Osamu Aramaki

Long-term outcome of laparoscopic cystogastrostomy performed using a posterior approach with a stapling device.

Background: Internal drainage of an acute pancreatic pseudocyst is indicated 6 weeks after its first detection. Laparoscopic treatment of pancreatic pseudocysts enables definitive drainage with faster recovery. Pseudocysts located adjacent to the posterior gastric wall are best drained by pseudocyst gastrostomy. Although the anterior approach for drainage has frequently been reported, reports on the posterior approach are rare. Methods: Seven patients underwent laparoscopic cystogastrostomy for pancreatic pseudocysts. The posterior approach that enables the direct visualization of the posterior gastric wall and pseudocyst was used, and the cyst was drained with a needle. After creating a sufficient drainage orifice, the cyst was thoroughly debrided. Cystogastrostomy was performed using the posterior approach with a stapling device. The insertion site of the stapling device closed using a hernia stapler. Results: Cystogastrostomy was performed using the posterior approach with a stapling device in all patients, without requiring conversion to the anterior approach or open surgery. There were neither operative complications nor late recurrences during the follow-up period (median 65 months). Conclusion: Laparoscopic cystogastrostomy using the posterior approach, which facilitates adequate internal drainage, is a safe and feasible procedure for pancreatic pseudocyst, and it is not accompanied with a risk of recurrence in the long term.

Preoperatively undetected solitary bile duct hamartoma (von Meyenburg complex) associated with esophageal carcinoma

Bile duct hamartomas, also known as von Meyenburg complexes, are benign neoplasms consisting of cystic dilatation of the bile duct surrounded by fibrous stroma. We report a rare case in a 60-year-old man who presented with coexistent von Meyenburg complex and esophageal carcinoma. Preoperative computed tomography did not reveal any liver tumors. Intraoperatively, a small lesion was discovered in segment III of the liver; the lesion was suspected to be a solitary liver metastasis from the esophageal carcinoma. Partial resection of the liver was performed, and pathological findings revealed bile duct hamartoma (von Meyenburg complex). As von Meyenburg complexes are small cystic lesions located throughout the liver, and as they do not present characteristic imaging findings, their preoperative morphological diagnosis and differential diagnosis from liver metastasis is extremely difficult. In conclusion, von Meyenburg complex should be considered in the differential diagnosis of intrahepatic cystic neoplasms.

Mediastinoscopy-assisted esophagectomy is useful technique for poor surgical-risk patients with thoracic esophageal cancer.

Elderly and poor surgical-risk patients with esophageal cancer experience several complications and often cannot undergo standard transthoracic esophagectomy. Mediastinoscopy-assisted esophagectomy (MAE) recently has been applied in patients with thoracic esophageal cancer. We herein report 2 poor surgical-risk patients of lower thoracic esophageal cancer treated with MAE. Patient 1 was a 60-year-old man with respiratory impairment due to pulmonary tuberculosis whereas patient 2 was an 80-year-old man with poor performance status and nutritional condition. In these patients, MAE was performed because standard esophagectomy by thoracotomy is too difficult to perform. We performed MAE using the mediastinoscope approaches via both the neck and hiatus. An approach via the hiatus is useful for mobilization of lower thoracic esophagus and via the neck is useful for direct visualization of recurrent nerve. These patients were successfully treated without complications. MAE enables the mobilization of the thoracic esophagus under the direct visualization in the mediastinum, and it may be considered to be safe and useful technique for elderly and poor surgical-risk patients.

Palliative enteric bypass for malignant gastric outflow obstruction after pancreaticoduodenectomy in early recurrent pancreatic cancer.

BACKGROUND/AIMSnRecurrent pancreatic cancer has a poor prognosis and there are no established therapeutic strategies. We retrospectively studied patients who underwent palliative surgery for recurrent disease with gastric outlet obstruction (GOO) after an initial pancreaticoduodenectomy (PD) for pancreatic cancer.nnnMETHODOLOGYnWe retrospectively studied 4 patients who had undergone a bypass operation, including a modified Devine gastrojejunostomy with vertical stomach reconstruction (MDVSR) for GOO to ensure a direct dietary route to the jejunum, thereby, enabling the gastric contents to easily reach the jejunum.nnnRESULTSnMDVSR was performed in 4 patients, and in addition to the bypass, 1 patient underwent a jejunojejunostomy, and 1 patient an ileocolostomy. The median operative time and blood loss were 123min (range, 95-150 min) and 164mL (range, 115-235 mL). After the second surgery, 2 of 4 patients received chemotherapy (1 patient: gemcitabine + S1, 1 patient: gemcitabine alone). The remaining 2 patients did not receive chemotherapy. The mean survival after the second operation was 145 days (range, 34-386 days).nnnCONCLUSIONSnPalliative surgery including MDVSR is useful to improve a patients nutritional state and it is more effective than chemotherapy for treating recurrent disease with GOO after a PD for pancreatic cancer.

Modified duval procedure for small-duct chronic pancreatitis without head dominance.

BACKGROUND/AIMSnIn the case of small-duct chronic pancreatitis, surgery for pain relief is broadly divided into resection and drainage procedures. These procedures should be selected according to the location of dominant lesion, diameter of the pancreatic duct and extent of the disease. The appropriate procedure for the treatment of small-duct chronic pancreatitis, especially small-duct chronic pancreatitis without head dominance, remains controversial. We developed the modified Duval procedure for the treatment of small-duct chronic pancreatitis without head dominance and determined the efficacy of this procedure.nnnMETHODOLOGYnWe retrospectively studied 14 patients who underwent surgical drainage with or without pancreatic resection for chronic pancreatitis with small pancreatic duct (<7mm) without head dominance. These patients were divided into 2 groups; the modified Puestow procedure group and the modified Duval procedure group.nnnRESULTSnNo complications occurred in the modified Duval group. In the modified Puestow procedure group, complete and partial pain relief were observed in 62.5%, and 37.5% of patients respectively. In contrast, complete pain relief was observed in all the patients in the modified Duval procedure group.nnnCONCLUSIONSnOur modified Duval procedure is useful and should be considered the appropriate surgical technique for the treatment of small-duct chronic pancreatitis without head dominance.