Robotic Left Hepatectomy Using the Glissonean Approach and Saline-Linked Bipolar Clamp-Crush Technique.

BACKGROUND: We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. METHODS: The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. RESULTS: The median operative time and estimated blood loss were 395 min and 50 mL, respectively. The median length of postoperative hospital stay was 9 days. Pneumothorax was the only severe postoperative complication. CONCLUSIONS: Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.

Clinical epidemiology of the endoscopic, laparoscopic, and surgical resection of malignant gastric tumors in Japan, 2014-2021: a retrospective study using open data from a national claims database.

BACKGROUND: Gastric cancer is a common malignancy with a high incidence in East Asia. Gastric resection ranges from endoscopic resection to open total gastrectomy. However, nationwide data are lacking. METHODS: This observational study analyzed data from the publicly accessible National Database of Health Insurance Claims and Specific Health Checkups, which includes most national health insurance claims data in Japan. Trends in the types of resection performed for malignant gastric tumors between 2014 and 2021, patients' age and sex distributions, and regional disparities were investigated. RESULTS: The annual number of resections was highest in 2015 (109,000) and lowest in 2020 (90,000) after the COVID-19 pandemic. The proportion of endoscopic resections increased from 47% in 2014 to 57% in 2021 while that of total gastrectomies decreased from 17 to 10%. In 2021, 70% of patients who underwent resection were men. That year, 83.8% of all patients who underwent any type of gastric resection and 87.1% of those who underwent endoscopic submucosal dissection were aged ≥ 65 years. The annual incidence of gastric resection per million population was highest in Tottori (n = 1236) and lowest in Okinawa (n = 251). The proportion of endoscopic resections was highest in Miyagi (66%) and lowest in Aichi (45%) and that of open surgery was highest in Aomori (36%) and lowest in Wakayama (5%). CONCLUSIONS: Gastric malignancy is increasingly treated by endoscopic submucosal dissection rather than open total gastrectomy. However, regional disparities remain in resection type. Standardization of treatment and a more even distribution of specialists are needed.

Application of Extended Reality (Virtual Reality and Mixed Reality) Technology in Laparoscopic Liver Resections.

Background and purpose Laparoscopic liver resection (LLR) has recently gained popularity owing to advances in surgical techniques. Difficulties in LLR may be influenced by anatomical factors. This study presents a comprehensive overview of LLR performed using extended reality (XR) technology. Methods Six patients underwent LLR performed wearing HoloLens2® XR (Microsoft Corporation, Redmond, Washington, United States) technology. We performed dynamic contrast-enhanced CT scans before surgery and used the data to construct three-dimensional images. Results Of the six patients, two were diagnosed with colorectal liver metastases, two with hepatocellular carcinoma, and one with intrahepatic cholangiocarcinoma. The median maximum tumor diameter was 31 mm (range, 23-80 mm). One patient had liver cirrhosis, with Child-Pugh classification grade B. Anatomical resection was performed in three patients (60%), with a median difficulty score of 7 (intermediate). No conversions to open surgery were necessary. The median operative time and estimated blood loss were 444 minutes (range, 337-597 minutes) and 200 mL (range, 100-1000 mL), respectively. Postoperative complications (Clavien-Dindo classification grade II) were observed in one patient. All six cases achieved negative surgical margins. Conclusions LLR using XR technology enhances surgical visualization and anatomical recognition. The incorporation of XR technology into LLR offers advantages over traditional two-dimensional imaging.

Preoperatively diagnosed intraductal oncocytic papillary neoplasm of the pancreas with prominent invasion: a case report.

Previously considered as one of the less-invasive subtypes of intraductal papillary mucinous neoplasm, intraductal oncocytic papillary neoplasm (IOPN) has recently been acknowledged as a new entity of pancreatic tumor. We herein present a case of preoperatively diagnosable IOPN invasion in the stomach and colon. A 78-year-old woman was referred to our hospital for evaluation of anorexia and gastroesophageal reflux. Upper gastrointestinal endoscopy revealed a gastric subepithelial lesion with ulcerated mucosa that required hemostasis. Computed tomography revealed a 96-mm-diameter solid tumor with a well-defined border and centrally positioned necrotic area, extending from the stomach to the transverse colon and pancreatic tail. Because it was suspected to be a pancreatic solid tumor with direct stomach invasion, endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) was performed, which led to a preoperative diagnosis of IOPN. Moreover, laparoscopic pancreatosplenectomy, proximal gastrectomy, and transverse colectomy were performed. Analysis of the surgical specimen revealed that the tumor was IOPN and had invaded the stomach and transverse colon. Lymph node metastasis was also confirmed. These findings indicate that IOPN can manifest as an invasive tumor, and EUS-FNB may be equally helpful for assessing the invaded area of a cystic lesion as it is for a solid lesion.

