Bowline knot of a monofilament suture eliminates C-loop formation in intracorporeal ligation

We describe how we developed a new method of tying an intracorporeal suture of monofilament material using a bowline knot, which eliminates the troublesome C-loop formation for winding the thread on the rod. The winding-forceps point to the site of suturing, and the needle end of the thread is placed under the rod of the forceps during the knot tying. This position allows for easy winding of the line even when the forceps-angle is as narrow as 10° because the winding-forceps and suture line are in parallel. This method resolves the problems of C-loop formation with a narrow forceps-angle. Thus, our bowline method of knot-tying provides an easy, secure, and rapid intracorporeal ligation requiring a short learning curve, as an alternative to the conventional C-loop method.     

Predicting the Amount of Intraperitoneal Fluid Accumulation by Computed Tomography and Its Clinical Use in Patients With Perforated Peptic Ulcer

The correlation between the amount of peritoneal fluid and clinical parameters in patients with perforated peptic ulcer (PPU) has not been investigated. The authors'' objective was to derive a reliable formula for determining the amount of peritoneal fluid in patients with PPU before surgery, and to evaluate the correlation between the estimated amount of peritoneal fluid and clinical parameters. We investigated 62 consecutive patients who underwent emergency surgery for PPU, and in whom prediction of the amount of accumulated intraperitoneal fluid was possible by computed tomography (CT) using the methods described by Oriuchi et al. We examined the relationship between the predicted amount of accumulated intraperitoneal fluid and that measured during surgery, and the relationship between the amount of fluid predicted preoperatively or measured during surgery and several clinical parameters. There was a significant positive correlation between the amount of fluid predicted by CT scan and that measured during surgery. When patients with gastric ulcer and duodenal ulcer were analyzed collectively, the predicted amount of intraperitoneal fluid and the amount measured during surgery were each associated with the period from onset until CT scan, perforation size, the Mannheim peritoneal index, and the severity of postoperative complications according to the Clavien–Dindo classification. Our present results suggest that the method of Oriuchi et al is useful for predicting the amount of accumulated intraperitoneal fluid in patients with PPU, and that this would be potentially helpful for treatment decision-making and estimating the severity of postoperative complications.Key words: Peptic ulcer, Perforation, Peritoneal fluid, Gastric ulcer, Duodenal ulcer, Computed tomographyPerforated peptic ulcer (PPU) remains a life-threatening condition, especially in elderly patients for whom treatment is often delayed, with reported mortality rates of 10–40%.^1–3 Surgical treatment for PPU that includes simple closure or placement of an omental patch using a conventional open approach or laparoscopy has become widely accepted.⁴ A patient age of >60 years, delayed treatment, or shock at presentation are reported to be factors that predict an unfavorable outcome after surgery.^5,6 Computed tomography (CT) is reported to be a more sensitive diagnostic modality than conventional X-ray examination for detection of extra-luminal free air, recognition of the presence of peritoneal fluid, or even the perforation site.^7–13 Although the amount of accumulated peritoneal fluid may correlate with the severity of peritonitis caused by PPU, no adequate formula for predicting the amount of ascites before surgery has yet been reported. Oriuchi et al14 have proposed a simple method for calculating the amount of peritoneal fluid in gastric cancer patients with peritoneal carcinomatosis from CT scan images. In the present study, we calculated the amount of peritoneal fluid using Oriuchi''s method, and compared it with the actual amount of peritoneal fluid collected during surgery. In addition, we investigated the correlation between the amount of peritoneal fluid predicted preoperatively or that measured during surgery and several clinical parameters or operative outcome.     

The technique of laparoscopically assisted total gastrectomy with jejunal interposition for early gastric cancer

BACKGROUND: In recent years, laparoscopic gastrectomy has been applied to the treatment of gastric cancer in Japan. However, there are few reports of laparoscopic or laparoscopically assisted total gastrectomy in the treatment of gastric cancer because of the difficulty of the surgical technique. Laparoscopically assisted total gastrectomies with jejunal interpositions were performed on four patients with early gastric cancer located in the upper portion of the stomach. METHODS: Four surgical ports were inserted into the abdomen. The stomach was lifted to the abdominal wall using newly developed retraction tubes. Gastric arteries were divided using ultrasonically activated coagulating shears and ligated with ligation forceps. Following these steps, a total gastrectomy reconstruction was performed by jejunal interposition through a small transverse laparotomy. An esophagojejunostomy and a jejunoduodenostomy were made with circular staplers. RESULTS: The mean operating time and blood loss were 246 min and 236 ml, respectively. The operations were performed without serious complications. All patients were pain free and ambulatory after the laparoscopically assisted total gastrectomy, and the mean postoperative hospital stay was 16 days. CONCLUSION: We successfully performed laparoscopically assisted total gastrectomies in a relatively short period of time. When patients are carefully selected, the laparoscopic procedure can be curative and minimally invasive as a treatment for early gastric cancer.     

