Takashi Tanida

Development of a novel multichannel port (x-Gate®) for reduced port surgery and its initial clinical results

Abstract Background: In order to reduce clashing between the instruments during single-incision endoscopic surgery or reduced port surgery we have developed a new multichannel port with wider distance between the channels. Material and methods: We used the newly developed multichannel port (x-Gate®) in 34 patients undergoing a variety of reduced port surgery procedures. The operation records of these patients were reviewed. Results: Overall performance of x-Gate® was sufficient in the clinical experience. There have been no complications attributed to x-Gate®. We found that with the x-Gate® the conflicts among the forceps have been drastically improved compared with other multi-channel ports we had used before, which had a shorter distance between the channels.

Long-term outcomes of percutaneous endoscopic intragastric surgery in the treatment of gastrointestinal stromal tumors at the esophagogastric junction.

BackgroundThe treatment options for gastrointestinal stromal tumors (GITSs) at the esophagogastric junction (EGJ) are controversial. There have been reports on enucleation for EGJ GISTs in order to avoid gastrectomy. But the number of patients is too small, or the follow-up period is too short to evaluate it. The purpose of this study was to review our experience of 59 patients with EGJ GISTs treated by enucleation by percutaneous endoscopic intragastric surgery (PEIGS) and assess the clinical outcomes.MethodsPEIGS is performed as described below. Access ports are placed through the abdominal wall and the anterior wall of the stomach. Through the access ports, an endoscope and surgical instruments are inserted into the gastric lumen and tumor enucleation and closure of the defect are carried out. In this study, 59 patients with EGJ GISTs treated by PEIGS between 2005 and 2013 were enrolled. Their hospital records were reviewed, and follow-up data for 8xa0years were collected to analyze the outcomes.ResultsEn-bloc enucleation was achieved without tumor rupture in all. Average operation time was 172.3xa0min. Postoperative complications occurred in 3 (one localized peritonitis, one bleeding, and one surgical site infection). Average tumor size was 35.6xa0mm. Pathological findings confirmed negative margin in all specimens. The maximum follow-up period was 101xa0months. Multiple liver metastases were detected in two patients (at 12 and 29xa0months). The survival rate was 100xa0%. The disease-free rate was 98.3xa0% at 12xa0months and 96.6xa0% at 29xa0months, respectively.ConclusionsAs far as the short- and long-term outcomes of our experience are reviewed, PEIGS seems as curative as other aggressive resection methods such as proximal gastrectomy. Tumor enucleation by PEIGS, offering a chance to preserve the stomach, can be a preferable option in carefully selected patients with EGJ GISTs, when performed by a skilled surgeon.

Transanal endoscopic microsurgery for surgical repair of rectovesical fistula following radical prostatectomy

AbstractBackgroundnRectovesical fistula is a rare complication following prostatectomy, associated with significant symptoms such as urinary drainage from anus or faecaluria. While several surgical procedures have been described to treat this condition, none of them has been accepted as the universal standard. Transanal endoscopic microsurgery (TEM) is a well-established endoluminal procedure for local excision of rectal tumors. But its application to the repair of rectovesical fistula has been almost unknown.MethodsWe performed TEM as a surgical repair for refractory rectovesical fistula developing after radical prostatectomy in 10 patients. Under the magnified three-dimensional view, through the stereoscope, the fistula and the surrounding rectal mucosa were precisely resected. The defect and the muscle layer of the rectum were closed by hand-sew technique in four layers.ResultsFistula was completely closed in 7 patients, who eventually underwent enterostomy closure, while in the other 3 patients the fistula recurred. In the three recurrent cases, the fistula was associated with wide, tough scar tissue due to previous irradiation, HIFU, or repeated surgical repair attempts.ConclusionsRectovesical fistulas associated with wide, tough scar tissue due to multi-time attempt of surgical repair or any type of energy ablation should not be indicated for repair by TEM. However, for simple fistulas without tough, fibrotic surroundings, TEM can be indicated as a minimally invasive surgical option with very low morbidity, without any incision in healthy tissue for approach.

