Laparoscopic Roux-en-Y reconstruction using conventional linear stapler in robotic total gastrectomy for gastric cancer

BackgroundRobotic stapling devices have been designed to create staple formation equivalent to conventional laparoscopic stapling. In gastric cancer surgery, however, any advantages the robotic stapler has in maneuverability compared to standard laparoscopic stapling devices remain unclear [1]. We applied robotic-assisted laparoscopic stapling techniques during reconstruction after robotic total gastrectomy (RTG) for gastric cancers (GCs) as “fusion surgery”. Here, we outline our stapling technique and retrospectively evaluate surgical outcomes of laparoscopic staplers in patients undergoing RTG for GCs.MethodsThis is a single-center retrospective analysis of prospectively collected data. We performed robotic gastrectomy (RG) for GCs on 70 patients at the Wakayama Medical University Hospital (WMUH) between May 1, 2017 and July 31, 2019. RG was adopted for all patients with GCs in whom curative gastrectomy was applicable. All operations were performed by a single surgeon (T.O.). Of our 70 consecutive patients who underwent robotic gastrectomy for GCs, 22 underwent RTG with Roux-en-Y reconstruction using laparoscopic staplers. All RTG procedures were performed using the da Vinci Surgical System. The duodenum and abdominal esophagus were transected using a 45 mm long laparoscopic linear stapler. After total gastrectomy, we performed antecolic Roux-en-Y reconstruction. Jejunojejunostomy was completed under direct vision following retrieval of the stomach. In robotic view, an intracorporeal side-to-side esophagojejunostomy was constructed using a laparoscopic linear stapler [2]. The 22 patients were followed-up for at least 3 months. Follow-up data were obtained from the hospital database, including the patient background, tumor characteristics, and surgical data. Postoperative complications higher than Clavien–Dindo grade 2 were regarded as clinically significant postoperative complications [3].ResultsThe duration of operation and reconstruction were 385 min and 81 min, respectively. The median intraoperative bleeding was 45 ml. There were no conversions to conventional laparoscopy or open surgery in all patients. Of these 22 patients, one patient had postoperative pneumonia (Grade 2) and another developed postoperative intraabdominal bleeding (Grade 3a) [3]. No anastomosis-related complications developed in all patients.ConclusionsRegarding short-term surgical outcomes, robotic-assisted laparoscopic stapling techniques for reconstruction after RTG, “fusion surgery” are both feasible and safe for GCs. This study had several limitations. It was a retrospective study. Moreover, it was conducted at a single institution and the sample size was small (n = 22).     

Delta-shaped anastomosis in totally laparoscopic D2 radical distal gastrectomy

With less injury and faster postoperative recovery, laparoscopic techniques have been widely applied in D2 radical gastrectomy for distal gastric cancer. Billroth I anastomosis is a common reconstruction procedure in D2 radical gastrectomy for distal gastric cancer. The delta-shaped anastomosis, an intra-abdominal Billroth I reconstruction, has been increasingly applied by gastrointestinal surgeons. This surgical video demonstrates the delta-shaped anastomosis in laparoscopic-assisted D2 radical gastrectomy for distal gastric cancer.Key Words: Gastric cancer, delta-shaped anastomosis, laparoscopyIn 2002, Professor Seiichiro Kanaya from Japan Himeji Medical Center first introduced the delta-shaped anastomosis (1), which was a Billroth I side-to-side anastomosis of the posterior walls of the remnant stomach and the duodenum using a laparoscopic linear stapler. During the anastomosis, the staple line was in a “V” shape, which would turn into a triangular shape after the anastomosis was closed, hence the name “delta-shaped anastomosis”. With increasing application of laparoscopic techniques in the D2 radical treatment of distal gastric cancer, the delta-shaped reconstruction has been gradually adopted in China.In April 2013, a 54-year-old woman presented with dull abdominal pain for three months was diagnosed with adenocarcinoma of the gastric angle by gastroscopic biopsy. The lesion had a diameter of about 3 cm. After routine preoperative preparation, total laparoscopic D2 distal gastrectomy was performed; the delta-shaped anastomosis was used to reconstruct the gastrointestinal tract during operation. An ultrasonic scalpel (Johnson & Johnson, U.S.) was used for anatomical separation, and the anastomosis was completed with a gastroscopic linear stapler (Tri-Staple).After general anesthesia, the patient was put in supine position with the head elevated and legs apart. During the surgery (Video 1), five trocars were inserted. CO₂ pneumoperitoneum of 12 mmHg was established. Standing on the left side of the patient, the surgeon divided the stomach and duodenum using an ultrasonic scalpel, and dissected the related lymph nodes according to the 2002 edition of the Gastric cancer treatment guidelines in Japan (2). A 60 mm gastroscopic linear stapler was inserted through the left upper trocar, which was used to transect the duedenum by rotating 90° from back to front. This would help to ensure the blood supply for anastomotic stoma. The stomach was then resected by successively transecting from the greater curvature to the lesser curvature with the stapler. A small incision was made to the remnant stomach and the edge of the duodenum respectively by the ultrasonic scalpel. The upper and lower anvils of a 60 mm linear stapler were inserted into one end respectively to close the posterior walls of the stomach and the duodenum. The stapling length was adjusted to 45 mm. Then the anastomosis of both ends was triggered. Upon confirmation of no leakage and bleeding of the anastomosis, the gastric tube was inserted into the distal anastomotic end of the duodenum. Finally, the common opening of the stomach and the duodenum was closed with the linear stapler.Open in a separate windowVideo 1Delta-shaped anastomosis in totally laparoscopic D2 radical distal gastrectomyThroughout the surgery, the delta-shaped anastomosis procedure lasted about more than 10 minutes. Both resected specimens had negative margins. A total of 30 lymph nodes were dissected. Pathological staging was T2N0M0. Flatus occurred three days after the surgery. Liquid diet was started on the fourth day, and the patient was discharged on the eighth day. Based on the follow-up so far, the patient has been free of postoperative complications.In short, the application of delta-shaped anastomosis with a linear stapler as part of the intraperitoneal Billroth I reconstruction is safe and feasible (3), allowing satisfying postoperative recovery and outcomes.     

