An advanced bipolar device helps reduce the rate of postoperative pancreatic fistula in laparoscopic gastrectomy for gastric cancer patients: a propensity score-matched analysis.

BACKGROUND: Advanced bipolar devices (ABD; e.g., LigaSure™) have a lower blade temperature than ultrasonically activated devices (USAD; e.g., Harmonic® and Sonicision™) during activation, potentially enabling accurate lymph node dissection with less risk of postoperative pancreatic fistula (POPF) due to pancreatic thermal injury in laparoscopic gastrectomy. Therefore, we compared the efficacy and safety of ABD and USAD in laparoscopic gastrectomy for gastric cancer patients. METHODS: A retrospective cohort study was conducted on patients who underwent laparoscopic distal gastrectomy (LDG) between August 2008 and September 2020. A total of 371 patients were enrolled, and short-term surgical outcomes, including the incidence of ISGPF grades B and C POPF, were compared between ABD and USAD. The risk factors for POPF in LDG were investigated by univariate and multivariate analyses. RESULTS: A propensity score-matching algorithm was used to select 120 patients for each group. The POPF rate was significantly lower (0.8 vs. 9.2%, p < 0.001), the morbidity rate was lower (13.3 vs. 28.3%, p < 0.001), the length of postoperative hospitalization was shorter (14 vs. 19 days, p < 0.001), and the lymph node retrieval rate was higher (34 vs. 26, p < 0.001) with an ABD than with a USAD. There were no mortalities in either group. A multivariate analysis showed that a USAD was the only independent risk factor with a considerably high odds ratio for the occurrence of POPF (USAD/ABD, odds ratio 8.38, p = 0.0466). CONCLUSION: An ABD may improve the safety of laparoscopic gastrectomy for gastric cancer patients.

Repeated partial tissue bite with inadequate cooling time for an energy device may cause thermal injury.

BACKGROUND: Over the past three decades, the use of ultrasonically activated device (USAD) and advanced bipolar device (ABD) has grown in minimally invasive surgeries. However, the thermal profile differences during repeated dissection with different grasping ranges of energy devices, which provide valuable information for preventing thermal injury by energy devices, remain unclear. METHODS: We developed an ex vivo benchtop model to examine the temperature profile of the blade and jaws of two USADs (HARMONIC® ACE + and Sonicision™) and a ABD (Ligasure™ Maryland) with different grasping ranges (partial tissue and full tissue bite) in repeated dissection with minimum cooling time. The maximum temperature, time required for completion to dissection of 10 cm of porcine muscle, thermal spread, and cooling time to reach 60 °C were continuously measured using video thermography. In addition, to evaluate one more grasping range "no tissue", we performed a stress test that activated the USAD without tissue intervention to assess the effects of excessive load on the blade and jaw. RESULTS: Repeated dissection of energy devices with minimal cooling time results in high blade and jaw temperatures proportional to the incision distance. In particular, the USADs with partial tissue bite showed a significantly higher temperatures at the blade and jaw, longer cooling times, and higher lateral thermal spread than those with a full tissue bite and the ABD. The stress test with a USAD showed an extremely high blade temperature exceeding 400 °C, with the tissue pad melting only 13.2 s after activation. CONCLUSION: Although USAD with partial tissue bite help ensure precise dissection, repeated long activation with inadequate cooling time may increase the risk of thermal injury during surgery. These results suggest that surgeons should use energy devices properly while understanding the risks of adjacent organ damage that could result from abuse of the device.

iTriangular Stapling Technique: A Novel Reconstruction Method and Clinical Outcomes of Cervical Esophagogastric Anastomosis after Esophagectomy.

BACKGROUND: We herein report the feasibility and safety of cervical end-to-end anastomosis by the iTriangular stapling technique (iTST), which was developed as an extension of the triangular stapling technique (TST) after minimally invasive esophagectomy (MIE). METHODS: A total of 45 patients with thoracic esophageal cancer who underwent reconstruction with cervical esophagogastric anastomosis by iTST using a linear stapler after MIE between January 2016 and January 2019 were retrospectively reviewed. We modified and improved upon the TST by adding a 1- to 2-cm vertical incision on the anterior wall of the remnant esophageal stump to enlarge the anastomotic lumen and thereby reduce the risk of anastomotic stenosis. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures. RESULTS: The median operating time was 686 (range, 319-1110) minutes, and the median blood loss was 170 (range, 5-1180) ml. There were no cases of anastomotic stenosis in this study, although 2 patients (4.4%) developed minor anastomotic leakage. A case (2.2%) of tracheal fistula due to the apex of the triangular anastomosis was resolved simply by delaying the patient's oral intake. The mean length of the hospitalization was 21 days. CONCLUSIONS: The iTST provides a larger lumen unlimited by the size of the esophagus in cervical esophagogastric anastomosis. This technique is feasible, and sufficient short-term results have been achieved. Further studies with the accumulation of more cases will be required to prove the benefits of iTST for reconstruction after MIE.

