Yoshiyuki Hoya

The advantages and disadvantages of a Roux-en-Y reconstruction after a distal gastrectomy for gastric cancer

In Japan, the Billroth I and Billroth II operations have been used for reconstruction after a distal gastrectomy for gastric cancer. However, a Roux-en-Y reconstruction is increasingly performed to prevent duodenogastric reflux. We herein discuss the indications for Roux-en-Y in gastric surgery and review the literature to determine its advantages and disadvantages. Indications for Roux-en-Y reconstruction after a distal gastrectomy are: (a) When the primary lesion has directly invaded the duodenum or head of the pancreas, the Billroth I operation is likely to result in local recurrence near the anastomosis; (b) in addition, the Billroth I operation is not indicated after a subtotal gastrectomy due to an unacceptable anastomotic tension; reconstruction using a nonphysiological route is therefore preferred. The advantages of Roux-en-Y reconstruction after a distal gastrectomy include a reduction of reflux gastritis and esophagitis, a decreased probability of gastric cancer recurrence, and a reduction in the incidence of surgical complications such as ruptured suture lines. The disadvantages of Roux-en-Y reconstruction include the possible development of stomal ulcer, an increased probability of cholelithiasis, increased difficulty with an endoscopic approach to the ampulla of Vater, and the possibility of Roux stasis syndrome. The principal advantage of a Roux-en-Y reconstruction is that it is less likely than the Billroth I operation to result in duodenogastric reflux. Roux-en-Y reconstruction or Billroth I operation can only be selected after considering their respective advantages and disadvantages.

The use of nonpharmacological interventions to reduce anxiety in patients undergoing gastroscopy in a setting with an optimal soothing environment.

Patients develop anxiety before undergoing gastroscopy. By removing such distressing feelings, patients are more likely to experience gastroscopy more smoothly. This study was designed to examine changes in anxiety levels in patients undergoing gastroscopy and the effect of an optimal soothing environment (OSE) as a new nonpharmacological intervention to reduce patient anxiety prior to gastroscopy. During a 6-month period, 50 outpatients referred for gastroscopy were randomly assigned to two groups (control group, n = 24 patients; OSE group, n = 26 patients). This study was performed at the digestive endoscopy service of a 150-bed acute care hospital in Japan. The patient anxiety was assessed using the Face Scale score. Pre- and postprocedural systolic blood pressures were measured and values were compared with blood pressure upon arrival at the hospital. The tools for an OSE, including a safe essential oil burner with lavender essential oil and a digital video disk program entitled “Flow” manufactured by NHK (Japan Broadcasting Corporation) software, were provided to patients in the waiting room before gastroscopy. The score for self-assessed anxiety level just before gastroscopy was significantly higher than that on arrival at the hospital but returned to baseline after gastroscopy in the control group, whereas the score did not increase before starting gastroscopy in the OSE group. Systolic blood pressure measurements just before and after gastroscopy were significantly higher than those on arrival at the hospital and the baseline values in the control group, whereas it was not increased before starting gastroscopy in the OSE group. Providing an OSE before and during gastroscopy is useful to minimize patient anxiety regarding experiencing a gastroscopy. This nonpharmacological method is a simple, inexpensive, and safe method of minimizing anxiety before and during gastroscopy.

Disadvantage of Operation Cost in Laparoscopy-Assisted Distal Gastrectomy under the National Health Insurance System in Japan

Background: The utility and problems including the socioeconomic aspect of laparoscopy-assisted distal gastrectomy for gastric cancer have not been fully evaluated. Subjects and Methods: We compared open distal gastrectomy and laparoscopy-assisted distal gastrectomy for the clinical benefit, quality of life, and problems of operation cost by the reference documents in which the difference between open distal gastrectomy and laparoscopy-assisted distal gastrectomy was examined in detail. The reference documents retrieved by the key words ‘gastric, cancer, laparoscopic, surgery’ were 22 in PubMed with the following limits activated: Humans, Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Review, English, Core clinical journals, published in the last 10 years. Results: The operation time of laparoscopy-assisted distal gastrectomy is longer than that of open distal gastrectomy. However, if skilled, the blood loss of laparoscopy-assisted distal gastrectomy is less, the hospitalization days and the duration of fasting after laparoscopy-assisted distal gastrectomy are shorter than those after open distal gastrectomy. The number of excised lymph nodes and the incidence of postoperative complications were similar between laparoscopy-assisted distal gastrectomy and open distal gastrectomy. On the other hand, in the national health insurance system, the operation fee of open distal gastrectomy was USD 6,637 as compared to USD 7,586 for laparoscopy-assisted distal gastrectomy. In spite of the USD 949 difference in the operation fee, the use of disposable instruments for laparoscopy-assisted distal gastrectomy results in a deficit of USD 1,500 over open distal gastrectomy. Conclusion: In spite of the medical superiority of laparoscopy-assisted distal gastrectomy over open distal gastrectomy (if a skilled surgeon operates) as less invasive surgery, laparoscopy-assisted distal gastrectomy is associated with less financial benefit to the hospital as compared to open distal gastrectomy in the current Japanese health insurance system.

