Long-term outcomes of single-incision laparoscopic colectomy for right-sided colon cancer utilising a craniocaudal approach.

INTRODUCTION: This study aimed to evaluate the short- and long-term outcomes of single-incision laparoscopic colectomy (SILC) for right-sided colon cancer (CC) using a craniocaudal approach. PATIENTS AND METHODS: The data of patients who underwent SILC for right-sided CC at our hospital between January 2013 and December 2022 were retrospectively collected. Surgery was performed using a craniocaudal approach. Short- and long-term operative outcomes were analysed. RESULTS: In total, 269 patients (127 men, 142 women; median age 74 years) underwent SILC for right-sided CC. The cases included ileocaecal resection (n = 138) and right hemicolectomy (n = 131). The median operative time was 154 min, and the median operative blood loss was 0 ml. Twenty-seven cases (10.0%) required an additional laparoscopic trocar, and 9 (3.3%) were converted to open surgery. The Clavien-Dindo classification Grade III post-operative complications were detected in 7 (2.6%) cases. SILC was performed by 25 surgeons, including inexperienced surgeons, with a median age of 34 years. The 5-year cancer-specific survival (CSS) was 96.1% (95% confidence interval [CI] 91.3%-98.2%), and CSS per pathological disease stage was 100% for Stages 0-I and II and 86.2% (95% CI 71.3%-93.7%) for Stage III. The 5-year recurrence-free survival (RFS) was 90.6% (95% CI 85.7%-93.9%), and RFS per pathological disease stage was 100% for Stage 0-I, 91.7% (95% CI 80.5%-96.6%) for Stage II and 76.1% (95% CI 63.0%-85.1%) for Stage III. CONCLUSIONS: SILC for right-sided CC can be safely performed with a craniocaudal approach, with reasonable short- and long-term outcomes.

Inguinal single-port approach of endoscopic component separation for abdominal wall defects: A case series.

Background: The component separation (CS) technique is widely used for abdominal wall defects, particularly in infected wounds. CS is associated with many wound complications due to subcutaneous blood flow disturbance. Endoscopic component separation (ECS) has fewer wound complications compared to CS and has been performed recently. However, there are various port required placements for ECS, and this technique requires proficiency. One approach for ECS is the inguinal single-port approach, which can be performed from an inguinal incision similar to that used in open surgery for inguinal hernias. Case presentation: We performed ECS with an inguinal single-port approach in three older adults. All patients had abdominal wall defects with infection at the central abdominal wound site. A 2-3-cm incision was created in the middle of the inguinal ligament, and a single-port surgical device with two 5-mm trocars was placed in the incision. The external oblique muscle was separated from the internal oblique muscle, and the external oblique aponeurosis was released. The muscle flap of the abdominal wall was moved to the central line. Tension-free abdominal wall closure was possible using a one-handed approach. Conclusions: ECS, which has fewer wound complications, requires proficiency. This procedure is a simple and easy-to-perform procedure using an inguinal incision that surgeons are familiar with.

Transanal total mesorectal excision after incomplete endoscopic submucosal dissection for early-stage low rectal cancer: A small case series.

Endoscopic submucosal dissection (ESD) for colorectal cancer is challenging but is gradually being performed worldwide. It is less invasive than surgical resection and can be performed on lesions in which malignancy cannot be diagnosed. In low rectal cancers, changes such as scarring after ESD may make it challenging to preserve the anus when additional surgical resection is required. Transanal total mesorectal excision (TaTME) is a novel surgical technique involving transanal endoscopic manipulation. It is useful for lesions in the deep pelvis near the anus. Herein, we report six cases of TaTME after ESD for early-stage low rectal cancer that resulted in incomplete resection. As a representative case, a 77-year-old female was referred to our hospital, and colonoscopy revealed low rectal cancer. ESD was performed, and the pathological diagnosis was an invasion of the submucosal layer and microscopic lymphovascular invasion. We performed an additional laparoscopic low anterior resection with TaTME. Lymph node metastasis was observed, and the final diagnosis was pT1b, pN1a, pStage IIIa, and R0. In other cases, the anus can also be preserved, and the distal margin can be secured. TaTME enabled anal preservation without being affected by the ESD scars. It is considered useful for additional resection after ESD of low rectal cancer.

Safety and feasibility of laparoscopic and endoscopic cooperative surgery for duodenal neoplasm: a retrospective multicenter study.

