Toru Obuchi

Tailored laparoscopic resection for suspected gastric gastrointestinal stromal tumors

BACKGROUND The aim of the present study was to evaluate the long-term outcomes of tailored laparoscopic resections for suspected gastric gastrointestinal stromal tumors (GISTs) based on the tumor size, location, and growth morphology. METHODS Between February 1994 and April 2009, 64 patients undergoing gastric resections of suspected gastric GISTs were identified in a prospectively collected database. Medical records were reviewed for patient demographics, perioperative outcomes, and follow-up. RESULTS Forty-five patients underwent attempted laparoscopic resections, with 44 completed laparoscopically. Twenty-eight neoplasms were located in the upper third of the stomach (including 6 neoplasms at the esophagogastric junction), 9 in the middle third, and 8 in the lower third (including 4 prepyloric neoplasms). Laparoscopic approaches included 35 exogastric (3 single incision access) and 10 transgastric approaches. Median operating time was 100min (range, 30-240), and blood loss was 5ml (range, 1-80). Median tumor size and operative margin were 32mm (range, 16-74) and 7mm (range, 1-20), respectively. One patient was converted to an open, pylorus-preserving gastrectomy. One patient developed a complication. The histopathologic risk assessment classifications of 37 GISTs were 2 very low, 26 low, 7 intermediate, and 2 high risk. Although 1 patient developed a local recurrence after intragastric resection, all 45 patients were disease free at a median follow-up of 74 months (range, 1-181). CONCLUSION Although technically demanding, tailored laparoscopic resection based on tumor characteristics in most patients with suspected gastric GIST is safe and feasible and resultis in good both surgical and oncologic outcomes.

Bariatric surgery and non-alcoholic fatty liver disease: current and potential future treatments

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly common cause of chronic liver disease worldwide. The diagnosis of NASH is challenging as most affected patients are symptom-free and the role of routine screening is not clearly established. Most patients with severe obesity who undergo bariatric surgery have NAFLD, which is associated insulin resistance, type 2 diabetes mellitus (T2DM), hypertension, and obesity-related dyslipidemia. The effective treatment for NAFLD is weight reduction through lifestyle modifications, antiobesity medication, or bariatric surgery. Among these treatments, bariatric surgery is the most reliable method for achieving substantial, sustained weight loss. This procedure is safe when performed by a skilled surgeon, and the benefits include reduced weight, improved quality of life, decreased obesity-related comorbidities, and increased life expectancy. Further research is urgently needed to determine the best use of bariatric surgery with NAFLD patients at high risk of developing liver cirrhosis and its role in modulating complications of NAFLD, such as T2DM and cardiovascular disease. The current evidence suggests that bariatric surgery for patients with severe obesity decreases the grade of steatosis, hepatic inflammation, and fibrosis. However, further long-term studies are required to confirm the true effects before recommending bariatric surgery as a potential treatment for NASH.

Laparoscopic Cholecystectomy in Patients with a History of Gastrectomy

PurposePrevious gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of LC in patients with a history of gastrectomy.MethodsFrom a database of 1 104 consecutive patients with symptomatic gallstone disease, who underwent LC between April 1992 and January 2007, 51 (4.6%) had undergone previous gastrectomy: for gastric cancer (n = 36) or gastroduodenal ulcer (n = 15). We compared the operative time, blood loss, conversion rate, morbidity rate, diet resumption, and postoperative hospital stay between patients with, and those without, a history of gastrectomy.ResultsThe incidence of common bile duct stones was significantly higher (33.3% vs 8.6%, P < 0.001) and operative time was significantly longer (111.2 min vs 77.9 min, P < 0.001) in the patients with a history of gastrectomy. There was no significant difference in operative time between the first-half and second-half periods. Conversion to an open cholecystectomy was required in two patients. There was no significant difference between the two groups in blood loss, conversion rate, morbidity rate, diet resumption, or postoperative hospital stay.ConclusionLaparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstone disease in patients with a history of gastrectomy, although previous gastrectomy is associated with an increased need for adhesiolysis and a longer operative time.

Laparoscopic subtotal cholecystectomy for severe cholecystitis.

PurposeTo evaluate the efficacy and outcome of laparoscopic subtotal cholecystectomy (LSC) for patients with severe cholecystitis.MethodsBetween April 1992 and May 2008, 1226 patients underwent laparoscopic cholecystectomy (LC). From 2000 onward 60 patients with severe cholecystitis underwent LSC. The outcomes of LC were compared between patients who underwent the procedure between 1992 and 1999 (group A; n = 643) and those who underwent the procedure between 2000 and 2008 after the introduction of LSC (group B; n = 583), respectively. In Group B, operative outcomes were also compared between the LC and LSC groups.ResultsThe incidence of bile duct injury (1.6% vs 0.3%, P = 0.040) and conversion to open cholecystectomy (2.2% vs 0.3%, P = 0.046) was significantly lower in group B. The mean operative time was significantly longer (119.6 min vs 71.0 min., P < 0.001), and the mean blood loss was significantly higher (53.4 ml vs 12.9 ml, P < 0.001) in the LSC group. No significant differences were observed between LC and LSC in the incidence of postoperative morbidities or postoperative hospital stay. No patient had remnant gallstones or gallbladder cancers after a median follow-up of 42 months.ConclusionsLaparoscopic subtotal cholecystectomy is safe and effective for preventing bile duct injuries and lowering the conversion rate in patients with technically difficult severe cholecystitis.

