Technique of totally robotic delta-shaped anastomosis in distal gastrectomy.

BACKGROUND: We aimed to clarify the utility of delta-shaped anastomosis (Delta), an intracorporeal Billroth-I anastomosis-based reconstruction technique used after laparoscopy-assisted distal gastrectomy (LADG), in robot-assisted distal gastrectomy (RADG). METHODS: RADG was performed in patients with clinical Stage I gastric cancer, and reconstruction was performed using Delta. The Delta procedure was the same as that performed after LADG, and the operator practiced the procedure in simulated settings with surgical assistants before the operation. After gastrectomy, the scope and robotic first arm were reinserted from separate ports on the right side of the patient. Then, a port on the left side of the abdomen was used as the assistant port from which a stapler was inserted, with the robotic arm in a coaxial mode. The surgical assistant performed functional end-to-end anastomosis of the remnant stomach and duodenal stump using a powered stapler. RESULTS: The mean anastomotic time in four patients who underwent Delta after RADG was 16.5 min. All patients were discharged on the post-operative day 7 without any post-operative complications or need for readmission. CONCLUSIONS: Pre-operative simulation, changes in ports for insertion of the scope and robotic first arm, continuation of the coaxial operation, and use of a powered stapler made Delta applicable for RADG. Delta can be considered as a useful reconstruction method.

Technique of Roux-en-Y reconstruction using overlap method after laparoscopic total gastrectomy for gastric cancer: 100 consecutively successful cases.

BACKGROUND: We have established a standard procedure for Roux-en-Y (RY) reconstruction in laparoscopic total gastrectomy (LTG) using esophagojejunostomy by the overlap method (OL). We report on our RY reconstruction technique and special approaches, and evaluate the usefulness of our reconstruction method based on the surgical results of 100 patients we have experienced to date. METHODS: We performed LTG in 100 patients with gastric cancer. After total gastrectomy using five ports, the resected stomach was extracted through a small laparotomy. Through that, we performed sacrifice of the jejunum, Y limb anastomosis, creation of the lifted jejunum. As the OL, a side-to-side anastomosis of the lifted jejunum to the esophageal stump was laparoscopically performed using a linear stapler in an isoperistaltic direction, and the entry hole was closed with full-thickness suturing. The lifted jejunum was fixed with suture to the duodenal stump at a location where the esophagojejunostomy site was made linear, and the duodenal stump was buried. The mesenteric gap was laparoscopically closed with suture. RESULTS: The median operative time in 100 patients undergoing LTG was 385 min, the median blood loss was 65 mL, and the median time required for the OL was 32 min. The mean hospitalization period was 10 days, and postoperative complications included bleeding requiring reoperation in one patient; other complications such as pancreatic fistula in five patients (5 %) were treated conservatively. No complication associated with anastomosis occurred. CONCLUSION: In RY reconstruction using the OL, there were no complications associated with the anastomosis site in 100 consecutive patients, such as anastomotic leak or stenosis, indicating that it is a very useful and safe reconstruction method.

Evaluation of the delta-shaped anastomosis in laparoscopic distal gastrectomy: midterm results of a comparison with Roux-en-Y anastomosis.

BACKGROUND: Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and published, whereas only a limited number of reports are available on the utility of the delta-shaped anastomosis (Delta). This study compared Delta and Roux-en-Y anastomoses (RY), with the aim to clarify the utility of Delta. METHODS: Stage 1 gastric cancer patients who had undergone LDG with Delta (group D, n = 68) and those who had undergone LDG with RY (group RY, n = 60) were compared in terms of operative outcomes, postoperative clinical symptoms, gastrointestinal fiberscopic findings, and changes in body weight. RESULTS: Both the operative and anastomotic times were significantly shorter in group D (230 and 13 min, respectively) than in group RY (258 and 38 min, respectively) (p < 0.001). Among the complications observed at the anastomotic site, obstruction was seen in one group D patient and two group RY patients but was relieved with conservative management. Postoperative clinical symptoms were reported for 26.4% of the group D patients but had decreased to 5.9% 1 year later. Group RY yielded similar results. Upper gastrointestinal fiberscopy performed 1 year postoperatively showed no intergroup differences in the incidence of gastritis or residual retention and a significantly more frequent occurrence of bile reflux in group D. Postoperative weight changes did not differ between the two groups. CONCLUSIONS: Delta reconstruction after LDG is a safe and effective procedure that is totally laparoscopic, less time consuming, and associated with a favorable postoperative course and a better quality of life.

Simultaneous transabdominal preperitoneal hernia repair and laparoscopic cholecystectomy: A report of 17 cases.

INTRODUCTION: Inguinal hernia repair and cholecystectomy are frequently performed in the field of gastrointestinal surgery. However, reports describing surgical procedures that involve simultaneous transabdominal preperitoneal hernia repair (TAPP) and laparoscopic cholecystectomy (LC), as well as the safety and usefulness of this combination, are limited. Herein, we report a surgical procedure involving simultaneous TAPP and LC (TAPP + LC) and present the outcomes of patients who have undergone this combined surgical procedure, with a particular focus on its safety and usefulness. METHODS: We simultaneously performed TAPP + LC in 17 patients (mean age, 66.5 ± 8.1 years) with concomitant inguinal hernia and gallbladder stones. We assessed surgical outcomes. RESULTS: The mean operative time was 157 ± 39 min, and mean postoperative hospital stay was 3.2 ± 0.6 days. The median cost was $7673 for TAPP + LC. The mean postoperative length of hospital stay was 1.1 ± 0.6 day for TAPP alone and 3.4 ± 1.4 days for LC alone. The median costs of TAPP alone and LC alone were $4932 and $5453, respectively. Regarding intraoperative complications, the inferior epigastric vessels were damaged in two patients, and seroma was detected as a postoperative complication in one; these complications were spontaneously resolved. No mesh- or infection-related complications were noted. CONCLUSION: Simultaneous TAPP + LC is safe and can be regarded as a standard surgical procedure for patients with concomitant inguinal hernia and gallbladder stones. The TAPP + LC combination appears to help prevent the need for two hospitalizations and, thereby, reduces hospital stay and economic burden.