BACKGROUND: A delayed perforation can often occur after endoscopic treatment for duodenal neoplasms and may be fatal due to leakage of pancreatic and bile juices. We aimed to evaluate the feasibility and safety of laparoscopic and endoscopic cooperative surgery for duodenal neoplasms (D-LECS) in a multicenter, retrospective study. METHODS: The clinical characteristics and surgical outcomes of 206 patients with duodenal neoplasms in whom D-LECS had initially been attempted at one of 14 institutions were reviewed retrospectively. RESULTS: Of the 206 patients, 63 (30.6 %), 128 (62.1 %), and 15 patients (7.3 %) had lesions at the bulb, second portion, and third portion of the duodenum, respectively. The rates of en bloc and R0 resections during D-LECS were 96.1 % and 95.1 %, respectively. Intraoperative and delayed perforations occurred in 10 (4.9 %) and 5 patients (2.4 %), respectively. No cases of recurrence were observed. Surgical duration of ≥ 180 minutes was an independent risk factor for postoperative complications. CONCLUSIONS: The results revealed that D-LECS was performed with oncological safety and technical feasibility.

Resection of mediastinal goiter extending to the carina with use of artificial pneumothorax, two-lung ventilation, and thoracoscopy, with the patient in a prone position.

A 67-year-old woman was presented with a mediastinal tumor extending from the left lobe of the thyroid and passing through the posterior trachea, causing displacement of the esophagus to the left side of the patient and then descending into the right side of the mediastinum to below the carina. Surgery was performed under two-lung ventilation with the patient in a prone position; general anesthesia was performed with a single-lumen tube combined with artificial pneumothorax. In thoracoscopic surgery, we were able to confirm and preserve anatomical structures. After detachment of the tumor at the level of the left and right subclavian arteries, the patient was placed supine, a cervical incision was added, and the tumor was extracted. The tumor was diagnosed as a nonmalignant mediastinal goiter (MG). No such surgical report was found in the literature, and one would be useful for this new approach to MG removal.

Atypical presentation of a cushion sign-positive stomach gastrointestinal stromal tumor with cystic formation: A case report.

Gastrointestinal stromal tumors (GIST) typically appear as solid masses, and cystic formation is uncommon. Most stomach GISTs with cystic formation progress outside the gastric wall and are frequently misdiagnosed as epigastric cystic tumors derived from pancreas or liver. An asymptomatic 72-year-old male underwent esophagogastroduodenoscopy, which revealed a submucosal tumor (SMT), approximately 50 mm in diameter, at the anterior wall of the gastric angle. The SMT was very soft with positive cushion sign. Endoscopic ultrasonography and contrast-enhanced computed tomography revealed that the SMT was a cystic tumor with solid component. Laparoscopic and endoscopic cooperative surgery were performed to remove the tumor. Histopathological analysis revealed that the tumor was a GIST with cystic formation. To the best of our knowledge, this the first documented case of a cushion sign-positive stomach GIST with cystic formation, which had mainly developed inside the stomach. This case suggests that we should keep in mind the possibility of cystic formation of GIST when the tumor has a solid component, even if it appears as a cushion sign-positive SMT.

Laparoscopic and luminal endoscopic cooperative surgery can be a standard treatment for submucosal tumors of the stomach: a retrospective multicenter study.

Background and study aims We have developed a combined laparoscopic and luminal endoscopic surgery technique for resection of gastric submucosal tumors (SMTs) that can be performed without excessive resection of the stomach. In a multicenter retrospective study we aimed to evaluate the feasibility and safety of laparoscopic and endoscopic cooperative surgery (LECS) for gastric SMT resection. Patients and methods Between October 2007 and December 2011, 126 patients with gastric SMTs underwent LECS at 8 institutions. Patient demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed. Results 16 tumors (12.7 %) were located in the upper third of the stomach, 88 (69.8 %) in the middle third, 5 (4.0 %) in the lower third, and 17 (13.5 %) at the esophagogastric junction. The mean (standard deviation [SD]) operation time for LECS was 190.2 (66.8) min, with a mean estimated blood loss of 15.1 (38.6) mL. In 2 cases (1.6 %), the procedure was converted to open surgery because of intra-abdominal adhesions or stenosis. Morbidity was found in 6 cases (4.8 %), including 2 leakage, 2 gastric stasis, 1 fever, and 1 cystitis. Histologically, a gastrointestinal stromal tumor (GIST) was found in 86 (68.3 %) cases. The median follow-up period was 54.7 months; no local or distant tumor recurrence was observed and all patients were alive. Conclusions LECS proved to be a safe and feasible procedure for the resection of gastric SMTs, with a reasonable operation time, low bleeding, and an acceptable complication rate in this multicenter study in Japan.