The initial experience of dual port laparoscopy-assisted total gastrectomy as a reduced port surgery for total gastrectomy

Reduced port surgery (RPS), in which fewer ports are used than that in a conventional laparoscopic procedure, is becoming increasingly popular for various surgeries. However, the application of RPS to the field of gastrectomy is still underdeveloped. We started laparoscopy-assisted total gastrectomy through an umbilical port plus another 5 mm port (dual port laparoscopy-assisted total gastrectomy: DP-LATG) as an RPS for laparoscopy-assisted total gastrectomy (LATG). A SILS? port was inserted into an umbilical incision, while another 5 mm port was inserted at the right flank region. We performed DP-LATG on ten early gastric cancer cases consecutively from May 2011 onwards, with the surgeries all performed by a single surgeon. The results of DP-LATG were compared with the resuls of ten conventional LATGs (C-LATGs) that were performed between March 2010 and April 2011. There were no significant differences in the mean operation time (DP-LATG, 253.0 ± 26.8 min; C-LATG, 235.5 ± 20.6 min; p = 0.119), mean blood loss (33.4 ± 23.7, 39.8 ± 60.4 mL, p = 0.759), and number of lymph nodes dissected (31.6 ± 12.3, 40.9 ± 18.7, p = 0.205). There were no intraoperative complications, there was no need for additional ports, and there were no conversions to open surgery nor postoperative complications in the DP-LATG cases. We successfully and safely performed DP-LATG without incurring any notable differences from C-LATG in terms of operation time, blood loss, and number of lymph nodes dissected.     

全腹腔镜近端胃切除术的适应证及消化道重建方式的选择

近年来，世界范围内胃上部癌发病率逐年升高，严重威胁人类健康。目前，根治性胃切除术仍然是胃上部癌的主要治疗方法，其主要术式为全胃切除术或近端胃切除术。近端胃切除术因其保留部分胃的功能，对患者营养状况影响较小而越来越受到关注。随着腹腔镜技术的进步，胃癌的腹腔镜治疗效果不断改善。近年来，全腹腔镜技术被应用于胃上部癌的治疗，但该手术方式在根治范围及消化道重建等问题上尚存争议。本文将重点介绍全腹腔镜近端胃切除术的适应证及如何合理地选择消化道重建的方式。      

Laparoscopic Retroperitoneal Nephroureterectomy is a Safe and Adherent Modality for Obese Patients with Upper Urinary Tract Urothelial Carcinoma

Objective: We evaluated the association of body mass index (BMI) with perioperative outcomes in patientswho underwent laparoscopic or open radical nephroureterectomy. Materials and Methods: This retrospectivesingle-center study included 113 patients who had been diagnosed with upper urinary tract cancer fromJanuary 1998 to June 2013 and were treated with laparoscopic nephroureterectomy (Lap group, n=60) or opennephroureterectomy (Open group, n=53). Laparoscopic nephroureterectomy was performed via a retroperitonealapproach following an open partial cystectomy. The two surgical groups were stratified into a normal-BMI group(<25) and a high-BMI group (BMI≥25). The high-BMI group included 27 patients: 13 in the Lap group and14 in the Open group. Results: Estimated blood loss (EBL) in the Lap group was much lower than that in theOpen group irrespective of BMI (p<0.01). Operative time was significantly prolonged in normal-BMI patientsin the Lap group compared to those in the Open group (p=0.03), but there was no difference in operative timebetween the Open and Lap groups among the high-BMI patients. Multivariate logistic regression analysis of thedata for all the cohorts revealed that the open procedure was a significant risk factor for high EBL (p<0.0001,hazard ratio 8.02). Normal BMI was an independent predictor for low EBL (p=0.01, hazard ratio 0.25). Therewas no significant risk factor for operative time in multivariate analysis. There were no differences in bloodtransfusion rates or adverse event rates between the two surgical groups. Conclusions: Laparoscopic radicalnephroureterectomy via a retroperitoneal approach can be safely performed with significantly reduced EBLeven in obese patients with upper urinary tract cancer.     

