Yoshinori Tanaka

Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results

Background: The efficacy of thoracoscopic radical esophagectomy for cancer of the thoracic esophagus and the learning curve required have yet to be clearly established. Methods: Eighty treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm minithoracotomy and four trocar ports. The outcomes in the first 34 patients (group 1) and the last 46 patients (group 2) were compared. Results: There were no differences in background or clinicopathologic factors between the two groups. The duration of the thoracoscopic procedure and blood loss were less (p <0.0001), the incidence of postoperative pulmonary infection was less (p = 0.0127), and the number of mediastinal nodes retrieved was greater (p = 0.0076) in group 2. Multivariate analysis demonstrated that surgical experience (number of cases performed) predicted the risk of pulmonary infection (p = 0.0331). Conclusion: Video-assisted thoracoscopic radical esophagectomy can be performed with safety and efficacy comparable to those of open esophagectomy. Morbidity decreases with the surgeons experience.

Laparoscopic gastrectomy for gastric cancer : experience with more than 600 cases

BackgroundAmong the less invasive operations noted in recent years, laparoscopic gastrectomy for gastric cancer has become popular because of advances in surgical techniques. The authors performed laparoscopic gastrectomy with regional lymph node dissection for 612 cases of gastric malignancies between March 1998 and August 2006. The technique and results of laparoscopic gastrectomy for gastric cancer are presented.MethodsOf the 612 gastric malignancy cases, distal gastrectomy was performed in 485 cases, proximal gastrectomy in 42 cases, and total gastrectomy in 85 cases. In all the cases, D1 or D2 lymph node dissection was performed according to the general rule of the Japanese Gastric Cancer Association.ResultsQuicker recovery was observed in the laparoscopic gastrectomy cases than in the open cases. The postoperative complications with this technique were within a permissible range. No statistical difference was seen in the survival curve after surgery between the laparoscopic group of advanced cases preoperatively diagnosed as surgical T2N1 or lower and the open group.ConclusionThe laparoscopic technique is not only less invasive, but also similarly safe and curative compared with open gastrectomy.

Video-assisted thoracoscopic esophagectomy and radical lymph node dissection for esophageal cancer: A series of 75 cases

AbstractsBackground: The efficacy of thoracoscopic radical esophagectomy for cancer has yet to be established, mainly because previous reports have not included a sufficient number of cases. Methods: Seventy-five treatment-naive patients with esophageal cancer without contiguous spread underwent esophageal mobilization and extensive mediastinal lymphadenectomy through a 5-cm mini-thoracotomy and four trocar ports. Results: Video-assisted thoracoscopic surgery was performed without major intraoperative complications or emergency conversion to open surgery. We retrieved 34.1±13.0 mediastinal nodes, including 11.5±3.8 tracheobronchial nodes and 6.2±3.0 recurrent laryngeal nodes. Mean time of operation and blood loss were less in the last 39 patients than the first 36 (186.7±25.3 min and 165.4±101.8 g vs 270. 2±96.0 min and 421.5±31.2 g, respectively: p <0.0001 and p <0.001). Pulmonary morbidity was 5% in the later 39 patients. Survival was 90%, 80%, and 57% at 1, 2, and 5 years after surgery. Conclusion: Thoracoscopic radical esophagectomy has less morbidity and comparable survival to conventional surgery, after a moderate amount of experience. Mini-thoracotomy is essential to perform the procedure safely and effectively.

Intracorporeal Billroth 1 reconstruction by triangulating stapling technique after laparoscopic distal gastrectomy for gastric cancer.

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patients figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The “triangulating stapling technique” (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patients figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

Ambulatory intraesophageal bilirubin monitoring in Japanese patients with gastroesophageal reflux

Background: The role of reflux of duodenal contents in gastroesophageal reflux in Japanese patients, which may be different from that in Western patients, was studied. Methods: Intraesophageal pH and the bilirubin concentration were monitored, using the Bilitec 2000, in 43 patients with reflux symptoms and 10 normal volunteers. The percentage of the time that spectrophotometric absorbence was 0.15 or more and pH was less than 4.0 was defined as the holding times (HTs) of bilirubin and acid, respectively. Severity of esophagitis was classified using the Savary-Miller (S-M) classification. Results: Esophagitis was present in 37 patients; 5, 10, 13, and 9 patients had S-M grades 1, 2, 3, and 4, respectively. Both HTs in the volunteers were less than 5%. Bilirubin HT was more than 5% in 3 of the 6 patients without esophagitis, but the acid HT was less than 5% in these 6 patients. Acid HT was less than 5% in 4, 2, 2, and 2 patients with S-M grades 1, 2, 3, and 4, respectively. Bilirubin HT was less than 5% in 1 patient with S-M grade 2 esophagitis. Bilirubin HT in patients with S-M grades 3 and 4 esophagitis (50.9 ± 5.8%) was higher than that in grades 1 and 2 (14.9 ± 2.9%) (P < 0.0001), but this was not so for acid HT. In 32 patients, bilirubin HT exceeded acid HT. Bilirubin HT did not correlate with acid HT. Conclusions: Duodenogastroesophageal reflux occurred independently of and exceeded acid reflux. The amount of duodenogastroesophageal reflux correlated with the severity of esophagitis.

Pseudotumor of the omentum with a fishbone nucleus.

