Laparoscopic distal gastrectomy with intracorporeal handsewn Billroth-I anastomosis (ICHSA).

BACKGROUND: The number of cases of laparoscopic surgery has been increasing. Lymph node dissection has been standardized, and the enlarged view provided by laparoscopes allows for the procedure to be performed successfully entirely within the abdominal cavity, but many cases of reconstruction using the Billroth-I method are performed under direct vision through a small incision. In this study, by placing an anchor thread on a suture line on the lesser curvature of the stomach, we simplified the procedure for handsewn anastomosis and safely performed gastroduodenal anastomosis at low cost to obtain good results. METHODS: From January 2009 to December 2010, we performed handsewn gastroduodenal anastomosis in 18 cases. After performing lymph node dissection, the duodenum and the stomach were separated using an automatic stapling device. Anchor sutures were placed on the suture line of the lesser curvature of the stomach. First, the seromuscular layer of the stomach and the seromuscular layer of the duodenum were sutured by performing interrupted suturing using an extracorporeal knot-tying method. With the stomach and the duodenum in a fixed state, the anastomosis area was opened. The thread of the anchor suture was pulled toward the abdominal wall, and then all layers of the stomach and the duodenum at the posterior wall were continuously sutured. Similarly, for the anterior wall, all layers were continuously sutured from the lesser curvature toward the greater curvature. RESULTS: We performed this anastomotic procedure in 18 patients with early gastric carcinoma. The mean time required for the anastomosis was 64.6 ± 17.1 min, and the estimated blood loss was 53.1 ± 91 g. All operations were curative, and the mean number of retrieved lymph node was 27.1 ± 10.8. A nasogastric tube was removed on the first or second day. An upper gastrointestinal series performed on postoperative days 5-6 showed no anastomotic leakage and normal transit. Oral intake was started on days 6-7. Postoperative complications included one case of a ruptured suture, but this was resolved through a conservative approach. There was no mortality. Postoperative endoscopy revealed that the anastomosis area was extremely soft, and no abnormalities were observed. Moreover, the only costs related to the anastomosis were for the thread and needles, and although more time was required compared with mechanical anastomosis, the cost was extremely low. CONCLUSIONS: We performed gastroduodenal anastomosis under a total laparoscopic approach by handsewn. This method is economical, because it does not require the use of machinery for anastomosis, and the duodenal stump is short. We believe that this method, which can be performed in a similar manner even for obese patients, can be used as a standard method of anastomosis.

Clinical outcomes of Roux-en-Y and Billroth I reconstruction after a distal gastrectomy for gastric cancer: What is the optimal reconstructive procedure?

BACKGROUND/AIMS: The aim of this study was to evaluate the clinical advantages of Roux-en-Y (R-Y) and Billroth-I (B-I) reconstruction after distal gastrectomy for gastric cancer by examining the postoperative symptoms based on a patient questionnaire and patient nutrition. In addition, this study determined which of the R-Y or B-I procedures is preferable following distal gastrectomy. METHODOLOGY: Fifty-one patients who had undergone R-Y reconstruction and 50 patients who had undergone B-I reconstruction were retrospectively enrolled in this study. The operative and postoperative findings such as operating time, blood loss, complications, and postoperative hospital stay were evaluated as short-term clinical outcomes. Postoperative serum nutrition parameters, transition of body weight, incidence of residual gastritis, and clinical symptoms were evaluated as mid-term clinical outcomes. An assessment of symptoms was based on a questionnaire concerning dumping symptoms, reflux symptoms, food intake, and satisfaction with the operation. RESULTS: No significant differences were observed in the operative and postoperative clinical parameters without stage grouping. The transition of serum nutrition parameters revealed no significant differences between the two groups for the preoperative and postoperative states. Dumping symptoms, reflux symptoms, and abdominal symptoms were less frequent in R-Y patients, but there were no significant differences between the two groups. Moreover, the differences in body weight recovery rates were not found to be statistically significant between two groups. However, the incidence of residual gastritis was significantly less in R-Y patients (21.2%) than in B-I patients (68.8%) (p < 0.05). The questionnaire results regarding food intake and surgery satisfaction were not significantly different between the two groups. CONCLUSIONS: Definite clinical advantages were not recognized in patients with R-Y reconstruction. B-I and R-Y reconstructive procedures should be selected according to the condition of each patient. However, the advantages of these reconstruction procedures following distal gastrectomy would only be revealed in large randomized controlled trials.

Long-term outcome of laparoscopic surgery for T1 cancer patients of the colorectum.