Single-incision laparoscopic gastric resection for submucosal tumors: Report of three cases

Between March and April 2009, three consecutive patients underwent single-incision laparoscopic gastric wedge resection for a submucosal tumor located in the anterior wall or greater curvature of the stomach. First, we placed two or three trocars through the same infra-umbilical skin incision. Then, we either elevated the tumor with a mini-loop retractor or retracted the gastric wall near the tumor with a laparoscopic grasper. Finally, we resected the tumor using an endoscopic linear stapler. Single-incision laparoscopic gastric resection was successfully completed in all three patients without the need for any extraumbilical skin incisions or conversion to conventional laparoscopic procedures. There was no morbidity. The mean operating time and blood loss were 86 min and 4 ml, respectively, and the mean tumor size and surgical margin were 34 mm and 8 mm, respectively. Histopathologically, two tumors were diagnosed as gastrointestinal stromal tumors and one as a carcinoid tumor. Thus, single-incision laparoscopic gastric resection for submucosal tumors is safe and feasible when performed by experienced laparoscopic surgeons using conventional laparoscopic instruments.

Laparoscopic surgery for splenic artery aneurysm.

Purpose We describe 6 cases of laparoscopic splenectomy for multiple, fusiform splenic artery aneurysm (SAA) in patients difficult to treat with interventional radiology procedure and present a literature review. Methods Between November 1999 and May 2008, 6 patients with SAA underwent laparoscopic surgery. Among these patients, 4 had splenectomy alone and 2 had splenectomy with distal pancreatectomy. The mean size of the aneurysm was 3.1 cm (range: 2 to 4 cm). Results Laparoscopic surgeries for SAA were completed successfully in all the 6 patients. The mean operative time and the blood loss were 186.7 minutes (range: 115 to 300 min) and 187.8 mL (range: 3 to 850 mL). The length of the hospital stay was 8.5 days (range: 3 to 15 d). In only 1 case, portal system thrombosis was observed, and the other serious morbidities such as hemorrhage or pancreatic leakage were not observed. No recurrence was observed during a mean follow-up period of 116 months (range: 14 to 260 mo). Conclusions Laparoscopic surgery should be considered to be a safe therapeutic option for SAA patients with the risk of rupture who are difficult to treat with interventional radiology therapy.

Laparoscopic Excision of Retroperitoneal Tumors: Report of Three Cases

Retroperitoneal neural tumors are rarely excised laparoscopically, with fewer than ten cases reported in the literature. Between February 2005 and December 2007, we performed successful planned laparoscopic excision of retroperitoneal tumors using the four-trocar technique in three patients. All three patients were women, with a mean age of 40.7 years. The mean tumor size was 4.8 cm. The mean operative time was 126 min and the mean blood loss 14.3 ml. The postoperative pathological diagnosis was schwannoma in one patient and ganglioneuromas in two. There was no morbidity or mortality. Although difficult to diagnose preoperatively, neural tumors in the retroperitoneal space are most often benign, with a good prognosis. Laparoscopic surgical techniques for retroperitoneal tumors are safe, and their use is encouraged when an appropriate diagnosis is made, after exclusion of malignant subtypes.

Minimally invasive surgical enucleation for esophageal leiomyoma: report of seven cases.

Benign esophageal tumor is a rare entity, with leiomyoma being the most common lesion. We present our experience with enucleation of esophageal leiomyomas using a minimally invasive approach. Between March 1998 and June 2008, seven patients with esophageal leiomyoma underwent right thoracosopic enucleation (n=4) or laparoscopic transhiatal enucleation (n=3). A Dor (n=2) or Toupet fundoplication (n=1) were added for laparoscopic procedure. The mean tumor size was 3.9 cm (range, 1.5-5.5 cm). Tumor locations were upper (n=2), middle (n=1), and lower (n=4) thirds of the esophagus. No major morbidities including postoperative leakage or mortalities occurred. At a mean follow-up period of 60.1 months (range, 14-260 months), no evidence of recurrences were observed. Thoracoscopic and laparoscopic transhiatal enucleation for esophageal leiomyomas is a safe and feasible procedure. The optimal approaches should be tailored based on the location and size of the tumor.

Laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: Report of three cases

Between March 2003 and March 2007, three patients with benign pancreatic tumors underwent a planned laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Four trocars were placed, and an endoscopic linear stapler was used to transect of the pancreas. The perioperative data and surgical outcomes were examined. This procedure was successfully completed in three patients. The mean operative time was 158.3 min, with mean blood loss of 14.7 ml. The postoperative pathological diagnoses included one insulinoma, one solid pseudopapillary tumor, and one intraductal papillary-mucinous adenoma. The mean size of the tumors was 29.3 mm. Oral intake was initiated on day 1.7, and the length of postoperative hospital stay was 8.7 days on average. No morbidity or mortality was observed. A laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is a safe and feasible treatment option without compromising the splenic function for benign or borderline malignant tumors in the distal pancreas.

Assessment of gastric motor function by cine magnetic resonance imaging.

Background and Aim:  The aim of the present study was to evaluate gastric motor function by magnetic resonance imaging (MRI) and investigate whether this examination is a useful tool for therapeutic efficacy or postoperative gastric motor function.