Robotic D2 total gastrectomy with en-mass removal of the spleen and body and tail of the pancreas for locally advanced gastric cancer

BackgroundSafety and efficacy of robotic surgery in advanced gastric cancers (AGC) have not been proven by randomized control trials (Ojima et al., 2018) [1], and therefore, standard procedure for AGC is still open surgery. Robotic surgery, however, plays an essential role in ergonomics and offers advantages, such as motion scaling, tremor filtering, seven degrees of wrist-like motion, and three-dimensional vision. Here, we initially report successful robotic gastric cancer surgery on a 49-year-old male with proximal gastric cancer adherent to tail of pancreas and mesentery of the colon.MethodsThe patient underwent a diagnostic laparoscopy 10 days before surgery, confirming negative peritoneal dissemination and washing cytology. The patient was placed in a supine position and we inserted five ports. We performed robotic D2 total gastrectomy with en-mass removal of the spleen and body and tail of the pancreas using the da Vinci Xi Surgical System (Intuitive, Sunnyvale, CA) (Japanese Gastric Cancer Association, 2017) [2]. After gastrectomy, to evaluate the blood supply of transverse colon, we employed Indocyanine Green fluorescence using the da Vinci Firefly system and performed a partial resection of the transverse colon and a colostomy. In order to avoid anastomotic leakage of colocolostomy due to pancreatic fistula, we chose to have end colostomy. Roux-en-Y esophago-jejunostomy and jejuno-jejunostomy reconstruction were performed robotically (Ojima et al., 2019) [3]. After the operation, a nasal feeding tube was inserted.ResultsThe operation took 472 min with no intraoperative complications and blood loss of 105 ml. Final pathological examination showed poorly-differentiated adenocarcinoma (T4BN1M0, TNM stage IIIC). The patient was discharged uneventfully on postoperative day 25. He is receiving adjuvant chemotherapy. At six months, there was no evidence of complications or recurrence.ConclusionsRobotic D2 total gastrectomy with en-mass distal pancreatectomy and splenectomy are feasible and safe in advanced gastric cancer, however, its oncological value has yet to be determined.     

Esophagojejunostomy through minilaparotomy after laparoscopic total gastrectomy

Although laparoscopic distal gastrectomy (LDG) has been accepted as a surgical option for the treatment of early gastric cancer, laparoscopic total gastrectomy (LTG) has been adopted less often, because a more difficult surgical technique is required for reconstruction. To reduce the technical difficulties, we made some modifications to the functional end-to-end anastomosis technique and performed esophagojejunal anastomosis through a minilaparotomy. First, for easier handling of the esophagus, the first application of the linear stapler to create the esophagojejunal anastomosis was performed before transection of the esophagus. Second, the jejunal limb was anastomosed to the left side of the esophagus, which, compared with the right side, made available more free space, sufficient to operate the stapling device. Third, to close the entry hole and complete the gastrectomy concurrently, a linear stapler was applied through the left lower trocar. With this technique, the closure of the access opening was performed easily and was monitored directly through the minilaparotomy. We successfully performed LTG with Roux-en-Y reconstruction using our modified procedure in seven patients without any anastomotic complications. We believe our procedure is a secure and reliable method for reconstruction after LTG and will facilitate adoption of LTG as a surgical option for patients with early upper gastric cancers.     

Subtotal gastrectomy for gastric tube cancer after esophagectomy: a safe procedure preserving the proximal part of gastric tube based on intraoperative ICG blood flow evaluation

Recent improvements in the survival of patients after esophagectomy have led to an increase in the occurrence of gastric tube cancer (GTC). Total resection of the gastric tube with lymphadenectomy is a standard and reliable treatment for GTC, but problems may arise during or after surgery, such as laryngeal nerve injury, reduced selection of organs for reconstruction, and impaired swallowing function. We recently performed a less invasive procedure, subtotal gastrectomy with preservation of the upper region of the gastric tube, in two patients. In these patients, blood supply to the gastric tube was evaluated by indocyanine green fluorescence imaging. Blood flow was confirmed as passing from the remnant esophagus to the upper region of the gastric tube through the esophago-gastric anastomotic site by indocyanine green fluorescence imaging. Therefore, we resected the gastric tube while preserving the upper region of the gastric tube. There was no necrosis of the remnant gastric tube or anastomotic leakage postoperatively, and postoperative swallowing and eating functions were quite good in both patients. In summary, subtotal gastrectomy as a treatment for GTC is potentially safe, curative, and beneficial for the patient's quality of life.     