BACKGROUND/AIMS: Many reports of laparoscopic colorectal surgery (LCS) for advanced cancer have been published indicating that LCS is an optimal and less invasive surgical treatment. On the other hand, there are few reports that address the early stages of cancer, especially with regard to the long-term outcome. This study analyzed the short- and long-term outcomes after LCS in patients with T1 cancer. METHODOLOGY: Between 1994 and 2005, a total of 135 LCS, including 129 laparoscopic colectomies and 6 laparoscopic anterior resections were performed in patients with T1 cancer that was diagnosed after the operation. The median follow-up was 83.5 months (range, 33-165). RESULTS: Postoperative complications included 6 wound infections (4%), 3 bowel obstructions (2%), 2 anastomotic leakage (1.3%), 1 atelectasis (0.67%). None of the patients required a re-operation. Oral intake was started after a mean of 2.9 postoperative days and the mean postoperative hospital stay was 14.4 days. There was no mortality and the overall survival was 100% in long-term follow up. CONCLUSIONS: LCS for T1 cancer is technically and oncologically safe based on the long-term outcomes when performed by surgeons with sufficient experience in laparoscopic techniques.

Clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing Crohn's disease: when and how were the seton drains removed?

BACKGROUND/AIMS: Perianal fistulas are often found in patients with Crohn's Disease (CD), however, the complete management of such fistulas tends to be difficult. The aim of this study is to critically evaluate the clinical advantages of combined seton placement and infliximab maintenance therapy for perianal fistulizing CD. METHODOLOGY: Fourteen patients (9 males, 5 females) were evaluated for perianal fistulizing CD with the seton and infliximab therapy. Almost all patients were examined for the presence of either an abscess or fistulas by computed tomography (CT) and/or Magnetic Resonance Imaging (MRI) in addition to their physical findings. Seton placement was performed under general anesthesia, following the administration of inflixmab at a dose of 5 mg/kg for weeks 0, 2 and 6, and then about every 8 weeks as a maintenance therapy. RESULTS: For all patients average number of inserted drains was 4.5 and the average number of infliximab infusions was 9.4 times. The mean follow-up period was 12.1 months. A redness and/or swelling in perianal lesion were seen in 12 patients, moreover, pus discharge was seen in 7 patients, and serous exudate was seen in 7 patients. After the administration of these treatments, a reversal of the redness and/or swelling was seen in the exudate and a wet-to-dry wound change was found in all patients. Furthermore, the seton drains were completely removed in 11 patients. In most patients, seton drains were completely removed after 5 rounds of infliximab infusion. Following the removal of the seton drains from all the patients, they reported their post-treatment health and well-being to be good while also reporting a good quality of life (QOL). In addition, no serious adverse events were observed. CONCLUSIONS: The combined seton placement and infliximab maintenance therapy for perianal fistulizing CD was therefore found to be effective in terms of fistula closure and the removal of seton drains. This treatment modality is therefore considered to be a safe clinical procedure which improves the QOL in patients with CD.

[Evaluation of bevacizumab for advanced colorectal cancer].

BACKGROUND: Recently, Bevacizumab became one of the major therapeutics in the care of advanced and recurrent colorectal cancer patients in Japan. The present study evaluated the efficacy and the adverse events in 23 patients who were treated with Bevacizumab. METHODS: From April, 2007 to February, 2009, 23 colorectal cancer patients were treated with Bevacizumab. We evaluated the adverse events and the time to progression (TTP). RESULTS: The median age of the patients was 60 years old. Advanced cases were 14 and recurrence cases were 9. The basic combination chemotherapy with Bevacizumab included FOLFOX (14 patients), FOLFIRI (8 patients), and IFL (1 patient). Although grade 3 of melena was recognized in one patient, the other mild adverse events were treated without accident. The median TTP was 108 days, and was not significantly different between combination with mFOLFOX6 or FOLFIRI. In combination therapy of Bevacizumab and mFOLFOX6, the TTP of Bevacizumab first-line treatment was significantly longer than that of second-line treatment (p<0. 05). In contrast, the TTP was no different in FOLFIRI therapy with or without Bevacizumab. CONCLUSION: Although one grade 3 side effect was observed, most patients were treated safely with Bevacizumab. mFOLFOX6 with Bevacizumab was recommended for first-line therapy of advanced or metastatic colorectal cancer.

Prospective randomized trial of a closed-suction drain versus a Penrose drain after a colectomy.

