Simultaneous robotic distal gastrectomy and distal pancreatectomy: Avoiding total gastrectomy using indocyanine green fluorescence imaging

Remnant gastric ischemia is the most significant complication in distal pancreatectomy (DP) after distal gastrectomy (DG). Some studies have reported the safety of asynchronous DP in patients who underwent DG. We report a case of simultaneous robotic DG and DP. A 78-year-old man was diagnosed with gastric and pancreatic cancer. We preoperatively confirmed the absence of anomalies in the left inferior phrenic artery. Robotic simultaneous DG and DP was performed; subtotal resection of the stomach was carried out, enabling the left inferior phrenic artery to maintain perfusion of the remnant stomach, even after ligation of the splenic artery. The remnant stomach was preserved as scheduled, and indocyanine green fluorescence imaging confirmed sufficient remnant stomach tissue perfusion. Robotic surgery using the da Vinci surgical system (with a fluorescence imaging system and technology enabling surgical precision) is suitable for this surgical procedure because it considers tumor radicality and allows for function preservation.     

Helicobacter pylori infection in gastric remnant cancer after gastrectomy

Patients who have undergone distal gastrectomy for peptic ulcer are at higher risk of developing gastric remnant cancer, and chronic bile reflux is believed to increase the risk of cancer in remnant stomach. In remnant stomach, carcinogenesis may be prevented by selecting the anastomosis method with a few reflux of intestinal juice including a bile acid. How Helicobacter pylori(H. pylori) infection participate in stomal gastritis and gastric remnant cancer, same as early gastric cancer in the intact stomach, is attended. H. pylori positive rate of remnant stomach is different by examination method and a report, but its rate is decreased every year after gastrectomy and in particular low in Billroth-II(B-II) anastomosis. B-II anastomosis is followed by a significantly lower rate than B-1. This may reflect the role of bile reflux because bile reflux interferes with colonization by H. pylori. Gastric cancer excision usual increase complicates gastric remnant stomach and H. pylori infection, but while H. pylori infection lasts after gastrectomy for gastric cancer, cell proliferation increase in remnant stomach. In remnant stomach after gastrectomy for gastric cancer, while H. pylori infection continues, H. pylori infection may cause remnant gastritis and a second cancer of remnant stomach. H. pylori infection and bile reflux seem to have a synergistic effect on cell proliferation in remnant stomach and may explain the increased risk of gastric remnant cancer. The cancer-causing dominant role might changed from H. pylori infection predominance to bile reflux every year after gastrectomy. Furthermore, a prophylactic effect to carcinogenesis by H. pylori eradication therapy is expected. Eradication of H. pylori after gastrectomy for gastric cancer has been recommended.     

Usefulness of indocyanine green fluorescence imaging: A case of laparoscopic distal gastrectomy after distal pancreatectomy with splenectomy

Safe preservation of the remnant stomach during distal gastrectomy in patients who have undergone distal pancreatectomy is important. During distal pancreatectomy, the splenic artery that supplies arterial blood to the cardiac part of stomach is resected. Previous reports suggested that blood flow to the remnant stomach may be insufficient when supplied by only the left inferior phrenic artery. In the present case, a 79‐year‐old woman who underwent distal pancreatectomy with splenectomy 20 years before she was diagnosed with gastric cancer and referred to our hospital. We performed laparoscopic distal gastrectomy and Roux‐en‐Y reconstruction because preoperative CT scan indicated a developed left inferior phrenic artery. To evaluate the blood supply, we employed indocyanine green fluorescence and were able to safely preserve the remnant stomach. Our experience suggests that indocyanine green fluorescence is potentially useful for evaluating blood flow to the remnant stomach.     

