Prone position in thoracoscopic esophagectomy improves postoperative oxygenation and reduces pulmonary complications.

BACKGROUND: While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest. METHODS: A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis. RESULTS: Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P. CONCLUSION: The findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.

Successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly.

We report a case of successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly. A 76-year-old female patient was admitted with a diagnosis of advanced gastric cancer at the anterior wall to the lesser curvature of the antrum (cT3N0M0 cStage IIA). Dynamic computed tomography showed the ectopia of the common hepatic artery branched from the left gastric artery. We made a diagnosis of an Adachi type VI (group 26) vascular anomaly and performed the abovementioned operation. In this anomaly pattern, scrupulous attention is required to remove the suprapancreatic lymph nodes because the portal vein is located immediately dorsal to those lymph nodes and is at increased risk for the injury in this situation. The common hepatic artery is branched from the left gastric artery, and the hepatic perfusion from the superior mesenteric artery is not present in group 26. Planning to preserve the artery will improve safety when it is possible oncologically. There were no postoperative complications, and the patient was discharged 9 days after the operation. To our knowledge, the present case is the first reported case of a laparoscopic distal gastrectomy with D2 lymph node dissection with an Adachi type VI (group 26) vascular anomaly. Preoperative diagnostic imaging is very important to prevent surgical complications because the reliable identification of vascular anomaly during an operation is very difficult.

Comparing the short-term outcomes of laparoscopic distal gastrectomy with D1+ and D2 lymph node dissection for gastric cancer.

INTRODUCTION: Laparoscopic distal gastrectomy (LDG) with D1+ lymph node dissection (LND) for early gastric cancer has been widely accepted. However, LDG with D2 LND for advanced gastric cancer remains in limited use. The aim of this retrospective study was to clarify the safety of LDG with D2 LND for gastric cancer. METHODS: From January 2010 to September 2014, 296 patients underwent LDG; those who received D1+ LND (n = 230) or D2 LND (n = 66) were included in this study. The clinicopathological characteristics and short-term outcomes of both groups were investigated and compared. RESULTS: There were no significant differences in the incidence of postoperative complications between the two groups. However, the frequency of infectious intra-abdominal complications was higher in the D2 LND group than in the D1+ LND group. Additionally, a lower risk of infectious intra-abdominal complications was seen with certified than with uncertified operators. CONCLUSION: The evaluation of short-term outcomes demonstrated that LDG with D2 LND is generally feasible. However, the risk of infectious intra-abdominal complications is higher with D2 LND than with D1+ LND. Also, D2 LND should be performed by trained operators.

Prognostic significance of pathological response to preoperative chemoradiotherapy in patients with locally advanced rectal cancer.

BACKGROUND: Preoperative chemoradiotherapy (CRT) is widely used in the treatment of locally advanced rectal cancer (LARC). Pathological response to CRT has been shown to be a potential prognostic predictor in rectal cancer patients. The aim of this study was to determine the prognostic significance of pathological response to preoperative CRT in LARC patients. METHODS: Thirty-two patients with LARC were retrospectively analyzed to determine the relationships of pathological response and clinicopathological characteristics to survival outcomes. Patients received CRT with tegafur/uracil and leucovorin. Radiotherapy was administered in fractions of 1.8 Gy/day and 5 days per week. The total dose of radiation delivered was 45 Gy. RESULTS: All patients underwent total mesorectal excision with lymph node dissections after CRT, and resected specimens were examined pathologically. Four patients showed pathological complete response, 14 showed good response, and 14 showed poor response. Pathological complete or good response was associated with longer survival (P = 0.041). Clinicopathological factors excluding gender were not correlated with outcome. No factor was associated with recurrence. CONCLUSION: Pathological response to preoperative CRT may be a useful prognostic predictor in patients with LARC.

Changes in modified Glasgow prognostic score after neoadjuvant chemotherapy is a prognostic factor in clinical stage II/III esophageal cancer.