A single surgeon's experience with transanal endoscopic microsurgery over 20 years with 153 early cancer cases.

Abstract Background: The first author performed transanal endoscopic surgery (TEM) in 302 patients in Japan for the last 20 years, 153 of which were early rectal cancer cases. The short- and long-term outcomes of the early rectal cancer cases are herein reported. Material and methods: The original technique of TEM developed by Gerhard Buess was performed in all cases. The hospital records were reviewed to assess the clinical outcomes. A questionnaire was sent to the patients to analyze the long-term outcomes. Results: One-hundred and fifty-three early cancer cases included 115 T0 and 38 T1 lesions. Full-thickness resection was performed in 36 patients, while 117 underwent submucosal dissection. Conversion to laparoscopic low anterior resection occurred in one case. Mortality was nil. Major operative complication was noted in only one patient, who developed stenosis. Seven patients underwent immediate salvage surgery. Six patients died of recurrence of rectal cancer. Disease-free survival rate at year 5 was 93.7%. Conclusions: Our study, one of the largest series in the world, confirms that TEM is a preferable option in the surgical treatment of T0 and T1a rectal carcinoma. As long as early cancer cases are treated, submucosal resection seems to be sufficient. When risk of recurrence is found by pathological examination, immediate salvage operation is mandatory to improve the prognosis.

Development of scar-less laparoscopic hernia repair (TAPP-252) facilitated by new 2mm instruments

Abstract Introduction: To minimize the invasiveness of laparoscopic transabdominal preperitoneal hernia repair (TAPP) for the treatment of adult inguinal hernia, we developed a new operative technique with the use of only one 5u2009mm port and two 2u2009mm punctures (TAPP-252). Material and methods: To facilitate TAPP-252, we developed seven kinds of new 2u2009mm instruments, including grasping forceps, hook shaped electrode, mesh pusher, needle driver, scissors, laparoscope and port. Results: TAPP-252 was stably performed in 35 patients with minimal abdominal wall destruction and excellent cosmetic result without any recurrence or morbidity. Conclusions: The newly developed 2u2009mm devices showed sufficient performance and durability in TAPP-252. Further investigation is necessary to assess durability and long-term outcomes.

Percutaneous endoscopic intragastric surgery: an organ preserving approach to submucosal tumors at esophagogastric junction

As an organ preserving option in the treatment of submucosal tumor found at the esophagogastric junction (EGJ), percutaneous endoscopic intragastric surgery (PEIGS) plays an important role, while it is not commonly performed and there have been very few reports on this unique operation. The current authors have been performing PEIGS since 1993 and have reported on its short- and long-term outcomes from one of the world largest series. Herein its confusing terminology is discussed and techniques of three different types of PEIGS (original PEIGS, single incision PEIGS, and needlescopic PEIGS) are precisely described. Although reports on clinical outcomes of PEIGS have been rarely published, both short-term and long-term outcomes seem acceptable, as far as we review our own experiences and the past literatures. PEIGS needs to be accessed by the data from larger series or RCT to be further justified and spread for the patients with submucosal tumors at EGJ to salvage their stomach.

Wedge Gastric and Endo-Gastric Resection

Two different operative techniques for resection of gastric submucosal tumors through a single incision and one needle-puncture are described. One involves an extragastric approach, which is indicated for tumors at a location distant from the esophagogastric junction. The other involves an endoluminal approach, which is indicated for tumors located at the esophagogastric junction. We use the x-Gate ® multichannel port (Sumitomo Bakelite, Tokyo, Japan), through which two or three instruments are inserted. In addition we use BJ needle ® (Niti On Co., Chiba, Japan), a 2-mm grasper, through a puncture site. With the extragastric approach, tumors are excised in full-thickness by an ultrasonically activated device, and this is followed by manual suturing. With the endoluminal approach a temporary gastros- tomy is constructed at the navel, through which the x-Gate ® (Sumitomo Bakelite) is fi xed in the gastric cavity. Under percutaneous gastroscopic view, tumors at the esophagogastric junction are resected in full thickness, and this is followed by manual suturing. The techniques described here can be safely performed, and the cosmetic result of both techniques is satisfactory.

