Takashi Okuyama

Budding as a risk factor for lymph node metastasis in pT1 or pT2 well-differentiated colorectal adenocarcinoma.

AbstractPURPOSE: Lymph node metastasis is an important indicator of tumor stage and prognosis in pT1 and pT2 colorectal adenocarcinomas. Lymphovascular invasion is an established risk factor of lymph node metastasis, whereas budding at the invasive front of tumors is also reported to correlate with lymph node metastasis. We examined whether the coexistence of lymphovascular invasion and budding provides any better information than lymphovascular invasion alone in the prediction of lymph node metastasis of pT1 or pT2 well-differentiated colorectal adenocarcinomas. nMETHODS: Surgically resected specimens of 101 pT1 or pT2 well-differentiated colorectal adenocarcinomas were studied. Using sections stained with hematoxylin-eosin, we examined lymphovascular invasion and budding according to Morodomi’s definition. nRESULTS: Lymphovascular invasion was present in 39 lesions (38 percent), whereas budding was found in 42 lesions (41 percent). Budding was more frequently detected in pT2 tumors than in pT1 tumors. The presence of budding significantly correlated with lymphovascular invasion. Sensitivity, specificity, positive predictive value, and negative predictive value of lymphovascular invasion alone for lymph node metastasis were 79, 76, 34, and 96 percent, respectively, whereas those of the combination of lymphovascular invasion and budding (either lymphovascular invasion or budding) were 93, 52, 24, and 98 percent, respectively. nCONCLUSION: Because the risk of lymph node metastasis in pT1 or pT2 well-differentiated colorectal adenocarcinomas having neither lymph node metastasis nor budding is very low, budding in combination with lymphovascular invasion seems to be a simple and inexpensive pathologic marker in predicting lymph node metastasis. Therefore, the presence or absence of budding should be examined in the routine pathologic diagnosis of pT1 or pT2 well-differentiated colorectal adenocarcinomas.

Laparoscopic resection of a retroperitoneal pelvic schwannoma

Schwannomas are rarely located in the pelvis. A 54-year-old woman was found incidentally to have a tumor in the abdomen. Abdominal computed tomography and magnetic resonance imaging revealed a well-defined, heterogeneous tumor, 5 cm in diameter, in the pelvic cavity. With a diagnosis of a mesenteric tumor, a laparoscopic procedure was performed. Intra-operatively, an elastic tumor was identified in the pelvis adjacent to the right internal iliac vein and ureter. The tumor was dissected free from adjacent structures using Liga-Sure and blunt maneuvers. A complete laparoscopic excision was performed. Histopathological examination revealed a benign schwannoma. The patient had an uneventful post-operative course, and was discharged on the fourth post-operative day. Laparoscopic treatment is useful and feasible for retroperitoneal pelvic schwannoma, with minimal invasiveness and an early post-operative recovery. Thus, this procedure may be the first-choice surgical procedure for retroperitoneal pelvic schwannomas.

Intragastric surgery using laparoscopy and oral endoscopy for gastric submucosal tumors

We review the techniques and outcomes of the intragastric resection for gastric submucosal tumors (GSTs) using laparoscope and oral endoscope. In the literature, the mean operation time, intraoperative blood loss, pathological size of the tumor and postoperative hospital stay were 134 min, minimal, 31 mm and 6.4 d, respectively. There were no particular perioperative complications during the follow-up period (mean: 121.3 mo). Intragastric surgery using laparoscopy and oral endoscopy can be considerably beneficial for patients with GSTs locating in the upper third of the stomach between 2-5 cm in diameter and < 8 cm(2) in cross-sectional area and located in the upper third of the stomach.