Quick and Easy Application Method of TachoSil®ï¸ During Laparoscopic and Robotic Liver Resections.

TachoSil®ï¸, a fibrin sealant patch, is a sheet-type hemostatic agent. Therefore, it is technically demanding to put it on the target place especially in laparoscopic surgeries due to the motion restriction of straight-fixed instruments. This article describes a quick and easy technique of TachoSil application during laparoscopic liver surgeries, by sewing it to the laparoscopic gauze in advance. This method allows for one-handed operation and stress-free application even in the situation of active bleeding.

Non-Stick Liver Parenchymal Transection With Saline-Linked Bipolar Clamp-Crush Technique in Robotic Liver Resection.

Background Without satisfactory instruments, liver parenchymal transection during robotic liver resection (RLR) remains challenging. We combined the commonly used bipolar clamp-crush technique with the saline drip, achieving a comfortable liver resection without coagulated liver tissues sticking to the bipolar forceps. Methods Between December 2022 and March 2023, six RLRs were performed using the saline-linked bipolar clamp-crush method for both anatomical and non-anatomical liver resections. We assessed the safety and feasibility of our robotic liver parenchymal transection technique. Results Three of six patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), and the other with intrahepatic bile duct stricture. Three of the six patients received anatomical liver resection, and the other three underwent non-anatomical liver resection. There were no conversions to open surgery. The median operative time and estimated blood loss were 406.5 minutes (196-670 minutes) and 5 ml (5-465 ml), respectively. The median length of the postoperative hospital stay was nine days (7-10 days). Postoperative complications (Clavien-Dindo classification grade II or more) or mortality were not encountered in this cohort. Conclusion We presented here our saline-linked bipolar clamp-crush method for liver parenchymal transection in RLR. By simply adding the saline drip to the commonly used bipolar clamp-crush technique, non-stick and comfortable liver parenchymal transection is now possible. This technique may help overcome the limitations of currently available robotic instruments for liver parenchymal resection.

High predictive ability of apparent diffusion coefficient value for wall-invasion pattern of advanced gallbladder carcinoma.

PURPOSE: The wall-invasion pattern classification of advanced gallbladder carcinoma (GBC) has been reported. However, its association with clinical findings remains unclear. We aimed to clarify relationships between clinicopathological characteristics, prognosis, and apparent diffusion coefficient (ADC) values of advanced GBC based on the wall-invasion pattern. METHODS: We reviewed the data of 37 patients who had undergone advanced GBC cholecystectomy at our institution between 2009 and 2021. Clinicopathological findings, prognosis, and ADC values were retrospectively analyzed. RESULTS: Based on the wall-invasion pattern, patients were classified into infiltrative growth (IG) type (n = 22) and destructive growth (DG) type (n = 15). In the DG-type, the incidence of venous invasion (P = 0.027), neural invasion (P = 0.008), and lymph node metastasis (P = 0.047) was significantly higher than in the IG-type, and recurrent-free survival (RFS) was significantly shorter (P = 0.015); the median RFS was 11.4 months (95% confidence interval, 6.3-16.5 months) in the DG-type and not reached in the IG-type. The ADC value in the DG-type was significantly lower than in the IG-type (median, 1.19 × 10-3 mm2/s vs. 1.86 × 10-3 mm2/s, P < 0.001). The area under the receiver operating characteristic curve for the ADC values to differentiate wall-invasion patterns was 0.95 (95% confidence interval, 0.87-1.00). The optimal cutoff ADC value was 1.45 × 10-3 mm2/s (sensitivity, 92.9%; specificity, 90.9%). CONCLUSIONS: The wall-invasion pattern of advanced GBC is associated with its aggressiveness and prognosis, and can be predicted by ADC values with high accuracy.

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery.

