Clinical Outcome and Surgical Technique of Laparoscopic Posterior Rectopexy Using the Mesh With Anti-adhesion Coating.

We herein present an innovative technique of laparoscopic posterior mesh rectopexy (LPMR) for full-thickness rectal prolapse and report the clinical outcomes in our institution. Ten consecutive patients who were treated with our latest LPMR technique using mesh with an anti-adhesion coating from June 2014 to May 2017 were retrospectively analyzed. All patients were women with a mean age of 63.6 years (range, 39 to 82 y). The median operative time and blood loss volume were 197.5 minutes (range, 156 to 285 min) and 0 mL (range, 0 to 152 mL), respectively. No perioperative complications occurred, including surgical site infection, pneumonia, urinary dysfunction, and intestinal obstruction. The median follow-up duration was 768 days (range, 396 to 1150 d). During the follow-up, the cumulative incidence of full-thickness rectal prolapse and any mesh-related complications was 0. It may be possible to eliminate retroperitoneal closure using a mesh with an anti-adhesion coating. Our LPMR technique appears safe and acceptable.

Three cases of synchronous laparoscopic resection for gastric and colonic cancer.

Case 1 was an 84-year-old female who suffered from a superficial elevated lesion within depressed area (0 IIc+IIa) from the lesser curvature to the posterior wall at the middle corpus of the stomach and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. Case 2 was a 70-year-old male who suffered from a superficial depressed lesion (0 IIc) at the lesser curvature of the gastric angle and a superficial elevated lesion (0 IIa) at the cecum. Case 3 was a 58-year-old male who suffered from a superficial depressed lesion (0 IIc) from the lesser curvature to the posterior wall at the middle corpus of the stomach, and an elevated lesion (type 1) and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. In 3 cases, we first inserted 5 or 6 trocars and performed laparoscopic distal gastrectomy with groups 1 and 2 lymph node dissection according to the Japanese Classification of Gastric Carcinoma. Subsequently, in case 1, 1 additional port was inserted at the right lower quadrant for sigmoidectomy; in case 2, two trocars were added for ileocecal resection; and in case 3, one additional port was inserted at the median hypogastric region for sigmoidectomy. In cases 1 and 2, Billroth II reconstruction was performed using a laparoscopic linear stapling device (endo-GIA) and, in case 3, Roux-en-Y reconstruction was performed using endo-GIA, after distal gastrectomy. The double stapling technique using a conventional circular stapling device was performed after pulling out the specimen from the paraumbilical port after colectomy in case 1, whereas an end-to-end triangular suture using endo-GIA was used extracorporeally through the paraumbilical port in case 2 and the median hypogastric port in case 3. The operative durations of cases 1, 2, and 3 were 315, 340, and 495 minutes and the amounts of blood loss were 80, 300, and 440 mL, respectively. Except for the need to retain the drain until the tenth postoperative day because of serous discharge in case 1, no postoperative complications occurred. The postoperative commencement of oral feeding was on the fifth day in case 1 and on the third day in cases 2 and 3. All cases made a quick recovery and they were discharged from hospital on the nineteenth, thirteenth, and tenth day after operation, respectively. Double cancer patients with gastric and colonic carcinomas were thought to be very suitable for laparoscopic surgery because by avoiding a total median skin incision, there is less wound pain and quicker postoperation recovery.

[Resection of cancer of the cardia enabled by combined treatment with S-1 and paclitaxel after esophageal stenting for impaired patency complicating stage IV gastric cancer - a case report].

The patient was a 47-year-old man who was discovered to have Borrmann type 4 cancer of the cardiac region of the stomach associated with esophageal invasion during upper GI endoscopy and was histopathologically diagnosed with poorly-differentiated adenocarcinoma. Invasion of the aorta was suspected based on a CT examination, and resection was judged to be impossible. Since the tumor was associated with impaired patency, after first inserting a metallic stent, the patient was treated with 4 cycles of S-1 100 mg/body for 2 weeks and paclitaxel (PTX) 120 mg/body by intravenous drip infusion on days 1 and 15 for 2 weeks followed by a 2-week rest period. The tumor regressed considerably, and total gastrectomy and lower esophagectomy with D1+ a lymph node resection through a left thoracolaparotomy became possible. A bypass operation or palliative resection is sometimes performed when complicated by impaired patency. In our patient, after achieving an improvement in QOL by stenting, resection became possible as a result of a response to chemotherapy with S-1. However, when considering resection after chemotherapy it seemed necessary to be careful to insert the stent as close as possible to the proximal margin of the tumor so as not to broaden the extent of the esophageal resection.

Self-expandable metallic stent for unresectable malignant strictures in the esophagus and cardia.

OBJECTIVE: Self-expandable metallic stent (EMS) placement has been the first choice for dysphagia because of the certainty over its safety, low invasiveness, and immediate efficacy. However, there still remain some problems in relation to the EMS placement site and anticancer therapies before and after EMS placement. METHODS: Consecutive 78 patients in whom EMS was placed due to the unresectable malignant stricture in the esophagus or cardia from July 1995 to August 2003 in our department were studied. RESULTS: Gastroesophageal reflux was found in 5 of 8 patients after placement of conventional EMS for the stricture in the gastroesophageal junction. Meanwhile, acid and bile reflux into the esophagus were not detected by pH and bilirubin monitoring, respectively, in 6 patients after placement of the EMS with an anti-reflux mechanism for the stricture in the gastroesophageal junction. The median survival period of all patients after EMS placement was 123 days. The median survival period of 7 patients with radiotherapy only after EMS placement was 138 days and that of 17 patients with radiotherapy before EMS placement was 60 days, which was shorter than that of the former (p<0.05). On the other hand, the median survival period after hospital admission due to dysphagia of these 7 patients was longer than that of 17 patients with radiotherapy only before EMS placement, although, the difference was not significant. CONCLUSION: EMS with an antireflux mechanism is not commercially available in Japan and approval is urgently required. The indication of radiotherapy associated with EMS placement is to be studied further.

Surgical repair of esophagobronchial fistula caused by radiation injury.

We present an unusual case of a benign esophagobronchial fistula caused by radiotherapy to treat esophageal carcinoma which was closed successfully. A 62-year-old man with superficial squamous cell carcinoma of the esophagus underwent radiotherapy, including 60 Gy externally and 10 Gy intraluminally from January to March 1995. Esophagography revealed a fistula between the esophagus and left main stem bronchus on January 14, 1996. No residual cancer existed. Neither stenting with a silicone tube nor with a covered flexible metallic stent occluded the fistula. Thoracic esophagectomy, closure of the esophagobronchial fistula using a 2-cm nubbin of esophageal wall, surrounding the orifice of the fistula and antesternal gastric pull-through reconstruction with mediastinal lymphadenectomy were performed. The postoperative course was uneventful and there is no evidence of recurrence of the fistula or the cancer 5 years postoperatively. Radiotherapy may cause esophagobronchial fistula even in cases of superficial esophageal cancer. Bypass surgery should be considered because stenting is not effective for benign fistula without stricture.