Shigenao Kan

Endoscopic thyroidectomy by the axillary approach

Neck surgery has recently become one of the newest fields for the application of endoscopic surgery because the resultant scar is small and inconspicuous. Still, some patients feel even a small scar on the neck is not cosmetically acceptable. We therefore have developed a new technique of endoscopic thyroidectomy by the axillary approach that leaves no scar on the neck at all. When this method is used, the small scar in the axilla is completely covered by the patients arm in a natural manner. The cosmetic result is excellent, and sensory loss in the neck is negligible because the area of surgical dissection is small. We believe that endoscopic thyroid surgery by the axillary approach will find a role in the treatment of thyroid disease.

Endoscopic thyroidectomy and parathyroidectomy by the axillary approach: A preliminary report

Background: The use of endoscopic procedures leads to a reduction in the size of the surgical scar, making it more inconspicuous. In this paper, we evaluated the merits and limits of endoscopic neck surgery. Methods: Between August 1999 and July 2000, 102 patients underwent neck surgery in our department for thyroid or parathyroid disease. Twenty-eight of them were treated by the axillary. A 12-mm and two 5-mm trocars were inserted through the skin of the axilla. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed. Results: Endoscopic procedures were performed successfully in 26 cases (19 thyroidectomies and seven parathyroidectomies). There were two conversions to open procedures. The mean operating times for the thyroidectomies and parathyroidectomies were 212 and 171 min, respectively. No evidence of injury to the recurrent laryngeal nerve was observed in any of the cases. The postoperative cosmetic status of the patients was excellent. Conclusion: We believe that endoscopic thyroidectomy and parathyroidectomy by the axillary approach will find a role in the treatment of endocrine diseases in the neck.

Operational tolerance induced by pretreatment with donor dendritic cells under blockade of CD40 pathway.

Background. Dendritic cells can mount immune response as competent antigen presenting cells. Recently, it has been reported that immature dendritic cells induce prolongation of allograft survival. However, the ability of mature dendritic cells to induce operational tolerance is unclear. Therefore, in this study, we examined the ability of splenic mature dendritic cells to induce operational tolerance to fully allogeneic antigens using mouse heterotopic heart transplantation model. Methods. CBA (H2k) mice received i.v. injections with donor splenic dendritic cells or B cells in the absence or presence of monoclonal antibody (mAb) specific for CD40 ligand or CD80/CD86 2 weeks before transplantation of a C57BL/10 (H2b) heart. Results. When donor dendritic cells were injected i.v. 2 weeks before transplantation, rejection response was accelerated compared with that of naive mice [median survival time (MST) = 7 and 8 days, respectively]. However, when CD40 pathway was blocked by anti-CD40 ligand mAb, i.v. injection of donor dendritic cells but not B cells induced indefinite graft survival (MST >100 and 20 days, respectively). Mice treated with anti-CD40 ligand mAb alone rejected their grafts with a MST of 18 days. Intravenous injection of donor dendritic cells and B cells in combination with anti-CD80/CD86 mAbs was less effective to induce graft prolongation (MST = 9.5 and 13 days, respectively). Conclusions. Therefore, under blockade of CD40 pathway, mature dendritic cells were tolerogens in vivo independent of CD80/86 pathways.

Endoscopic total parathyroidectomy by the anterior chest approach for renal hyperparathyroidism

Background: During the past 3 years, minimally invasive procedures have been adopted for the surgical treatment of primary hyperparathyroidism, and we have tried to perform endoscopic total parathyroidectomy for renal hyperparathyroidism. Methods: Five 5-mm trocars were inserted through the skin of the anterior chest under a general anesthesia. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed. Results: Endoscopic procedure was successfully performed in five patients. The mean duration of total parathyroidectomies was 236 min. No evidence of injury to the recurrent laryngeal nerve was observed in any cases. At follow-up, the serum calcium and parathyroid hormone levels had returned to within the normal range in all patients. Postoperative cosmetic status was excellent. Conclusion: We believe that endoscopic total parathyroidectomy by the anterior chest approach will find a role in the treatment of renal hyperparathyroidism.

Laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein

Background: We perform laparoscopic partial adrenalectomy without sectioning the adrenal central vein has been described because it is important to preserve this vein in the remnant adrenal gland in order to maintain its function. In this article, we describe our technique for laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein. Methods: The procedures were performed in four patients with aldosterone-producing adenomas (APA) and two patients with pheochromocytomas. Results: There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed that remnant adrenal function had been preserved in all cases. Conclusion: Since the vascular bed adjacent to the remnant adrenal gland is integral to the preservation of its function, it is important to perform procedures that do not separate the remnant adrenal gland from the retroperitonium space. Because the operative field is clearly visualized on the high-magnification video monitor, this delicate procedure can be performed with a high degree of accuracy via the laparoscopic approach. We consider this operative technique to be useful for selected cases.

Thoracoscopic esophagectomy combined with mediastinoscopy via the neck.

Although thoracoscopic techniques have been introduced to esophageal surgery, the identification of the left recurrent laryngeal nerve and lymph node dissection along the nerve remain quite difficult. A mediastinoscopic technique via the neck enables an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve. Therefore, a thoracoscopic esophagectomy combined with this technique allows mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily and safely dissected.

Hand-assisted laparoscopic proximal gastrectomy with jejunal interposition and lymphadenectomy.

