Yuichi Okamoto

Laparoscopy-assisted combined resection for synchronous gastric and colorectal cancer: Report of three cases

In gastric cancer patients, the most common form of synchronous cancer is colorectal cancer. To reduce the invasiveness of the resection, a laparoscopy-assisted combined resection was performed in three patients with synchronous gastric and colorectal cancer. Although all gastric lesions were in the early stages, two colorectal lesions were advanced cases. In all cases, the laparoscopic gastric resection and reconstruction was performed first, followed by the colorectal resection. In the case of right-side colon cancer in addition to gastric cancer, it was relatively easy to perform the combined resection with lymph node dissection sharing the same ports used for the gastrectomy, although we needed an additional port. In one case, in which rectal cancer was present in addition to gastric cancer located in the upper portion of the stomach, a totally laparoscopic proximal gastrectomy was combined with a laparoscopy-assisted low anterior resection, leaving only a lower abdominal minilaparotomy wound. All patients quickly returned to normal activity without remarkable complications, with the exception of a wound infection in one patient. With a mean follow-up of 30.7 months, all patients survived without any sign of recurrence. This procedure represents a feasible option for minimally invasive treatment of synchronous gastric and colorectal cancer.

Focus on the Conditions of Resection and Reconstruction in Gastric Cancer

To assess the roles of the extent of gastric resection and duodenal food passage reconstruction in gastric cancer, we examined a consecutive series of 1,061 patients who underwent total or partial (proximal and distal) gastrectomies with or without duodenal food passage reconstruction between August of 1974 and January of 2002, and received gastrectomies with D2–3 lymph node dissection. Patients who underwent distal or proximal gastrectomy were found to have significantly better survival rates than those who underwent total gastrectomy in stages 1A (10-year survival: 86.6 and 78.9 vs. 61.6%), 2 (56.5 and 65.6 vs. 34.4%), 3A (45.9 and 33.3 vs. 15.2%), and 4 (5-year survival rates: 23.7 and 50.0 vs. 7.1%). Additionally, patients with duodenal food passage reconstruction or double tract reconstruction also showed significantly better survival rates than those without duodenal food reconstruction in stages 1A (10-year survival: 86.4 and 82.5 vs. 61.7%), 1B (69.9 and 90.6 vs. 54.1%), 2 (60.5 and 63.3 vs. 16.5%), and 3A (39.9 and 47.4 vs. 23.1%). In multivariate analysis, the independent prognostic factors were age at operation, depth of tumor, duodenal food passage reconstruction, and lymph node metastasis. Our results indicate that both the extent of gastric resection and duodenal food passage reconstruction were important factors in the outcome of gastric cancer patients, and that surgeons should perform minimal gastric resection with preservation of the duodenal food passage when the gastric stump is tumor-free.

Effects of Liposome-Encapsulated Hemoglobin on Gastric Wound Healing in the Rat

Liposome-encapsulated hemoglobin (LEH) may improve microcirculation and oxygen (O2 ) metabolism at a surgical wound to accelerate its healing. Ten mL/kg of LEH with high (h-LEH) or low O2 -affinity (l-LEH), homologous red blood cells (RBC), empty liposome or saline as a control was infused before a 10-mm incision and interrupted suture closure of the gastric wall in a total of 110 rats. Two and 4 days later, the stomach was excised for bursting pressure determination and histological sampling. The dose-response relationship was examined in 70 additional rats receiving progressively reduced doses of h-LEH. Hypoxia-inducible factor-1α (HIF-1α) was stained immunohistochemically in 54 other rats to examine its accumulation at the anastomotic sites. Bursting pressure of the surgical wound was significantly higher 2 days after surgery only in the h-LEH-treated rats (P < 0.05), but not at 4 days after surgery, when other rats showed increased bursting pressure to a nonsignificant level. Histological examination revealed less granulocyte infiltration, better granulation, and more macrophage infiltration in h-LEH-treated rats at 2 days, but no longer at 4 days postsurgery. Dose-response study revealed that 0.4 mL/kg of h-LEH (hemoglobin 24 mg/kg) was effective for elevating bursting pressure at 2 days. h-LEH-treated rats had significantly suppressed HIF-1α accumulation in the wound 6, 24, and 48 h after surgery as compared with control animals treated with homologous RBC or saline. In conclusion, the results suggest that h-LEH, but not l-LEH or homologous transfusion, may accelerate wound healing early after gastric incision and anastomosis in the rat. The mechanism(s) appears to be related to improved O2 supply, aerobic metabolism, and suppressed inflammation in the wound.

Impact of difference in the definition of extranodal spread on the outcome of node-positive patients with gastric cancer

PurposePrevious studies have reported that extranodal spread is a prognostic factor in patients with several solid cancers. However, the definition of extranodal spread varies with the reporting investigator and has not been standardized yet. Therefore, we selected several widely used definitions from previous reports and comparatively assessed the clinicopathologic significance of these definitions.MethodsExtranodal spread in the 103 node-positive patients who had received curative resections for gastric cancer was classified into two groups, viz., (a) capsule rupture, where cancer cells infiltrated into the perinodal fatty tissue beyond the capsule of the involved lymph node, and (b) no capsule rupture, where nests of cancer cells were detected demonstrable in adjacent tissues around the metastatic lymph node without rupture of the capsule.ResultsSixty-five (63.1%) of the 103 patients showed extranodal spread. Of the 65 patients, 50 patients showed the capsule rupture type and 15 showed the no capsule rupture type of extranodal spread. The 5-year survival rate was significantly poorer in the capsule rupture group as compared with that in the no capsule rupture group and extranodal spread-negative group (P < 0.05 and P < 0.01, respectively). In regard to the mode of recurrence, the rate of peritoneal recurrence was significantly higher in the capsule rupture group (P < 0.01).ConclusionsIn the assessment of patients with extranodal spread, it is considered important to classify the patients based on the status of extranodal spread into the capsule rupture group and no capsule rupture group.

Endoscopy‐assisted anastomosis: a modified technique for laparoscopic side‐to‐side esophagojejunostomy following a total gastrectomy

Introduction: Esophagojejunostomy with a circular stapling device is sometimes difficult to perform in a laparoscopic setting. On the other hand, a side‐to‐side anastomosis with a linear stapling device is technically challenging.