Seiichiro Kanaya

Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy.

Recently, laparoscopic gastrectomy has become popular for the treatment of benign gastroduodenal diseases or early gastric carcinomas. Several procedures can now be performed intraabdominally because of advances in technology and surgical techniques, but Billroth I reconstruction after laparoscopic distal gastrectomy is commonly performed extraabdominally because of the complexity of intraabdominal anastomotic procedure. We have developed a new method of intraabdominal Billroth I anastomosis using only endoscopic linear staplers. Our procedure is simple, easy, and safe. In this article, we describe the technique and present the results of our initial trials.

Laparoscopic Total Gastrectomy With D2 Lymph Node Dissection for Gastric Cancer

OBJECTIVE To evaluate the safety and effectiveness of laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer. DESIGN Review of findings from a prospectively acquired institutional database. SETTING University hospital. PATIENTS Fifty-five consecutive patients operated on by the same surgeon between October 1997 and March 2008. MAIN OUTCOME MEASURES Blood loss, complication rate, and survival. RESULTS All operations were accomplished without conversion to open laparotomy. The median operative time was 406 minutes. The median blood loss was 102 mL. A median of 46 lymph nodes were harvested. The TNM stages of the tumor were I in 17 patients (31%), II in 12 (22%), III in 16 (29%), and IV in 10 (18%). A total of 21 complications occurred in 18 patients (33%) with no postoperative mortality. At last follow-up, 44 of the 55 patients were alive without tumor recurrence and 3 with recurrence at a median follow-up of 16 months, whereas 8 had died of recurrence or another cause. CONCLUSIONS The mortality rate of zero and acceptable morbidity of our series indicate that laparoscopic total gastrectomy with D2 lymphadenectomy is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncologic outcome.

Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer

BackgroundTo facilitate acceptance of laparoscopic total gastrectomy (LTG) for patients with upper gastric cancer, a simple, secure technique of reconstruction is necessary. The authors developed a new technique for intracorporeal esophagojejunal anastomosis that does not require hand sewing.MethodsFrom September 2006 to January 2008, 16 patients (11 men and 5 women) with gastric cancer underwent LTG at the authors’ institution. Laparoscopic esophagojejunal anastomosis using the following method was attempted for all patients. The esophagus was transected while being rotated by about 45° counterclockwise to make the subsequent anastomosis easier. After the Y-anastomosis was created, an endoscopic linear stapler was applied to create a side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was first closed roughly with hernia staplers. Subsequently, an endoscopic linear stapler was applied so that all hernia staplers could be removed and the closure completed.ResultsLaparoscopic esophagojejunal anastomosis was successfully performed for 15 patients. Intracorporeal anastomosis failed for one patient because a nasogastric tube was caught between the jaws of an endostapler, which resulted in a conversion to open procedure. No postoperative anastomotic complications occurred.ConclusionsUsing the new technique, intracorporeal linear-stapled esophagojejunal anastomosis can be performed easily and securely. This technique could become one of the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with upper gastric cancer.

A Protective Technique for Retraction of the Liver During Laparoscopic Gastrectomy for Gastric Adenocarcinoma: Using a Penrose Drain

BackgroundRetraction of the liver is necessary to ensure an adequate working space in laparoscopic surgery, but the retraction force applied may cause transient liver dysfunction. We have introduced the technique using a Penrose drain to suspend the liver with the performance of laparoscopic gastrectomy for gastric adenocarcinoma.Methods111 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy using either a Penrose drain (n = 47) or a Nathanson’s retractor (n = 64) for displacement of the liver. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, alkaline phoshatase (ALP) and albumin were compared among the groups at baseline, immediately after operation, and on postoperative days (POD) 1, 2, 3, 5, and 7.ResultsThe levels of ALT on POD 2, 3, and 5 were significant higher in the Nathanson’s retractor group than in the Penrose drain group. Levels of AST on POD 2 and 3 were also higher in the Nathanson’s retractor group than in the Penrose drain group. There was no significant difference in total bilirubin, ALP, and serum albumin levels between groups.ConclusionsThe use of the Penrose drain for retraction of the liver appears to attenuate postoperative liver dysfunction during laparoscopic gastrectomy for gastric adenocarcinoma.

Clinical Outcome and Clinicopathological Characteristics of Recurrence after Laparoscopic Gastrectomy for Advanced Gastric Cancer

Background: Although laparoscopic gastrectomy has been recognized as a treatment of early gastric cancer, the indication for laparoscopic gastrectomy with D2 lymph node dissection has remained controversial. D2 lymph node dissection is considered to be feasible for advanced gastric cancer in some high-volume institutions specifically trained for the laparoscopic procedure. This study was undertaken to determine the clinical outcome and clinicopathological characteristics of patients who showed recurrence following laparoscopic gastrectomy for advanced gastric cancer. Methods: From August 1999 through February 2009, among 805 patients who underwent laparoscopic gastrectomy associated with regional lymph node dissection, a total of 209 patients undergoing gastrectomy associated with lymph node dissection who consequently obtained complete resection for advanced gastric cancer were subjected to the retrospective analysis to evaluate clinical outcome. Results: The mean period of postoperative observation was 1,068 days. The final stages of the 209 cases were as follows: 83 in IB, 56 in II, 46 in IIIA, and 24 in IIIB. The 5-year survival rate was 89.1% in stage IB, 93.1% in stage II, 52.5% in stage IIIA, and 46.5% in stage IIIB, respectively. A total of 27 patients (12.9%) had recurrence. Postoperative recurrence of gastric carcinoma occurred in peritoneal dissemination in 13 patients, liver in 7, distant lymph nodes in 6, ovary in 3, lung in 2, skin in 1, and meninges in 1 patient. There were neither port-site metastases nor locoregional recurrence. Conclusion: The characteristics and the rate of postoperative recurrence after laparoscopic gastrectomy for advanced gastric cancer were not greatly different from those of the open conventional procedure. Although further observation is required to finally conclude long-term survival, laparoscopic radical gastrectomy may possibly be indicated for patients with advanced gastric cancer.

