Yushi Fujiwara

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.

Respiratory Function after Laparoscopic Distal Gastrectomy—An Index of Minimally Invasive Surgery

BackgroundAs the techniques of laparoscopic surgery have improved, various institutions have performed laparoscopic gastrectomies with regional lymph node dissection, as well as open surgery. Although alleviation of postoperative pain and prompt recovery have been reported in the literature, objective indexes of the minimal invasiveness of laparoscopic procedures are as yet very few.MethodsWe performed distal gastrectomy with regional lymph node dissection for gastric cancer patients using three kinds of procedures, namely, open gastrectomy, hand-assisted laparoscopic surgery (HALS), and totally laparoscopic gastrectomy. Ablation of the stomach, lymph node dissection, and reconstruction of the digestive tract were all carried out intracorporeally with or without HALS in the laparoscopic procedures. The ordinary respiratory function test was performed pre- and postoperatively for 50 patients operated on by each procedure, and the reduced percentages of the measured values were calculated.ResultsPostoperative respiratory function was consistently excellent, with minimal loss of vital capacity and forced expiratory volume per second in the totally laparoscopic group compared to HALS or open cases.ConclusionsAlthough it may be a complicated technique, totally laparoscopic distal gastrectomy is considered a minimally invasive procedure for gastric cancer from the viewpoint of postoperative respiratory function.

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.

Laparoscopic colorectal surgery in patients with prior abdominal surgery.

Purpose: We retrospectively investigated the impact of prior abdominal surgery on the outcome of laparoscopic colorectal surgery. Patients: Among 607 colorectal cancer patients who underwent laparoscopic surgery, 192 patients had previously undergone abdominal surgery (S group) and 415 had not (non-S group). Results: The percentage of female patients was higher in the S group than in the non-S group. The incidence of conversion to open surgery was higher in the S group (5.2%, 10/192) than in the non-S group (2.6%, 11/415), but the difference was not significant (p = 0.108). Although the mean operating time and estimated blood loss were similar in the two groups, right and transverse colectomy after prior gastrectomy and ipsilateral colectomy after prior colectomy took longer and were associated with greater blood loss. The morbidity rates of the two groups were similar (S group: 15.6%, 30/192; non-S group: 14.5%, 60/415). There were 5 intraoperative small-bowel injuries or postoperative small-bowel perforations in the S group, especially in the patients with prior gastrointestinal-tract surgery. Conclusion: Our findings suggest that there is no reason to avoid laparoscopic procedures in most patients with prior abdominal surgery despite a higher conversion rate, but caution is warranted in patients who have undergone major gastrointestinal-tract surgery.

A case of long-term survival after pulmonary resection for metachronous pulmonary metastasis of basaloid squamous cell carcinoma of the esophagus

INTRODUCTION Basaloid squamous cell carcinoma of the esophagus (BSCE) is a rare malignancy among esophageal cancers. We reported a case of 63-year-old woman with metachronous pulmonary metastasis of BSCE, successfully treated by metastasectomy of the left lung. PRESENTATION OF CASE Biopsy specimens of upper gastrointestinal fiberscopy led to diagnosis of poorly differentiated squamous cell carcinoma of the esophagus. Computed tomography revealed metastatic lymph nodes surrounding the bilateral recurrent laryngeal nerve and no evidence of metastasis to distant organs. Curative esophagectomy with three-field lymph node dissection was performed through thoracoscopic approach. Pathological examination of the resected specimens led to diagnosis of BSCE with invasion into the submucosal layer of the esophageal wall. Two years later, a solitary oval-shaped pulmonary lesion of approximately 10mm was detected in the left lung. Wedge resection of the left upper lobe was performed via thoracoscopic approach. The postoperative course was uneventful. Histologically, the pulmonary lesion was diagnosed as metastatic BSCE. Follow-up indicated no recurrence 9 years after the initial surgery. DISCUSSION Surgical intervention was acceptable on this case of solitary pulmonary metastasis. However, data are lacking about the efficacy of pulmonary resection for metachronous pulmonary metastasis of BSCE because the postoperative outcome is usually poor. The efficacy of surgical intervention for metastatic lesions of BSCE is debatable and requires further examination. CONCLUSION Although the usefulness of surgical intervention for metastatic lesions from BSCE is controversial, the patients with metachronous solitary metastasis to the lung and without extrapulmonary metastasis would be good candidate for pulmonary resection.

Lymphoid hyperplasia detected as a single mass in the gallbladder: report of a case

We herein report a case of lymphoid hyperplasia of the gallbladder that showed unique images on computed tomography and ultrasonography. A 42-year-old female was referred to our hospital for evaluation and treatment of a gallbladder tumor. Ultrasonography and computed tomography showed a mass in the wall of the gallbladder neck, without typical findings of benign or malignant tumors. The serum levels of tumor markers, such as carcinoembryonic antigen, carbohydrate antigen 19-9, alpha-fetoprotein, and cytokeratin 19 fragment, were all within normal limits. Laparoscopic cholecystectomy was therefore performed. There were no stones in the gallbladder. Macroscopically, the submural tumor had a clear border without a capsule and a cystic portion. Its cut surface was grayish white. Microscopically, many lymph follicles with germinal centers were recognized in the subserosal layer. The lymphocytes were morphologically normal. We diagnosed lymphoid hyperplasia with chronic cholecystitis. Lymphoid hyperplasia of the gallbladder is extremely rare.

Modified triangulating stapling technique for closure of a temporary loop stoma

PurposeTo describe a new stapling technique for closure of a temporary loop stoma and report the results of a retrospective investigation of its efficacy.MethodsThirty-nine patients underwent a total of 40 loop stoma closure procedures, performed by the same surgeon using the same method, between 2004 and 2009. Thirty-six procedures were performed after rectal surgery, 1 was done for rectal malignant lymphoma, 2 were performed in the same patient after resection of rectal gastrointestinal stromal tumor, and 1 was performed after colonic surgery. The short-term outcomes were evaluated retrospectively. For this technique, after the minimum necessary dissection of both limbs of the bowel from the abdominal wall, the everted part of the oral limb is returned to its proper anatomy. The stoma is closed in the vertical direction using two lines of staples in an everted fashion.ResultsThe stoma was located in the terminal ileum (n = 36), transverse colon (n = 3), or sigmoid colon (n = 1). The mean operating time was 55 min and the estimated blood loss was 32 g. There were two postoperative wound infections and one anastomotic stenosis.ConclusionStapling closure of a temporary loop stoma with two lines of staples may be a feasible alternative that decreases morbidity and reduces the operating time.