Shusuke Haruta

The importance of grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer.

Although the three‐field lymphadenectomy has established as a standard operation for esophageal cancer in Japan, criticism remains due to the lack of randomized controlled trials with a high EBM level. This retrospective study aims to clarify the effectiveness of the three‐field lymphadenectomy using the data obtained from 906 consecutive patients with esophageal cancer who underwent R0 esophagectomy with the three‐field lymphadenectomy.

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.

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.

Feasibility and safety of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors, including esophagogastric junction tumors.

Recently, the use of endoscopic submucosal dissection (ESD) for gastric submucosal tumor (gSMT) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either preservation of the stomach or minimization of the extent of partial resection. In the present study, the outcomes following the recent introduction of LECS for gSMT are presented. The aim of this retrospective study was to evaluate the feasibility and safety of LECS for gSMT, including esophagogastric junction (EGJ) SMT.

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.

Mixed adeno(neuro)endocrine carcinoma arising from the ectopic gastric mucosa of the upper thoracic esophagus.

We report a case of mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. A 64-year-old man who had been diagnosed with an esophageal tumor on the basis of esophagoscopy was referred to our hospital. Upper gastrointestinal endoscopy revealed the presence of ectopic gastric mucosa and an adjacent pedunculated lesion located on the posterior wall of the upper thoracic esophagus. Subtotal esophagectomy with three-field lymph node dissection was performed. A microscopic examination revealed that there was a partially intermingling component of neuroendocrine carcinoma adjacent to a tubular adenocarcinoma which was conterminous with the area of the ectopic gastric mucosa. Although the tubular adenocarcinoma was confined to the mucosa and submucosa, the neuroendocrine carcinoma had invaded the submucosaand there was vascular permeation. Each component accounted for 30% or more of the tumor, so the final histopathological diagnosis was mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. Adjuvant chemotherapy was not performed, because the postoperative tumor stage was IA. The patient was well and had no evidence of recurrence 16 months after surgery.

New Combined Medical Treatment With Etilefrine and Octreotide for Chylothorax After Esophagectomy: A Case Report and Review of the Literature.

AbstractPostoperative chylothorax is a rare but well-known complication of general thoracic surgery. Medical treatment of chylothorax was reported in the past, but there is still considerable controversy on the appropriate management strategies.Two patients with esophageal cancer underwent esophagectomy, 2-field lymph node dissection, and resection of thoracic duct together with ileocolic reconstruction via the retrosternal route at our hospital. Chylothorax developed on the 32nd postoperative day (POD) in 1 patient and the 12th POD in the other, manifesting as a change in the character of thoracic drainage to turbid white. Both were immediately started on octreotide (300 &mgr;g/ day) and etilefrine (120 mg/day). When the amount of pleural effusion decreased to <50 mL/day, we performed pleurodesis with Picibanil (OK432). Thereafter, the patients gradually made satisfactory progress and resumed oral food intake, and the thoracotomy tubes were eventually removed. They have remained recurrence-free at the time of writing.In this report, we demonstrated the clinical efficacy of etilefrine for the management of postesophagectomy chylothorax. New medical treatment options for this condition are now broad and the usefulness of combined therapy consisting of a sclerosing agent, etilefrine, and octreotide is underscored, regardless of the status of the thoracic duct.

Tracing Dissectable Layers of Mesenteries Overcomes Embryologic Restrictions when Performing Infrapyloric Lymphadenectomy in Laparoscopic Gastric Cancer Surgery

