Shingo Kanaji

Multidetector computed tomography for preoperative identification of left gastric vein location in patients with gastric cancer

BackgroundThe area near the left gastric vein (LGV) is a challenging site at which to perform dissection of the lymph nodes during gastrectomy. Therefore, knowledge of the precise location of the LGV is important. The objective of this study was to examine the usefulness of multidetector computed tomography (MDCT) for the identification of the LGV.MethodsEighty-one patients with gastric cancer underwent MDCT, which was performed with contrast media in 76 patients and without contrast media in 5 patients. A 5-mm thin slice of the frontal image was reconstructed. These images were examined preoperatively to detect the location of the LGV. Upon gastrectomy, the LGV was identified and its location compared to that determined by MDCT.ResultsThe LGV was identified by MDCT in 76 of the 81 patients (93.8%). The LGV was subsequently located during the operation in all 81 patients. The LGV was located dorsal to the common hepatic artery in 40 patients (49.4%), ventral to the common hepatic artery in 18 patients (22.2%), ventral to the splenic artery in 17 patients (21.0%), dorsal to the splenic artery in 2 patients (2.5%) and in other positions in 4 patients (4.9%). In all patients, the location of the LGV detected using MDCT was consistent with that identified during gastrectomy. In the 4 patients with relatively unusual locations of the LGV, these 4 LGV variants were identified preoperatively by MDCT.ConclusionMDCT was useful for identifying the location of the LGV prior to gastrectomy.

Changes in modified Glasgow prognostic score after neoadjuvant chemotherapy is a prognostic factor in clinical stage II/III esophageal cancer

The inflammation-based modified Glasgow prognostic score (mGPS) has been shown to be a prognostic factor for esophageal cancer, but its changes in relation to neoadjuvant chemotherapy (NAC) have never been discussed. The purpose of this study was to evaluate the potential prognostic role of mGPS with regard to NAC. mGPS was evaluated on the basis of admission blood samples taken before chemotherapy and before surgery. Patients with elevated C-reactive protein (CRP) serum levels (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a score of 2, patients with elevated CRP serum levels without hypoalbuminemia were allocated a score of 1, and patients with normal CRP serum levels with or without hypoalbuminemia were allocated a score of 0. A total of 100 patients with clinical stage II/III squamous cell esophageal cancer, who underwent NAC and esophagectomy between January 2007 and August 2012, were investigated. From the multivariate analysis, the grade of response to chemotherapy and post-NAC mGPS level was found to be independent prognostic factors. The overall survival rate was significantly higher in the conserved mGPS group than in the worse mGPS group (P = 0.030). Changes in mGPS during chemotherapy affected the prognosis of patients, and post-NAC mGPS is an independent prognostic factor in patients with clinical stage II/III thoracic esophageal squamous cell cancer.The inflammation-based modified Glasgow prognostic score (mGPS) has been shown to be a prognostic factor for esophageal cancer, but its changes in relation to neoadjuvant chemotherapy (NAC) have never been discussed. The purpose of this study was to evaluate the potential prognostic role of mGPS with regard to NAC. mGPS was evaluated on the basis of admission blood samples taken before chemotherapy and before surgery. Patients with elevated C-reactive protein (CRP) serum levels (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a score of 2, patients with elevated CRP serum levels without hypoalbuminemia were allocated a score of 1, and patients with normal CRP serum levels with or without hypoalbuminemia were allocated a score of 0. A total of 100 patients with clinical stage II/III squamous cell esophageal cancer, who underwent NAC and esophagectomy between January 2007 and August 2012, were investigated. From the multivariate analysis, the grade of response to chemotherapy and post-NAC mGPS level was found to be independent prognostic factors. The overall survival rate was significantly higher in the conserved mGPS group than in the worse mGPS group (P = 0.030). Changes in mGPS during chemotherapy affected the prognosis of patients, and post-NAC mGPS is an independent prognostic factor in patients with clinical stage II/III thoracic esophageal squamous cell cancer.