A Giant Duodenal Leiomyoma Showing Increased Uptake on 18F-Fluorodeoxyglucose Positron Emission Tomography.

BACKGROUND: Although 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) is now widely used in their differential diagnosis, it is sometimes difficult to distinguish between benign and malignant diseases. CASE PRESENTATION: A 44-year-old woman was found to have abnormalities on health screening. Magnetic resonance imaging for detailed examination showed an intra-abdominal tumor measuring 12 cm in the major axis near the cranial end of the uterus. Upper gastrointestinal tract endoscopy showed a tumor with an ulcer in the third part of the duodenum, involving half the circumference. Heterogeneous uptake was observed within the tumor on FDG-PET/CT. Based on these findings, the patient underwent surgery for suspected primary malignant lymphoma of the duodenum or gastrointestinal stromal tumor. Laparotomy revealed a 12 cm tumor in the third part of the duodenum. Partial duodenectomy and end-to-end duodenojejunostomy were performed. Pathological findings showed a solid tumor growing from the muscle layer of the duodenum to outside the serous membrane; based on immunostaining, it was diagnosed as a leiomyoma. CONCLUSIONS: Duodenal leiomyomas are originally benign; to date, there have been no reports of uptake in duodenal leiomyomas on FDG-PET/CT; therefore, our case is rare. Leiomyomas should be considered in the differential diagnosis of duodenal neoplastic diseases.

Primary mesenteric neuroendocrine tumor that changed its internal composition from cystic to solid: a case report.

Mesenteric neuroendocrine tumors are usually metastases originating from the small intestine; however, primary mesenteric cases are rare. We present an interesting case of a mesenteric neuroendocrine tumor that changed its internal composition from cystic to solid. A 72-year-old male visited our hospital because of epigastralgia 4 years earlier. A 25-mm tumor was recognized around the terminal duodenum on computed tomography and magnetic resonance imaging, and was diagnosed as a cystic lesion. Over the following 2 years, the tumor grew to 40 mm and its internal composition changed from cystic to solid. The lesion showed positive findings on fluorodeoxyglucose positron emission tomography. Upon laparotomy, a solid tumor was detected in the mesentery of the jejunum near the ligament of Treitz. The tumor was extracted without intestinal resection and was diagnosed as a low-grade neuroendocrine tumor after histopathological and immunohistochemical examination. One year has passed since the operation, and there has been no recurrence.

Treatment of a patient with hemophilia A and hepatitis C virus-related cirrhosis by living-related liver transplantation from an obligate carrier donor.

BACKGROUND: Decompensated hepatitis C virus (HCV)-related cirrhosis is the main indication for liver transplantation. We report the first successful living-related liver transplantation in a 49-year-old hemophilia A patient with end-stage HCV-related cirrhosis using a graft obtained from his 20-year-old daughter, an obligate carrier. METHODS: The donor's autologous fresh-frozen plasma rich in factor VIII (FVIII) by treatment with 1-deamino-8-D-arginine vasopressin was prepared before the operation. At induction, 1-deamino-8-D-arginine vasopressin was given to the donor to increase plasma FVIII level. In addition, autologous fresh-frozen plasma containing high FVIII concentrate was infused intraoperatively. The right lobe was harvested from the donor and transplanted orthotopically. The recipient was treated postoperatively with recombinant FVIII and immunosuppressive agents. RESULTS: The donor did not receive recombinant FVIII or allogenic blood during perioperative periods. No bleeding was encountered in the donor perioperatively. The recipient showed a steady increase in FVIII activity postoperatively and was discharged 40 days after transplantation. Ribavirin and interferon-alpha were provided for 3 months postoperatively to prevent potential recurrence of HCV infection. Serum HCV-RNA by RT-PCR became negative after such treatment. CONCLUSIONS: End-stage liver disease in patients with hemophilia A can be an indication for living-related liver transplantation. Furthermore, a graft from a living-related donor with hemophilia A carrier seems to be suitable provided such individuals receive adequate support for coagulopathies.

Liver transplantation as a therapeutic option for hepatocellular carcinoma.

Better outcomes of the patients receiving liver transplantation for viral hepatitis and hepatocellular carcinoma (HCC) are achieved by improved patient selection and perioperative treatment with antiviral agents including lamivudine, ribavirin and interferon. Patient selection is accomplished by high-quality imaging as well as exclusion of patients with large tumors, obvious extrahepatic disease or macroscopic vascular invasion. Using such criteria, a 5-year survival of 92% has been reached in the Queensland Liver Transplant Service on a small number of highly selected patients with HCC. The treatment algorithm of Makuuchi has guided us in recommending resection, estimating to what extent the liver resection can be performed safely, and timing liver transplantation when it is the only option. Adult-to-adult living-donor liver transplantation is being performed safely in many centers worldwide. The transplantation of liver from living donors to HCC patients, when standard criteria for the likelihood of good outcomes are fulfilled, will increase in Japan in the near future.