Yoshitake Sugamata

Poor Neorectal Evacuation as a Cause of Impaired Defecatory Function After Low Anterior Resection: A Study Using Scintigraphic Assessment

AbstractPurpose. Patients who have undergone low anterior resection (LAR) of the rectum occasionally complain of symptoms related to impaired neorectal evacuation. Using scintigraphy, we assessed neorectal evacuation in 22 patients who underwent LAR and straight anastomosis, and correlated the results with clinical defecatory function, clinical factors, and anorectal manovolumetric parameters. Methods. After the introduction of an artificial stool containing 99mTc-DTPA into the neorectum, sequential lateral gamma images were obtained. From the time–activity curve of radioactivity in the whole pelvis, the time taken to eva-cuate half of the introduced artificial stool (T1/2) and the percentage of artificial stool evacuated in 1 min (Evac1) were calculated. Results. The Evac1 was significantly lower in the patients who had undergone LAR than in reference normal volunteers. A long T1/2 was significantly associated with worse defecatory function. The Evac1 was also significantly lower in patients with a low anastomosis. The rectal sensory threshold was significantly greater in patients with a shorter T1/2. The maximum tolerable volume of the neorectum was significantly greater in patients with a shorter T1/2 and a higher Evac1. Conclusion. Poor neorectal evacuation is associated with impaired defecatory function after LAR. Therefore, it is suggested that optimizing both reservoir function and evacuation of the neorectum would improve defecatory function after LAR.

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.

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.

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.

Laparoscopic surgery to remove a cage that migrated to the retroperitoneal space during posterior lumbar interbody fusion: A case report

Cage migration into the retroperitoneal space during posterior lumbar interbody fusion rarely occurs. Here, we report a patient who underwent laparoscopic surgery to remove a migrated cage from the retroperitoneal space.

A Case of Poorly Differentiated Adenocarcinoma with Signet Ring Cell Carcinoma of the Duodenal Bulb: A Case Report

Duodenal cancers are rare. Histopathologically, most duodenal cancers are adenocarcinoma. Signet ring cell carcinoma (SRCC) is a rare tumor more commonly found in the stomach than at other sites in the digestive tract. SRCC is extremely uncommon in the duodenum, with most of these tumors occurring in the ampulla. Until now, there are few case reports of duodenal cancers with SRCC. To accumulate case reports, we report a rare case of nonampullary duodenal bulb SRCC. A 74-year-old man was admitted to our hospital with melena. Esophagogastroduodenoscopy (EGD) showed a duodenal bulb ulcer. He was treated with a proton pump inhibitor. However, 1 month later, he was readmitted to our hospital with epigastric pain and nausea. A second EGD examination showed an ulcer at the duodenal bulb. Biopsies taken from the ulcer showed SRCC. Distal gastrectomy and duodenal bulb resection were performed. Histologic examination of the specimen showed a type 4 lesion located from the duodenal bulb to the pyloric antrum. The tu...

Types of Liver Biopsy

Liver biopsy (LB) is an important procedure in the diagnosis and treatment of liver diseases. However, procedures for performing LB vary amongst institutions, and no universal guide‐ lines exist. LB is performed for two main reasons: diagnosis of a liver condition itself, and as an adjunct to an existing surgical procedure. Recently, it has become possible to employ both approaches with minimal invasiveness using the transjugular route or under the guid‐ ance of ultrasound, computed tomography, or laparoscopic and endoscopic ultrasound. Techniques for liver tissue sampling include percutaneous liver biopsy [1-6], transjugular liver biopsy [7-14], laparoscopic liver biopsy [15], and transgastric liver biopsy [16-20]. This chapter introduces these techniques and evaluates their outcomes.