Robotic-Assisted Distal Gastrectomy for Gastric Cancer Using an Oval-Shaped Port Device.

INTRODUCTION: This report describes the techniques and outcomes of robot-assisted distal gastrectomy (RDG) for gastric carcinoma using an oval-shaped port device. MATERIALS AND METHODS: A total of 15 patients underwent RDG with lymphadenectomy using the E‧Z Access/LAP-PROTECTOR oval-type device (Hakko Co., Ltd., Tokyo, Japan) performed by a single surgeon between 2018 and 2019. This device was introduced to the umbilicus under two settings, depending on the patient's figure. A horizontal setting (n=7) was used to reduce the number of trocar skin incisions in thin patients by placing a scope trocar and assist port within the E-Z Access. The vertical setting (n=8) was used for large and obese patients, enabling the endoscope position to move 50mm toward the cephalad side by rotating the device 180° to improve the surgical view of the suprapancreatic area ("dual port position" using the E‧Z Access oval-type device). The intracorporeal Billroth-I anastomosis or Roux-en-Y method was used for reconstruction. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures. RESULTS: The E-Z Access oval-type device was useful for maintaining an optimal surgical field and reducing the number of skin incisions and the level of surgeon stress. Furthermore, its removal cap and wound protector allowed for an airtight seal, umbilical wound protection, and smooth specimen removal and re-pneumoperitoneum. R0 resection was accomplished in all cases without the need for conversion to open or conventional laparoscopic surgery. The median operating time was 323 (range, 245-590) minutes, and the median blood loss was 5ml. The median number of retrieved lymph nodes was 30. Neither major postoperative complication, including umbilical skin damage, nor postoperative mortality, was observed. The mean length of the hospitalization was 12.5 days. CONCLUSIONS: Our robotic approach using an oval-shaped port device for gastric cancer patients is feasible in terms of patient safety and curability.

Surgery for Pancreatic Neuroendocrine Tumor G3 and Carcinoma G3 Should be Considered Separately.

BACKGROUND: The role of surgery in pancreatic neuroendocrine neoplasm grade 3 (pNEN-G3) treatment remains unclear. We aimed to clarify the role of surgery for pNEN-G3, which has recently been reclassified as pancreatic neuroendocrine tumor-G3 (pNET-G3) and pancreatic neuroendocrine carcinoma-G3 (pNEC-G3), with and without metastases, respectively. METHODS: We analyzed a subgroup of patients from the Japanese pancreatic NEC study, a Japanese multicenter case-series study of pNEN-G3. Pathologists subclassified 67 patients as having pNET-G3 or pNEC-G3 based on morphological features. We compared the overall survival (OS) rates among patients who were grouped according to whether they had undergone tumor-targeted surgery for tumors without (SwoM) or with (SwM) metastases, or non-surgical procedures (NS). RESULTS: Data from 21 patients with pNET-G3 (SwoM, n = 6; SwM, n = 5; NS, n = 10) and 46 patients with pNEC-G3 (SwoM, n = 8; SwM, n = 5; NS, n = 33) were analyzed. OS of patients with pNET-G3 was significantly longer after SwoM and SwM than with NS (p = 0.018 and p = 0.022). In contrast, OS did not significantly differ between either SwoM or SwM and NS (p = 0.093 and p = 0.489) among patients with pNEC-G3. CONCLUSION: The role of surgery should be considered separately for pNET-G3 and pNEC-G3. Although SwoM and SwM can be considered for pNET-G3, caution is advised before considering SwM and SwoM for pNEC-G3.

Giant Adrenal Myelolipoma in a Patient without Endocrine Disorder: A Case Report and a Review of the Literature.

We herein present a surgically treated case of huge adrenal myelolipoma. A 62-year-old woman presented to our surgical outpatient clinic with a retroperitoneal tumor. A clinical examination revealed an elastic soft, smooth-surfaced, painless, child-head-sized tumor with poor mobility, which was located in the left upper abdomen. Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed an uneven tumor surrounding the stomach, spleen, pancreas, and left kidney, which was 20 × 18 × 10 cm in size. The retroperitoneal tumor was resected. The tumor was attached to the surrounding organs, including the pancreas, spleen, and left kidney, but had not directly invaded these organs. The tumor was yellow and elastic soft and covered with a thin film. The origin of the tumor was suggested to be the left adrenal gland. The weight of the excised tumor was 1500 g. The histopathological diagnosis was adrenal myelolipoma. The patient had an uneventful recovery and was discharged from the hospital on the thirteenth day after the operation. She has been followed up in our outpatient clinic.

A Review of 7 Cases of Laparoscopic Cholecystectomy for Pediatric Cholecystolithiasis.