Postoperative functional evaluation of jejunal interposition with or without a pouch after a total gastrectomy for gastric cancer

BACKGROUND: The objective of this study was to compare the motility of a gastric substitute after jejunal interposition without a pouch and jejunal interposition with a pouch and to evaluate the relationship of both methods with nutritional outcome. METHODS: Twelve patients with gastric cancer treated by total gastrectomy and reconstruction with jejunal interposition without a pouch (J-I) and 14 patients treated by total gastrectomy and reconstruction with jejunal interposition with a pouch (J-P) were investigated in regard to the motor activity of the interposed jejunum and changes in body weight and dietary intake. RESULTS: Phase III of the interposed jejunum without a pouch was observed over a 3-month follow-up, but phase III of the interposed jejunum with a pouch was not observed in any patient within 3 months of surgery. In the fed state, the motor activity of the interposed jejunum without a pouch increased significantly in patients within 12 months of follow-up, but in the interposed jejunum with a pouch, it did not. The amount of food consumed by the J-I group was significantly greater than that consumed by the J-P group. CONCLUSIONS: This study demonstrates that the interposed jejunum with a pouch shows marked disturbances from the motor pattern of a normal jejunum during the fasting and fed states. These motor abnormalities may be responsible for insufficient food intake of the J-P group.     

18F-Fluorodeoxyglucose Positron Emission Tomography: Useful Technique for Predicting Malignant Potential of Gastrointestinal Stromal Tumors

The malignant potential of gastrointestinal stromal tumors (GISTs) is difficult to diagnose before surgery because the diagnoses are based on tumor diameter and mitotic index. The progression of small GISTs is always observed because they do not seem to have malignant potential. ¹⁸F-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is a useful technique for assessing tumor activity. The objective of this study was to determine if FDG-PET is useful for predicting the malignant potential of gastric GISTs. Ten patients diagnosed with gastric GISTs participated. FDG-PET was performed on all of them before tumor resection. A whole-body image was initiated 40 minutes after the injection of 275 to 370 MBq FDG. FDG uptake was assessed by a standardized uptake value. All tumors had FDG uptake. There was a significant correlation between the FDG uptake and both the Ki67 index and the mitotic index but not the tumor diameter. The FDG uptake and malignant potential of gastric GISTs had a significant correlation. FDG-PET may be of considerable value for predicting the malignant potential of gastric GISTs before surgery. A gastric GIST with a high FDG uptake should be regarded as having malignant potential.     

An evaluation of motor function in transverse colon transplants after total gastrectomy

(Received for publication on July 10, 1996; accepted on May 12, 1997)     

Clinical Significance of Melanoma Antigen-Encoding Gene-1 (MAGE-1) Expression and its Correlation with Poor Prognosis in Differentiated Advanced Gastric Cancer

Background

Melanoma antigen-encoding gene-1 (MAGE-1), a cancer/testis antigen, has been reported to be expressed in various types of cancer. We investigated the clinicopathological features and prognostic significance of MAGE-1 expression in advanced gastric cancer (AGC).

Methods

Immunohistochemical staining for MAGE-1 was performed on surgical specimens obtained from 135 patients with AGC.

Results

Positive expression of MAGE-1 detected in cytoplasm was observed in 44 of 135 cases (32.6%) in primary tumors and 26 of 96 (27.1%) in lymph node metastases. In noncancerous gastric tissues, apparent MAGE-1 expression was not detected. MAGE-1 in primary tumor was correlated with advanced age (P < 0.001), macroscopic infiltrated type (P = 0.035), and presence of vascular invasion (P = 0.027). The 5-year cancer-specific survival rates of AGC patients with positive MAGE-1 expression were significantly lower than those of patients with negative MAGE-1 (positive: 31.6%, negative: 57.6%, P = 0.038). On multivariate analysis, MAGE-1 expression was not an independent prognostic predictor of AGC (P = 0.064). In differentiated AGC patients, MAGE-1 expression was correlated with advanced age (P = 0.003), macroscopic infiltrated type (P = 0.009), and presence of lymph node metastasis (P = 0.033). The cancer-specific survival rates of differentiated AGC patients with positive MAGE-1 were significantly lower than those of patients with negative MAGE-1 (P = 0.003). Positive MAGE-1 expression was an independent prognostic factor of differentiated AGC patients on multivariate analysis (P = 0.031).

Conclusions

These findings suggest that MAGE-1 protein expression can serve as a predictive marker of poor prognosis in differentiated AGC patients.