Immunoglobulin G4-related disease presenting as a pulmonary nodule with an irregular margin.

We report a case of immunoglobulin G4 (IgG4)-related lung disease presenting as a solitary pulmonary nodule with an irregular margin on computed tomography. The nodule showed a high standardized uptake value on positron emission tomography. A malignant pulmonary tumour could not be excluded. Middle lobectomy was performed. Histological analysis revealed marked lymphoplasmacytic infiltration and storiform fibrosis. Immunostaining indicated the presence of IgG4-positive plasma cells. A definitive diagnosis of IgG4-related disease was confirmed.

Impact of elemental diet on early recovery after laparoscopic colectomy: findings of a randomized controlled trial.

PURPOSE: An amino acid-containing elemental diet (ED) does not require digestion for nutritional absorption, making it a good option for patients with gastrointestinal malabsorption. We conducted a randomized trial to confirm that perioperative ED enhanced the recovery of patients undergoing laparoscopic colectomy. METHODS: Patients in the intervention arm received commercially available ED from the day prior to surgery until postoperative day (POD) 3, whereas patients in the control group received a conventional perioperative diet program. To verify the endpoints, "estimated minimum length of stay in hospital after surgery" (emLOS) was defined as the number of days necessary to reach all the five criteria; namely, "sufficient oral intake", "sufficient pain control", "withdrawal of intravenous alimentation", "no abnormal findings in routine examinations", and "no rise in fever". RESULTS: A total of 102 patients were randomized, 94 of whom were analyzed (ED 45, control 49). There was no morbidity or mortality. Shorter emLOS (POD 4 vs. POD 7; p = 0.018), earlier resumption of sufficient oral intake (POD 3 vs. POD 4; p = 0.034) and faster recovery to defecation (2.2 vs. 3.1 days; p = 0.005) were observed in the ED group vs. the control group. CONCLUSIONS: The perioperative ingestion of ED by patients undergoing laparoscopic colectomy is safe and can reduce the postoperative hospital stay by supporting the acceleration of oral intake.

Evaluation of hands-on seminar for reduced port surgery using fresh porcine cadaver model.

BACKGROUND: The use of various biological and non-biological simulators is playing an important role in training modern surgeons with laparoscopic skills. However, there have been few reports of the use of a fresh porcine cadaver model for training in laparoscopic surgical skills. The purpose of this study was to report on a surgical training seminar on reduced port surgery using a fresh cadaver porcine model and to assess its feasibility and efficacy. MATERIALS AND METHODS: The hands-on seminar had 10 fresh porcine cadaver models and two dry boxes. Each table was provided with a unique access port and devices used in reduced port surgery. Each group of 2 surgeons spent 30 min at each station, performing different tasks assisted by the instructor. The questionnaire survey was done immediately after the seminar and 8 months after the seminar. RESULTS: All the tasks were completed as planned. Both instructors and participants were highly satisfied with the seminar. There was a concern about the time allocated for the seminar. In the post-seminar survey, the participants felt that the number of reduced port surgeries performed by them had increased. CONCLUSION: The fresh cadaver porcine model requires no special animal facility and can be used for training in laparoscopic procedures.

[Surgical Treatment for Refractory Metastatic Lung Tumors from Urachal Carcinoma after Chemotherapy].

A 33-year-old man underwent radical surgery for urachal cancer. Histology of the cancer revealed an adenocarcinoma of the urachus, Sheldon stage ⅢA. He developed a right lung nodule 23 months after the surgery. Partial lobectomy was performed;it revealed an adenocarcinoma compatible with urachal carcinoma. Additionally, 2 right lung metastases measuring 0.5 cm and 1.6 cm in diameter were found 12 months after partial lobectomy. The patient was treated with 4 different chemotherapy regimens including TS-1 and cisplatin, paclitaxel, folinic acid・fluorouracil・oxaliplatin(FOLFOX), and folinic acid・fluorouracil・irinotecan (FOLFIRI). Computed tomography reports showed progression of the pulmonary nodules, now measuring 1.4 cm and 10 cm in diameter. There was no evidence of distant metastasis except for in the lung and local recurrence. Right pneumonectomy was performed;the histology of the specimen confirmed urachal adenocarcinoma. Three months later, he developed cerebellar metastasis. The tumor was removed by neurosurgeons. The patient died of widespread metastases 6 months after the pneumonectomy.

[A Well-differentiated Mediastinal Liposarcoma that Expanded into the Right Thoracic Cavity with Dedifferentiation].