Pediatric cholecystolithiasis is a relatively rare disease, but it is recently increasing in Japan. Laparoscopic cholecystectomy (LC) is a standard procedure for cholecystolithiasis not only in adults but also in children, and we are aggressively introducing single-incision laparoscopic cholecystectomy (SILC) at our hospital. We reviewed the patient characteristics, operation procedures and outcomes of 7 children (15 years old and under) with cholecystolithiasis who underwent LC in our hospital between August 1995 and December 2015. The 7 patients included 5 males and 2 females, with a mean age of 8 years 6 months. Underlying diseases were found in 5 patients (cerebral palsy in 2 patients, pancreaticobiliary maljunction with common bile duct stones in 1, acute lymphocytic leukemia in 1, hereditary stomatocytosis in 1), and none were found in the other 2. LC (3 conventional LC and 2 SILC) was performed in 5 of the patients. Laparoscopic choledocholithotomy was performed in 1 patient and laparoscopic splenectomy (LS) was performed in 1 patient at the same time. The mean operative time in all the cases of LC was 108 (70-140) minutes (conventional LC 113 (70-140) min, SILC 100 (90-100) min). Intraoperative cholangiography was performed in 4 cases and omitted in 3 cases. The only postoperative complication was a wound infection in 1 patient. The umbilical skin incision length in the SILC was 2.0 cm. We conclude that LC can be safely performed for children with cholecsytolithiasis, and that SILC is feasible and advantageous in terms of its improved cosmesis.

Rb Loss and KRAS Mutation Are Predictors of the Response to Platinum-Based Chemotherapy in Pancreatic Neuroendocrine Neoplasm with Grade 3: A Japanese Multicenter Pancreatic NEN-G3 Study.

Purpose: Patients with pancreatic neuroendocrine neoplasm grade-3 (PanNEN-G3) show variable responses to platinum-based chemotherapy. Recent studies indicated that PanNEN-G3 includes well-differentiated neuroendocrine tumor with G3 (NET-G3). Here, we examined the clinicopathologic and molecular features of PanNEN-G3 and assessed the responsiveness to chemotherapy and survival.Experimental Design: A total of 100 patients with PanNEN-G3 were collected from 31 institutions, and after central review characteristics of each histologic subtype [NET-G3 vs. pancreatic neuroendocrine carcinoma (NEC-G3)] were analyzed, including clinical, radiological, and molecular features. Factors that correlate with response to chemotherapy and survival were assessed.Results: Seventy patients analyzed included 21 NETs-G3 (30%) and 49 NECs-G3 (70%). NET-G3 showed lower Ki67-labeling index (LI; median 28.5%), no abnormal Rb expression (0%), and no mutated KRAS (0%), whereas NEC-G3 showed higher Ki67-LI (median 80.0%), Rb loss (54.5%), and KRAS mutations (48.7%). Chemotherapy response rate (RR), platinum-based chemotherapy RR, and prognosis differed significantly between NET-G3 and NEC-G3. Chemotherapeutic outcomes were worse in NET-G3 (P < 0.001). When we stratified PanNEN-G3 with Rb and KRAS, PanNENs-G3 with Rb loss and those with mutated KRAS showed significantly higher RRs to platinum-based chemotherapy than those without (Rb loss, 80% vs. normal Rb, 24%, P = 0.006; mutated KRAS, 77% versus wild type, 23%, P = 0.023). Rb was a predictive marker of response to platinum-based chemotherapy even in NEC-G3 (P = 0.035).Conclusions: NET-G3 and NEC-G3 showed distinct clinicopathologic characteristics. Notably, NET-G3 does not respond to platinum-based chemotherapy. Rb and KRAS are promising predictors of response to platinum-based chemotherapy for PanNEN-G3, and Rb for NEC-G3. Clin Cancer Res; 23(16); 4625-32. ©2017 AACR.

KIAA1199 is induced by inflammation and enhances malignant phenotype in pancreatic cancer.

BACKGROUND: Recent evidence suggests a critical role of hyaluronan (HA), especially low-molecular-weight HA (LMW-HA), in the aggressive tumor phenotype. Increased expression of KIAA1199, a newly identified protein involved in HA degradation, has been reported in various cancers, including pancreatic ductal adenocarcinoma (PDAC). However, little is known about the functional significance of KIAA1199 in PDAC. METHODS: Using siRNA knockdown and forced expression models, we investigated the effects of KIAA1199 expression on malignant behaviors (proliferation, migration, and invasion) of PDAC cells. We also examined the effect of inflammation on the transcriptional regulation of KIAA1199 using a pro-inflammatory cytokine and anti-inflammatory agent. RESULTS: Knockdown of KIAA1199 expression using siRNA resulted in decreased cell migration and proliferation. On the other hand, forced expression of KIAA1199 using gene transduction significantly enhanced the migration and invasion. Importantly, increased KIAA1199 expression was associated with an increased level of LMW-HA in the conditioned medium. Exposure to a pro-inflammatory cytokine, interleukin-1ß, increased the KIAA1199 transcription and enhanced the migration. In contrast, treatment with NS-398, a cyclooxygenase-2 inhibitor, decreased the KIAA1199 expression and inhibited the migration. CONCLUSIONS: These findings suggest that increased KIAA1199 expression may contribute to the aggressive phenotype partly through increasing the LMW-HA concentration. Our present results also suggest a possible link between inflammation, induced KIAA1199 expression, and enhanced migration during PDAC progression.