Surgical resections of ulcerative colitis associated with dysplasia or carcinoma

BackgroundUlcerative colitis (UC) patients have an increased risk of colorectal dysplasia and carcinoma. The purpose of this study was to analyze the clinical features and surgical treatment of ulcerative colitis associated with dysplasia or carcinoma.MethodsWe operated on 41 UC patients since April 2000. Twelve of the cases were associated with dysplasia or carcinoma. Ten patients were male and two were female; the median age was 58.0 years, and the average duration of disease was 19.2 years. Nine cases were pancolitis type and three were left-sided type. Six cases were remission-relapsing type and six were chronic inflammation type. In 10 of 12 cases, dysplasia or carcinoma was diagnosed before the operations. Nine cases were primary operations and two were second-time operations.ResultsAmong ten patients who underwent primary operations, four patients had open surgery and six patients had hand-assisted laparoscopic surgery (HALS). Seven patients received anus/anal sphincter-preserving operations with reconstruction by the ileal pouch technique. Ileal pouch anal-canal anastomosis (IPACA) was performed in five cases and ileal pouch anal anastomosis (IPAA) in two cases. Abdomino-peritoneal resection was performed in two cases, proctcolectomy with permanent ileostomy in one case, and right hemicolectomy in one case. A 39-year-old patient was unresectable due to dissemination of the carcinoma. A 55-year-old patient who underwent IPACA showed night soiling postoperatively. Other patients who received IPAA and IPACA showed favorable anal function postoperatively. Histological examination showed low-grade dysplasia in two cases, high-grade dysplasia in three cases, and adenocarcinoma in seven cases. In the seven cases of adenocarcinoma, four, two, and one cases were stage 1, 3, and 4 according to TNM classification. Three of five cases with dysplasia were detected by surveillance colonoscopy. All patients with carcinoma were symptomatic and did not undergo surveillance colonoscopy.ConclusionsIPACA by HALS was safely performed as an anal-preserving operation in UC patients with dysplasia or carcinoma. Non-anal-preserving operations for aged patients showed a preferable postoperative course. Surveillance colonoscopy is essential for detecting dysplasia before the development of carcinoma.

Fluorescence Cholangiography in Laparoscopic Cholecystectomy: Experience in Japan

We describe a new modality for intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) and its evaluation in 15 patients diagnosed as having gallbladder stones who were scheduled to undergo laparoscopic cholecystectomy. The patients included 6 males and 9 females with a mean age of 54 years and a mean BMI of 22.3. Standard four-port laparoscopic cholecystectomy was performed in 11 patients and single-incision laparoscopic cholecystectomy in the other 4. ICG was infused 1 h before surgery. We observed the biliary tract under real-time fluorescence imaging guidance, and confirmed the positions of the gallbladder, cystic duct, and common bile and hepatic duct on the monitor. The cystic artery was also observed after reinjection of ICG. The procedure was completed successfully in all cases, and no additional ports or conversion to open cholecystectomy were necessary. The mean operation time was 88 min. We obtained a clear view of the biliary tract in all patients, and the cystic artery was confirmed 10 s after reinjection of ICG. There were no specific perioperative complications related to the intravenous injection of ICG. The median postoperative hospital stay was 3 days. Intraoperative exploration of the biliary tract using ICG is a useful approach for identification of the biliary anatomy without cannulation into the cystic duct, X-ray equipment or use of radioactive materials. We expect that this modality will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.

Mullerian duct cyst: a curable entity of male infertility. Two case reports

PurposeMullerian duct cyst is a rudiment of a Mullerian duct in the fetal period which causes ejaculatory duct obstruction and male infertility.Case reportWe report two patients with Mullerian duct cyst that presented with low ejaculate volume, oligoasthenoteratozoospermia and azoospermia syndrome. Transrectal ultrasound (TRUS) and magnetic resonance image (MRI) revealed a midline prostatic cystic structure. In each case, we performed a TRUS guided transperineal aspiration of the cyst. Seminograms of the patients improved and one of their wives got spontaneously pregnant 3xa0months after the surgery.ConclusionWe should assume the TRUS guided aspiration of Mullerian duct cyst.

Laparoscopic Intra-Gastric Resection of Gastric Sub-Mucosal Tumors under Oral Endoscopic Guidance

Introduction: A laparoscopic approach is often selected for resection of gastric submucosal tumor (GST), and several variations of this procedure have been reported. The approach selected greatly depends on the characteristics of the tumor, including its size or location, and also the experience and skill of the surgeon. Here we report our experience with intragastric resection of GSTs under oral endoscopic guidance. Methods: We performed laparoscopic intragastric resection of GSTs in 13 patients. The criteria for this approach were a tumor less than 5 cm in diameter and 8 cm2 in cross-section, and a tumor location on the posterior gastric wall in the upper and middle stomach or near the esophagogastric junction. Under general anesthesia, two or three ports were directly inserted into the stomach. Partial resection of the stomach including the tumor and an adequate margin in all directions was performed using a linear stapler. The resected specimen was retrieved orally using a plastic bag. Results: Laparoscopic intragastric resection of GST was successful in all patients. The mean maximum tumor diameter was 27 mm. The mean operation time was 176 min, and intraoperative blood loss was minimal. One patient required a gastrostomy and enlargement of one of the port sites in order to remove the tumor. There was no intra- or postoperative complications. The mean postoperative hospital stay was 7.5 days. The diagnosis after pathological examination of the tumor was gastrointestinal stromal tumor in 8 patients, leiomyoma in 4 and a cyst in one in one. There were no recurrences during a mean follow-up period of 121.7 months. Conclusion: A laparoscopic intragastric approach is well suited for patients who have a GST located in the upper and middle part of the stomach. It is anticipated that an oral endoscope will be used increasingly during laparoscopic procedures in the future.