Modified Billroth-I reconstruction after distal gastrectomy

To the Editor: Although Billroth I (B-I) or Billroth II (B-II) has traditionally been the method for reconstruction after distal gastrectomy, Roux-en-Y (R-Y) is now being increasingly employed at many institutions, mainly to prevent duodenogastric refl ux and to ensure safe anastomosis. We do perform R-Y in our department, but only in limited cases in patients with special conditions, i.e., locally invasive tumors in the pylorus or the antrum in which the tumor may recur locally, or in patients having a subtotal distal gastrectomy for which a gastroduodenal anastomosis would result in excessive tension. The advantages of R-Y after distal gastrectomy include the absence of or a low incidence of refl ux gastritis and esophagitis [1] and a possible reduction in the future development of stump carcinoma [2]. On the other hand, with R-Y, stomal ulcer may develop [3, 4] and the incidence of cholelithiasis, for which endoscopic sphincterotomy is almost impossible, may increase [5, 6]. The notorious Roux stasis syndrome [7] may also develop in some cases. The advantages of B-I over R-Y include food passage through the physiological route, single anastomosis, low risk of stomal ulcer or cholelithiasis, and easy access to the duodenal papilla in case there is cholelithiasis or pancreatic disease. Thus, we select B-I reconstruction whenever possible. Because the main problem with B-I is duodenogastric refl ux, we recently developed a modifi ed B-I technique, in which the gastric mucosa is inverted like a checkvalve in the duodenum to prevent refl ux (Fig. 1). Since we fi rst reported the technique in 2007 [8], ten such patients have been followed up for a mean of 17.7 Fig. 1. Schematic view of the newly developed modifi ed Billroth I technique. With permission from the publishers of Surgery [8]

Laparoscopic intragastric full-thickness excision (LIFE) of early gastric cancer under flexible endoscopic control--introduction of new technique using animal.

Background We have developed a new method for the treatment of stomach lesions in early gastric cancer, which we refer to as laparoscopic intragastric full-thickness excision under flexible endoscopic control. In this procedure, the diseased lesion of the gastric wall is pulled inwards and removed under endoscopy and laparoscopy guidance. A lesion in the anterior wall of the stomach, for which a direct percutaneous transgastric puncture can be performed, is a good indication for laparoscopic intragastric full-thickness excision, similarly to the lesion-lifting method. The purpose of the study is to describe the surgical techniques in the procedure and to assess the clinical relevance of the approach. Surgical Technique Three trocars are used in the normal procedure. To perform sentinel lymph node navigation surgery, indocyanine green is injected into the submucosal layer in 4 quadrants under endoscopy. The periphery of the lesion is punctured with the first trocar (trocar&U2460;) by the percutaneous transgastric route. The wire of the T-bar is introduced into the stomach through trocar&U2460;. The tip of the wire is pulled into the stomach using the forceps of the endoscope. The T-bar, after passing through the abdominal wall, is fixed outside the gastric wall. The second trocar (trocar&U2461;) is placed at the subumbilical region in the abdominal cavity to accommodate the laparoscope, whereas the third trocars (trocar&U2462;) are percutaneously punctured into the abdominal cavity. The indocyanine green-colored sentinel lymph node is detected using instruments positioned through trocar&U2460; and trocar&U2462;, and the absence of lymph node metastasis is quickly confirmed by pathologic examination. Trocar&U2462; is repositioned in the stomach by the percutaneous transgastric route. The stomach anterior wall is pulled inwards by the T-bar, and the lesion is removed by several excisions with laparoscopic stapling devices inserted through trocar&U2462;; extraction of the specimen is achieved through trocar&U2462;. The gastrotomy site is sutured using instruments positioned through trocar&U2460; and trocar&U2462; under laparoscopy. The stomach surgery is performed under gastroscopic guidance, whereas the intra-abdominal procedures are performed under laparoscopy. Conclusions On the basis of the introduction of new technique using pigs, we believe that this procedure is useful for intramucosal carcinoma, which exceeds the standard indication for endoscopic mucosal resection, and for carcinoma invading the submucosa without lymph node metastasis.