Endoscopic surveillance for gastric remnant cancer after early cancer surgery

BACKGROUND AND STUDY AIMS: The aims of this article were to clarify the incidence of gastric remnant cancer after surgery for early gastric cancer, and to develop surveillance programs for patients who have undergone partial gastrectomy in order to detect such lesions at an early stage. PATIENTS AND METHODS: A total of 642 patients with partial gastrectomy for early gastric cancer were enrolled in a surveillance program for gastric remnant cancer between 1985 and 1996. In 509 patients, the interval between endoscopic examinations was no more than 2 years. RESULTS: Among the 509 patients examined periodically, 15 patients were diagnosed as having gastric remnant cancer; in 12 patients, the cancers were detected at an early stage. All gastric remnant cancers were found distant from the site of the anastomosis, and in eight patients the cancers were located on the lesser curvature. The cumulative 5-year prevalence rate was estimated as 2.4 % and the 10-year prevalence rate as 6.1 %. The initial tumors in the patients with gastric remnant cancer were of the microscopically intestinal type, without exception. The interval between the preceding examination and diagnosis was shorter in the patients with early cancer than in those with advanced cancer ( P < 0.01). CONCLUSIONS: Periodical surveillance endoscopy for gastric remnant cancer is recommended after surgery for early gastric cancer, particularly in patients whose cancers are of the intestinal type. The examinations can be repeated at 2 - 3-year intervals, and special attention should be given to the lesser curvature away from the anastomotic site.     

Innovative marking method using novel endoscopic clip equipped with fluorescent resin to locate gastric cancer

An asymptomatic 76-year-old man presented to our department for the treatment of gastric cancer. Esophagogastroduodenoscopy revealed a superficial elevated lesion with an irregular central depression in the lower third of the stomach; this was confirmed to be adenocarcinoma by biopsy, while abdominal contrast-enhanced CT revealed no abnormal lesions. Based on the patient's clinical diagnosis of early gastric cancer, we planned laparoscopic gastrectomy with preoperative placement of four endoscopic marking clips equipped with indocyanine green-conjugated resin to determine the resection margin. During surgery, a dedicated laparoscopic system was used to detect indocyanine green fluorescence emitted by the clips and determine their precise position. The clips helped to identify an accurate resection line for the stomach, enabling accurate laparoscopic distal gastrectomy with regional lymphadenectomy. We successfully demonstrated the usefulness of clips with fluorescent resin for detecting gastric cancer in patients. We report the first case using the clips to accurately locate a site of interest.     

Laparoscopic surgery for sigmoid colon cancer after multiple operations including urinary diversion with Indiana pouch: A case report

A 73‐year‐old man with lower abdominal pain was diagnosed at our hospital with sigmoid colon cancer. He had previously undergone radical cystectomy with Indiana pouch construction and gastrectomy to treat bladder cancer and gastric cancer, respectively. We performed a laparoscopic Hartmann's operation with Japanese D3 lymph node dissection. We observed severe adhesion in the abdominal cavity; adhesions between the urostomy and sigmoid colon were particularly severe. The tumor had invaded to the distal rectum, which had adhered to the pubic bone and the previously reconstructed urinary pouch. By performing careful and persistent laparoscopic dissection, we completed the operation without damaging the urostomy and with no remnant tumor tissue (R0). The postoperative course was uneventful, and the patient was doing well with no evidence of cancer recurrence 1 year after surgery.     

Current controversies in treating remnant gastric cancer: Are minimally invasive approaches feasible?

The incidence of remnant gastric cancer (RGC) is still increasing. Minimally invasive approaches including endoscopic resection, laparoscopic and robotic approaches, and function-preserving gastrectomy have been utilized as curative treatment methods for primary gastric cancer. However, adhesions and anatomical alterations due to previous gastrectomy make the use of minimally invasive approaches complicated and difficult for RGC. Application of these approaches for the treatment of RGC is still controversial. Endoscopic submucosal dissection is a favorable alternative therapy for the resection of early gastric cancer that occurs in the remnant stomach and can prevent unnecessary complications. The majority of retrospective studies have shown that endoscopic submucosal dissection is an effective and oncologically safe treatment modality for RGC. Subtotal gastrectomy could serve as a function-preserving gastrectomy for patients with early RGC and improve postoperative late-phase function. However, there are only two studies that demonstrate the feasibility and oncological efficacy of subtotal gastrectomy for RGC. The non-randomized controlled trials showed that compared to open gastrectomy, laparoscopic gastrectomy for RGC led to better short-term outcomes and similar oncologic results. Because of the rarity of RGC, future multicenter studies are required to determine the indications of minimally invasive treatment for RGC.     