Robot-assisted surgery for gastric cancer: experience at our institute.

Objective: The robot-assisted surgical system was developed for minimally invasive surgery and is thought to have the potential to overcome the shortcomings of laparoscopic surgery. We introduced this system for the treatment of gastric cancer in 2008. Here we report our initial experiences of robot-assisted surgery using the da Vinci system. Methods: A retrospective review of robot-assisted gastrectomy for gastric cancer patients was performed in our institute. The clinicopathological features and surgical outcomes were analyzed. Whereas the procedures of the gastrectomy were similar to those of the usual laparoscopic surgery, several aspects such as the port placement and the role of the assistant were modified from those for conventional laparoscopic surgery. Results: From January 2008 to December 2010, 61 patients with gastric cancer underwent robot-assisted surgery. Gastrectomy was distal in 46 patients, total in 14, proximal in 1 and no operation was converted to the open procedure. D2 lymph node dissection was performed on 28 patients in the distal gastrectomy group and on 11 in the total gastrectomy group. Complications occurred in 2 cases (4%): these consisted of ruptured sutures and hemorrhage from the anastomotic site. Conclusions: This study demonstrated that robot-assisted gastrectomy using the da Vinci system can be applied safely and effectively for patients with gastric cancer.

Topographic anatomy and laparoscopic technique for dissection of no. 6 infrapyloric lymph nodes in gastric cancer surgery

We focused on the embryology and topographic anatomy of the infrapyloric lymph region, which is frequently involved in node metastases but technically complicated for dissection in gastric cancer surgery. Gastrointestinal organs possess their own mesenteries composed of double layers of peritoneum that enclose the intermediate adipose layer providing pathways for vessels, nerves, and lymphatic channels. The frontal layer of the mesoduodenum, in which no. 6 infrapyloric nodes lie, directly faces the pancreas and during gestation is overlain by the greater omentum and transverse mesocolon through the membranous connective tissue called the fusion fascia. Therefore, we performed no. 6 node dissection using the following process: (1) we traced out the mesoduodenum by detachment of the greater omentum and transverse mesocolon; (2) we transected the fusion fascia and (3) removed the adipose layer on the anterior face of the pancreas with its included lymph nodes together with the right gastroepiploic and infrapyloric vessels. The described technique is feasible and in keeping with the anatomical logic for oncologically reliable dissection of no. 6 infrapyloric nodes.

Intracorporeal anastomosis in laparoscopic gastric cancer surgery.

Laparoscopic gastrectomy has become widely used as a minimally invasive technique for the treatment of gastric cancer. When it was first introduced, most surgeons preferred a laparoscopic-assisted approach with a minilaparotomy rather than a totally laparoscopic procedure because of the technical challenges of achieving an intracorporeal anastomosis. Recently, with improved skills and instruments, several surgeons have reported the safety and feasibility of a totally laparoscopic gastrectomy with intracorporeal anastomosis. This review describes the recent technical advances in intracorporeal anastomoses using circular and linear staplers that allow for totally laparoscopic distal, total, and proximal gastrectomies. Data that demonstrate advantages in early surgical outcomes of a total laparoscopic method compared to laparoscopic-assisted operations are also discussed.

Totally laparoscopic pancreaticoduodenectomy for locally advanced gastric cancer.

BackgroundIn patients having locally advanced cancer of the stomach with suspected tumor infiltration to the pancreatic head or the duodenum, a concurrent pancreaticoduodenectomy with gastrectomy is occasionally prerequisite to achieve a microscopically tumor-free surgical margin.Materials and methodsWe present the first series of successful totally laparoscopic pancreaticoduodenectomy (TLPD) for advanced gastric cancer with suspected infiltration to the pancreatic head.ResultsTLPD was successfully performed without adverse events during surgery and resulted in favorable short-term outcomes of three patients with locally advanced gastric cancer with suspected invasion to the pancreas.ConclusionsAlthough TLPD for locally advanced gastric cancer is a technically difficult challenging operation that requires careful dissection along the major vessels, intracorporeal tie sutures, and the placement of an external drainage tube into a narrow pancreatic duct, this procedure is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncological outcome.

Laparoscopic excision of subdiaphragmatic bronchogenic cyst occurring in the retroperitoneum: report of a case.

Although bronchogenic cysts (BCs) are benign congenital malformations usually occur in thoracic cavity, retroperitoneal location is extremely uncommon. We reported a case of BC occurred in the retroperitoneum, which was excised laparoscopically. A 64-year-old Japanese woman was admitted to the hospital because of submucosal tumor in the upper part of the stomach. An upper gastrointestinal endoscopy revealed a submucosal tumor located just distal to the esophagogastric junction. The abdominal computed tomography scan revealed a cystic mass located in contact with lesser curvature of the stomach and the dorsal surface of the liver. As the cystic mass was well-circumscribed and showed no positive findings suggestive of malignancy, the laparoscopic excision of the cystic mass was performed. The cystic tumor was completely excised with a laparoscopic procedure. The histologic findings indicated that the cyst was surfaced by the ciliated pseudostratified epithelium without the presence of the cartilage, which was compatible with the BC of the retroperitoneum. This case highlights the safety and the feasibility of complete laparoscopic excision of retroperitoneal BC. Laparoscopic excision of retroperitoneal BC definitely provides all advantages of minimally invasive procedure, which improves postoperative patient discomfort and pain and shortens hospital stay. Laparoscopic procedure may definitely be a standard approach for the excision of retroperitoneal BC.