Laparoscopic complete mesocolic excision for right-sided colon cancer using a cranial approach: anatomical and embryological consideration

BackgroundComplete mesocolic excision (CME) with central vascular ligation (CVL) should be employed for the treatment of colon cancer patients because of its superior oncological outcomes. However, this technique is technically challenging in laparoscopic right hemicolectomy because of the anatomical complexity of the transverse mesocolon.MethodsWe focused on the embryology and anatomy of the transverse mesocolon to overcome the difficulty of this surgery. The validity and efficacy of a cranial approach in achieving CME with CVL in laparoscopic right hemicolectomy was elucidated from the embryological point of view.ResultsIn total, 28 consecutive patients with right-sided colon cancer were treated by laparoscopic right hemicolectomy using a cranial approach. There were no conversion to open surgery or switching to another approach. Using this approach, torsion and fusion of the transverse mesocolon, which occurred during embryological development, could be reversed and the complex anatomy of the transverse mesocolon could be simplified before performing CVL of colonic vessels.ConclusionsA cranial approach is considered valid and useful for CME with CVL in laparoscopic right hemicolectomy from the embryological point of view.

Prone position in thoracoscopic esophagectomy improves postoperative oxygenation and reduces pulmonary complications.

BackgroundWhile thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest.MethodsA total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis.ResultsTwo patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P.ConclusionThe findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.

Appendicitis with psoas abscess successfully treated by laparoscopic surgery.

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.

Treating patients with advanced rectal cancer and lateral pelvic lymph nodes with preoperative chemoradiotherapy based on pretreatment imaging

Preoperative chemoradiotherapy (CRT) and lateral pelvic lymph node (LPLN) dissection (LPLD) based on pretreatment imaging are performed to improve oncological outcomes at our institution. However, the advantage of LPLD following preoperative CRT in advanced rectal cancer remains unclear. The objective of the present study was to assess the validity of this approach. Thirty-two patients with advanced rectal cancer were included in the study. All patients were treated with preoperative CRT and curative operation. Of these, 16 patients who were treated between August 2005 and June 2008 underwent LPLD on both sides (LPLD group). Sixteen patients who were treated between July 2008 and January 2013 underwent LPLD only on the side with suspected LPLN metastasis determined by pretreatment imaging; in cases without LPLN metastasis, only total mesorectal excision was performed (limited-LPLD group). The overall survival and relapse-free survival between the LPLD and the limited-LPLD groups were compared. Preoperative CRT was able to lower clinical lymph node status in 50% of the cases. In addition, pathological lymph node status did not exceed the pretreatment clinical lymph node status stage in the LPLD group. There were no differences in the overall survival and relapse-free survival between the two groups (P=0.729 and P=0.874, respectively). We conclude that multi-imaging studies have a very low risk of overlooking pathologically positive LPLN metastases. Therefore, limited LPLD is a feasible strategy for patients with advanced rectal cancer and suspicious LPLN metastases based on pretreatment imaging.

Laparoscopic partial resection for hemangioma in the third portion of the duodenum.

Benign duodenal tumors are rare and less common than malignant tumors. Furthermore, vascular lesions of the duodenum, including hemangiomas, are rare causes of gastrointestinal bleeding. This report describes a case with bleeding hemangiomas in the third portion of the duodenum and jejunum and their successful treatment using a laparoscopic approach. There is no report of totally laparoscopic resection for tumor in the third portion of duodenum. After performing a laparoscopic Kocher maneuver, the location of the duodenal hemangioma was confirmed by endoscopic and laparoscopic observation. The lesion was excised using ultrasonic coagulating shears and the defect in the duodenal wall was sutured laparoscopically. The hemangioma of the jejunum was treated extracorporeally through a 3.0 cm umbilical incision. The operating time was 241 min and blood loss was negligible. The postoperative course was uneventful. For benign duodenal tumors in the third portion, if endoscopic resection is not adapted, this less invasive technique may be a standard treatment.

