Intragastric free cancer cells may be attached to automatic staplers during anastomosis in patients with gastric cancer.

BACKGROUND: Automatic staplers are often used to reconstruct the digestive tract during surgeries for gastric cancer. Intragastric free cancer cells adhering to automatic staplers may come in contact with the laparoscopic port area and progress to port site recurrence. This study aimed to investigate the presence/absence of cancer cells adhering to automatic staplers during gastric cancer surgery using cytological examinations. We further determined the positive predictive clinicopathological factors and clinical implications of free cancer cells attached to automatic staplers. METHODS: This study included 101 patients who underwent distal gastrectomy for gastric cancer. Automatic staplers used for anastomosis in gastric cancer surgeries were shaken in 150 ml of saline solution to collect the attached cells. Papanicolaou stains were performed. We tested the correlation between cancer-cell positivity and clinicopathological factors to identify risk factors arising from the presence of attached cancer cells to the staplers. RESULTS: Based on the cytology, cancer cells were detected in 7 of 101 (6.9%) stapler washing fluid samples. Univariate analysis revealed that circular staplers, type 1 tumors, and positive lymph nodes were significantly associated with higher detection of free cancer cells adhering to staplers. No significant differences in other factors were detected. Of the seven cases with positive cytology, one developed anastomotic recurrence. CONCLUSIONS: Exfoliated cancer cells adhered to the automatic staplers used for anastomoses in 6.9% of the staplers used for distal gastrectomies in patients with gastric cancer. Staplers used for gastric cancer surgeries should be handled carefully.

Early-stage gastric cancer with solitary brain metastasis four years after curative surgery: a case report and literature review.

Brain metastasis post-curative gastrectomy for early-stage gastric cancer is extremely rare. We present herein, a case of solitary brain metastasis that developed 4 years post-curative surgery for early-stage gastric cancer. A 60-year-old man had early-stage gastric cancer 4 years prior to presentation and underwent laparoscopy-assisted distal gastrectomy with lymph node dissection. The pathological TNM classification was T1b (submucosal) N0M0. He underwent scheduled examinations and had no recurrence. 4 years postoperatively, he presented to the emergency department with sudden onset of nausea, vomiting, and inability to speak clearly. Brain computed tomography revealed a 17-mm nodule in the right cerebral hemisphere and midline shift. The tumor could not be radically resected for anatomical reasons, and incisional biopsy was performed for histological examination. Histological examination confirmed the diagnosis of a poorly differentiated adenocarcinoma from the previous gastric cancer. Gamma knife radiosurgery and chemotherapy were scheduled. 28 months after brain metastasis, multiple liver and lung metastases appeared. The patient died 30 months after developing brain metastasis. Brain metastasis may occur during long-term follow-up even after curative resection of early-stage gastric cancer. In patients with a history of gastric cancer and neurological symptoms, brain metastasis should be considered.

Bilateral Flank Compression Maneuver for Reducing Pain on Coughing after Abdominal Surgery: A Prospective Study.

BACKGROUND: Despite the major advances in analgesic techniques, pain relief in coughing after abdominal surgery remains challenging. Cough-related pain causes postoperative respiratory complications by impairing sputum clearance; nevertheless, an effective technique to abolish it is not yet available. We devised the bilateral flank compression (BFC) maneuver, in which the flanks are compressed medially using both hands. We conducted a prospective, single-center, single arm, nonrandomized, open-label, interventional trial, to investigate whether the BFC maneuver relieves cough-related pain after abdominal surgery and examined the efficacy of this maneuver in relation to patient characteristics and surgical factors. STUDY DESIGN: Participants were patients who underwent gastroenterologic surgery (except for open inguinal hernia repair) at the Department of Surgery, Kyorin University School of Medicine. We evaluated postoperative pain, from postoperative days (PODs) 1 to 7, on coughing, with and without the BFC maneuver, using the Prince Henry pain scale. RESULTS: We finally analyzed 514 patients. On each of the first 7 PODs, the BFC maneuver significantly relieved cough-related pain, especially on POD1; (the mean pain scores [standard deviation] with and without the BFC maneuver were 0.98 [1.030] vs 1.63 [1.112] points, p < 0.0001). On each POD, more patients were free of cough-related pain with than without the BFC maneuver, with the most marked difference on POD7 (52.0% [208/400] vs 16.8% [67/400], p < 0.0001). CONCLUSIONS: The BFC maneuver relieves cough-related pain after abdominal surgery and may help prevent of postoperative pulmonary complications.

