Yukio Maezawa

A propensity score-matching analysis comparing the oncological outcomes of laparoscopic and open surgery in patients with Stage I/II colon and upper rectal cancers

PurposePrevious studies from Western countries have shown similar survival outcomes after both open and laparoscopic resections. In Japan, radical D3 dissections performed by open resection have been routinely performed for ≥T2- or ≥N1-stage cancers, and relatively favorable survival outcomes were obtained. This study compared the survival in patients with Stage I/II colon and upper rectal cancers undergoing laparoscopic and open resection.MethodsA total of 145 patients were initially enrolled. Propensity score matching was applied to assemble a study cohort. D2 lymph node dissection for T1 cancer and D3 for ≥T2- and ≥N1-stage cancers were applied. The primary outcome measure was the disease-free survival; the cancer-specific and overall survival rates were secondary outcomes.ResultsA total of 64 patients were matched for the analysis. The length of hospitalization, postoperative complication rates, number of lymph nodes removed and surgical margins were similar between the groups. The disease-free survival following laparoscopic surgery was better than that following open surgery, but the difference was not statistically significant. Neither the cancer-specific nor overall survival rates following laparoscopic surgery were inferior to those associated with open surgery.ConclusionsThe outcomes of the laparoscopic approach were comparable to those for open surgeries accompanied by radical lymph node dissection.

Chylorrhea following laparoscopy assisted distal gastrectomy with D1+ dissection for early gastric cancer: A case report

INTRODUCTION Chylorrhea is a form of lymphorrhea involving digested lipid products absorbed in the small intestine. Here we report a rare case of chylorrhea after laparoscopy-assisted distal gastrectomy (LADG) with D1+ dissection that resolved following administration of a low-fat diet. PRESENTATION OF CASE A 35-year-old woman with early gastric cancer underwent LADG with D1+ dissection, and on postoperative day 4, the drain output increased and the fluid with a high triglyceride level (740 mg/dL) changed from clear to milky. On postoperative day 6, oral intake of a low-fat diet was initiated after a 2-day fast, and the daily drain output decreased from postoperative day 9. The drain tube was withdrawn on postoperative day 15, and the patient was discharged on postoperative day 17. DISCUSSION D1+ dissection does not typically cause injury to the lymphatic trunks, cisterna chyli, or thoracic duct. The maximum output of chylous ascites was minimal, and thus, we assumed that chylorrhea occurred from slightly injured lymphatics with anatomical variation. CONCLUSION Chylorrhea after LADG with D1+ dissection is very rare. The fasting of our case followed by a low-fat diet without TPN would be an effective therapy. As a result, our case recovered favorably without further therapy.

Prediction of postoperative inflammatory complications after esophageal cancer surgery based on early changes in the C-reactive protein level in patients who received perioperative steroid therapy and enhanced recovery after surgery care: a retrospective analysis

BackgroundSerum C-reactive protein (CRP) level can be an indicator of the early stage of infectious complications. However, its utility in advanced esophageal cancer patients who receive radical esophagectomy with two- or three-field lymph node dissection with perioperative steroid therapy and enhanced recovery after surgery (ERAS) care is unclear.MethodsThe present study retrospectively examined 117 consecutive esophageal cancer patients who received neoadjuvant chemotherapy followed by radical esophagectomy. All patients received perioperative steroid therapy and ERAS care. The utility of the CRP value in the early detection of serious infectious complications (SICs) was evaluated based on the area under the receiver operating characteristic curve (AUC). Univariate and multivariate logistic regression analyses were performed to identify the risk factors for SICs.ResultsSICs were observed in 20 patients (17.1%). The CRP level on postoperative day (POD) 4 had superior diagnostic accuracy for SICs (AUC 0.778). The cut-off value for CRP was determined to be 4.0 mg/dl. A multivariate analysis identified CRP ≥ 4.0 mg/dl on POD 4 (odds ratio, 18.600; 95% confidence interval [CI], 4.610–75.200) and three-field lymph node dissection (odds ratio, 7.950; 95% CI, 1.900–33.400) as independent predictive factors.ConclusionsCRP value on POD 4 may be useful for predicting SICs in esophageal cancer patients who receive radical esophagectomy with perioperative steroid therapy and ERAS care. This result may encourage the performance of imaging studies to detect the focus and thereby lead to the early medical and/or surgical intervention to improve short-term outcomes.