The learning effect of using stereoscopic vision in the early phase of laparoscopic surgical training for novices

BackgroundRecently to improve depth perception, the performance of three-dimensional (3D) laparoscopic surgeries has increased. However, the effects of laparoscopic training using 3D are still unclear. This study aimed to clarify the effects of using a 3D monitor among novices in the early phase of training.MethodsParticipants were 40 novices who had never performed laparoscopic surgery (20 medical students and 20 junior residents). Three laparoscopic phantom tasks (task 1: touching markers on a flat disk with a rod; task 2: straight rod transfer through a single loop; and task 3: curved rod transfer through two loops) in the training box were performed ten times, respectively. Performances were recorded by an optical position tracker. The participants were randomly divided into two groups: one group performed each task five times initially under a 2D system (2D start group), and the other group performed each task five times under a 3D system (3D start group). Both groups then performed the same task five times. After the trial, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and the learning curves for both groups.ResultsScores for all tasks performed under the 3D system were significantly better than scores for tasks using the 2D system. Scores for each task in the 2D start group improved after switching to the 3D system. However, scores for each task in the 3D start group were worse after switching to the 2D system, especially scores related to technical errors.ConclusionsThe stereoscopic vision improved laparoscopic surgical techniques of novices from the early phase of training. However, the performance of novices trained only by 3D worsened by changing to the 2D environment.

Outcomes and prognostic factors of selective lateral pelvic lymph node dissection with preoperative chemoradiotherapy for locally advanced rectal cancer

PurposeThe clinical significance of preoperative chemoradiotherapy (CRT) and lateral lymph node dissection (LLND) for locally advanced rectal cancer remains unclear. We have employed total mesorectal excision and selective LLND following preoperative CRT for patients with locally advanced rectal cancer. The validity of our strategy was evaluated.MethodsA total of 45 patients with locally advanced rectal cancer who underwent curative surgery after CRT from November 2005 to September 2016 were retrospectively analyzed. LLND was performed only for the patients with lateral lymph nodes suspected to have metastasis based on the pretreatment images.ResultsRates of 5-year overall survival (OS) and 5-year relapse-free survival (RFS) were 85.7 and 61.8%, respectively. Univariate and multivariate analyses detected only histological response (grades 2 and 3 vs. grade 1) as a significant prognostic factor for OS and local recurrence. ypN and ypStage were significant factors for RFS by univariate analysis, while no significant factor was detected by multivariate analysis. There was no significant factor for distant recurrence. In good responders (grades 2 and 3), the local recurrence rate was 0% (P = 0.006, vs. grade 1), while distant recurrence developed in 4 of 20 cases (20%, P = 0.615, vs. grade 1). There was no local recurrence in LLND (−) group regardless the histological response.ConclusionsAlthough selective LLND with preoperative CRT seems effective and valid for good responders, new treatment strategy is necessary for poor responders. Therefore, development of reliable biomarkers for histological response to CRT is an urgent need.

Quantitative comparison of operative skill using 2- and 3-dimensional monitors during laparoscopic phantom tasks

Background. The recent development of stereoscopic images using 3‐dimensional monitors is expected to improve techniques for laparoscopic operation. Several studies have reported technical advantages in using 3‐dimensional monitors with regard to operative accuracy and working speed, but there are few reports that analyze forceps motions by 3‐dimensional optical tracking systems during standardized laparoscopic phantom tasks. We attempted to develop a 3‐dimensional motion analysis system for assessing laparoscopic tasks and to clarify the efficacy of using stereoscopic images from a 3‐dimensional monitor to track forceps movement during laparoscopy. Methods. Twenty surgeons performed 3 tasks (Task 1: a simple operation by the dominant hand, Task 2: a simple operation using both hands, Task 3: a complicated operation using both hands) under 2‐dimensional and 3‐dimensional systems. We tracked and recorded the motion of forceps tips with an optical marker captured by a 3‐dimensional position tracker. We analyzed factors such as forceps path lengths, operation times, and technical errors for each task and compared the results of 2‐dimensional and 3‐dimensional monitors. Results. Mean operation times and technical errors were improved significantly for all tasks performed under the 3‐dimensional system compared with the 2‐dimensional system; in addition, mean path lengths for the forceps tips were shorter for all tasks performed under the 3‐dimensional system. Conclusion. We found that stereoscopic images using a 3‐dimensional monitor improved operative techniques with regard to increased accuracy and shorter path lengths for forceps movement, which resulted in a shorter operation time for basic phantom laparoscopic tasks.