Transhiatal laparoscopic esophagectomy with extended lymphadenectomy guided by green-indocyanine imaging for adenocarcinoma of the esophagogastric junction

IntroductionSurgical treatment for adenocarcinoma of the esophagogastric junction (AEGJ) has been long-established, from resection margins to the extension of lymphadenectomy [1,2,4]. The addition of cyanine dye, namely indocyanine green (ICG), to identify suspicious lymph nodes (LN) and evaluate organ vascularization may improve results and outcomes [3].VideoA 58-year-old female patient with Siewert type II AEGJ was administered mFLOX neoadjuvant treatment. After three cycles, she underwent surgical treatment. The day before surgery, an upper endoscopy was performed to inject 0.2 ml ICG 0.5 cm from the proximal and distal tumor margins. The patient underwent laparoscopic transhiatal esophagectomy with extended lymphadenectomy due to a 4 cm distal esophagus compromised margin. We describe the primary steps of the procedure and demonstrate the role of the ICG in the lymphadenectomy.ResultsSurgery was carried out laparoscopically with a cervical approach (McKeown access), and posterior mediastinal gastric tube reconstruction and cervical gastroplasty were performed. During the standard lymphadenectomy, we observed an ICG-positive LN in station 10, which was found positive in the subsequent pathology examination. After these findings, we performed an extended lymphadenectomy through the splenic hilum. The final pathologic assessment was T3N2 (two perigastric and one positive LN at station 10 among 60 retrieved LN). The operative time was 360 min. The patient started a liquid diet on the seventh postoperative day, and she was discharged on the tenth postoperative day.ConclusionsICG may be helpful to guide both extended lymphadenectomy and distal margin evaluation in transhiatal laparoscopic esophagectomy.     

Esophageal reconstruction surgery in oncologic patients: determination of gastric emptying time

All parts of the gastrointestinal tract are accessible for study using nuclear medicine techniques. We have studied the effect of esophageal reconstruction surgery, in different periods of time, after surgical procedure. Oncologic patients (19) were evaluated after esophageal reconstruction surgery with gastric (group II - 14 patients) or colonic tube (group III - 5 patients) and they were compared with 15 healthy volunteers (group I). Gastric emptying was performed in the same subjects using solid food (egg sandwich) labeled with 99mTc-phytate. In emptying gastric studies, the mean (T1/2) of the patients was much faster than those of the control (p<0.05) when 1/3 distal tube was considered as stomach. However, there was no difference between the T1/2 of group II and group III. We concluded that this nuclear medicine method could be useful in the monitoring the surgical reconstruction of the esophagus.     

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument “Endo-PSI (II)” and circular stapler

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the “Endo-PSI (II)”, and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.     

腹腔镜辅助经胃腔切除术治疗胃黏膜下肿瘤12例临床分析

  目的  分析腹腔镜辅助经胃腔切除术治疗胃黏膜下肿瘤的临床疗效,探讨其安全性、可行性及临床应用价值。  方法  回顾性分析自2015年1月至2021年5月湖北民族大学附属民大医院采取腹腔镜辅助经胃腔切除术治疗的12例胃黏膜下肿瘤患者的临床资料,探讨该方法治疗肿瘤胃黏膜下肿瘤的安全性和可行性。  结果  12例患者均顺利完成手术,未中转开腹手术。1例患者切除肿瘤时胃壁穿孔,行胃壁楔形切除及胃腔内全层缝合关闭缺损。手术时间为40～120 min,平均80 min;出血量为10～100 mL,平均40 mL。术后无出血、吻合口瘘、贲门狭窄、反酸等并发症发生,术后第1～2天拔除胃管、饮水,术后第2～3天进食流质饮食,引流管留置时间3～5天,住院天数5～7天。术后病理提示1例为平滑肌瘤,余均为间质瘤,肿物直径约17～56 mm,环周切缘5～20 mm。12例术后6～12个月行胃镜检查,见手术部位愈合良好,无溃疡及瘢痕形成,未见肿瘤复发。  结论  腹腔镜辅助经胃腔切除术治疗胃黏膜下肿瘤安全、可行,进一步降低了患者手术创伤,较好地保留了器官功能。      

Laparoscopy-assisted D2 radical distal gastrectomy for gastric cancer (Billroth Ⅱ anastomosis)