A Comparison of the Body Composition Changes Between Laparoscopy-assisted and Open Total Gastrectomy for Gastric Cancer

Background/Aim: Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer may prevent the loss of body weight or lean body mass after surgery due to its reduced surgical stress compared with open total gastrectomy (OTG). Patients and Methods: A total of 303 patients were examined in this study. All patients received the same perioperative care via fast-track surgery. The body weight and composition were evaluated using a bioelectrical impedance analyzer within 1 week before and at 1 week, 1 month, and 3 months after surgery. Results: Two hundred and eight patients received OTG, and 95 received LATG. Although the clinical T factor and N factor were significantly different between these two groups, other clinical factors were similar. The respective body weight loss (1 week/1 month/3 months) was -4.7%/-8.0%/-11.9% in the OTG group and -4.7%/-8.2%/-11.6% in the LATG group, that were not significantly different between the two groups at any time point of measurement (p=0.698/0.528/0.534, respectively). The respective lean body mass loss (1 week/1 month/3 months) was -4.2%/-6.4%/-7.4% in the OTG group and -4.0%/-5.8%/-6.2% in the LATG group, that were not significantly different between the groups (p=0.503/0.588/0.946, respectively). Conclusion: The body composition changes were similar between the OTG and LATG groups using the same perioperative care of fast-track surgery. Adopting a laparoscopic approach would not help in reducing loss of body weight or lean body mass after gastric cancer surgery.

Priority of lymph node dissection for proximal gastric cancer invading the greater curvature

BackgroundThe therapeutic efficacy of dissection of the splenic hilar lymph nodes (#10) has not been fully evaluated in locally advanced proximal gastric cancer (LAGC) invading the greater curvature of the stomach.MethodsPatients with LAGC invading the greater curvature who underwent D2 total gastrectomy with splenectomy between January 2000 and May 2015 were retrospectively examined. The therapeutic value index was calculated by multiplying the metastatic rate of a station and the 5-year survival of patients with metastasis to that station; the metastatic rate and the index of each lymph node station were then compared.ResultsIn total, 82 patients were eligible for the present study. The most frequent metastatic node was #3, followed by #1, #4d and #7, #2, #4sa and #10, and #4sb and #9. These lymph nodes had a metastatic rate of more than 10%. The node station with the highest index was #3, followed by #7, #4d, #1, #4sb, #4sa, #2, and #9. The index of #10 was lower, but exceeded those of #8a and #11p.ConclusionsThe metastatic rate of #10 was relatively high at 13%, and the therapeutic value index was as high as those of other suprapancreatic nodes. D2 dissection for proximal cancer located in the greater curvature should include removal of node #10.

Our connection procedure for an EEA™ XL stapler and anvil head using EEA OrVil™ for laparoscopic total or proximal gastrectomy: Connecting procedure for OrVil

We describe an easy technique to connect the anvil and center rod of the EEA™ OrVil™.

Safety of Laparoscopic Surgery for Colorectal Cancer in Patients with Severe Comorbidities

Background/Aim: Previous studies have shown that laparoscopic colorectal cancer surgery is highly safe and effective compared to laparotomy. However, whether laparoscopic colorectal cancer surgery can be safely performed in patients with severe comorbidities remains unclear. The aim of this study was to evaluate the safety of laparoscopic colorectal cancer surgery in patients with severe comorbidities. Patients and Methods: A total of 82 consecutive patients with colorectal cancer who underwent laparoscopic surgery were retrospectively divided into two groups according to whether they had severe comorbidity (50 patients) or non-severe comorbidity (32 patients). An age-adjusted Charlson comorbidity index of ≥6 was defined as severe comorbidity. Results: Operative time, blood loss, and rate of conversion to laparotomy did not differ between the groups. Postoperative complications and the length of the postoperative hospital stay also did not differ significantly between the groups. Conclusion: Laparoscopic colorectal cancer surgery is feasible and safe, even in patients with severe comorbidities.