The effect of the AirSeal® insufflation system on hemodynamic parameters, especially end-tidal carbon dioxide (EtCO2), during laparoscopic abdominal surgery remains unclear. This retrospective single-center study included 333 consecutive patients who underwent laparoscopic hepatectomy (n = 43), gastrectomy (n = 69), colectomy (n = 137), or proctectomy (n = 84) using the AirSeal®. Patient demographics and intraoperative hemodynamic parameters, such as EtCO2, peripheral capillary oxygen saturation (SpO2), and arterial systolic blood pressure (ABP), were collected and analyzed. EtCO2 was evaluated during the entire operative period (whole period) as well as the pneumoperitoneum period until specimen removal (pneumoperitoneum period). We defined "positive respiratory and circulatory responses" (positive responses) as a decrease in EtCO2 ≥ 3 mmHg in addition to decreases in SpO2 ≥ 3% and ABP ≥ 10 mmHg simultaneously, which suggest possible carbon dioxide (CO2) embolism. The median EtCO2 values of hepatectomy, gastrectomy, colectomy, and proctectomy in the whole period/pneumoperitoneum period were 37.3/37.4, 37.1/37.3, 37.4/37.9, and 38.2/38.4 mmHg, respectively. The EtCO2 of proctectomy was significantly higher than that of gastrectomy during the whole and pneumoperitoneum periods (P < 0.05). In contrast, the EtCO2 of hepatectomy was comparable to that of the other three surgeries in the whole and pneumoperitoneum periods. Meanwhile, nine (2.7%; eight hepatectomies and one proctectomy) patients showed positive responses, and one who underwent a partial hepatectomy developed a clinically manifested CO2 embolism. Positive responses occurred during venous exposure or bleeding in all nine cases. Although the EtCO2 of hepatectomy was comparable to that of the other surgeries using the AirSeal®, laparoscopic hepatectomy showed a tendency of CO2 embolism. Thus, a secure and careful surgical approach is mandatory for laparoscopic hepatectomy using the AirSeal® insufflation system.

Dissection Around the Superior Mesenteric Artery (SMA) Using LigaSure Maryland During Left Posterior Approach for Pancreaticoduodenectomy.

R0 resection for pancreatic head cancer without exposing the tumor demands complete resection of "mesopancreas". In other words, dividing the proximal jejunal artery and vein at their roots of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) respectively during pancreaticoduodenectomy (PD) is absolutely essential. We present here our standardized dissection procedures around the SMA during the left posterior approach for PD. This procedure is safe and reproducible owing to the secure sealing performance of LigaSureTM Maryland.

Standardized Methods Using EUS-guided Fine-needle Biopsy and a Minimal Medium Creates Three Pancreatic Cancer Organoids.

BACKGROUND/AIM: Recently, endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has been conducted for diagnosing pancreatic ductal adenocarcinoma (PDAC), after which obtained samples were used in organoid cultures. However, no standardized method for PDAC organoid cultures exists. Therefore, to standardize or simplify sample collection and culture methods for PDAC organoids, we performed a floating culture using non-minced specimens obtained by EUS-FNB in a minimal medium, lacking growth factors or inhibitors for pancreatic organoids. PATIENTS AND METHODS: A total of 38 patients with clinically diagnosed PDAC were enrolled in the study. First, EUS-FNB was conducted using a 22- or 25-gauge biopsy needle. Then, a surplus of samples was collected for organoid formation after rapid on-site cytological evaluations of sample adequacy. Subsequently, the established organoids were compared with clinical data and pathological diagnosis, following periodic observations and evaluations for morphology. RESULTS: PDAC organoids were successfully created in 24 of the 38 cases (63.2%), including four cases with pathologically inconclusive EUS-FNB results. Afterward, PDAC organoid morphology was classified into ductal, dormant, and adhesive small cluster (ASC) types. Although the ductal and ASC types were seen separately, they were also seen together in other cases, which we named "mixed type". CONCLUSION: We propose a feasible and straightforward method for establishing organoids, especially for diagnosing PDAC, particularly when the result of EUS-FNB is pathologically inconclusive. Furthermore, PDAC organoids are morphologically classified into three types reported for the first time.

Crucial Roles of the Assistant Surgeon During Laparoscopic Left Hemihepatectomy.