A 77-year-old man was referred to our hospital because of massive opacification of the right hemithorax on chest radiography. Chest computed tomography (CT) revealed a 25×18-cm heterogeneous tumor in the right hemi-thorax. Chest CT scan obtained 6 years before the referral showed an 8×2-cm homogeneous lipomatous mass in the anterior mediastinum suggesting a well-differentiated liposarcoma. The follow-up chest CT scan obtained 12 months before the referral showed a 4×2-cm heterogeneous solid component within the lipomatous mass of the mediastinum suggesting the development of a dedifferentiated liposarcoma. The tumor was completely resected through a median sternotomy and anterior right thoracotomy. The pathological diagnosis was dedifferentiated liposarcoma originating from a well-differentiated liposarcoma of the anterior mediastinum.

[Successful Treatment of a Giant Emphysematous Bulla with Intracavity Drainage and Bronchial Occlusion in a Patient Receiving Home Oxygen Therapy].

A 74-year-old man was brought to our hospital for an acute exacerbation of respiratory failure. He had severe progressive dyspnea for a few days and had received home oxygen therapy for 4 years. Chest radiography revealed a giant bulla occupying the entire right hemithorax with a remarkable shift of the mediastinum to the left. Chest radiographies of previous 4 years had shown the bulla occupying half of the right hemithorax. It had expanded to its present size over the past month. Treatment consisted of immediate puncturing of the bulla followed by elective intracavity drainage. An urinary catheter was inserted into the bulla under local anesthesia. There was persistent aid leakage from the bulla. A histoacryl-lipiodol mixture was used for bronchial occlusion, and intracavity instillation of minocycline was performed to collapse the bulla. Air leakage from the bulla had ceased on the next day, and the bulla was completely eliminated.

[Simultaneous bilateral spontaneous pneumothorax; report of a case].

Simultaneous bilateral spontaneous pneumothorax (SBSP) occurred in a 16-year-old male. He presented with severe dyspnea. Chest X-ray showed bilateral pneumothorax. Computed tomography revealed bilateral apical bullas. Chest tubes were promptly inserted bilaterally. The patient underwent single-stage bilateral video-assisted thoracoscopic surgery( VATS). Bilateral bullectomy was performed sequentially. Saline poured in to test for air leakage did not escape to the opposite pleural cavity, suggesting no pleuro-pleural communication. Post-operative course was uneventful. A bilateral single-stage VATS by a conventional lateral approach with intra-operative patient repositioning is a safe, feasible and familiar technique for treatment of SBSP.

Efficacy and safety of artificial pneumothorax under two-lung ventilation in thoracoscopic esophagectomy for esophageal cancer in the prone position.

BACKGROUND: Thoracoscopic esophagectomy for esophageal cancer performed using two-lung ventilation in the prone position has many advantages, such as convenient anesthesia induction and maintenance, and good oxygenation. We examined the safety of surgery and anesthetic management by following chronological changes in intraoperative respiration and hemodynamics. METHODS: We focused on the most recent and consecutive 14 cases of thoracoscopic esophagectomy for esophageal cancer in the prone position performed from November 2010 until recently. We measured the following items by use of FloTrac system : cardiac index (CI), central venous pressure (CVP), mean arterial pressure, partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), peak airway pressure (APmax), and tidal volume. RESULTS: No major changes were observed in CI, systolic blood pressure, and TV after the start of pneumothorax (statically not significant). Conversely, CVP increased immediately after pneumothorax (p < 0.05) and decreased almost to its original level thereafter. The mean APmax value was 18-20 cm H2O [mean increase, 4.2 cm H2O; (p < 0.05)]. The mean P/F ratio and mean PaCO2 were 244.4 and 48.3 mmHg, respectively, during artificial pneumothorax. CONCLUSION: No excessive increases in airway pressure or clear circulatory depressions were observed because of artificial pneumothorax under two-lung ventilation in thoracoscopic esophagectomy for esophageal cancer in the prone position. These results suggest that artificial pneumothorax under two-lung ventilation is beneficial for maintaining stable hemodynamics and oxygenation in thoracoscopic esophagectomy in prone position.

[Reexpansion pulmonary edema following thoracentesis].