Experience with laparoscopic treatment for paraesophageal hiatal hernia.

Paraesophageal hiatal hernia is often associated with a number of complications such as intestinal obstruction, gastric volvulus and acute pancreatitis, each of which can result in critical conditions requiring surgery. Herein, we report our surgical procedure for paraesophageal hiatal hernia.

Therapeutic effects of oxaliplatin-based neoadjuvant chemotherapy and chemoradiotherapy in patients with locally advanced rectal cancer: a single-center, retrospective cohort study

BackgroundNeoadjuvant chemoradiotherapy (NACRT) has now become the standard treatment for locally advanced rectal cancer (LARC). NACRT has decreased local relapse (LR) rate in patients with LARC; however, distant relapse has recently attracted much attention. This study aimed to assess the feasibility and efficiency of neoadjuvant chemotherapy (NAC) for LARC.MethodsData on patients with cT3/4 and N+ rectal cancer who were treated in our institution from April 2010 to February 2016 were reviewed retrospectively. Twenty-seven patients who received 2–9xa0cycles of oxaliplatin-based NAC and 28 patients who received NACRT (45xa0Gy delivered in 25 fractions and 5-fluorouracil-based oral chemotherapy) were analyzed. The primary and secondary endpoints of the present study were the 3-year relapse-free survival (RFS) and the local and distant relapse rates, respectively.ResultsRegardless of the kind of neoadjuvant therapy, no patient experienced any grade 3–4 therapy-related adverse events. The frequent toxic events were grade 1 diarrhea in patients with NACRT and neutropenia in patients with NAC. A significantly higher proportion of patients with NAC underwent laparoscopic surgery and anterior resection (pu2009=u20090.037 and pu2009=u20090.003, respectively). The percentages of patients with lymph node yield less than 12 in the NAC group, and those in the NACRT group were 26 and 68%, respectively (pu2009=u20090.002). Comparing the NAC with the NACRT groups, the local relapse and distant relapse rates were 7.4 and 7.1% and 7.4 and 18%, respectively. There were no significant differences in 3-year RFS and 4-year overall survival (OS) between NAC and NACRT (3-year RFS 85.2 vs. 70.4%, pu2009=u20090.279; 4-year OS 96.3 vs. 89.1%, pu2009=u20090.145, respectively). With an analysis excluding patients who received postoperative adjuvant chemotherapy, no patients who received NAC had a distant relapse, and there was a significant difference in 3-year RFS compared with the NACRT groups (94.4 vs. 63.2%, pu2009=u20090.043).ConclusionThese outcomes suggest that the therapeutic effect of oxaliplatin-based NAC is at least equal to that of NACRT and that NAC is a feasible and promising option for LARC.

Portal encasement: Significant CT findings to diagnose local recurrence after pancreaticoduodenectomy for pancreatic cancer

BACKGROUND/OBJECTIVESnTo demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).nnnMETHODSnA total of 61 patients who underwent PD for PDAC were included in this retrospective study. Portal stenosis was evaluated by sequential postoperative computed tomography (CT) scans and correlated with disease recurrence. In addition to the conventional LR diagnostic criterion of a growing soft tissue mass, LR was evaluated using portal encasement as an additional diagnostic criterion. Portal encasement was defined as progressive stenosis of the portal system accompanied by a soft tissue mass, notwithstanding the enlargement of the mass.nnnRESULTSnBenign portal stenosis was found on the first postoperative CT imaging in 16 patients. However, stenosis resolved a median of 81 days later in all but one patient whose stenosis was due to portal reconstruction during PD. Portal encasement could be distinguished from benign portal stenosis based on the timing of emergence of the portal stenosis. Portal encasement developed in 13 of the 19 patients with LR, including 6 patients in whom the finding of portal encasement led to the diagnosis of LR a median of 147 days earlier with our diagnostic criterion compared with the conventional diagnostic criteria.nnnCONCLUSIONSnPortal encasement should be considered as a promising diagnostic criterion for earlier diagnosis of LR after PD for PDAC.