The inflammation-based modified Glasgow prognostic score (mGPS) has been shown to be a prognostic factor for esophageal cancer, but its changes in relation to neoadjuvant chemotherapy (NAC) have never been discussed. The purpose of this study was to evaluate the potential prognostic role of mGPS with regard to NAC. mGPS was evaluated on the basis of admission blood samples taken before chemotherapy and before surgery. Patients with elevated C-reactive protein (CRP) serum levels (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a score of 2, patients with elevated CRP serum levels without hypoalbuminemia were allocated a score of 1, and patients with normal CRP serum levels with or without hypoalbuminemia were allocated a score of 0. A total of 100 patients with clinical stage II/III squamous cell esophageal cancer, who underwent NAC and esophagectomy between January 2007 and August 2012, were investigated. From the multivariate analysis, the grade of response to chemotherapy and post-NAC mGPS level was found to be independent prognostic factors. The overall survival rate was significantly higher in the conserved mGPS group than in the worse mGPS group (P = 0.030). Changes in mGPS during chemotherapy affected the prognosis of patients, and post-NAC mGPS is an independent prognostic factor in patients with clinical stage II/III thoracic esophageal squamous cell cancer.

A cure with successful staged treatment of aortoesophageal fistula.

Aortoesophageal fistula is a fatal disease which needs immediate control of bleeding and infection. We report a case of aortoesophageal fistula successfully treated with extra-anatomical bypass and complete resection of infected aorta and esophagus following endovascular repair. He was discharged after reconstruction of esophagus and recurrence of infection has not been observed for the past 5 years.

Treating patients with advanced rectal cancer and lateral pelvic lymph nodes with preoperative chemoradiotherapy based on pretreatment imaging.

Preoperative chemoradiotherapy (CRT) and lateral pelvic lymph node (LPLN) dissection (LPLD) based on pretreatment imaging are performed to improve oncological outcomes at our institution. However, the advantage of LPLD following preoperative CRT in advanced rectal cancer remains unclear. The objective of the present study was to assess the validity of this approach. Thirty-two patients with advanced rectal cancer were included in the study. All patients were treated with preoperative CRT and curative operation. Of these, 16 patients who were treated between August 2005 and June 2008 underwent LPLD on both sides (LPLD group). Sixteen patients who were treated between July 2008 and January 2013 underwent LPLD only on the side with suspected LPLN metastasis determined by pretreatment imaging; in cases without LPLN metastasis, only total mesorectal excision was performed (limited-LPLD group). The overall survival and relapse-free survival between the LPLD and the limited-LPLD groups were compared. Preoperative CRT was able to lower clinical lymph node status in 50% of the cases. In addition, pathological lymph node status did not exceed the pretreatment clinical lymph node status stage in the LPLD group. There were no differences in the overall survival and relapse-free survival between the two groups (P=0.729 and P=0.874, respectively). We conclude that multi-imaging studies have a very low risk of overlooking pathologically positive LPLN metastases. Therefore, limited LPLD is a feasible strategy for patients with advanced rectal cancer and suspicious LPLN metastases based on pretreatment imaging.

Ultrasonic shears assistance can shorten the console time in robotic gastrectomy for early gastric cancer.

BACKGROUND: Robotic gastric surgery has been introduced and is being performed in many Japanese facilities. There are some limitations of devices capable to be used in the robotic arms in the da Vinci Surgical System. We have reviewed our first ten cases with early gastric cancer who underwent robot-assisted gastrectomy and have compared the operative time between cases who underwent the operation only with an electric cautery device and those in whom laparoscopic coagulating shears (LCS) through an assistant port were used. FINDINGS: We used an electric cautery device only in cases 1-3, and LCS in cases 4-10 except case 9. The mean operative time was 454 min in cases where only robotic devices were used and 414 min in those with LCS assist. The mean console time of 251 min in those with LCS assist was significantly shorter than that of 306 min in cases where only robotic devices were used. The number of dissected lymph nodes was satisfactory, and the estimated blood loss was small. Postoperative complications in two cases were slight and transient with short hospital stay. CONCLUSION: Assistant use of ultrasonic shears is useful to shorten the console time in robotic gastrectomy.

Successful treatment of quintuple primary cancer, including esophageal cancer: A case report.