presented at the American College of Surgeons Clinical Congress, Video-based Education Session, San October 2014. Received December 20, 2014; Revised February 22, 2 February 22, 2015. From the Department of Gastroenterological Surgery, Tora tal, Tokyo, Japan (Shinohara, Haruta, Ohkura, Udagawa) a ment of Surgery, Kyoto University Graduate School of M Japan (Shinohara, Sakai). Correspondence address: Hisashi Shinohara, MD, PhD, Gastroenterological Surgery, Toranomon Hospital, 2-2Minato-ku, Tokyo 105-8470, Japan. email: shinohara@tor a 2015 by the American College of Surgeons Published by Elsevier Inc. SURGEON AT WORK Tracing Dissectable Layers of Mesenteries Overcomes Embryologic Restrictions when Performing Infrapyloric Lymphadenectomy in Laparoscopic Gastric Cancer Surgery Hisashi Shinohara, MD, PhD, Shusuke Haruta, MD, Yu Ohkura, MD, Harushi Udagawa, MD, PhD, FACS, Yoshiharu Sakai, MD, PhD, FACS The infrapyloric lymph nodes (LNs), categorized as station 6 (no. 6 LNs) by the Japanese Gastric Cancer Association, drain the afferent lymphatic flow from the greater curvature of the stomach to the terminal nodes situated around the celiac and superior mesenteric trunks. Tumors in the lower or middle third of the stomach frequently metastasize to the no. 6 LNs. However, standard surgical procedures for dissection of these LNs have not been established due to the anatomic complexity of the infrapyloric area. Embryologically, gastrointestinal organs possess separate mesenteries. The stomach has the mesogastrium and the duodenum has the mesoduodenum (Fig. 1A). Both of these mesenteries consist of a layer of adipose tissue enclosed by a double layer of peritoneum. It provides pathways for blood vessels, nerves, and lymphatic nodes and vessels. The no. 6 LNs arise contained within the mesoduodenum beyond the border of the mesogastrium. However, the mesoduodenum is overlaid by the transverse mesocolon and greater omentum during development, when the latter is derived from the expanded mesogastrium. Furthermore, the mesoduodenum incorporates the pancreas, which arises from primitive buds in the duodenal wall (Fig. 1B). Therefore, the no. 6 LNs lie behind the transverse mesocolon and greater omentum on the anterior surface of the pancreas. These complex embryologic events mean there are some critical restrictions when performing no. 6 lymphadenectomy. 100 Annual Francisco, CA,

Benign esophageal stricture after thermal injury treated with esophagectomy and ileocolon interposition

Thermal injuries of the esophagus are rare causes of benign esophageal stricture, and all published cases were successfully treated with conservative management. A 28-year-old Japanese man with a thermal esophageal injury caused by drinking a cup of hot coffee six months earlier was referred to our hospital. The hot coffee was consumed in a single gulp at a party. Although the patient had been treated conservatively at another hospital, his symptoms of dysphagia gradually worsened after discharge. An upper gastrointestinal endoscopy and computed tomography revealed a pin-hole like area of stricture located 19 cm distally from the incisors to the esophagogastric junction, as well as circumferential stenosis with notable wall thickness at the same site. The patient underwent a thoracoscopic esophageal resection with reconstruction using ileocolon interposition. The pathological findings revealed wall thickening along the entire length of the esophagus, with massive fibrosis extending to the muscularis propria and adventitia at almost all levels. Treatment with balloon dilation for long areas of stricture is generally difficult, and stent placement in patients with benign esophageal stricture, particularly young patients, is not yet widely accepted due to the incidence of late adverse events. Considering the curability and quality-of-life associated with a long expected prognosis, we determined that surgery was the best treatment option for this young patient. In this case, we decided to perform an esophagectomy and reconstruction with ileocolon interposition in order to preserve the reservoir function of the stomach and to avoid any problems related to the reflux of gastric contents. In conclusion, resection of the esophagus is a treatment option in patients with benign esophageal injury, especially in cases involving young patients with refractory esophageal stricture. In addition, ileocolon interposition may help to improve the quality-of-life of patients.

Effectiveness of postoperative intravenous acetaminophen (Acelio) after gastrectomy: A propensity score-matched analysis.

AbstractThe aim of this study was to investigate the efficacy of postoperative scheduled intravenous acetaminophen to reduce the opioid use and enhance recovery after gastrectomy.Opioid use is reportedly associated with delayed recovery of gastrointestinal (GI) peristalsis and postoperative nausea/vomiting (PONV) despite of acceptable efficacy for pain control.Of 147 and 96 consecutive patients who underwent gastrectomy for gastric cancer before and after introduction of postoperative scheduled intravenous acetaminophen, propensity score matched population was created and short-term clinical outcomes were compared.Significant defervescence was demonstrated in Acetaminophen group (A-group) compared with control group (C-group) during the perioperative period (P < 0.001), whereas no significant difference was observed in postoperative inflammatory parameters. The incidence of postoperative complications was similar between the groups. The number of patient-controlled analgesia (PCA) pushes was significantly reduced in the A-group (P = 0.007) and the frequency of use of other nonopioid analgesics was also significantly reduced in the A-group (P < 0.001). Both daily and cumulative opioid use was significantly reduced in the A-group (P < 0.001). The time to first flatus and defecation was decreased in the A-group (P < 0.001 and P = 0.038, respectively). The incidence of PONV was significantly reduced from 26.0% to 12.5% after introduction of intravenous acetaminophen (P = 0.017), and hospital stay tended to be decreased in the A-group (13.2 vs 14.7 days, P = 0.069)Postoperative scheduled intravenous acetaminophen decreased opioid use and may be associated with enhanced recovery after gastrectomy.