imaging revealed a well-defined, heterogeneous tumor, 5 cm in diameter, in the pelvic cavity. With a diagnosis of a mesenteric tumor, a laparoscopic procedure was performed. Intra-operatively, an elastic tumor was identified in the pelvis adjacent to the right internal iliac vein and ureter. The tumor was dissected free from adjacent structures using Liga-Sure and blunt maneuvers. A complete laparoscopic excision was performed. Histopathological examination revealed a benign schwannoma. The patient had an uneventful post-operative course, and was discharged on the fourth post-operative day. Laparoscopic treatment is useful and feasible for retroperitoneal pelvic schwannoma, with minimal invasiveness and an early post-operative recovery. Thus, this procedure may be the first-choice surgical procedure for retroperitoneal pelvic schwannomas.

Incarceration of a large cell neuroendocrine carcinoma arising from the proximal stomach with an organoaxial gastric volvulus through an esophageal hiatal hernia: report of a case.

An 86-year-old woman was admitted to the hospital to undergo an examination for tarry stools. Laboratory tests showed hypoproteinemia and renal dysfunction. Upper gastrointestinal endoscopy demonstrated a type 5 tumor located in the upper body of the stomach. An upper gastrointestinal series and computed tomography revealed an organoaxial gastric volvulus and the dislocation of the proximal stomach through an esophageal hiatal hernia. The preoperative diagnosis was the incarceration of a gastric carcinoma arising from the proximal stomach with an organoaxial gastric volvulus through an esophageal hiatal hernia. A total gastrectomy and hernia repair were performed. A microscopic examination of the surgical specimen revealed a gastric large cell neuroendocrine carcinoma (GLCNEC). The patient was discharged 22 days after the surgery. Although the prognosis of GLCNEC is significantly worse than that of a conventional adenocarcinoma, the patient was doing well without recurrence at 15 months after surgery. The details of this case are reported with some bibliographical comments.

Structural equation modeling of the relationship between posttraumatic growth and psychosocial factors in women with breast cancer

Posttraumatic growth (PTG) is a positive psychological change occurring after struggling with a highly challenging experience. The purposes of this study were to investigate how womens demographic and clinical characteristics as well as psychosocial factors are associated with PTG and to reveal the influence of PTG on depressive symptoms.

Tokyo Guidelines 2018 surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo‐biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail‐out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail‐out procedure should be chosen if, when the Calots triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvières sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Laparoscopic Intra-Gastric Resection of Gastric Sub-Mucosal Tumors under Oral Endoscopic Guidance

Introduction: A laparoscopic approach is often selected for resection of gastric submucosal tumor (GST), and several variations of this procedure have been reported. The approach selected greatly depends on the characteristics of the tumor, including its size or location, and also the experience and skill of the surgeon. Here we report our experience with intragastric resection of GSTs under oral endoscopic guidance. Methods: We performed laparoscopic intragastric resection of GSTs in 13 patients. The criteria for this approach were a tumor less than 5 cm in diameter and 8 cm2 in cross-section, and a tumor location on the posterior gastric wall in the upper and middle stomach or near the esophagogastric junction. Under general anesthesia, two or three ports were directly inserted into the stomach. Partial resection of the stomach including the tumor and an adequate margin in all directions was performed using a linear stapler. The resected specimen was retrieved orally using a plastic bag. Results: Laparoscopic intragastric resection of GST was successful in all patients. The mean maximum tumor diameter was 27 mm. The mean operation time was 176 min, and intraoperative blood loss was minimal. One patient required a gastrostomy and enlargement of one of the port sites in order to remove the tumor. There was no intra- or postoperative complications. The mean postoperative hospital stay was 7.5 days. The diagnosis after pathological examination of the tumor was gastrointestinal stromal tumor in 8 patients, leiomyoma in 4 and a cyst in one in one. There were no recurrences during a mean follow-up period of 121.7 months. Conclusion: A laparoscopic intragastric approach is well suited for patients who have a GST located in the upper and middle part of the stomach. It is anticipated that an oral endoscope will be used increasingly during laparoscopic procedures in the future.

Experience with laparoscopic treatment for paraesophageal hiatal hernia.

Paraesophageal hiatal hernia is often associated with a number of complications such as intestinal obstruction, gastric volvulus and acute pancreatitis, each of which can result in critical conditions requiring surgery. Herein, we report our surgical procedure for paraesophageal hiatal hernia.