STK11 p.F354L Germline Mutation in a Case of Multiple Gastrointestinal Tumors.

Serine/threonine kinase 11 (STK11) is known as a critical tumor-suppressor gene that is frequently mutated in a broad spectrum of human cancers. Among these, the p.F354L mutation of STK11 has been identified in sporadic colon or lung cancer cases. Here, we report the case of a 75-year-old male patient who underwent surgical treatment for multiple tumors of the gastrointestinal system. Genetic mutations were screened in all resected samples, including duodenal high-grade adenoma, gastric high-grade adenoma, rectal adenocarcinoma, and liver metastasis of rectal adenocarcinoma, by next-generation sequencing for mutational hotspots involving 50 oncogenes and tumor suppressor genes. The characteristic hamartomatous polyp of Peutz-Jeghers syndrome was not detected in any tumor specimen. However, all samples as well as the normal rectal mucosa harbored the genetic mutation p.F354L in STK11. In addition, somatic mutations coexisted in the tumor samples, including KRAS p.A146T, TP53 p.G238X, and APC p.T1556fs in the duodenal adenoma; TP53 p.G238Y and APC p.T1556fs in the gastric adenoma; and TP53 p.R282W in the rectal adenocarcinoma and metastatic liver cancer. No somatic mutation was detected in the normal rectal mucosa as a control sample. To our knowledge, this is the first report of an STK11 germline mutation in a patient with multiple tumors of the gastrointestinal tract.

Gastric washing by distilled water can reduce free gastric cancer cells exfoliated into the stomach lumen.

PURPOSE: Intragastric free cancer cells in patients with gastric cancer have rarely been studied. The purpose of this study was to investigate the detection rate of intragastric free cancer cells in gastric washes using two types of solutions during endoscopic examination. We further clarified risk factors affecting the presence of exfoliated free cancer cells. METHODS: A total of 175 patients with gastric cancer were enrolled. Lactated Ringer's solution (N = 89) or distilled water (DW; N = 86) via endoscopic working channel was sprayed onto the tumor surface, and the resultant fluid was collected for cytological examination. We compared the cancer-cell positivity rate between the two (Ringer and DW) groups. We also tested the correlation between cancer-cell positivity and clinicopathological factors in the Ringer group to identify risk factors for the presence of exfoliated cancer cells. RESULTS: The cancer-cell positivity rate was significantly higher in the Ringer group than that in the DW group (58 vs 6%). Cytomorphology in the Ringer group was well maintained, but not in the DW group. The larger tumor size (≥ 20 mm) and positive lymphatic involvement were significant risk factors of exfoliated free cancer cells. CONCLUSIONS: Cancer cells can be highly exfoliated from the tumor surface into the gastric lumen by endoscopic irrigation in large gastric cancer with lymphatic involvement. Gastric washing by DW can lead to cytoclasis of free cancer cells; therefore, it may minimize the possibility of cancer-cell seeding in procedures carrying potential risks of tumor-cell seeding upon transluminal communication, such as endoscopic full-thickness resection and laparoscopy-endoscopy cooperative surgery.

Comparison between endoscopic and laparoscopic removal of gastric submucosal tumor.

BACKGROUND AND AIM: A retrospective study was conducted to compare two resection methods, namely, endoscopic resection (ER) procedures (endoscopic submucosal dissection [ESD], endoscopic muscularis dissection [EMD], and endoscopic full-thickness resection [EFTR]) and laparoscopic resections (LR) (laparoscopic endoscopic cooperative surgery [LECS] and laparoscopic wedge resection). METHODS: Seventy-three patients who underwent ER (N = 33: ESD, N = 4; EMD, N = 15; EFTR, N = 14) or LR (N = 39: LECS, N = 16; wedge resection, N = 23) for gastric submucosal tumor (G-SMT) smaller than 50 mm were included in this study. Patient/tumor characteristics and intra/postoperative factors were compared between the ER and LR groups. RESULTS: The ER group had a significantly higher percentage of intraluminal growing type of tumor (100% vs 41%) and smaller tumor size (23 vs 33 mm) than the LR group. The ER group had a significantly shorter operative time (93 vs 145 min) and less blood loss (13 vs 30 mL) than the LR group. In the ER group, three patients who had tumors located on the anterior wall of the stomach required laparoscopic closure after EFTR because of difficulty in endoscopic closure of the gastric-wall defect. Postoperative complication rates and duration of postoperative hospital stays did not differ between the two groups. CONCLUSIONS: ER may be technically feasible, safe, less invasive, and oncologically appropriate options for selected patients with the intraluminal growing type of G-SMT smaller than 30 mm. EFTR may be more reasonable alternatives to LR in selected patients with a small G-SMT located on the lesser curvature side.