Successful cholecystectomy during robotic gastrectomy

Abstract

Background: Surgeons have successfully combined various laparoscopic procedures with increasing technical ease. However, few reports exist regarding the feasibility of combined robotic operations. We present our institution's successful concomitant robotic surgery for early gastric cancer and coexisting gallbladder disease. Material and methods: From our prospectively collected database, seven patients who received robotic cholecystectomies during their robotic gastric cancer operations were retrospectively compared to 247 patients who underwent robotic gastrectomies alone. Preoperative patient characteristics, operative factors, postoperative length of stay, and complications were evaluated. Results: The preoperative patient characteristics and operative factors did not differ between the two groups. All robotic cholecystectomies were performed with the same ports and instruments used during robotic gastrectomies without open conversion, robot redocking or patient repositioning. Mean time to perform robotic cholecystectomies was 15.1 + 3.2 minutes. The combined group had no mortality, one wound infection, and one intraabdominal fluid collection at the gastric resection bed, which were comparable to the gastrectomy alone group. The mean postoperative length of hospital stay was unaltered by the addition of the cholecystectomy. Conclusions: Robotic cholecystectomies can safely and efficiently be combined with robotic gastric cancer surgery, yielding several benefits. Improving robotic technology and experience may allow surgeons to efficiently combine more complicated procedures.     

Real-time vessel navigation using indocyanine green fluorescence during robotic-assisted gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery

Injury to the right gastroepiploic artery (RGEA) graft during gastrectomy after coronary artery bypass grafting (CABG) can cause critical coronary failure. A man in his 60s with advanced gastric cancer and a history of CABG was admitted to our hospital. His cardiac blood flow was dependent on RGEA, and a gastrectomy with RGEA preservation was necessary. Robot-assisted distal gastrectomy with real-time vessel navigation using indocyanine green (ICG) fluorescence imaging and Da Vinci Firefly technology was planned. Intraperitoneal observation revealed severe adhesions around the graft. Two milliliters ICG (2.5 mg/mL) was injected intravenously, and RGEA was visualized. An RGEA-preserving robot-assisted distal gastrectomy was successfully performed. The operation time was 279 minutes, and the blood loss was 5 mL. The postoperative course was good and there were no complications.     

Robotic surgery for the upper gastrointestinal tract: Current status and future perspectives

More than 4000 da Vinci Surgical Systems have been installed worldwide. Robotic surgery using the da Vinci Surgical System has been increasingly performed in the last decade, especially in urology and gynecology. The da Vinci Surgical System has not become standard in surgery of the upper gastrointestinal tract because of a lack of clear benefits in comparison with conventional minimally invasive surgery. We initiated robotic gastrectomy and esophagectomy for patients with upper gastrointestinal cancer in 2009, and we have demonstrated the potential advantages of the da Vinci Surgical System in reducing postoperative local complications after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. However, robotic surgery has the disadvantages of a longer operative time and higher costs than the conventional approach. In this review article, we present the current status of robotic surgery for gastric and esophageal cancer, as well as future perspectives on this approach, based on our experience and a review of the literature.     

Is ICG-enhanced image able to help predicting pancreatic fistula in laparoscopic pancreaticoduodenectomy?

Laparoscopic pancreaticoduodenectomy (PD) has been reported to be technically feasible and safe. Successful pancreatico-enteric anastomosis in particular is important for safe PD. Intraoperative perfusion of the remnant pancreas can be evaluated with ICG technology and be applied in pancreatic reconstruction in PD. A 68-year old female patient with distal common bile duct cancer underwent laparoscopic pylorus-preserving pancreaticoduodenectomy. After pancreaticojejunostomy (PJ), we checked perfusion of the anastomosis line using an ICG imaging system and noticed a perfusion defect at the anterior wall. The patient developed a grade A postoperative pancreatic fistula, but was discharged without major sequelae. Even though pancreatic perfusion after laparoscopic PJ appeared adequate based on white light, hypo-perfusion was noted under infrared light. Our experience suggests that ICG technology may be more sensitive than white light for detecting pancreatic perfusion in pancreatic anastomoses. However, the clinical implications of this require further investigation.     

Lymphome malin non hodgkinien sur moignon de gastrectomie: �� propos d��un nouveau cas

Gastric stump cancer is a well-known complication of gastrectomy, and the most common histological type is adenocarcinoma. Gastric stump lymphoma after distal gastrectomy appears to be very rare (with only thirty cases reported in the literature). We report a new case of B cell non-Hodgkin??s lymphoma of a stomach remnant 20 years after a gastrectomy for benign gastric ulcer in a 76-year-old patient.     