The present study reports the rare case of a patient with quintuple primary cancer that underwent systematic treatment, including surgical intervention. A 63-year-old male patient was initially diagnosed with primary esophageal cancer and hypopharyngeal cancer. The patient underwent total pharyngolaryngoesophagectomy using a thoracoscopic method and reconstruction using the free jejunal flap and gastric tube and was subsequently administered adjuvant chemotherapy (80 mg/m2 intravenously on day 1, cisplatin; 800 mg/m2 continuous intravenous administration on days 1-5, 5-fluorouracil). At 66 years old, the patient was diagnosed with left maxillary sinus cancer and underwent chemoradiotherapy (four 100 mg/m2 arterial cisplatin injections; 70 Gy/35 f radiotherapy, 2 Gy per day over 35 days). At 68 years old, the patient was diagnosed with gastric tube cancer and underwent gastric tube resection followed by pedicled jejunum flap reconstruction. At 69 years old, the patient was diagnosed with tongue cancer and underwent resection and reconstruction of the tongue by pectoralis major myocutaneous flap. Six years subsequent to the primary surgery, the patient remains alive, without metastasis of the lesions. To the best of our knowledge, the present study is the first report of a patient that underwent a curative procedure for the treatment of five primary multiple cancers in five organs, including esophageal cancer.

A Case of Benign Esophageal Schwannoma Causing Life-threatening Tracheal Obstruction.

A 59-year-old woman presented with a 1-year history of dysphagia. She suffered from a large mediastinal mass obstructing trachea and bilateral main bronchus, which led to dyspnea and disturbed consciousness. Immediate intubation and surgery was required. A solid tumor that included esophagus and right vagal nerve, and adhered to the membranous part of the bronchus was found. However, the tumor could be resected en bloc and the patient has been free from recurrence. Pathologically, the tumor exhibited proliferative spindle cells and was diffusely positive for S-100 protein. It was therefore diagnosed as a benign esophageal schwannoma. To our knowledge, this is the first report of tracheal obstruction from a benign esophageal schwannoma, which we successfully treated with emergency subtotal esophagectomy.

Simple and Easy Technique for the Placement of Seprafilm During Laparoscopic Surgery.

Laparoscopic surgery is a minimally invasive surgery, and the incidence of postoperative small bowel obstruction (SBO) is not high. However, SBO is a disease that detracts from the benefits of laparoscopic surgery due to the need for additional therapies or prolongation of hospital stay. Seprafilm is effective in reducing adhesions and preventing the occurrence of SBO. However, it is very difficult to place the Seprafilm during laparoscopic surgery compared to open surgery. Herein, we report a simple and easy method. The Seprafilm including the holder paper is divided into six pieces; each piece is wound around the end of the forceps and the reduction sleeve is slid over it. The forceps with the reduction sleeve is inserted through a 12-mm trocar and moved closer to the target place. Then, the reduction sleeve is slid down the forceps to expose the Seprafilm. This method does not require any special preparation or training. Based on our experience, this method can easily overcome the problems that the Seprafilm is vulnerable to tear and is difficult to spread out in the abdominal cavity.

[A Case of Salvage Chemoradiotherapy for Regional Recurrence after Curative Esophagectomy].

We report a case of regional recurrence of esophageal cancer after curative esophagectomy. The patient has experienced long-term survival after treatment with salvage chemoradiotherapy (CRT). A 69-year-old woman had received esophagectomy for advanced thoracic esophageal cancer (pathological T3N1M0, Stage Ⅲ). Recurrence in the cervical regional lymph nodes was diagnosed 1 year 4 months after surgery. She was treated with salvage chemoradiotherapy consisting of 60 Gy radiation and cisplatin/5-fluorouracil. The metastatic lymph nodes disappeared(a complete response). She has been alive without recurrence for 7 years and 5 months since completing salvage CRT. Approximately 30-50% of patients develop recurrences of esophageal cancer after curative esophagectomy, and these patients rarely survive longer than a year. Therefore, it is important that we examine this rare case of long-term survival after recurrence of esophageal cancer.

Carbon dioxide pneumoperitoneum led to no severe morbidities for the elderly during laparoscopic-assisted distal gastrectomy.

