Shinsuke Masubuchi

Effect of previous abdominal surgery on outcomes following laparoscopic colorectal surgery.

OBJECTIVE: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colectomy was retrospectively investigated. DESIGN: This retrospective cohort study was conducted from December 1996 through December 2009. SETTING: This study was conducted at Osaka Medical College Hospital. PATIENTS: A total of 1701 consecutive patients who had undergone laparoscopic resection of the colon and rectum were classified as not having previous abdominal surgery (n = 1121) or as having previous abdominal surgery (n = 580). MAIN OUTCOME MEASURES: Short-term outcomes were recorded, and risk factors for conversion to open surgery were analyzed. RESULTS: There were no significant differences in operative time, blood loss, number of lymph nodes removed, or conversion rate between the groups. The rate of inadvertent enterotomy was significantly higher in the previous abdominal surgery group than in the not having previous abdominal surgery group (0.9% versus 0.1%; p = 0.03), and the postoperative recovery time was significantly longer in the previous abdominal surgery group than in the not having previous abdominal surgery group. Ileus was more frequent in the previous abdominal surgery group than in the not having previous abdominal surgery group (3.8% versus 2.1%; p = 0.04). Significant risk factors for conversion to open surgery were T stage ≥3 (OR, 2.81; 95% CI, 1.89–3.75), median incision (OR, 4.34; 95% CI, 1.23–9.41), upper median incision (OR, 2.78; 95% CI, 1.29–5.42), lower median incision (OR, 1.82; 95% CI, 1.09–3.12), and transverse colectomy (OR, 1.76; 95% CI, 1.29–2.41). CONCLUSION: The incidence of successfully completed laparoscopic colectomy after previous abdominal surgery remains high, and the short-term outcomes are acceptable.

An internal hernia projecting through a mesenteric defect following laparoscopic-assisted partial resection of the transverse colon to the lesser omental cleft: report of a case

We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy to the lesser omental cleft in a 61-year-old female. We performed laparoscopic-assisted partial resection of the transverse colon to treat transverse colon cancer. Three years and 6 months after the operation, the patient developed a bowel obstruction requiring surgical intervention. When we observed the intraperitoneal space under laparoscopy, we determined that the small intestine had passed into the bursa omentalis through the mesenteric defect. Additionally, an abnormal opening of the lesser omentum was present with a portion of the small intestine escaping into the space inferior to the liver. We performed reintegration of the escaped bowel and closed the mesenteric defect laparoscopically. This is the first case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy that we have experienced out of more than 2400 cases. Further research is needed to identify the patients who would benefit from the closure of mesenteric defects during laparoscopic-assisted colectomy.

Laparoscopic resection of transverse colon cancer at splenic flexure: technical aspects and results

Laparoscopic resection of transverse colon cancer at splenic flexure is technical demanding and its efficacy remains controversial. The aim of this study was to investigate its technical aspects such as pitfalls and overcoming them, and to demonstrate the short-term and oncologic long-term outcomes. To overcome the difficulty in laparoscopic resection of transverse colon cancer at splenic flexure, we recognized the following technical tips as essential. First of all, we have to precisely identify major vessels variations feeding tumor. Secondary, anatomical dissection of mesocolon through medial approach is indispensible. Third, safe takedown of splenic flexure to fully mobilization of left hemicolon is mandatory. This cohort study analyzed 95 patients with stage II (43) and III (52) underwent resection of transverse colon cancer at splenic flexure. 61 laparoscopic surgeries (LAC) and 34 conventional open surgeries (OC) from December 1996 to December 2009 were evaluated. Short-term and oncologic long-term outcomes were recorded. Operative time was longer in LAC. However, blood loss was less, recovery of bowel function and hospital stay were shorter in LAC. There was no conversion in LAC and no significant difference in the postoperative complications. Regarding oncologic long-term outcomes, there were no significant differences between OC and LAC. Laparoscopic resection of transverse colon cancer at splenic flexure resulted in acceptable short-term and oncologic long-term outcomes. Once technical tips acquired, laparoscopic resection of transverse colon cancer at splenic flexure could be feasible as minimally invasive surgery.