Reduced Port Distal Gastrectomy With a Multichannel Port Plus One Puncture (POP).

BACKGROUND: This report describes the techniques and outcomes of reduced port distal gastrectomy (RPDG) with a multichannel port plus one puncture (POP) for gastric cancer patients. PATIENTS AND METHODS: A total of eight patients underwent a RPDG using the Eï½¥Z Access™/LAPPROTECTOR™ (Hakko Co. Ltd., Tokyo, Japan) oval type devices with POP by a single surgeon. The median age of the patients was 66 years (range 48-75 years), and their median BMI was 22.3 kg/m2 (range 17.7-26.8 kg/m2). One (12.5 %) of eight patients was female. A thin caliber trocar MiniPort™ (Covidien, New Haven, CT) was inserted at the left upper quadrant by puncture without incision. An assistant used Endo Relief™ (Hope Denshi Co. Ltd., Chiba, Japan) needlescopic forceps. In three cases, the pre-bent forceps (KTY-I, Adachi Industry Co. Ltd., Gifu, Japan) was introduced for surgeon's left hand. After the liver was retracted with a 2-0 Prolene suture, a distal subtotal resection of the stomach with D1+ or D2 lymph node dissection was performed. The Roux-en-Y method or Billroth-I anastomosis was used for reconstruction. The short-term patient outcomes were investigated to evaluate the feasibility of RPDG with POP. RESULTS: We employed this technique without the use of additional trocars in every patient except one. No conversion to laparotomy was observed. Both the Endo Relief™ forceps and prebent forceps were useful to maintain countertraction and keep triangulation. The median length of the operation was 374 (range, 268-420) minutes, and the median estimated blood loss was 45 (range, 5-180) ml. The median number of dissected lymph nodes was 32 (range 22-46). Neither major postoperative complications, such as anastomotic leakage and stricture, nor postoperative mortality were observed. The mean length of the hospital stay was 1,5 days. The umbilical wound was indistinct. CONCLUSION: RPDG with POP using a needlescopic device procedure is feasible in terms of patient safety and curability.

Rare combination of familial adenomatous polyposis and gallbladder polyps.

Familial adenomatous polyposis is associated with a high incidence of malignancies in the upper gastrointestinal tract (particularly ampullary adenocarcinomas). However, few reports have described a correlation between familial adenomatous polyposis and gallbladder neoplasms. We present a case of a 60-year-old woman with familial adenomatous polyposis who presented with an elevated mass in the neck of the gallbladder (measuring 16 mm × 8 mm in diameter) and multiple small cholecystic polyps. She had undergone a total colectomy for ascending colon cancer associated with familial adenomatous polyposis 22 years previously. The patient underwent laparoscopic cholecystectomy under a preoperative diagnosis of multifocal gallbladder polyps. Pathologic examination of the resected gallbladder revealed more than 70 adenomatous lesions, a feature consistent with adenoma of the gallbladder. This case suggests a requirement for long-term surveillance of the biliary system in addition to the gastrointestinal tract in patients with familial adenomatous polyposis.

Synchronous occurrence of early neuroendocrine carcinoma and tubular adenocarcinoma in the stomach.

This report describes a patient with early neuroendocrine carcinoma (NEC) and tubular adenocarcinoma in the stomach. A 74-year-old Japanese male experienced epigastralgia. Endoscopic examination revealed two small lesions; one was an elevated lesion with ulceration at the posterior wall of the pre-pylorus and the other was a depressed lesion at the greater curvature of the antrum. Pathological diagnosis of the biopsies indicated poorly differentiated adenocarcinoma from the lesion on the pre-pylorus and well differentiated adenocarcinoma from the lesion on the antrum. He was referred to the surgical outpatient clinic with early double cancer of the stomach. A distal partial gastrectomy with lymph node dissection was performed. A histopathological examination revealed NEC at the lesion on the pre-pylorus and well differentiated tubular adenocarcinoma at the lesion on the antrum. These two lesions were completely separate from each other. Therefore, this case is thought to demonstrate the synchronous occurrence of early NEC and tubular adenocarcinoma in the stomach.