A Novel Three-Step Approach for Secure Splenectomy During Laparoscopic Total Gastrectomy for Gastric Cancer.

BACKGROUND: Splenectomy during total gastrectomy increases operative morbidity (Nakata et al. in Surgical endoscopy 7:1817-1822, 2015). Establishing a safe approach to laparoscopic splenectomy is one of the most urgent issues in the treatment of proximal advanced gastric cancer, which invades to the greater curvature (Kawamura et al. in Gastric Cancer 3:662-668, 2015). We developed a novel three-step procedure for splenectomy during laparoscopic total gastrectomy (LTG). METHODS: Splenectomy consisted of three steps. Step 1 (dorsal approach): The pancreatic tail and spleen were mobilized. This step delineates the dissection plane and the anatomy around the pancreatic tail. Step 2 (suprapancreatic approach): The suprapancreatic peritoneum was incised to fenestrate to the mobilized space. The no. 11d station was dissected. The inferior branch of the splenic artery was exposed. Step 3 (splenic hilum approach): The spleen was lifted up to straighten the splenic hilum. The aim was to prolong the splenic vasculature and enable the surgeon to transect splenic vasculatures easily despite their anatomical diversity. Division of the splenic branches promotes mobility of the pancreatic tail, enabling precise dissection and preservation of its blood supply. RESULTS: Of 45 patients with gastric cancer who underwent LTG, seven underwent concurrent splenectomy. In all cases, splenectomy was successfully accomplished. The median operation time, duration of splenectomy, blood loss, number of total retrieved lymph nodes, lymph node counts from stations 10 and 11d, and drain amylase levels on the third postoperative day were 382 min, 94 min, 30 ml, 51, 5, 5, and 158 IU/L, respectively. Postoperative morbidity more severe than Clavien-Dindo grade 2 occurred in one case, with no pancreas-related morbidity. No mortality or conversion occurred. CONCLUSIONS: This laparoscopic procedure allows adequate nodal dissection and safe splenectomy.

[A Case of HER2-Positive Inflammatory Breast Cancer for Which Preoperative Chemotherapy with Pertuzumab Resulted in a Pathological Complete Response].

A 52-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole right breast. Ultrasound revealed elevated subcutaneus fat density and a diffuse hypoechoic area. She was diagnosed with inflammatory breast cancer(T4dN2M0, Stage III B of the HER2 subtype). After 4 courses of EC treatment as primary systemic therapy, the hypoechoic area was still present. Subsequent chemotherapy with pertuzumab, trastuzumab, and docetaxel was effective, as hypoechoic area was not observed on ultrasound. She underwent mastectomy and axillary dissection, and pathological examination revealed pCR. At present, 2 years after surgery, the patient is alive with no reccurence.

Preoperative C-reactive protein and operative blood loss predict poor prognosis in patients with gastric cancer after laparoscopy-assisted gastrectomy.

INTRODUCTION: The aim of this study was to clarify the factors associated with postoperative complications and prognoses following laparoscopy-assisted gastrectomy for gastric cancer. METHODS: A total of 214 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer were enrolled in this retrospective study. Factors that were potentially associated with postoperative complications and prognosis were assessed using the following clinical and perioperative parameters: the Estimation of Physiologic Ability and Surgical Stress scoring system, the Prognostic Nutritional Index, and the Clavien-Dindo classification. RESULTS: Postoperative complications developed in 18.7% of patients. Blood loss ≥ 1% of body weight was significantly correlated with anastomotic leakage (P = 0.0108). Severe complications, based on the Clavien-Dindo classification, were more frequent in patients with proximal or total gastrectomies (P = 0.0324). A preoperative C-reactive protein level > 0.5 mg/dL, blood loss > 1% of body weight, age ≥ 70 years at the time of operation, and an Estimation of Physiologic Ability and Surgical Stress score ≥ 0.2 were significantly correlated with poor prognosis. Multivariate analysis revealed that two of these factors, preoperative C-reactive protein level ≥ 0.5 mg/dL and operative blood loss ≥ 1% of body weight, were independent prognostic factors (P = 0.0376 and P = 0.0112, respectively). The Prognostic Nutritional Index had no significant correlation with prognosis or the occurrence of postoperative complications. CONCLUSION: Operative blood loss ≥ 1% of body weight and type of resection were associated with an increased frequency of postoperative complications, while preoperative C-reactive protein levels and operative blood loss may be prognostic predictors for gastric cancer patients following laparoscopy-assisted gastrectomy.

Single-incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum.

We report a case involving a minimally invasive single-incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59-year-old man presented with a 35-mm lesion located in the second portion of the duodenum. A local resection was performed via single-incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single-incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.

Use of endoscopic surgical spacer to improve safety during thoracoscopic repair of congenital diaphragmatic hernia.

Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has recently become more common, and the challenge of managing neonatal cases is increasing. Meanwhile, there have been reported intraoperative complications or conversion to open surgery due to injury of herniated viscera and inability of organ reduction. We used the endoscopic surgical spacer SECUREA™ (Hogy Medical Co., Ltd., Tokyo, Japan), which is an elliptical sponge made of polyurethane with a radiopaque marker, for preventing these complications in three cases of CDH. The first case was a late presentation in a 10-month-old girl, and the second and third cases were prenatally diagnosed female neonates without severe pulmonary hypertension. All cases were left-sided hernias without sacs. At operation, the SECUREA was grasped using forceps, and the viscera were pushed back gently to avoid injuring the spleen or the short gastric vessels in the second and the third case. The SECUREA was intended to prevent intestinal injury during defect repair in all cases, with placement of the SECUREA between the edge of the diaphragm and the reduced intestine. The procedures in all patients were completed with no complications and without the need for conversion.

Podoplanin and SOX2 expression in esophageal squamous cell carcinoma after neoadjuvant chemo-radiotherapy.

Neoadjuvant chemo-radiotherapy (CRT) followed by surgery are the standard approaches for locally advanced esophageal cancer. However, the overall cure rate is very low. The aim of this preliminary study was to evaluate the expression of podoplanin and SOX2 known as stemness markers for esophageal squamous cell carcinoma (ESCC) and their association with clinical outcome. We obtained a total of 20 specimens from patients with ESCC who underwent neoadjuvant CRT (30-40 Gy; 5-fluorouracil plus cisplatin) followed by surgery. Podoplanin and SOX2 expression was evaluated using immunohistochemistry and the association of their expressions with clinicopathological variables was investigated. Podoplanin and SOX2 staining was detected not only in residual cancer cells, but also in the basal layer of adjacent normal mucosa after neoadjuvant CRT. High expression of podoplanin was correlated with lymph node metastasis, advanced postoperative stage and vascular invasion (P<0.05), while, high expression of SOX2 was correlated with lymphatic, vascular invasion, poor differentiated tumor and incomplete resection (P<0.05). High expression of podoplanin was significantly associated with poor overall survival (P<0.05). In conclusion, the expression levels of podoplanin and SOX2 expression may be useful prognostic markers for ESCC treated with neoadjuvant CRT.