Toshiharu Aotake

Reduced-port surgery aided by the newly developed free jaw clip and free loop plus for local resection of gastric submucosal tumors

Background: Gastric cancer requiring lymph node dissection is not often approached laparoscopically because of the surgical difficulty. However, in cases of gastric submucosal tumor, such as gastroin-testinal stromal tumor (GIST), lymph node dissection is not usually necessary. Local resection is generally sufficient, and GIST, then, is a good indication for reduced-port surgery (RPS). We describe RPS performed through two ports—one in the umbilicus and one in the left epigastric region. Two devices have been developed for this procedure: the free jaw (FJ) clip, which is used to grasp organs in the abdominal cavity, and the free loop plus, which is used pull suture threads from inside the abdominal cavity to outside the body. We have used the new devices with good outcomes in 11 patients undergoing resection of GIST. We describe the new devices, their use in RPS for GIST, and the case outcomes. Methods: The FJ clip is a short clip designed to assist with organ elevation. The clip comes in two sizes, one for use in a 5-mm port and the other for use in a 12-mm port, and in two lengths, 29.4 and 35.6 mm, respectively. Both clips are made of stainless steel, and they can be easily maneuvered with commonly-used laparoscopy forceps. The clips have a powerful grasping force (200±20 and 300±30 gf, respectively) but cause no or only negligible organ damage. The jaw surface is textured in a lattice-like relief to resist slippage. The free loop plus is used to puncture the abdominal wall and pull suture threads from inside the abdominal cavity to outside the body. It is fitted with a φ 0.1-mm NiTi alloy suture thread that passes through a 90-mm 21 G stainless steel needle. Generally, the device is attached to the FJ clip and used to guide the traction suture to outside the body. Results: In the 11 cases noted above, mean operation time was 156 minutes (78–287 minutes). The blood loss volume was ≤30 g per patient and so low in 8 patients that it could not be measured. In all 11 patients, the surgery was performed via two ports, one in the umbilicus and the other in the left epigastric region. Laparoscopic endoscopic cooperative surgery was performed in 4 of the 11 patients. There were no intraoperative or postoperative complications, and the mean postoperative hospital stay was 9.9 days (range, 8–11 days). Conclusions: Our success with the devices leads us to believe that the FJ clip will assume the role of forceps in many laparoscopic surgery settings in fields such as obstetrics and gynecology and urology. We are also led to believe that the FJ clip will pave the way for new developments in RPS.

A COMBINED CASE OF NONFUNCTIONING ENDOCRINE TUMOR OF THE PANCREATIC HEAD AND CANCER OF THE PANCREATIC BODY AND TAIL

症例は82歳,女性.糖尿病のコントロール不良にて前医に入院した.血液検査にてCA19-9が255.6U/ml,エラスターゼIが218ng/mlと上昇していた.腹部CT検査にて膵頭部の石灰化を伴うエンハンスされる腫瘍と主膵管の拡張を認めた.更に腹部超音波ならびにMRI検査の結果,膵頭部の神経内分泌腫瘍と膵体尾部癌が疑われた.当科に紹介入院更に精査を施行した.血中の膵,消化管ホルモンは正常値であり,腹部血管造影では膵頭部に腫瘍濃染を認め, ERCPで膵頭部で主膵管の圧排偏位を認めた.非機能性膵頭部内分泌腫瘍と膵体尾部癌の診断にて膵頭十二指腸切除術を施行した.膵頭部に約3 cmの境界明瞭な弾性硬の腫瘤と膵体尾部に約2 cmの浸潤性の腫瘤を認めた.病理診断は稀な膵頭部のendocrine tumorと膵体尾部のinvasive papilo-tubular adenocar-cinomaの併存例であった.