Laparoscopic radical gastrectomy has been increasingly applied in China. However, how to reduce surgery-related trauma, shorten operative time and achieve the long-term prognosis equal to the conventional open surgery is still hot research topics. Along with the change in learning curve and the optimization of endoscopic techniques, laparoscopic lymph node dissection can achieve or even exceed the extent that can be achieved in open surgery. Therefore, it has gradually replaced the conventional digestive tract reconstruction using an auxiliary incision. By completing the laparoscopic digestive tract reconstruction with EndoGIA, we describe the laparoscopy-assisted D2 radical distal gastrectomy for gastric cancer (Billroth II anastomosis).Key Words: Laparoscope, radical gastrectomy, Billroth II anastomosisA 64-year-old female patient was admitted due to “upper abdominal discomfort accompanied with belching for half a year”. Gastroscopy confirmed the presence of adenocarcinoma of gastric antrum (moderately differentiated). No evidence of distant metastasis was found during the preoperative imaging. The preoperative TNM stage was T3NxM0.During the surgery (Video 1), the patient was supine and in a split-legged position after endotracheal general anesthesia. The surgeon stood at the left side of the patient, the assistant at the right side of the patient, and the camera holder between her two legs. The CO₂ pneumoperitoneum was created, and its pressure was maintained at 12 mmHg. The umbilicus was used as the observation hole. Four ports were symmetrically established at the left and right sides of the axillary line and midclavicular line, with the port at the left side of the axillary line as the main working port. Abdominal exploration showed that the tumor was located in the gastric antrum and invaded the serosal layer, while no distant metastasis at liver or pelvic floor was found. The tumor surface was blocked with biological glue to avoid cell shedding during the surgery.Open in a separate windowVideo 1Laparoscopy-assisted D2 radical distal gastrectomy for gastric cancer (Billroth II anastomosis)After the greater omentum was flipped and raised by the assistant, the operator stretched the transverse colon and separated the gastrocolic ligament along the colon attachment to enter the omental bursa. After the removal of greater omentum, the operation continued leftwards to the lower pole of the spleen and rightwards to the duodenum. The greater omentum was rolled under the liver, withdrawing the stomach towards the head side to expose the pancreas thoroughly. The pancreatic capsule was disassociated along the pancreatic upper space. Then, the splenic vein was exposed at the tail of the pancreas. Along the splenci vein, the tail of the pancreas was dissociated to expose the left gastroepiploic artery and the vessels at the lower splenic pole; meanwhile, the station N4sb lymph nodes were dissected. While the vessels to the lower splenic pole were preserved, the left gastroepiploic artery was transected. The gastric greater curvature was exposed downwards; meanwhile, the station N4d lymph nodes were dissected. Pancreatic head and loop of Henle were exposed between the two lobes of transverse mesocolon; meanwhile, the station N14v was explored to identity whether it had become swollen. The right gastroepiploic vein was found by “climbing” the pancreas; it was dissociated along the loop of Henle, and then transected. Meanwhile, the station N6 lymph nodes between the arteries and veins were dissected. After the gastric body was uplifted by the assistant, the pancreas was gently pressed by the operator to lift the pancreatic capsule and expose the common hepatic artery, splenic artery, and the root of left gastric artery; meanwhile, the stations N11p and N7 were dissected. After the left gastric artery and coronary vein were exposed and transected, the station N9 was dissected till the diaphragmatic crus. The station N8a was dissected along the common hepatic artery. The right gastric artery was exposed from the lower approach and then transected. After the assistant continued to pick on the gastric body, the operator divided the posterior lobe of the hepatogastric ligament along the lesser curvature of the stomach, so as to prepare for the dissection of stations N1 and N3. Thus, after the gastric body was pulled downwards, the assistant uplifted the left liver, and the operator transected the hepatogastric ligament via the upper gastric approach. Since the right gastric artery and the proper liver artery had already been exposed via the lower gastric approach, the dissection of stations N12a and N5 became relatively easy. The anterior lobe of the hepatogastric ligament was divided along the lesser curvature of the stomach, and then the stations N1 and N3 were completely dissected. Thus, the D2 lymph node dissection was completed.The duodenum was closed 2 cm below the pylorus using an endoscopic linear stapler (3.5 mm blue cartridge EndoGIA, Covidien) and then the stomach was transected. Using the green stapler cartridge (height: 4.8 mm), the operator clamped the gastric body 5 cm above the tumor and then transected it. Upon removal, the specimen was placed in an endobag and extracted. The tumor was carefully protected to avoid shedding. Holes were made in the residual greater curvature of stomach and in the jejunum 15 cm away from the ligament of Treitz, respectively. The EndoGIA™ Universal staplers were applied to complete the anastomosis between the residual stomach and the jejunum. The common openings were closed by EndoGIA system. The anastomosis was further sutured under laparoscope. The surgical wound and anastomosis were explored to identify any active bleeding. Thus, the reconstruction of the gastrointestinal tract was completed.One drainage tube was placed in the right upper abdomen. After the laparoscope was removed, the puncture hole around the umbilicus was extended by 3 cm, and then the specimen was harvested.The duration of operation was 190 min, and the intra-operative blood loss was about 100 mL. No blood was transfused during the surgery. The post-operative pathological stage was T3N2aM0. The first anal exhaust after surgery occurred 48 hours after surgery. Five days after the surgery, she began taking liquid diet. She recovered well and was smoothly discharged 7 days after surgery.     