Chymase inhibitor ameliorates hepatic steatosis and fibrosis on established non-alcoholic steatohepatitis in hamsters fed a methionine- and choline-deficient diet

Chymase plays a role in the augmentation of angiotensin II formation, which is involved in liver fibrosis. The therapeutic effects of a chymase inhibitor, TY‐51469, on established hepatic steatosis and fibrosis were investigated in a model of developed non‐alcoholic steatohepatitis.

Chymase Inhibition Attenuates Monocrotaline-Induced Sinusoidal Obstruction Syndrome in Hamsters

Chymase stored in mast cells activates matrix metalloproteinase (MMP)-9, which may relate to the progression of sinusoidal obstruction syndrome (SOS). We investigated the preventive effect of a chymase inhibitor, TY-51469, on monocrotaline-induced SOS in hamsters. Hamsters were orally administrated with a single dose of monocrotaline (120 mg/kg) to induce SOS. Treatment with TY-51469 (1 mg/kg per day) or placebo had started 3 days before the monocrotaline administration. Two days after the monocrotaline administration, significant increases in aspartate aminotransferase, alanine aminotransferase and total bilirubin and a significant reduction of albumin were observed in plasma, but their changes were significantly attenuated by treatment with TY-51469. The numerous hepatic necrosis areas were observed in the placebo-treated group, but the ratio of necrotic area to total area in liver had been significantly reduced by treatment with TY-51469. Both chymase activity and MMP-9 level in liver were significantly augmented in the placebo-treated group. Furthermore, tumor necrosis factor (TNF)-α level in liver was also augmented in the placebo-treated group. However, the chymase activity and levels of MMP-9 and TNF-α were significantly attenuated in the TY-51469-treated group. Until 14 days after monocrotaline administration, survival rates in the placebo- and TY-51469-treated groups were 25% and 70%, respectively, and a significant difference was observed. In conclusion, chymase inhibition by TY-51469 may prevent the accelerating of severity in monocrotaline-induced SOS in hamsters.

Preoperative Chemotherapy May Not Influence the Remnant Liver Regenerations and Outcomes After Hepatectomy for Colorectal Liver Metastasis

BackgroundVarious chemotherapy regimens have been shown to improve outcomes when administered before tumor excision surgery. However, there is no consensus on the utility of multidisciplinary treatment with preoperative chemotherapy for treating colorectal liver metastasis (CLM).Materials and methodsTwo hundred-fifty patients who underwent hepatectomy were retrospectively analyzed using propensity score matching. Postoperative outcomes were evaluated with a focus on the effect of pre-hepatectomy chemotherapy on regeneration of the remnant liver in patients with CLM. The remnant liver volumes (RLVs) were postoperatively measured with multidetector computed tomography on days 7 and months 1, 2, 5, and 12 after the operation.ResultsRLV regeneration and blood test results did not significantly differ between patients who underwent preoperative chemotherapy versus those who did not immediately after surgery or at any time point from postoperative day 7 to postoperative month 12. The 1-, 2-, and 3-year overall survival (OS) rates for all patients were 94.6, 86.2, and 79.9%, respectively; the corresponding disease-free survival (RFS) rates were 49.3, 38.6, and 33.7%, respectively. There were no significant differences in OS and RFS between the two groups after hepatic resection. The recurrence rates, including marginal and intrahepatic recurrences, as well as resection frequency of the remnant liver were not significantly different between the two groups.ConclusionPreoperative chemotherapy may have no appreciable benefit for patients with CLM in terms of perioperative and long-term outcomes.