Minimally Invasive, Organ-preserving Surgery for Large Submucosal Tumors in the Abdominal Esophagus

Background: Surgical resection of submucosal tumors (SMTs) in the abdominal esophagus is not standardized. Enucleation may be a minimally invasive option, whereas its oncological validity is not very clear. Moreover, how to treat the esophageal wall defect after enucleation and necessity of additional antireflux procedure are also undetermined. Methods: In 13 patients with a SMT originating the abdominal esophagus laparoscopic enucleation was performed with preserving the integrity of submucosa. When the muscular layer defect was <4 cm it was directly closed by suturing, whereas it was left open in case the defect was larger. Fundoplication was added when the esophagus was dissected posteriorly or the myotomy was not closed. Results: Tumors were resected en-bloc without rupture in all cases. In 5 patients myotomy was closed, whereas in the remaining 8 it was left open. In 11 patients fundoplication was added (Toupet in 5 and Dor in 6). The patients developed neither regurgitation nor stenosis postoperatively. The histopathologic findings revealed leiomyoma in 9 patients, whereas the other 4 were miscellaneous. The average tumor size was 5.5 cm (range, 2.8 to 8.8). Microscopically surgical margin was negative in all cases. Conclusions: Laparoscopic enucleation of SMTs in the abdominal esophagus seems to be safe, reproducible operation enabling preservation of function of the lower esophagus and esophagogastric junction. Even when the muscular defect is not approximated additional fundoplication can minimize the risk of postoperative reflux disease.

Laparoscopic Surgery for Large Gastric Submucosal Tumors

Background: In general, laparoscopic resection for gastric gastrointestinal stromal tumors (GISTs) >5u2009cm is not recommended. However, there is a lack of evidence to support this recommendation. Patients and Methods: This study included 108 patients who underwent laparoscopic surgery for gastric GISTs. Of the 108 patients, 23 had GISTs>5u2009cm. The aim of this study is to evaluate the oncological safety of laparoscopic surgery for large gastric GISTs. In addition, we performed a rapid systematic review of laparoscopic surgery for large gastric GISTs. Results: In our cases, all patients were performed R0 resection without capsular rupture and surgical margins were negative on pathologic examination. In all studies, en bloc resection was achieved without capsular rupture in all patients. The average positive surgical margins rate was 1.6% in total reports. Conclusions: The laparoscopic approach for large gastric GISTs>5u2009cm has been proposed as safe when performed by experienced surgeons.

Needlescopic intragastric surgery facilitated by newly developed 2mm instruments

Abstract Background: Intragastric surgery is a percutaneous endoluminal surgery in the stomach aimed at resection of tumors located at the esophagogastric junction (EGJ). We developed needlescopic intragastric surgery performed via 2u2009mm, 2u2009mm, and 5u2009mm ports (PEIGS-225). Material and methods: In cooperation with Niti-On Co., Ltd. we developed a series of 2u2009mm instruments including grasping forceps, a cannula, a laparoscope, an electrocautery, scissors, and a needle holder. Operative technique: Two 2u2009mm trocars and a 5u2009mm one are inserted into the gastric lumen percutaneously. Intragastric procedures are performed by the instruments brought through those three ports. The specimen is extracted via the esophageal-oral route. The defect in the gastroesophageal wall is closed by hand-suture. After the intragastric procedure, the 5u2009mm stab wound on the gastric wall is closed by hand-suture, while the 2u2009mm wounds are left untreated. Patients: Between March and August 2015 PEIGS-225 was performed in five patients. Results: There was no operative conversion. The mean operation time was 96u2009minutes. There were no perioperative complications. Pathological findings indicated that the margin was negative in all cases. Conclusion: Needlescopic intragasric surgery performed via the smallest access (2u2009mm, 2u2009mm, 5u2009mm) is enabled by the 2u2009mm instruments developed by us.