Laparoscopy-assisted full-thickness resection of the duodenum for patients with gastrointestinal stromal tumor with ulceration.

INTRODUCTION: Gastrointestinal stromal tumor (GIST) with ulceration may potentially disseminate into the peritoneal cavity after laparoscopic local wedge resection (full-thickness resection) when the intestinal wall is opened under the aeroperitoneum. To prevent this intraoperative tumor seeding, we developed laparoscopy-assisted full-thickness resection (LAFTR) of the duodenum for GIST with ulceration. Here, we present the preliminary results of LAFTR. METHODS: Three patients with duodenal GIST with ulceration underwent LAFTR. LAFTR consists of four major procedures: (i) a laparoscopic Kocher maneuver (mobilization of the pancreatoduodenum); (ii) the creation of a small upper median laparotomy; (iii) the extracorporeal completion of the full-thickness resection under direct vision; and (iv) extracorporeal hand-sewn closure of the duodenal defect. RESULTS: LAFTR was successfully performed without any intraoperative adverse events. The mean operating time and estimated blood loss were 182 min and 34 mL, respectively. Postoperative contrast roentgenography showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. None of the patients developed peritoneal recurrence. CONCLUSIONS: LAFTR can eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracoporeally. Meticulously hand-sewn closures of the duodenal defect can minimize the possibilities of anastomotic insufficiency and deformity. LAFTR is a feasible, safe, and minimally invasive treatment for patients with GIST with ulceration in the first and second portions of the duodenum.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy.

A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.

Laparoscopy-assisted transduodenal excision of superficial non-ampullary duodenal epithelial tumors.

INTRODUCTION: Transduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low-grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy-assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non-ampullary duodenal epithelial tumors. METHODS: Three patients with superficial non-ampullary duodenal epithelial tumors (mucosal adenocarcinoma, n = 1; tubular adenoma, n = 2) underwent LATDE. LATDE consists of four major procedures: (i) laparoscopic wide Kocher maneuver (mobilization of the pancreaticoduodenum); (ii) extracorporeal approach to the fully mobilized duodenum through the upper median longitudinal incision (4 cm in length); (iii) tumor excision by submucosal dissection under direct vision through longitudinal duodenotomy (4 cm in length); and (iv) hand-sewn closure of the mucosal defect and duodenotomy. RESULTS: LATDE was successfully carried out without any intraoperative or postoperative adverse events. The mean operating time and estimated blood loss were 155 min and 17 mL, respectively. Contrast roentgenography on postoperative day 4 showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. CONCLUSIONS: LATDE could eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracorporeally. The meticulously hand-sewn closures of the mucosal defect and duodenotomy can minimize the possibility of postoperative hemorrhage and/or anastomotic leakage. LATDE is a feasible, safe, and minimally invasive treatment for patients with superficial non-ampullary duodenal epithelial tumors that have no risk of lymph node metastasis in the first and second portions of the duodenum.

Single-incision multiport laparoendoscopic surgery using a newly developed short-type flexible endoscope: a combined procedure of flexible endoscopic and laparoscopic surgery.

BACKGROUND AND OBJECTIVE: We hypothesized that using a flexible endoscope as a working scope in laparoscopic surgery through a single incision might provide many benefits. To this end, a short-type flexible endoscope with a working length of 600 mm was newly developed. In this animal experimental study, we aimed to evaluate the technical feasibility of our new approach, single-incision multiport laparoendoscopic (SIMPLE) cholecystectomy, using this endoscope. METHODS: Eight pigs were subjected to SIMPLE cholecystectomy using the short-type flexible endoscope. The endoscope was inserted through a 12-mm trocar in an SILS Port followed by the insertion of two additional 5-mm trocars in the SILS Port. Encirculation and ligation of the pedicle of the cystic artery and duct were carried out using laparoscopic instruments through the 5-mm trocars, while the dissection of the gallbladder from the intrahepatic fossa was predominantly performed using a cutting device through the endoscope. RESULTS: A complete gallbladder excision, with complete encirculation and ligation of the pedicle, was completed in all cases. The mean operating time was 58 min (range 34-78 min). The endoscope provided a good view of the operating field, and it allowed some degree of freedom to the working laparoscopic instruments without compromising the field of view. Dissection of the gallbladder using the cutting device through the endoscope was much easier than that using the laparoscopic device, because the articulating instruments together with the endoscope enabled operation with triangulation. Furthermore, the water-jet and suctioning functions and the self-cleaning lens capability of the endoscope served the surgery well. CONCLUSIONS: SIMPLE cholecystectomy using the newly developed short-type flexible endoscope is a technically feasible procedure. Using this flexible endoscope for various tasks, such as resection, suctioning, and smoke evacuation, can make the surgical procedures easier.