BACKGROUND: Our purpose was to evaluate the perioperative safety of laparoscopic-assisted distal gastrectomy (LADG) in elderly patients with clinical stage I gastric cancer. METHODS: From 527 consecutive patients who underwent distal gastrectomy for gastric cancer from 2000 to 2011, 38 elderly patients (aged 75 years or older) with clinical stage I disease who underwent LADG were compared with 28 elderly patients who underwent open distal gastrectomy (ODG) and with 41 nonelderly patients (younger than aged 65 years) who underwent LADG. Intraoperative cardiopulmonary changes following pneumoperitoneum and surgical outcomes were analyzed. RESULTS: A significant elevation in mean blood pressure (MAP) (by 44 %) and slight increase in heart rate (HR) (by 13 %) were observed 5 min after the beginning of pneumoperitoneum in the elderly LADG group, although they tended to remain stable since 30 min. The elevation of end-tidal CO2 (ETCO2) in the elderly LADG group remained at 8 % and did not differ from that in the nonelderly LADG group who were 20.5 years (median) younger, whereas percutaneous oxygen saturation (SpO2) did not worsen. Compared with the elderly ODG group, the elderly LADG group did not increase intraoperative cardiopulmonary impairment or complication, had lower incidence of postoperative medical complication (7.9 vs. 32.1 %, p = 0.012) and shortened postoperative recovery course (25 vs. 15 days, p < 0.001). Pneumoperitoneum did not necessarily impair cardiopulmonary dynamics or prognosis for elderly patients with declining cardiopulmonary function. CONCLUSIONS: Cardiopulmonary impairment caused by pneumoperitoneum was not critical but transitory. LADG led to superior perioperative course for elderly patients with early gastric cancer.

Successful laparoscopic gastric resection and safe introduction of a single-incision technique for gastric submucosal tumors located near the esophagogastric junction.

PURPOSE: Laparoscopic gastric resection cannot be easily applied for submucosal tumors near the esophagogastric junction (NEJ-SMTs). Furthermore, there have been no reports of single-incision laparoscopic surgery (SILS) for NEJ-SMTs. We evaluated our laparoscopic surgical outcomes for NEJ-SMTs, including a newly introduced phase of SILS. METHODS: We retrospectively reviewed a total of 18 patients diagnosed with NEJ-SMTs who underwent laparoscopic surgery between April 2002 and September 2013. RESULTS: All patients underwent laparoscopic gastric resection without local complications and with a negative surgical margin, including 12 patients treated with conventional laparoscopic surgery (CLS) and six patients treated with SILS. The mean length of the operation was 184.3 ± 52.3 min, and the mean blood loss was 19.2 ± 17.7 mL. All patients underwent complete resection. There were no statistically significant differences between the CLS and SILS groups in terms of the surgical outcomes. CONCLUSION: Despite this challenging location of the tumor, laparoscopic gastric resection for NEJ-SMTs is safe and feasible. Furthermore, SILS can provide a better cosmetic result, which can lead to better global patient satisfaction in carefully selected patients with NEJ-SMTs.

Laparoscopic partial resection for hemangioma in the third portion of the duodenum.

Benign duodenal tumors are rare and less common than malignant tumors. Furthermore, vascular lesions of the duodenum, including hemangiomas, are rare causes of gastrointestinal bleeding. This report describes a case with bleeding hemangiomas in the third portion of the duodenum and jejunum and their successful treatment using a laparoscopic approach. There is no report of totally laparoscopic resection for tumor in the third portion of duodenum. After performing a laparoscopic Kocher maneuver, the location of the duodenal hemangioma was confirmed by endoscopic and laparoscopic observation. The lesion was excised using ultrasonic coagulating shears and the defect in the duodenal wall was sutured laparoscopically. The hemangioma of the jejunum was treated extracorporeally through a 3.0 cm umbilical incision. The operating time was 241 min and blood loss was negligible. The postoperative course was uneventful. For benign duodenal tumors in the third portion, if endoscopic resection is not adapted, this less invasive technique may be a standard treatment.

Appendicitis with psoas abscess successfully treated by laparoscopic surgery.