The Negative Survival Impact of Infectious Complications After Surgery is Canceled Out by the Response of Neoadjuvant Chemotherapy in Patients with Esophageal Cancer

BackgroundThis study was designed to investigate whether postoperative infectious complications (ICs) are a risk factor for the prognosis in esophageal cancer patients who receive neoadjuvant chemotherapy by stratifying the response to neoadjuvant chemotherapy.MethodsThe present study retrospectively examined patients who received neoadjuvant chemotherapy followed by esophagectomy between January 2011 and September 2015. Risk factors for overall survival (OS) were examined by Cox proportional hazard analyses. Pathological responders to neoadjuvant chemotherapy were defined as those with a tumor disappearance of more than one-third of the initial tumor. Postoperative ICs were defined using the Clavien–Dindo classification.ResultsOf the 111 patients examined, 45 (40.5%) developed postoperative ICs. A pathological response to neoadjuvant chemotherapy was observed in 54 (48.6%) patients. The multivariate analysis demonstrated that postoperative ICs were a significant independent risk factor for the OS (hazard ratio [HR] 2.359; 95% confidence interval [CI] 1.057–5.263, p = 0.036). In the subset analysis, postoperative ICs were a marginally significant independent risk factor for OS in the nonresponders (HR 2.862; 95% CI 0.942–8.696, p = 0.063) but not in the responders (HR 0.867; 95% CI 0.122–6.153, p = 0.886).ConclusionsThese results suggested that the negative survival impact of postoperative ICs can be canceled out in esophageal cancer patients who respond to neoadjuvant chemotherapy.

Entral feeding tube insertion after esophagectomy: Technique via transgastric conduit or transduodenal.

210Background: We always used early enteral feeding after esophagectomy as perioperative management. The common procedure for feeding tube insertion is jejunostomy, but sometimes complication such as internal hernia was occurred. In case of retrosternal gastric tube reconstruction, we usually inserted feeding tube through gastric conduit. But in case of posterior mediastinal gastric tube reconstruction, this procedure was not available because of the distance between abdominal wall and gastric tube. So we have developed the new procedure for feeding tube insertion using the mobilized round ligament of liver. Methods: The aims of the study is to clarify the safety of these procedures. In case of retrosternal reconstruction, we usually inserted feeding tube from prepylorus of gastric conduit, and feeding tube was delivered through pyloric ring to 3rd portion of duodenum(Procedure A). Insertion point of the tube was always close to abdominal wall, and easy to be guided to extra-abdomen. On the other hand, in...

Risk factors for severe weight loss at 1 month after gastrectomy for gastric cancer

BACKGROUND Body weight loss (BWL) is frequently observed in gastric cancer patients who undergo gastrectomy for gastric cancer. The risk factors for severe BWL after gastrectomy remain unclear. METHODS The present study retrospectively examined patients who underwent curative gastrectomy for gastric cancer between January 2012 and June 2014 at Kanagawa Cancer Center. All patients received perioperative care based on the enhanced recovery after surgery protocol. The %BWL value was calculated based on the percentage of body weight at 1 month after surgery in comparison to the preoperative body weight. Severe BWL was defined as %BWL > 10%. The risk factors for severe BWL were determined by both univariate and multivariate logistic regression analyses. RESULTS There were 278 patients examined. The median age of the patients was 68 years. The operative procedures included total gastrectomy [n=97; open (n=61) and laparoscopic {n=36)] and distal gastrectomy (n=181). Surgical complications of grade ≥ 2 (as defined by the Clavien-Dindo classification) were observed in 37 patients, these included: pancreatic fistula (n=9), anastomotic leakage (n=5), and abdominal abscess (n=3). There were no cases of surgery-associated mortality. Both univariate and multivariate logistic analyses demonstrated that surgical complications, and total gastrectomy were significant risk factors for severe BWL. CONCLUSIONS Surgical complications and total gastrectomy were identified as being significant risk factors for severe BWL in the 1st month after gastrectomy. To maintain body weight after gastrectomy, physicians should pay careful attention to patients who undergo total gastrectomy and those who develop surgical complications.