Combined indocyanine green and quantitative perfusion assessment with hyperspectral imaging during colorectal resections

Anastomotic insufficiencies still represent one of the most severe complications in colorectal surgery. Since tissue perfusion highly affects anastomotic healing, its objective assessment is an unmet clinical need. Indocyanine green-based fluorescence angiography (ICG-FA) and hyperspectral imaging (HSI) have received great interest in recent years but surgeons have to decide between both techniques. For the first time, two data processing pipelines capable of reconstructing an ICG-FA correlating signal from hyperspectral data were developed. Results were technically evaluated and compared to ground truth data obtained during colorectal resections. In 87% of 46 data sets, the reconstructed images resembled the ground truth data. The combined applicability of ICG-FA and HSI within one imaging system might provide supportive and complementary information about tissue vascularization, shorten surgery time, and reduce perioperative mortality.     

Food residue at endoscopy in patients who have previously undergone distal gastrectomy: risk factors and patient preparation

BACKGROUND AND STUDY AIMS: Food residue is often seen in the gastric remnant after partial gastrectomy, making it difficult to diagnose early cancer in the residual stomach. The aims of this study were to clarify the risk factors for the accumulation of food residue, and to study methods of preparation for endoscopy in patients who had undergone distal gastrectomy. PATIENTS AND METHODS: 374 endoscopic examinations of patients who had undergone distal gastrectomy for gastric cancer were compared with 2168 endoscopic examinations in patients without a history of gastrectomy. Relationships between the presence of food residue and a number of clinical factors, including patient preparation, were evaluated by univariate and multivariate analyses. RESULTS: Food residue in the gastric remnant was observed in 70 examinations (18.7 %), a significantly higher proportion than that found in control patients (0.3 %). From multivariate analysis, underlying diseases (endocrine, metabolic, or connective tissue disease), Billroth type I reconstruction, and postoperative gastric retention were found to be independent risk factors for the accumulation of food residue. Diet preparation (a liquid diet plus aclatonium napadisilate) significantly decreased the incidence of food residue. CONCLUSIONS: Our diet preparation method can be recommended as a preparation for upper gastrointestinal endoscopy in patients who have undergone distal gastrectomy, especially in patients with additional risk factors.     

荧光纳米粒子在小鼠胃癌皮下瘤模型近红外成像中的实验研究

目的 合成特异性靶向胃癌纳米粒子,借助自主搭建的近红外荧光腹腔镜,探讨该纳米粒子在胃癌精确诊断及完整切除中的价值。方法 将吲哚菁绿（ICG）通过自主装方式包覆于双亲性聚合物二硬脂酰基磷脂酰乙醇胺-聚乙二醇-马来酰亚胺（DSPE-PEG-Mal）,同时,用精氨酸-甘氨酸-天冬氨酸（RGD）多肽修饰,制备靶向纳米粒子DSPE-PEG-RGD@ICG。通过核磁谱图验证产物,吸收光谱检测光学性质。建立小鼠胃癌皮下瘤模型,在自主搭建的近红外荧光腹腔镜下检测及切除肿瘤。结果 核磁谱图验证产物与预期相符,并表现出与游离ICG相似的吸收光谱。在体内实验中,DSPE-PEG-RGD@ICG可特异性靶向胃癌,指导胃癌的完整切除。静脉给药4 h后,荧光腹腔镜可清楚显示肿瘤位置。小鼠胃癌皮下瘤检出率为91.8%,检出肿瘤的最小直径为4.9 mm。结论 成功制备了特异性靶向胃癌的纳米粒子DSPE-PEG-RGD@ICG,其光学特性与ICG相似,在近红外荧光腹腔镜引导下,可有效地协助外科医师对小鼠胃癌皮下瘤进行定位及完整切除。     

Robotic distal gastrectomy with D2 lymphadenectomy for advanced gastric cancer with celiac-arterial anomaly (Adachi type VI,group 26): Case report

In gastric cancer surgery, some celiac-arterial anomalies are associated with a risk of anatomical misidentification and insufficient lymphadenectomy. We herein report a case of successful robotic distal gastrectomy with D2 lymphadenectomy based on preoperative, anatomical recognition using three-dimensional computed tomography (3D-CT) in a patient with advanced gastric cancer and a rare anomaly of the celiac artery. A 64-year-old, male patient was referred to our division with a diagnosis of advanced gastric cancer. The 3D-CT angiography demonstrated an Adachi type VI, group 26 celiac-arterial anomaly, in which the common hepatic artery branched from the left gastric artery but was widely dislocated from the supra-pancreatic region. Moreover, the left gastric artery branched three gastric branches, although the right gastric artery was absent. Robotic surgery enabled the safe and precise gastrectomy and lymphadenectomy.     