A 44-year-old female was presented to our department with a 4-day history of shortness of breath and chest pain. The chest X-ray showed pneumothorax with completely collapsed left lung. Thoracentesis was performed. She complained of dyspnea and the oxygen saturation decreased to 74% after thoracentesis. The 2nd chest X-ray and computed tomography demonstrated a left-sided pulmonary edema. A 67-year-old man came to our department complaining of persistent cough. The chest X-ray showed pneumothorax with collapsed right middle and lower lobes. Thoracentesis was performed. He complained of dyspnea and the oxygen saturation decreased to 87% after thoracentesis. The 2nd chest X-ray and computed tomography demonstrated an expanded right upper lobe, but also pulmonary edema in the right middle and lower lobes. Those patients were treated with supplemental oxygen without endotracheal intubation. Their oxygen saturation stabilized within 12 hours. They were successfully treated with the sole administration of oxygen.

[Diaphragmatic eventration with shock and respiratory distress requiring emergency plication; report of a case].

A 80-year-old female with an eventration of the left diaphragm, which had been noticed with routine chest roentgenogram in 2006, presented with severe dyspnea and shock vital in 2012. The chest X-ray on admission disclosed elevation of the left hemidiaphragm, dislocation of the heart to the right. The diagnosis of eventration of the diaphragm was confirmed with a computed tomographic scan. She underwent diaphragmatic plication with endostaplers by thoracoscopic surgery. The postoperative course was uneventful except for transient reexpansion pulmonary edema. The patient was extubated on the 5th postoperative day. Dyspnea has disappeared after the operation. She was in a good condition without requiring any additional oxygen.

Outcome of functional end-to-end esophagojejunostomy in totally laparoscopic total gastrectomy.

PURPOSE: Totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult. In fact, esophagojejunostomy is the most difficult surgical technique in TLTG. We adopted functional end-to-end anastomosis for esophagojejunostomy to simplify the procedure. The present study assesses the feasibility and surgical outcomes of TLTG with functional end-to-end esophagojejunostomy. METHODS: We assessed the intraoperative and postoperative outcomes of 65 consecutive patients who underwent TLTG with functional end-to-end esophagojejunostomy at Tonan Hospital between January 2006 and August 2011. RESULTS: The mean surgical duration was 271.5 ± 64.7 min, and the mean blood loss was 85.2 ± 143.2 g. One patient (1.5 %) was converted to open surgery, and two patients (3.1 %) required reoperation due to ileus because of an internal hernia and jejunojejunostomy leakage. No reoperation was associated with functional end-to-end esophagojejunostomy. The mean hospital stay was 21.4 ± 13.5 days. Ten patients (15.4 %) developed postoperative complications, of which three (4.6 %) were anastomotic stenosis associated with functional end-to-end esophagojejunostomy. All of these were resolved by endoscopic dilation. CONCLUSION: Functional end-to-end esophagojejunostomy in TLTG is safe and feasible.

Clinical evaluation of the feasibility of minimally invasive surgery in esophageal cancer.

INTRODUCTION: Open thoracotomy laparotomy with extended dissection for esophageal cancer is associated with problems such as delayed postoperative recovery and decreased quality of life. In contrast, in minimally invasive surgery, these problems can be improved. In the present study, we investigated the feasibility of minimally invasive surgery in esophageal cancer. METHODS: In this retrospective study, we evaluated esophagectomy performed by the same surgeon in 98 patients with thoracic esophageal cancer. Open surgery was performed in 30 patients (open group), and minimally invasive surgery was performed in 68 patients (MIS group). We compared the invasiveness and radical cure of cancer by minimally invasive surgery with that of open surgery. RESULTS: Comparison between the open and MIS groups showed that intraoperative blood loss, intraoperative and postoperative transfused blood volume, and surgical site infection rates were significantly lower in the MIS group. The duration of postoperative endotracheal intubation and hospital stay were significantly shorter in the MIS group. The histopathologic type was squamous cell carcinoma in 93.3% in the open group and 92.6% in the MIS group. The respective 3-year survival rates were 36.7% and 71.5%, and the respective 5-year survival rates were 26.7% and 61.5%. CONCLUSION: Based on a historical control study at a single institution, we are unable to conclude that minimally invasive surgery is superior to open surgery. However, our results indicate that minimally invasive surgery is feasible as a surgical procedure in esophageal cancer.

A new marking technique for peripheral lung nodules avoiding pleural puncture: the intrathoracic stamping method.

While performing thoracoscopic wedge resection of the lung, the location of the lesion is generally identified by visual inspection or palpation. When difficulty in identification of the lesion by thoracoscopy is anticipated, preoperative marking is performed. However, complications and technical difficulties plague current marking techniques. To overcome this problem, we designed a new, safe and easy marking technique that avoids pleural puncture, called the intrathoracic stamping method.