A case of recurrent gastric cancer with improvement of obstructive symptoms caused by carcinomatous peritonitis and prolonged survival by chemotherapy with combined use of Paclitaxel and 5-FU

A 29-year-old male underwent Cur B surgery including total gastrectomy, pancreaticoduodenectomy, transverse colectomy, and D 2 dissection for scirrhous gastric carcinoma accompanied by duodenal and pancreatic infiltration. Thereafter, the patient suffered from recurrence with development of ileus caused by carcinomatous peritonitis. Ileus tube was inserted, followed by conservative therapy without ingestion. But, as the symptoms aggravated without any alleviation, an emergency surgical procedure was conducted. As disseminated changes were observed in the entire region of the abdominal cavity of the epigastric region, ileus by-pass procedure and ileostomy were performed. Though ileus symptoms were improved, peroral intake was difficult,and the ileus tube had to be left in place. Thereafter, chemotherapy with combined use of paclitaxel and 5-FU was initiated, and peroral intake become possible. The Ileus tube could be removed after improvement of obstructive symptoms. The patient was treated at the outpatient clinic with nutritional help of HPN, but died 14 months after the recurrence.     

Bronchoesophageal fistula in a patient with non-Hodgkin’s lymphoma

Bronchoesophageal fistula secondary to lymphoma is a very rare condition, usually associated with chemo-radiotherapy. We report a case of a patient with a non-Hodgkin's lymphoma (NHL) who, after chemotherapy, developed an oesophago-tracheal fistula. Initially it was treated conservatively but due to the lack of response, a stent was inserted. After nearly one year without success, surgery was considered. Right thoracotomy oesophagectomy and closure of the tracheal defect with an intercostal muscle flap and pericardial patch was performed. This was followed by laparoscopic creation of a gastric tube, which was successfully anastomosed to the cervical oesophagus through a cervicotomy. Unlike oesophageal cancer, NHL can have a good prognosis, so curative treatment of the fistula can be considered. Conservative treatment must always be the first option, leaving stenting or surgery for when the problem persists.     

Surgical results of proximal gastrectomy for early-stage gastric cancer: jejunal interposition and gastric tube reconstruction

Background. The frequency of tumors in the upper one-third of the stomach has been increasing. The standard operation for proximal gastric cancer has been total or proximal gastrectomy. The aim of this study was to present the pathologic and surgical results of 30 patients with early-stage proximal gastric cancer managed by proximal gastrectomy. Methods. A consecutive series of 30 patients who underwent proximal gastrectomy for early-stage proximal gastric cancer was studied. Sixteen patients underwent jejunal interposition, while 14 underwent gastric tube reconstruction, which consisted of a direct anastomosis between the esophagus and the remnant of the tube-like stomach. Results. Twenty patients (67%) had no abdominal symptoms and the lesions were detected by screening gastric fiberscopy. The tumors were mostly located along the lesser curvature (73%), were grossly depressed type (IIc) (70%), and histologically well differentiated type (63%). The depth of wall invasion was the mucosa in 12 patients, submucosa in 15, and muscularis propria in 3; lymph node metastasis was absent in 28 patients (93%). When compared with patients with jejunal interposition, patients with gastric tube reconstruction had a shorter operation time (327 vs 165 min), less blood loss (508 vs 151 g), and shorter hospital stay after operation (31 vs 17 days). Endoscopy and 24-h pH monitoring showed no evidence of reflux esophagitis, except in 1 patient with gastric tube reconstruction, and no patient died of recurrence. Conclusions. Early-stage proximal gastric cancer can be successfully treated by proximal gastrectomy. Since gastric tube reconstruction is a simple, easy, and safe procedure, proximal gastrectomy followed by gastric tube reconstruction is recommended for patients with early-stage proximal gastric cancer. Received for publication on Jan. 5, 1999; accepted on Feb. 10, 1999     

