Syoichi Fujii

Learning curve for laparoscopy-assisted distal gastrectomy with regional lymph node dissection for early gastric cancer.

An assessment of the learning curve of laparoscopy-assisted distal gastrectomy (LADG) might encourage its worldwide spread among inexperienced surgeons. One hundred sixty-seven patients with early gastric cancer were enrolled in this study: 67 underwent conventional open distal gastrectomy and 100 underwent LADG after classification into 5 groups of 20 according to the surgeons level of experience. Patient characteristics and operative findings were compared between groups. Operation time was significantly longer, time to first flatus earlier, and blood loss reduced in the LADG groups compared with the open distal gastrectomy group. Surgeons with experience of 60 cases performed operations of similar times in both groups, and blood loss decreased with experience of 20 cases. There was no operative conversion, the frequency of nonsteroidal anti-inflammatory drugs administered were significantly less, and length of hospital stay were shorter by surgeons with experience of 60 cases. LADG is a technically feasible surgical procedure, depending on the surgeons technical proficiency. Experience of at least 60 cases of LADG seems to result in satisfactory patient outcomes.

Amphiregulin Is a Promising Prognostic Marker for Liver Metastases of Colorectal Cancer

Purpose: Aberrant activation of epidermal growth factor receptors (EGFR/HER1) by ligand stimulation or heterodimerization with human epidermal growth factor 2 (HER2) is considered to play an important role in the development of colorectal carcinoma. Amphiregulin (AR) is a ligand of EGFR that might be related to the development and progression of gastrointestinal tumors. The aim of this study was to determine the AR, EGFR, and HER2 protein expression levels and to evaluate their prognostic relevance to the clinical course of colorectal cancer. Experimental Design: The AR, EGFR, and HER2 protein levels in primary tumors of colorectal cancer (n = 106) were examined using immunohistochemistry. Metastatic sites in liver specimens (n = 16) were also analyzed in the same manner. Results: Thirteen (81.6%) metastatic lesions of the liver stained positive for AR. Among the primary lesions of colorectal cancer, 58 (54.7%) stained positive for AR, 13 (12.3%) stained positive for EGFR, and 5 (4.7%) stained positive for HER2. When the relationships between each protein expression level and the clinicopathologic factors were examined, only the AR expression level was significantly related to liver metastasis (P = 0.0296). A multivariate analysis of liver metastasis proved that AR expression was an independent prognostic factor of liver metastasis from colorectal cancer (P = 0.0217). Conclusions: AR expression in primary lesions of colorectal cancer is an important predictive marker of liver metastasis.

Impact of splenectomy in patients with gastric adenocarcinoma of the cardia.

Previous reports have suggested that splenectomy treatment of gastric carcinoma of the cardia results in poor patient outcome, but the reason for this is unclear. This study aimed to clarify the impact of splenectomy for gastric carcinoma patients. A total of 118 patients with gastric carcinoma of the cardia were enrolled in this study. The characteristics of patients with lymph node metastasis at the splenic hilum were determined, and the effects of lymph node dissection or splenectomy on postoperative morbidity, mortality, and pattern of recurrence were evaluated. Advanced tumors were common in patients with lymph node metastasis at the splenic hilum, Siewert type III, greater curvature sites, larger and deeper tumors, multiple metastatic lymph nodes, and high incidences of para-aortic lymph node metastasis frequently observed. The effectiveness of lymph node dissection of the splenic hilum was low and equal to that of dissection of the para-aortic lymph nodes. Postoperative morbidity, as represented by pancreatic fistula, was high following splenectomy or pancreaticosplenectomy, but patient mortality did not occur. Hematogenous metastasis was common, as well as peritoneal metastasis after curative gastrectomy. Splenectomy should be limited in those patients with gastric cardia tumors invading the spleen or with metastatic bulky lymph nodes extending to the spleen.

Randomized clinical trial of single‐incision versus multiport laparoscopic colectomy

The efficacy and safety of single‐incision laparoscopic colectomy (SILC) for colonic cancer remain unclear. The aim of this study was to determine the outcomes of SILC compared with multiport laparoscopic colectomy (MPLC) for colonic cancer.

Therapeutic strategy for esophageal cancer based on solitary lymph node metastasis.

BACKGROUND/AIMS It is essential to perform appropriate lymph node dissection in esophageal cancer. However, it may be beneficial if lymph node dissection could be minimized to reduce the surgical stress. METHODOLOGY Between April 1992 and March 2005, 121 esophageal cancer patients (42 patients with solitary lymph node metastasis and 79 N0 patients) were enrolled. The survival time, distribution of solitary lymph node metastasis and the pattern of recurrence were evaluated. RESULTS The distribution of solitary lymph node metastasis was extensively observed in cervical, thoracic and abdominal cavities and the site of lymph node recurrence could even be detected in non-regional lymph nodes in N0 patients. It was difficult to predict the site of initial lymph node metastasis in patients with esophageal cancer. CONCLUSIONS Systemic lymph node dissection for regional lymph nodes is recommended for resectable esophageal cancer as the concept of sentinel lymph nodes has not yet been proven.

Therapeutic management of elderly patients with esophageal cancer

BackgroundIn an aging population, it is important to evaluate the therapeutic management of diseases. Esophagectomy is a reliable treatment for esophageal cancer, but it remains controversial for elderly patients as it could carry additional postoperative risks.MethodsBetween April 1994 and March 2004, 418 patients with esophageal cancer were registered at our hospital. Clinicopathological factors and therapeutic outcomes for 65 patients aged over 75 years (elderly patients) and 353 patients aged under 75 years (nonelderly patients) were compared retrospectively.ResultsIn total, 19 patients aged over 75 years and 203 patients aged under 75 years underwent resection. The elderly patients were characterized by short operation times, surgery by transhiatal approach, organ reconstruction using the jejunum, fewer lymph nodes removed, and frequent comorbid disease. Curative resections were performed in 16 elderly patients (84.2%) and 173 nonelderly patients (85.2%). Postoperative morbidity did not differ between the two groups, but hospital death was more frequent in elderly patients. The overall survival time was significantly higher for nonelderly patients. However, the disease-specific survival did not differ between the two groups. Nonsurgical treatments were administered to 46 elderly patients and 150 nonelderly patients; no significant difference in survival was observed between the two groups. The overall survival times were not different between surgical treatment and nonsurgical treatment in the elderly group.ConclusionsElderly patients obtained similar therapeutic benefits from esophagectomy as did nonelderly patients through careful management of comorbid disease and good perioperative care. Also, nonsurgical treatment is a useful treatment option for elderly patients. A well-designed randomized trial, of surgical versus nonsurgical treatment, should be conducted in the elderly to clarify this concern.

Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer: High versus low tie of inferior mesenteric artery

The optimal level for inferior mesenteric artery ligation during anterior resection for rectal cancer is controversial. The aim of this randomized trial was to clarify whether the inferior mesenteric artery should be tied at the origin (high tie) or distal to the left colic artery (low tie).

Optimizing the selection of patients with low rectal cancer for intersphincteric resection by evaluating vertical invasion to the levator and external sphincter

The indications for intersphincteric (ISR) anterior resection are not clearly defined. The aim of this study was to evaluate vertical extension of T2 or T3 low rectal cancer treated by rectal amputation to optimize patient selection for ISR.