Noriaki Takiguchi

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument “Endo-PSI (II)” and circular stapler

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the “Endo-PSI (II)”, and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.

A Case of Popliteal Cystic Degeneration with Pathological Considerations

Adventitial cystic degeneration of the popliteal artery is seldom encountered; only 39 cases have been reported up to now in Japan. The pathogenesis of this disease remains controversial, and the authors describe a case in which the pathological findings differed from cases reported in the previous literature. The subject was a 74-year-old man admitted to our hospital complaining of intermittent claudication. The characteristic findings of cystic degeneration of the popliteal artery were uncovered by contrast-enhanced computed tomography (CT) and duplex sonography. The contrast-enhanced CT showed a low-density area and duplex sonography revealed a multi-lobulated low-echoic lesion. The Doppler signal of the low-echoic lesion could not be detected. While some cysts were found in the adventitia, they were mainly located in the media. The media also showed a remarkable decrease of smooth muscle cells and a prominent mucinous degeneration that had occurred circumferentially. These findings suggest that the medial degeneration noted had occurred prior to cystic formation. Because of this and other findings, we recommend the use of the termcystic degeneration of the popliteal artery in addition to the termcystic adventitial disease of the popliteal artery.

Hand-assisted Laparoscopic Esophagojejunostomy Using Newly Developed Purse-string Suture Instrument “endo-psi”

Although there are several reports on the esophagojejunostomy during laparoscopy-assisted total gastrectomy, the procedures still remain to be established. We report hand-assisted laparoscopic esophagojejunostomy using circular stapler and newly developed instrument “Endo-PSI.” Between April 2005 and April 2006, 13 patients received these products during laparoscopy-assisted total gastrectomy. The Endo-PSI was attached to the abdominal esophagus using hand-assisted laparoscopic surgery. The insertion of the straight needle with 2-0 polypropylene into the device and the cutting of the esophagus were also performed using hand-assisted laparoscopic surgery. The insertion of the anvil head into the esophagus and the ligation of the purse-string suture were performed laparoscopically. After the jejuno-jejunal anastomosis was performed extracorporeally, the combination of the circular stapler for esophagojejunostomy and the closure of the stump of the jejunum were performed laparoscopically. There were no complications attributable to this procedure and there were no cases that required conversion to conventional open procedure or required extension of median incision. This newly developed Endo-PSI was useful for laparoscopic purse-string suture.

Prognostic significance of gastric cancer metastasis in second-tier lymph nodes detected on reverse transcriptase–polymerase chain reaction and immunohistochemistry

To determine the prognostic significance of the methods used to determine the presence of metastasis in second‐tier lymph nodes of patients with gastric cancer, the authors studied lymph nodes surgically removed from 100 patients with gastric cancer (55 with early cancer, 45 with progressive). The results of HE staining were compared with those of immunohistochemistry using the anticytokeratin (CK) antibody and reverse transcriptase–polymerase chain reaction (RT‐PCR) assays. Lymph node 7 or 8a was obtained intraoperatively, then mRNA was extracted using an immunobeads method, and RT‐PCR with CK19 mRNA was performed. The P for Cox regression analysis for metastasis detected by HE staining, CK staining, and RT‐PCR of all 100 cases was 0.312, 0.426, and 0.021, respectively, while for second‐tier lymph nodes it was 0.154, 0.013, and 0.006, respectively. In conclusion, RT‐PCR and CK staining for detection of metastasis in second‐tier lymph nodes were more reliable prognostic indicators than conventional HE staining.

Spleen preservation versus splenectomy in laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer: A comparison of short-term outcomes

Splenic hilar lymph node dissection via a splenectomy for advanced proximal gastric cancer remains controversial. Recently, a laparoscopic spleen‐preserving hilar lymph node dissection procedure was described in several publications. To assess the feasibility and safety of spleen‐preserving laparoscopic total gastrectomy with D2 lymphadenectomy (LTG‐D2), the present retrospective study compared the short‐term surgical outcomes between spleen preservation and splenectomy during laparoscopic D2 total gastrectomy (LTG‐D2S).

Omental wrapping of esophageal rupture in combination with T-tube drainage

Esophageal rupture is a potentially fatal condition. Rapid and correct diagnosis and urgent surgical treatment are mandatory. Various surgical treatment methods have been reported. We introduced a new surgical procedure for treatment of spontaneous esophageal rupture. Upon thoracotomy continuing to laparotomy, a T-tube was inserted into the esophageal lumen through the ruptured site. The ruptured esophageal wall was sutured interruptedly, and the insertion site was covered with the pedicle omental flap. The T-tube was replaced by a thinner catheter tube from postoperative day (POD) 45 and finally withdrawn on POD 66. The patient was discharged in good condition on POD 98. The procedure described here is safe and effective. It is applicable for patients restricted to minimally invasive surgery, those with poor general condition and severely infectious contamination but without a widely necrotic esophageal wall around the ruptured site.

Reduced port surgery and reduced surgical staff surgery for gastric cancer

Background: We have been performing a triple incision lapa-roscopic distal gastrectomy (TIL-DG) as a reduced port surgery. This procedure is also useful for reducing the number of required surgical staff, since a TIL-DG requires only two operators. This concept can also be applied to a laparoscopic total gastrectomy (LTG). Methods: A total of 121 patients underwent a TIL-DG, and a total of 39 patients underwent a laparoscopic total gastrectomy performed by two surgical staff members (re-LTG). These cases were compared with those in a conventional laparo-scopic distal gastrectomy (LDG) group (59 cases) and a conventional LTG group (79 cases). Results: No significant differences were observed between the TIL-DG group and the LDG group in terms of the mean operative time, blood loss, or the length of the postoperative hospital stay. The mean number of retrieved lymph nodes in the TIL-DG group was slightly higher than that in the LDG group. No significant differences were observed between the Re-LTG group and the LTG group in terms of the mean op-erative time, blood loss, the number of retrieved lymph nodes, or the length of the post-operative hospital stay. Conclusions: TIL-DG and re-LTG are feasible and safe pro-cedures.

Perioperative management of juxtarenal aortic occlusion

The authors reviewed the surgical treatment and outcome in patients with juxtarenal aortic occlusion. From 1975 to 1993, 44 patients (37 men) with a mean age of 62.6 years underwent surgery for this condition. The vascular lesions included renal-level segmental aortic occlusion in 2 patients, infrarenal complete aortic occlusion in 30, and high aortic occlusion with a patent inferior mesenteric artery in 12. Four patients had subacute occlusion and 40 had chronic occlusion. In the chronic group, the symptom was intermittent claudication in 31 cases, rest pain in 4, and gangrene or ulceration in 5. Impotence was present in most of the men. Surgical treatment included transaortic thromboendarterectomy in 2 patients, axillobifemoral bypass in 12, and high aortic thromboendarterectomy plus aortobifemoral bypass in 29. Suprarenal aortic clamping was done in 22 patients, with a mean renal occlusion time of 9.3 minutes. Simultaneous renal artery reconstruction was performed in 3 patients. There were 4 operative deaths (mortality rate 9%), with 2 in the subacute group. Late death from unrelated causes occurred in 9 patients within five years. Lower limb ischemia was cured in all patients and impotence cured in 4 cases. Graft patency was satisfactory after both extra-anatomic and anatomic bypass. Transanal Doppler ultrasound monitoring during the surgery was easy to set and gave the authors useful information about accurate visceral circulation in reference to aortic reconstruction.