重建贲门、胃底预防食管癌术后反流性食管炎的临床价值分析

目的 通过在管胃的基础上重建贲门(人工贲门)、胃底(人工胃底)探讨手术方式对预防食管癌术后胃食管反流的临床效果.方法 将73例食管癌患者按手术方式不同分成单纯管胃组(37例)和管胃+抗反流组(36例),分别在术后的1、6、12个月对患者术后的反流症状、上消化道造影、24 h pH值监测及胃镜结果 进行比较.结果 全组无手术死亡患者.术后反流症状、上消化道造影、胃镜等结果 提示管胃+抗反流组与管胃组组间比较差异无统计学意义(P>0.05).两组患者在24 h pH值测定术后1个月、6个月的总反流数,术后1个月、6个月的反流>5 min数,术后6个月、1年的pH值<4时间比较,差异有统计学意义(P<0.05),提示管胃+抗反流组抗反流效果总体优于单纯管胃组.其中管胃+抗反流组无吻合口瘘出现,但吻合口狭窄发生率要高于管胃组(19.4%vs 10.8%).结论 管胃+重建贲门、胃底术式较单纯管胃术式能更好地控制食管癌术后胃食管反流,且降低了术后出现吻合口瘘的风险.     

Surgery Combined with Molecular Targeted Therapy Successfully Treated Giant Esophageal Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GISTs) are rare neoplasms arising from mesenchymal cells of the digestive tract and abdomen. Only a few isolated cases of giant esophageal GISTs (greater than 5 cm in size) have been reported with clinical features and surgical methods. Radical esophagectomy with negative margins, followed by gastric tube reconstruction, is recommended for giant esophageal GISTs. However, patients undergoing this type of surgery experienced a sharp decrease in food intake (due to the removal of most of the stomach) and were prone to eating regurgitation, resulting in poor quality of life. We describe the case of a 65-year-old man with a 16.3-cm giant esophageal GIST. The results of frozen quick pathology during the operation indicated an esophageal stromal tumor. Only resection of the esophageal mass was performed upon no consent for esophageal resection by family members. The patient received oral treatment with 400 mg of imatinib once daily after the operation. After 3 years of follow-up, the patient showed no signs of recurrence or metastasis. The successful management of this case suggests that molecular targeted therapy after surgery would avoid giant esophageal GIST recurrence. Therefore, giant esophageal GISTs probably do not need radical esophagectomy with negative margins, followed by gastric tube reconstruction.     

Repair of diaphragmatic injury and placement of tube thoracostomy during right upper quadrant peritonectomy

Objective

Patients with advanced or recurrent ovarian cancer often have metastatic disease in the upper abdominal region, especially to the right hemidiaphragm, which requires diaphragmatic resection in order to achieve optimal cytoreduction. The aim of this surgical video is to demonstrate repair of a diaphragmatic injury and placement of tube thoracostomy during right upper quadrant peritonectomy in a patient with recurrent ovarian cancer.

Methods

This is the case of a 45-year-old woman presented with platinum sensitive recurrent ovarian cancer. Abdomen computed tomography also confirmed peritoneal carcinomatosis and pelvic recurrent mass. HIPEC was administered after complete cytoreduction including bilateral upper quadrant peritonectomy, during which diaphragmatic injury occurred near the central tendon and pleural cavity was entered. We inserted a chest tube through the 6th intercostal space in the anterior axillary line in order to prevent postoperative massive pleural effusion. Diaphragmatic defect was closed primarily after the tube placement. The chest tube was withdrawn on the third postoperative day and the patient was discharged on postoperative day 25 without any complications.

Results

The central tendon of diaphragm is the most vulnerable part for lacerations. Diaphragmatic repairs could be performed by various techniques; interrupted or continuous, locking or non-locking sutures, with either permanent or absorbable materials. In our view, all of the techniques provide similar results and surgeons can choose any of them as long as they are comfortable with the procedure.

Conclusion

In most cases, these lacerations can be repaired primarily without necessitating tube thoracostomy. However, performance of HIPEC can cause massive pleural effusions which can lead to significant pulmonary morbidity. Therefore, retrograde placement of the chest tube under direct vision is quite straightforward when the diaphragm is opened.     

Total laparoscopic-assisted radical gastrectomy (D2+) with jejunal Roux-en-Y reconstruction