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.

Surgical outcomes in the newly introduced phase of intracorporeal anastomosis following laparoscopic distal gastrectomy is safe and feasible compared with established procedures of extracorporeal anastomosis.

BACKGROUND: Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis has been introduced to achieve safer anastomosis with good vision, and a small wound. However, little is known about the surgical outcomes of newly introduced TLDG compared with established procedures of laparoscopy-assisted gastrectomy (LADG) with extracorporeal anastomosis. METHODS: This retrospective study included 114 patients who underwent laparoscopic distal gastrectomy (LDG) between January 2010 and September 2012. The patients were classified into two groups according to the approach of reconstruction (LADG group: n = 74; TLDG group: n = 40). The parameters analyzed included patients, operation details, and operative outcomes. RESULTS: No complication was observed in the TLDG group. Surgical outcomes of the TLDG group, such as mean operation time, estimated blood loss, and rate of conversion to laparotomy were not inferior to the LADG group. Furthermore, postoperative hospital stay of the TLDG group was significantly shorter than the LADG group (p < 0.05). CONCLUSION: Surgical outcomes in the newly introduced phase of TLDG were safe as well as feasible compared with established LADG. TLDG has several advantages over LADG, such as shorter post-hospital stay, no incidence of operative complication, adequate working space, and small wound size. Although prospective, randomized control studies are warranted, we submit that TLDG can be used as a standard procedure for LDG.

[Laparoscopic abdominoperineal resection after preoperative chemoradiotherapy for advanced carcinoma associated with anal fistula].

The patient was a 71-year-old man who was diagnosed with anal fistula 50 years previously. He complained of mucous and bloody stools. He was diagnosed with a carcinoma associated with anal fistula after biopsy. Image examination showed that the tumor was filled with mucinous substances and that it had invaded the levator ani muscle, with left external iliac and left inguinal lymph node metastases. Therefore, preoperative chemoradiotherapy for locally advanced cancer was administered. After chemoradiotherapy, the tumor and metastatic lymph nodes reduced in size. We performed laparoscopic abdominoperineal resection. Histopathologically, the tumor was revealed as a mucinous adenocarcinoma, but no cancer cells were present on the surgical margin. This case suggested that preoperative chemoradiotherapy could be effective for locally advanced carcinoma associated with anal fistula.

Thoracoscopic esophagectomy in the prone position for esophageal cancer with right aortic arch: case report.

A congenital anomaly of the right aortic arch (RAA) is rare, and esophageal cancer associated with the vascular ring is even more rare. In such cases, it is very important to understand the anatomical situation in the upper mediastinum in order to perform a safe and curative operation. A 52-year-old man who presented with odynophagia was admitted to our department after a diagnosis of advanced esophageal cancer. Chest computed tomography revealed an RAA with an aberrant subclavian artery and showed that the esophagus was completely encircled by the RAA, aortic diverticulum, and pulmonary artery. By the thoracoscopic view with the patient in the prone position, we were able to easily and safely identify the anatomical location of the upper mediastinum and successfully perform thoracoscopic esophagectomy. To the best of our knowledge, this is the first report of a patient undergoing total thoracoscopic esophagectomy in the prone position without thoracotomy.

[A case of rectal carcinoid with multiple liver, lymph nodes and bone metastases that responded to an octreotide therapy].

A 45-year-old man was admitted to our hospital with a chief complaint of anal bleeding. Colonoscopy revealed a lower rectal tumor diagnosed as rectal carcinoid on biopsy. Multiple metastatic liver tumors were found on abdominal CT scan. We performed an abdomino-perineal resection, a partial hepatectomy, and TACE. There seemed to be no apparent residues of a carcinoid tumor on abdominal CT. About one year after the first therapy, CT scan had revealed multiple metastases to the liver, lymph nodes and bones. Therefore, we started an octreotide LAR, which remarkably reduced the size of metastatic tumors. The treatment of an octreotide LAR had controlled the progression of metastatic tumors for two and half years. In this case, the effect of an octreotide LAR for recurrence of rectal carcinoid after local therapies brought good controls of symptoms and an inhibition of tumor growth for long-term.