Background Although left hemihepatectomy has been widely performed via the laparoscopic approach, the roles of the assistant surgeon have not been well-documented so far. We herein present our standardized procedures of laparoscopic left hemihepatectomy without Spiegel's lobe resection, focusing on the crucial roles of the assistant surgeon. Methods During laparoscopic left hemihepatectomy without Spiegel's lobe resection, countertraction by the assistant surgeon is quite important especially during isolating the left Glissonean pedicle and transecting liver parenchyma. When securing the left hepatic pedicle using the Glissonean approach, the assistant surgeon pushes Segment 4 of the liver cranially and pulls the tape encircling the hepatoduodenal ligament caudally in the opposite way, orthogonal to the direction of the laparoscopic forceps toward the left portal triad. During liver parenchymal transection, the assistant surgeon pulls the hanging tape across the left lobe of the liver in order to provide a wide and stable liver transection plane. With this standardized technique, nine cases of laparoscopic left hemihepatectomy were performed over the last two years in our department, and the perioperative data were retrospectively analyzed. Results The median age of the nine patients was 70 years (range: 58 - 84 years). Most of the patients were males (77.8%). Five of nine patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), one with inflammatory pseudotumor, and the other one with hepaticolithiasis. There were no conversions to open surgery. The median operative time and estimated blood loss were 337 minutes (range: 219 - 478 minutes) and 100 ml (range: 41 - 375 ml), respectively. The median length of postoperative hospital stay was nine days (range: 7 - 16 days). Major complications (Clavien-Dindo classification grade III or more) were not encountered in our cohort postoperatively. Conclusion We presented here our standardized assistant roles during laparoscopic left hemihepatectomy without Spiegel's lobe resection, which was revealed to be safe and feasible in our cohort.

Oncological evaluation in the perioperative period using cfDNA with BRAF V600E mutation in patients with colorectal cancer.

The detection of circulating cell-free DNA (cfDNA) by liquid biopsy is reported to provide prognostic information in colorectal cancer (CRC). Although the frequency of BRAF V600E mutation in CRC is less than 10%, it is associated with poor responses to conventional chemotherapy. We conducted a prospective study to investigate the relationship between the perioperative mutant allele frequency (MAF) of BRAF V600E and tumor recurrence, and to evaluate the possibility of early detection of recurrence. Among 362 patients who underwent radical resection, cfDNA was extracted from the perioperative blood of 11 CRC patients with BRAF V600E mutation and analyzed using the digital polymerase chain reaction (dPCR) system. The median follow-up time was 22 months, and there were four cases of recurrence. Although there was no correlation between recurrence and the perioperative MAF of BRAF V600E, tumor diameter was correlated with the MAF (p = 0.024), and the MAF increased with time in two patients from whom additional samples were obtained prior to recurrence. In this study, we identified a correlation between the pathological tumor diameter and the MAF, but it was difficult to predict recurrence by measuring cfDNA with BRAF V600E mutation in the perioperative period of radical resection of CRC.

[Enhancement of Pesticide Peak Response in GC-MS in the Presence of Multiple Co-Existing Reference Pesticides].

We carried out a collaborative study in six laboratories to confirm the universality of the enhancing effect of co-existing reference pesticides on the GC-MS peak response to a target pesticide (malathion, procymidone, or flucythrinate). First, we confirmed the response enhancement of the target pesticides with increasing numbers of co-existing reference pesticides in solution. Then, using diluted green soybean matrix, we analyzed the target pesticides with two types of matrix-matched calibration, containing the target pesticides or 166 other pesticides. In both cases, the response-enhancing effect of co-existing pesticides was confirmed in all laboratories. The enhancement was reduced by addition of green soybean matrix to the sample and calibration solutions. Our results show that it is necessary to estimate the peak response-enhancing effect of co-existing pesticides in the calibration solution to obtain accurate results with GC-MS determination. The enhancing effect could be reduced by addition of food matrix to the sample and calibration solutions.

Efficacy and safety of endoscopic submucosal dissection under general anesthesia.

AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) under general anesthesia. METHODS: From January 2011 to July 2014, 206 consecutive patients had undergone ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum were enrolled in this retrospective study. The efficacy and safety of ESD under general anesthesia were assessed. RESULTS: The en bloc resection rate of esophageal, gastric, and colorectal lesions was 100.0%, 98.3%, and 96.1%, respectively. The complication rate of perforation and bleeding were 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. No cases of aspiration pneumonia were observed. All complications were managed by conservative treatment, with no surgical intervention required. CONCLUSION: With the cooperation of an anesthesiologist, ESD under general anesthesia appears to be a useful method, decreasing the risk of complications.

Long-term outcome of peroral endoscopic myotomy for achalasia treatment in a 9-year-old female patient.

Achalasia is a primary motility disorder with incomplete lower esophageal sphincter relaxation; it has an annual incidence of 0.11 cases per 100 000 children. Peroral endoscopic myotomy (POEM) is a new endoscopic treatment method for achalasia. Reports about POEM in pediatric patients are rare. We herein report the case of a 9-year-old female patient with achalasia who underwent POEM. The patient underwent endoscopic balloon dilatation because medication was not effective at a previous hospital; however, endoscopic balloon dilatation was not effective either. She then underwent successful POEM upon admission at our hospital. The patient was symptom-free at 2 years postoperatively with no signs of esophagitis in the absence of proton-pump inhibitor therapy.

Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first over 100 patients with short-term follow-up.

BACKGROUND: POEM is a recently developed achalasia treatment method, which combines the efficacy of surgical myotomy with the benefits of endoscopic procedures. Very few studies have focussed on the efficacy and usefulness of POEM in over 100 cases. METHODS: The first 100 adult patients treated according to standard POEM technique in a single center and followed up for 3 months were identified and included in this study (men 42; women 58; mean age 48.2 ± 18.8; range 9-91 years) The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and monitoring pH. RESULTS: Mean operative time was 150.8 ± 49.3 min (75-370 min). Adverse events over Grade IIIb by the Clavien-Dindo classification were not encountered. The mean preoperative and postoperative lower esophageal sphincter pressures were 43.6 ± 26.2 and 20.9 ± 12.7 mmHg, respectively, indicating a statistically significant decrease after POEM (P < 0.05). The mean preoperative and postoperative integrated relaxation pressure values were 33.5 ± 15.2 and 15.3 ± 6.5 mmHg (P < 0.05). Furthermore, the Eckardt score significantly decreased from 5.9 ± 2.5 preoperatively to 0.8 ± 0.9 postoperatively (P < 0.05). Clinical success was documented in 99 % of the patients. Short-term outcomes after POEM were extremely good and independent of the age, type of achalasia, and previous treatment method. The percent of monitoring time with a pH < 4 was 25.6 % (22/86) in patients not on proton-pump inhibitors. Nine patients were diagnosed with symptomatic gastroesophageal reflux disease (GERD); patients with reflux esophagitis and symptomatic GERD improved with PPI treatment. CONCLUSIONS: Our results confirm the efficacy of POEM in a large patient series and support POEM as one of the first-line achalasia therapies in the near future.

Successful treatment of gallbladder dyskinesia by laparascopic cholecystectomy: Report of a case.

A 75-year-old woman entered the hospital emergency room complaining of severe epigastric pain. She had experienced similar repeated abdominal pain for some time. Biliary tract dyskinesia was suspected based on the Roma III criteria. When drip infusion cholangiography-CT with egg yolk load was performed, the contraction rate of the gallbladder before and after applying the load was as low as 33.5%. Upon biliary tract scintigraphy, biliary excretion into the intestinal tract was found to be normal, but after the egg yolk load, the biliary excretion rate in the gallbladder decreased to 14.5%. Laparoscopic cholecystectomy was performed under a diagnosis of flaccid-type gallbladder dyskinesia. A few reports exist describing cases in which cholecystectomy was performed for gallbladder dyskinesia, so we are submitting this report with some bibliographic consideration.

Loss of follicle-stimulating hormone receptor function causes masculinization and suppression of ovarian development in genetically female medaka.

FSH, a glycoprotein hormone, is circulated from the pituitary and functions by binding to a specific FSH receptor (FSHR). FSHR is a G protein-coupled, seven-transmembrane receptor linked to the adenylyl cyclase or other pathways and is expressed in gonadal somatic cells. In some nonmammalian species, fshr expression is much higher in the ovary than in the testis during gonadal sex differentiation, suggesting that FSHR is involved in ovarian development in nonmammalian vertebrates. However, little is known of FSHR knockout phenotypes in these species. Here we screened for fshr mutations by a medaka (Oryzias latipes) target-induced local lesion in the genomes and identified one nonsense mutation located in the BXXBB motif, which is involved in G protein activation. Next, we used an in vitro reporter gene assay to demonstrate that this mutation prevents FSHR function. We then analyzed the phenotypes of fshr mutant medaka. The fshr mutant male medaka displayed normal testes and were fertile, whereas the mutant female fish displayed small ovaries and were infertile because vitellogenesis was inhibited. The mutant females also have suppressed expression of ovary-type aromatase (cyp19a1a), a steroidogenic enzyme responsible for the conversion of androgens to estrogens, resulting in decreased 17ß-estradiol levels. Moreover, loss of FSHR function caused female-to-male sex reversal in some cases. In addition, the transgenic overexpression of fshr in fshr mutants rescued FSHR function. These findings strongly suggest that in the medaka, FSH regulates the ovarian development and the maintenance mainly by the elevation of estrogen levels. We present the first FSHR knockout phenotype in a nonmammalian species.