Long-term outcomes of combination of endoscopic submucosal dissection and laparoscopic lymph node dissection without gastrectomy for early gastric cancer patients who have a potential risk of lymph node metastasis.

BACKGROUND: Our recently developed procedure, a combination of endoscopic submucosal dissection (ESD) and laparoscopic lymph node dissection (LLND), may lead to the elimination of unnecessary gastrectomy in early gastric cancer (EGC) patients having a potential risk of lymph node metastasis (LNM). OBJECTIVE: To examine the long-term outcomes of the combination of ESD and LLND. DESIGN: A retrospective study using consecutive data. SETTING: Single academic center. PATIENTS AND INTERVENTIONS: Twenty-one EGC patients having a potential risk of LNM were treated by ESD followed by LLND. MAIN OUTCOME MEASUREMENTS: Long-term outcomes of the combination of ESD and LLND. RESULTS: The histopathological examination of the dissected lymph nodes confirmed the absence of LNM in 19 of the 21 patients. Two patients who had LNM were followed without any additional surgery in accordance with the patients' wishes. During the median follow-up of 61 months, all of the patients were alive without any recurrent disease. Two patients (10%) had symptoms such as abdominal distention and belching, which were associated with disturbed gastric emptying between meals. Endoscopic examination 2 years postoperatively revealed food residue problems in 3 patients (15%). However, the preoperative quality of life was restored with no dietary restrictions, and body weight was well maintained in all of the patients. LIMITATIONS: A retrospective study with a small number of patients. CONCLUSIONS: The combination of ESD and LLND can be an effective, minimally invasive treatment that maintains long-term quality of life for selected EGC patients having a potential risk of LNM.

Laparoscopic lymph node dissection after endoscopic submucosal dissection: a novel and minimally invasive approach to treating early-stage gastric cancer.

BACKGROUND AND OBJECTIVE: Endoscopic submucosal dissection (ESD), a newly developed endoscopic mucosal resection (EMR) technique, can completely cure a differentiated mucosal gastric cancer smaller than 2 cm. For early-stage gastric cancers (EGCs) deviating from the above-mentioned criterion, gastrectomy with lymph node dissection is performed for potential risk of lymph node metastasis (LNM). However, many of surgical EGC cases actually do not have LNM, indicating this surgery may not be necessary for many cases of EGC. To avoid this unnecessary surgery, we have introduced laparoscopic lymph node dissection (LLND) after ESD. Standard gastrectomy with extended lymph node dissection is indicated for patients if LLND reveals LNM. We present our novel approach and the preliminary results of EGC patients having potential risk of LNM. METHODS: Five patients with EGC deviating from the EMR criterion underwent the combination of ESD and LLND. ESD was performed using a newly developed insulation-tipped diathermic knife. Lymph nodes, which were determined on the basis of the location of the primary tumor and lymphatic drainage of the stomach, were removed laparoscopically. The lymphatic drainage was visualized by submucosally injecting indocyanine green (ICG) around the post-ESD ulcerative scars during intraoperative gastroscopy. RESULTS: The ESD enabled en bloc resection without any complications. The resected margins of all the lesions were free of cancer cells vertically and horizontally. LLND was successfully performed without any complications. The mean number of the dissected lymph nodes was 15 (range 6 to 22). In 4 of the 5 patients, the dissected lymph nodes were free of cancer cells, and therefore, the combination of ESD and LLND was considered a definitive treatment. The remaining patient was found to have LNM but chose not to undergo any surgery. During follow-ups, the patients' previous quality of life was restored without any tumor recurrence. CONCLUSIONS: The combination of ESD and LLND enables the complete resection of the primary tumor and the histologic determination of lymph node status. This combination treatment is a potential, minimally invasive method, and may obviate unnecessary gastrectomy without compromising curability for EGC patients having the potential risk of LNM.