The utility of the subcuticular suture in hepatic resection

Aim of the study Despite recent technical progress and advances in the perioperative management of liver surgery, postoperative surgical site infection (SSI) is still one of the most common complications that extends hospital stays and increases medical expenses following hepatic surgery. Material and methods From 2001 to 2017 a total of 1180 patients who underwent hepatic resection for liver tumours were retrospectively analysed with respect to the predictive factor of superficial incisional SSI, using a propensity score matching by procedure (subcuticular or mattress suture). Results The incidence of superficial and deep incisional SSIs was found to be 7.1% (84/1180). By propensity score matching (PSM), 121 of the 577 subcuticular suture group patients could be matched with 121 of the 603 mattress suture group patients. Multivariate analysis demonstrated wound closure technique as the only independent risk factor that correlated significantly with the occurrence of superficial incisional SSIs (p = 0.038). C-reactive protein (CRP) levels on postoperative day 4 were significantly higher in patients with incisional SSIs than in those without (p < 0.001). Conclusions Wound closure technique with subcuticular continuous spiral suture using absorbable suture should be considered to minimise the incidence of incisional SSIs. Moreover, wounds should be carefully checked when CRP levels are high on postoperative day 4.

Comparison of resection site of standardized laparoscopic hepatic tumor resection

Introduction The degree of difficulty in laparoscopic hepatic resection (LHR) was higher in tumors involving the suprahepatic segments than other sites. However, thanks to surgical instruments and procedures being improved and standardized, LHR can be performed safely in all regions. Aim We report our standardized surgical techniques and outcomes in a series of patients undergoing LHR in our hospital and analyze the surgical outcomes, particularly with regard to the site of resection. Material and methods We retrospectively analyzed data from 238 patients who underwent standardized laparoscopic partial hepatic resection between 2010 and 2017. In standardized LHR, the operator formed a triangle with the laparoscope in the center, maintaining a co-axial position by changing the port where the laparoscope was inserted. Results Operative time for the resection of tumors of the right hepatic lobe was 202 ±92 min and 140 ±104 min for tumors of the left hepatic lobe (p = 0.0024); intraoperative blood loss was 80 ±170 ml and 19 ±127 ml, respectively (p = 0.0016). No differences were found in the surgical outcomes between the various segments of the right hepatic lobe. In the left hepatic lobe, operative time was significantly shorter with laparoscopic tumor resection in segment III (p = 0.0023). Conclusions During standardized LHR, a better field of vision with the greater ease can be established during resection of the left hepatic lobe compared to that of the right hepatic lobe. Nonetheless, LHR of the right lobe can be performed safely using various surgical instruments and techniques.

Intestinal endometriosis combined with colorectal cancer: a case series

BackgroundIntestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract.Case presentationThis case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4).ConclusionsTherefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

The Relationship Between Postoperative Chemotherapy and Remnant Liver Regeneration and Outcomes After Hepatectomy for Colorectal Liver Metastasis

BackgroundPostoperative chemotherapy for treating colorectal liver metastasis (CLM) has been introduced with the aim of improving therapeutic outcomes. However, there is no consensus on the utility of multidisciplinary treatments with postoperative chemotherapy. Therefore, we evaluated surgical outcomes in patients with CLMs who underwent hepatectomy, while focusing on the effects of post-hepatectomy chemotherapy on remnant liver regeneration.MethodsTwo hundred ninety patients who underwent hepatectomy were retrospectively analyzed using propensity score matching. Postoperative outcomes were evaluated with a focus on the effects of post-hepatectomy chemotherapy on regeneration of the remnant liver in patients with CLM. The remnant liver volumes (RLVs) were measured postoperatively using multi-detector computed tomography on day 7 and months 1, 2, 5, and 12 after the operation.ResultsRLV regeneration and postoperative blood laboratory data did not differ significantly between patients who received postoperative chemotherapy and those who did not receive postoperative chemotherapy immediately after surgery or at any time point from postoperative day 7 to postoperative month 12. The recurrence rates, including same and other segmental intrahepatic recurrences, as well as the resection frequency of the remnant liver were not significantly different between the two groups.ConclusionPostoperative chemotherapy may be of small significance for patients with CLM in terms of the remnant liver volume regeneration and functional recovery.