Blood transfusion requirement for gastric cancer surgery: Reasonable preparation for transfusion in the comprehensive health insurance system

We investigated the necessity of preparation for blood transfusion in gastric cancer surgery to save costs for blood typing, antibody screening, cross-matching, and disposal of the blood product. The subjects of the study were 52 patients who underwent gastric cancer surgery at our department between 2000 and 2004. The requirement for blood transfusion during surgery was investigated in terms of patient characteristics, hemoglobin before surgery, and performance status as well as treatment regimen. Furthermore, economic effects were investigated when typing and screening (T&S) were performed instead of typing and cross-matching (T&X). Of 9 patients who received blood transfusion, 8 had gastric cancer of stage IIIB or higher, or underwent combined resection. Blood transfusion was not used in surgery for patients with early gastric cancer. The volumes of blood prepared, lost, and disposed of in 28 patients who underwent T&X were 831.3+/-249.4, 219.3+/-228.5 and 600+/-333.1 ml, respectively, whereas the blood loss in 24 patients who underwent T&S was 161.1+/-95.6 ml; this difference had a major economic effect. The practice of T&S for patients undergoing gastric surgery in the absence of combined resection for early gastric cancer seems to be a safe and cost-effective practice that abrogates disposal of blood in hospital management.

Laparoscopic intragastric full-thickness excision (LIFE) of posterior gastric lesions under flexible endoscopic control- : A feasibility study

BackgroundWe have developed a new technique for treatment of intramucosal carcinomawhich exceeds the standard indication for endoscopic mucosal resection and carcinoma invading the submucosa without lymph node metastasis that are located in the posterior wall of the stomach, which we refer to as laparoscopic intragastric full-thickness excision (LIFE) under flexible endoscopic control.Surgical TechniqueThree pigs were used for the study. Three trocars were used. The first trocar (trocar # 1) was placed in the subumbilical region to introduce the videoscope, whereas the second and third trocars (trocar # 2 and trocar # 3) were punctured percutaneously into the abdominal cavity. A straight needle with 3-0 silk suture was attached to a T-bar on the wire side and inserted into the abdominal cavity. An area adjacent to the lesion in the posterior wall of the stomach was pierced by the straight needle, which was then pulled into the stomach using the forceps of the endoscope. The T-bar, after being passed through the abdominal wall, was fixed outside the gastric wall, and trocar # 3 was repositioned in the stomach by the percutaneous transgastric route. The posterior wall of the stomach was pulled inward by the T-bar, and the lesion was removed by several excisions with laparoscopic stapling devices inserted through trocar # 3; extraction of the specimen was achieved through trocar # 3. The gastrotomy site was suture-closed using instruments positioned through trocar # 2 and trocar # 3 under laparoscopy.ConclusionsBased on a feasibility study in pigs, the LIFE procedure can be performed for lesions of the posterior wall of the stomach.

The Simulation of Operation Cost in Laparoscopy-Assisted and Laparoscopic Distal Gastrectomy Under the National Health Insurance System in Japan

The utility and problems including the socioeconomic aspect of laparoscopy-assisted (LADG) and laparoscopic distal gastrectomy (LDG) for gastric cancer has not been fully evaluated. We compared between open distal gastrectomy (ODG), LADG and LDG, the clinical benefit and quality of life by the reference documents. The problems of operation cost were derived by simulating the material used for each operation with Billroth I (B-I) reconstruction, and calculating the operation fee under the national health insurance system in Japan. The operation time of LADG and LDG was longer than that of ODG. However, the intraoperative blood loss of LADG and LDG was less and the postoperative hospital stay as well as the duration of fasting after LADG and LDG were shorter than those after ODG. The number of excised lymph nodes and the incidence of postoperative complications were comparable between LADG, LDG and ODG. On the other hand, in the national health insurance system, the operation fee of ODG was US

Novel drain fixation device to reduce the peritoneal drain-related complications after gastroenterological surgery

7187 as compared to US

Usefulness of ICG Clearance Meter in Assessing the Pathogenesis of the Liver Dysfunction : Report of a Hepatic Carcinoma Patient

8012 for LADG and US