Total laparoscopic-assisted radical gastrectomy and the jejunal Roux-en-Y anastomosis were performed to treat cancer of the upper gastric body and fundic region. In the case of open anastomosis during total laparoscopic-assisted radical gastrectomy, an incision of 6-8 cm would be required due to the need for placing the stapler anvil. If using the Roux-en-Y procedure, however, the incision could be reduced to as small as 4-5 cm without increasing the length of operation and intraoperative bleeding that favors postoperative recovery.Key Words: Gastric cancer, laparoscopy, gastrectomy, gastrointestinal anastomosisA 42-year-old woman was admitted for “repeated abdominal pain and discomfort for more than a month.” Gastroscopic pathology showed adenocarcinoma of the “gastric angle and gastric body” (NO: 13-10963). CT indicated gastric cancer and abdominal lymph node metastases. Ultrasound showed a solid mass in the lower gastric body and the lesser curvature side of the gastric angle (gastric cancer was suspected, which had protruded the serosal layer, Borrmann III type), complicated with multiple enlarged lymph nodes close to the lesser curvature suspected of metastases. The preoperative diagnosis was gastric cancer, stating T3N1M0IIB. “Total laparoscopic-assisted radical gastrectomy (D2+) and jejunal Roux-en-Y reconstruction” was performed under general anesthesia on May 3, 2013.In this surgery (Video 1), the patient is placed in supine position with legs apart. Routine disinfection and draping of the surgical area is performed after successful endotracheal and intravenous anesthesia. The surgeon stands on the left side of the patient, the first assistant on the right side, and the camera assistance between the patient’s legs. A 1-cm incision is made above the umbilicus for placement of a trocar. Pneumoperitoneum of 12 mmHg is established, and a 30-degree laparoscope is inserted. Abdominal exploration shows no ascites, and no evident mass of the liver, parietal peritoneum, or greater omentum. An infiltrative, ulcerative tumor is visible at the lesser curvature of the gastric body (Borrmann III), about 5 cm × 3 cm in size, which is solid and invading the serosa. Stations 1, 2, 7, 8, 11 and 12 lymph nodes are enlarged in a diameter of about 0.8 cm, which are moderately solid without fusion. Trocars are inserted using the 5-port technique. An ultrasonic scalpel is used to cut the greater omentum and the anterior lobe of the transverse mesocolon. The right gastroepiploic artery and vein are ligated at their roots and cut. Station number 6 lymph nodes are dissected, and the pancreatic capsule to the upper left area is cut. The left gastric vein and artery are successively transected. Stations number 7, 9 and 8 lymph nodes are dissected, through to the station 11d, and the dissection is continued to stations 4sh, 10, 4sa and 2 lymph nodes at the left upper region. In the anterior region, the small omentum is resected, and stations 3 and 1 lymph nodes are dissected. The duodenum is transected using a linear stapler, and stations 12p and 8p lymph nodes are dissected. The abdominal segment of the esophagus is cut with the linear stapler, and one suture is made for retraction. The transverse mesocolon is open, and the jejunum is dissociated by an ultrasonic scalpel 20 cm away from the Treitz ligament. The wall at the mesangial side is denuded. A hole is made to the esophagus with the scalpel, and a 60 mm linear stapler is inserted with the two ends at the distal stumps of the esophagus and the jejunum to establish the end-to-side anastomosis. Two sutures are made to the common opening at the side of the anastomosis for retraction, and the 60 mm linear stapler is again inserted to cut the tissue to complete the anastomosis. The stomach and the omental bursa are completely resected. A small hole is made using the ultrasonic scalpel about 40 cm below the opening of the anastomosis at the mesenteric edge for placement of the two firings of a 60 mm linear stapler through the proximal stump. Upon completion of the anastomosis, the two jejunal segments with a common opening are held with harmless forceps, and a 60 mm linear stapler is inserted to complete the jejunal Roux-en-Y anastomosis. When no anastomosis stenosis and bleeding is detected, a central incision of 4 cm is made to the upper abdomen to collect the total gastrectomy specimen, and the laparoscopic resection and anastomoses are completed.Open in a separate windowVideo 1Laparoscopic-assisted radical gastrectomy (D2+) with jejunal Roux-en-Y reconstructionThe surgery was uneventful. The operation time was 192 minutes, with intraoperative blood loss of about 60 mL. A feeding tube was inserted, in conjunction with antibiotics and nutritional support. A small dose of Peptison was administered through the nasogastric tube on the first day. Flatus and little bowel movement occurred on the morning of the third day. As the blood testing results and temperature gradually returned to normal, the nasogastric amount was increased as well. Semi-liquid food was given from the fifth day, and the patient was discharged on the eighth day after surgery. No obvious complication was observed after 30 days. Postoperative pathology showed: total gastrectomy specimen: (gastric lesser curvature) ulcerated moderately differentiated adenocarcinoma (tumor size 5.5 cm × 4 cm), involving the serosal fat and nerve; tumor vascular thrombosis was found; the upper and lower margins of the specimens, as well as the separate “upper resected margin” were negative for tumor tissue. Metastases were observed in the lesser curvature LN2/2, greater curvature LN1/3,“Station 1” LN0/8, “Station 2” LN0/2, “Station 3” LN0/14, “Station 6” LN0/4, “Station 7” LN0/2, “Station 8” LN1/3, “Station 9” LN0/2, and “Station 10” LN0/1. No LN was detected in “stations 5, 11 and 12.” IHC: tumor cells CgA (-), Syn focal (+), CD56 (-), CK8/18 (+), CK7 (-), Ki-67 20% (+). Pathologic staging was T4aN2MoIIIB.