Proximal gastrectomy is currently accepted by surgeons as the most favorable type of operation for the treatment of early gastric cancer in the upper third of the stomach, from both a hormonal and a nutritional perspective. In advanced gastric cancer, total gastrectomy combined with lymph node dissection, a radical procedure, is widely used, because these cases are often complicated by lymph node metastases along the lower part of the stomach. On the other hand, various surgical procedures that preserve organs and their functions to the greatest possible extent have been advocated and put into practice. Besides, several reports have demonstrated that lymph node metastases were found in the splenic hilum but were not found along the lower stomach when the depth of invasion was limited to the muscularis propria. Because of this, proximal gastrectomy with splenectomy is an acceptable treatment for gastric cancer in the upper third of the stomach when the depth of invasion is limited to the muscularis propria. Recently, minimally invasive surgical techniques have attracted interest in all surgical specialties. In this article, we report a hand-assisted laparoscopic procedure that allows lymph node dissection and gastrointestinal reconstruction to be safely and easily performed.

Is laparoscopic partial or cortical-sparing adrenalectomy worthwhile?

SummaryBackground: Since corticosteroids are indispensable hormones, partial or cortical-sparing adrenalectomies may be adopted for the surgical treatment of adrenal diseases. In this article, we describe the techniques and results of these procedures.Methods: Laparoscopic partial or cortical-sparing adrenalectomy was performed in nine patients. Six cases had an aldosterone-producing adenoma (APA) and three had a phaeochromocytoma. Two cases with an APA and one case with a phaeochromocytoma showed tumours located far from the adrenal central vein, and the vein could be preserved. Four cases with an APA and two with a phaeochromocytoma had tumours located close to the adrenal central vein, and it was necessary to section the central vein in order to resect them.Results: All endoscopic procedures were performed successfully. There were no postoperative complications. At follow-up, adrenal 131I-aldosterol scintigrams showed the preservation of remnant adrenal function in all patients.Conclusions: Laparoscopic partial or cortical-sparing adrenal surgery was safely performed, and adrenal function was preserved, irrespective of whether the adrenal central vein could be preserved or not. We consider this to be a useful operative technique in selected cases.ZusammenfassungGrundlagen: Da Kortikosteroide unerläßliche Hormone sind, kann eine partielle oder kortexsparende Adrenalektomie für die chirurgische Behandlung von Nebennierenkrankheiten eingesetzt werden. In diesem Artikel beschreiben wir die entsprechenden Techniken und die mit dieser Prozedur erhaltenen Ergebnisse.Methodik: Laparoskopische partielle oder kortexsparende Adrenalektomien wurden bei 9 Patienten durchgeführt. Sechs dieser Patienten hatten ein APA und drei ein Phäochromozytom. Bei zwei Patienten mit APA und einem Patienten mit Phäochromozytom lagen die Tumore weit entfernt von der zentralen Nebennierenvene, so daß die Vene erhalten werden konnte. Vier Patienten mit APA und zwei mit Phäochromozytom hatten Tumore, die sich dicht bei der zentralen Nebennierenvene befanden, so daß eine Sektion dieser Vene erforderlich war, um den Tumor zu entfernen.Ergebnisse: Alle endoskopischen Prozeduren wurden erfolgreich durchgeführt. Es gab keine postoperativen Komplikationen. Eine Folgeuntersuchung mit Hilfe von 131J-Aldosterol Szintigrammen zeigte bei allen Patienten eine Erhaltung der verbleibenden Nebennierenfunktion.Schlußfolgerungen: Partielle oder kortexsparende laparoskopische Adrenalektomie konnte sicher durchgeführt werden. Gleichzeitig konnte dabei die Nebennierenfunktion erhalten werden, unabhängig davon, ob die zentrale Nebennierenvene erhalten werden konnte oder nicht. Daher betrachten wir dies als eine nützliche operative Technik für ausgewählte Fälle.

Adrenal-sparing adrenalectomy in hereditary bilateral phaeochromocytoma

Bilateral phaeochromocytoma is typically found as a component tumour of multiple endocrine neoplasia (MEN) type 2 and Von Hippel–Lindau (VHL) disease.1–4 Total bilateral adrenalectomy has traditionally been employed to treat bilateral phaeochromocytoma but this requires long-term corticosteroid replacement. Because hereditary phaeochromocytomas are rarely malignant,4 we performed adrenal-sparing adrenalectomy in selected patients with MEN 2A. In the present report we describe the surgical and endocrine findings in a patient treated accordingly.

Reliable cervical anastomosis through the retrosternal route with stepwise gastric tube

OBJECTIVES An extra-anatomic reconstruction would be beneficial in preventing recurrent malignant dysphagia. A long gastric tube that allowed a sufficient blood flow was necessary to perform the successful cervical anastomosis through the retrosternal route. METHODS The gastric tube was created by means of separate division and closure of the seromuscular and submucosal-mucosal layers (stepwise group) in 15 consecutive patients and by means of full-thickness cutting of the stomach and closure of the seromuscular layer (standard group) in 22 patients. We compared these 2 types of gastroplasties in terms of total length of the tube, blood flow, and the incidence of anastomotic leakage. Blood flow was measured with a laser Doppler flowmeter during surgical intervention. RESULTS The gastric tube in the stepwise group was significantly longer than that in the standard group (P <.01, unpaired t test). Tissue blood flow at the site of anastomosis in the stepwise group was significantly greater than that in the standard group (P <.01, unpaired t test), and the rate of anastomotic leakage in the stepwise group was significantly lower than that in the standard group (P <.05, chi(2) test). CONCLUSION We consider this technique to be a useful procedure for retrosternal reconstruction after subtotal esophagectomy.