A 23‐year‐old Japanese man was admitted with a chief complaint of abdominal pain. He was previously healthy, and his past medical history was unremarkable. Local tenderness and rebound tenderness at McBurney’s point were elicited. Abdominal roentgenography was non‐diagnostic. Ultrasonography and computed tomography showed a tumor with a central core. Based on a diagnosis of appendicitis with omental inflammation or an omental tumor, laparotomy performed. Intraoperatively, no site of gastrointestinal perforation was detected; however, a 5‐cm omental granuloma was identified that proved to have a fishbone nucleus on pathological examination. The postoperative course was uneventful, and upper gastrointestinal endoscopy and barium enema were unremarkable. A large solitary omental pseudotumor is rare, and the clinical course in this case was atypical compared with the usual course of intestinal perforation by a foreign body and formation of an intra‐abdominal granuloma.

Sarcoid reaction in the spleen after sigmoid colon cancer resection: a case report

BackgroundA sarcoid reaction is a phenomenon characterized by histologically proven granulomatous lesions without evidence of sarcoidosis. This pathology is a benign tumor itself, but several reports have described sarcoid reactions accompanying malignant tumors. Sarcoid reactions occur in various cancers, such as skin, lung, ovary, stomach, and breast cancers. However, only a few published reports have described sarcoid reactions in patients with colorectal cancer.Case presentationA 76-year-old woman underwent laparoscopic sigmoidectomy for sigmoid colon cancer. The postoperative follow-up computed tomography and 18-fluorodeoxyglucose positron emission tomography–computed tomography findings were suspicious for splenic metastasis of the sigmoid colon cancer. The patient then underwent laparoscopic splenectomy. Histopathological examination of the resected lymph nodes and spleen showed a non-caseating epithelioid cell granuloma. The patient was diagnosed with a sarcoid reaction.ConclusionsTo our knowledge, this is the first report of a sarcoid reaction in the spleen and regional lymph nodes after colon cancer resection. The effect of a sarcoid reaction on the prognosis in patients with colorectal cancer has not been fully determined because of the small number of such cases. Further analyses involving a larger number of cases are necessary to evaluate the relationship between sarcoid reactions and prognosis in patients with colorectal cancer. We herein present an extremely rare case of a sarcoid reaction in the spleen and regional lymph nodes.

A case of using the remnant stomach as substitute after esophagectomy for esophageal cancer with history of distal gastrectomy

A 63-year-old man who had a distal subtotal gastrectomy and retrocolic end-to-side gastrojejunostomy was admitted because of a mid-thoracic esophageal cancer. He underwent a two-stage subtotal esophagectomy and reconstruction using the remnant stomach without microvascular anastomosis. We preserved the splenic artery, splenic vein, and the short gastric artery. The remnant stomach was pulled up together with the pancreas through the anterior sternal route. The superiority of this technique is that microvascular anastomosis is not needed because a sufficient blood supply from the splenic artery and only two anastomoses are needed, compared with three or four anastomoses when using the colon. This technique is also likely to be safer for patients requiring an esophagectomy after a distal gastrectomy.

A Case of Submucosal Basaloid Carcinoma of Cervico-thoracic Esophagus

症例は64歳の男性. 平成14年1月初旬より嚥下困難が出現し, 食道造影で頸胸境界部食道の右側に約2.5cmの隆起性病変を認め, 上部消化管内視鏡検査では, 門歯列より約20cmの食道右壁に1pl型の隆起性病変を認めた. CT, 超音波検査では明らかなリンパ節転移, 血行性転移は認めなかった. 以上より, T2N0M0, Stage IIの頸胸境界部食道癌と診断し, 平成14年5月8日に胸腔鏡下食道切除術および3領域リンパ節郭清術を施行した. 腫瘍は肉眼的に径22×16mm, 1pl型で, 病理組織診断では類基底細胞癌であった. 深達度はsmでly0, v1, pN0, pStage Ibであった. 類基底細胞癌は非常にまれであり, 予後不良とされている. リンパ節転移のない表在型は予後がよいとの報告もあるが, 頸胸境界部食道に発生した表在型類基底細胞癌は本邦では報告例がなく, また細胞増殖能が高いことより再発に留意し経過観察中である.

The Therapeutic Strategy of Submucosal Esophageal Cancer by Clinicophathological Findings and Lymph Node Metastasis.

食道粘膜下層癌の治療方針を臨床病理学的因子・リンパ節転移の状況より検討した.対象と方法:3領域リンパ節郭清術を施行した症例のうち主病巣の病理組織学的検索でpT1bであった50例を用いた.結果:リンパ節転移は18例にみられ, 転移陰性32例に高分化型扁平上皮癌, 脈管侵襲陰性例が多かった. 多変量解析では脈管侵襲の有無がリンパ節転移に最も関与した因子であった. 総郭清リンパ節2532個中63個に転移を認め, 長径10mm以下は41個・6mm以下は19個であった. 9mm以下のリンパ節で, 肉眼的転移判定は困難であった. リンパ節再発が2例, 血行性転移が3例にみられ, 5年生存率は84%で, 脈管侵襲陽性例の生存率が有意に悪かった.結語:粘膜切除可能なpT1b 食道癌には診断的粘膜切除を行い, 高分化型扁平上皮癌で脈管侵襲陰性の場合はリンパ節転移の可能性が低いが, これ以外の症例には追加治療としてリンパ節郭清が必要である.