Repeated robotic pancreatectomy for recurrent pancreatic metastasis of mesenchymal chondrosarcoma: A case report

Mesenchymal chondrosarcoma is a rare subset of sarcomas accounting for 3%–10% of all cases of chondrosarcomas. Radical resection is the only curative strategy, even in patients with metastatic tumors. However, data regarding treatment strategies remain limited owing to the small number of cases. Herein, we report a patient who underwent repeated robotic pancreatectomy for recurrent pancreatic metastasis originating from extraskeletal mesenchymal chondrosarcoma of the pelvis. First, robotic pancreaticoduodenectomy with a reconstruction of pancreaticogastrostomy was performed for synchronous pancreatic metastasis 5 months after the primary resection of mesenchymal chondrosarcoma. Ten months after robotic pancreaticoduodenectomy, tumor recurrence was observed at the tail end of the pancreas, which was removed by reperforming robotic distal pancreatectomy. Given the precise tissue manipulation that can be achieved with robotic articulated forceps, the peripheral splenic artery and pancreas were easily isolated and divided in close proximity to the tumor. The central part of the pancreas was preserved. Robotic surgery allowed safe and effective resection of the reconstructed remnant pancreas. The patient survived for 28 months after primary tumor resection. Repeated pancreatectomy with minimally invasive techniques is a feasible and curative treatment for metastatic mesenchymal chondrosarcoma.     

腹腔镜吲哚菁绿荧光显影指引淋巴结切除用于早期子宫内膜癌分期手术的临床价值

目的探究腹腔镜吲哚菁绿荧光显影指引淋巴结切除用于早期子宫内膜癌分期手术的临床价值。方法回顾性分析,选取2018年1月至2019年6月青海红十字医院收治的腹腔镜分期手术早期子宫内膜癌患者35例,术前给予吲哚菁绿注射,采集淋巴显影图,术后对显影、非显影淋巴结送检、分析,观察腹膜后淋巴显影情况、多区域淋巴显影的影响因素以及显影淋巴结对肿瘤转移状态的诊断效能,随访患者不良反应。结果35例患者中,共有33例成功显影,占94.29%,21例仅表现为盆腔淋巴结显影,11例为盆腔、腹主动脉旁淋巴结显影,1例仅腹主动脉旁区域显影;经过单因素Logistic回归分析,结果显示,显影效果与临床医师注射经验密切相关(P<0.05);显影淋巴结肿瘤状况对淋巴结转移预测灵敏度、假阴性率分别为85.67%、14.32%;阴性预测值为96.43%,准确率为97.12%。结论针对早期子宫内膜癌患者给予吲哚菁绿荧光显影安全、可行,能够有效预测腹膜后淋巴结有无肿瘤转移,在腹腔镜淋巴结切除术分期手术中有着较高的应用价值。     

术中动脉灌注化疗于胃癌根治术中的应用研究进展

胃癌发病率死亡率均较高,早期胃癌行根治性切除术后复发转移率较低,但进展期胃癌（AGC）即使行R0切除术后复发转移率仍较高,究其原因为外科手术治疗无法根除肿瘤微转移灶。术中动脉灌注化疗（IAIC）能使肿瘤及肿瘤周围组织形成高化疗浓度场所,杀灭外科根治术后残留癌细胞。对AGC行肿瘤R0切除加D2淋巴结清扫配合IAIC能达到宏观及微观上的根治,降低肿瘤的复发转移概率,延长患者生存时间,提高生存质量。IAIC起源于20世纪90年代,经过近30年的发展,其临床效果已得到认可,但缺乏相关大宗随机试验证据支持,其灌注血管选择、用药方案选择等仍未得到规范。本文就IAIC的研究现状做一综述,为相关临床工作提供参考。     

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.