BACKGROUND/AIMS: Prospective studies in the gastroenterological surgery literature have shown fewer wound related complications with a closed-suction drainage than with an open passive drainage. This study compared the SSI and cost of closed-suction drainage and open passive drainage in a randomized trial. METHODOLOGY: This study involved 112 patients undergoing colectomy from December, 2003 through April, 2007. A closed-suction or an open (Penrose) drainage was used based on the surgeon's preference. The cost and the incidence of complications including SSI was compared in the two drain types. RESULTS: The SSI rate was 13/112 cases 11.6%, but there was no significant difference between the drain groups. In addition, 18 laparoscopic surgery cases did not show any wound infection or drain infections. The closed-suction drain was not expensive regarding personnel expenses and the cost of changing the dressings. CONCLUSIONS: No statistically significant postoperative differences were observed between a closed-suction drain or an open drain after a colectomy. However, a closed-suction drain management is useful for the reduction of a cost, labor saving, and the decrease of medical waste.

Clinical outcomes and advantages of laparoscopic surgery for primary Crohn's disease: are they significant?

BACKGROUND/AIMS: The clinical outcomes and advantages of laparoscopic surgery for Crohn's disease have not yet been recognized in general. The aim of this study was to critically assess the clinical outcomes, safety, cosmesis, quality of life (QOL) and feasibility of laparoscopic surgery for primary Crohn's disease. METHODOLOGY: The study subjects consisted of 48 patients who had primary surgical treatment for Crohn's disease, 28 through conventional laparotomy and 20 in whom surgery was laparoscopically assisted. The short-term and long-term outcomes, cosmesis, and postoperative QOL were evaluated in both groups. RESULTS: There were no statistically significant differences in the patient characteristics between the two groups. In the laparoscopic group, non-resected procedures were significantly more frequent (p < 0.05), blood loss was less (p < 0.05), oral intake was started earlier (p < 0.05) and the length of the skin incision was shorter (P < 0.01). The C-reactive protein values and leukocyte counts were not significantly different in the two groups. The cosmetic results were very satisfactory in 11 patients (64.7%). There were no severe complications and no increase of the recurrence rate for laparoscopic surgery. Moreover, there was no definite clinical disadvantage and no prolonged operating time in the laparoscopic procedures. CONCLUSIONS: Laparoscopic surgery for primary Crohn's disease is safe and feasible in selected patients without severe adhesion, fistula or abscess, and was associated with better cosmesis than conventional open surgery. Therefore, laparoscopic procedures should be considered as the preferred operative approach for a primary bowel resection.

Protection of trocar sites from gallbladder cancer implantation in a murine model by physically covering the sites.

Laparoscopic surgery for malignant diseases is associated with a risk for port site recurrence (PSR), and this problem remains to be resolved. This study was performed to evaluate the role that Seprafilm and Interseed (TC7) play in the prevention of PSR, using a nude mouse model of PSR. Nude mice with 2-mm port sites were created. The resultant peritoneal defects were covered with either Seprafilm or Interseed (TC7). The protective effect of Seprafilm and Interseed (TC7) on GB-dl (a human gallbladder cancer cell line) implantation at port sites was assessed after 7 days. In addition, the effects of Seprafilm and Interseed (TC7) on wound healing at the port sites were also observed. The Seprafilm and Interseed (TC7) groups showed a significantly lower incidence of PSR than the control group. Both Seprafilm and Interseed (TC7) changed into a gel form and covered the ruptured muscle layer and injured peritoneum for 3-5 days. When the peritoneal defect, produced by trocar insertion, was physically covered with either Seprafilm or Interseed (TC7), the incidence of PSR was observed to significantly decrease. These materials seem to be promising modalities for the prevention of PSR.

Laparoscopic treatment of a gastric duplication cyst: report of a case.

Gastric duplications are rare benign tumors that are mainly discovered in relatively young patients. Although laparoscopic surgery, a less invasive surgical procedure, should be used for this condition, its application in the treatment of this disease has not yet been reported. A 14-year-old girl visited our hospital with the chief complaint of repeated episodes of upper abdominal pain. Because diagnostic imaging revealed a cystic tumor in the dorsal stomach, laparoscopic surgery was performed. The cystoma was intraoperatively found to contiguous with the posterior wall of the gastric cardia and was thus diagnosed to be a gastric duplication. With the intraoperative aid of gastroscopy, we were able to remove the cystoma from the continuous gastric wall safely without causing either a perforation or any other injury to the stomach. Gastric duplication is a congenital disease, and thus the majority of such cases are diagnosed in childhood. A laparoscopic resection of a duplicated stomach is less invasive and esthetically superior to other methods, and therefore it is considered to be a useful therapeutic modality.