Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema.

BACKGROUND: Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery. METHODS: Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium. RESULTS: The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs. CONCLUSION: The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.

From the Knife to the Endoscope-a History of Bariatric Surgery.

PURPOSE OF REVIEW: Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time. RECENT FINDINGS: This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

Minimal-invasive gastrectomy: what the west can learn from the east?

Minimal-invasive gastrectomy has been established as commonly used method for the early gastric cancer in Korea and Japan. From the first laparoscopic cancer gastrectomy in 1992 in Japan, numerous prospective randomized trials from these two countries have gained the evidence for non-inferiority or even specific benefits compared to open surgery. In Korea, the "Korean Laparoscopic Gastrointestinal Surgical Study Group" (KLASS group) founded, in 2004, successfully gained evidence not only in regards of oncological safety of laparoscopic gastrectomy, but also for the impact of different reconstruction methods and alternative extents of luminal resection on postoperative outcome and quality of life. Awaited results of latest studies from Korea, Japan, and China may suggest laparoscopic approaches as an option even in advanced gastric cancers. These studies could potentially be the starting point to find the role of laparoscopic gastrectomy in the west, where the incidence of gastric cancer is rather lower; the cancers are mostly diagnosed in advanced stages, and often, a perioperative chemotherapy is applied. Robotic (-assisted) gastrectomy was not shown to be superior to laparoscopic resection in Korea, but new technological developments should continuously be evaluated in clinical trials regarding a potentially favorable learning curve, which might play a key role in regards of the limited case load per center of gastric cancer in the west. This review summarizes the history of laparoscopic cancer gastrectomy in Asia and points out the important steps of establishing a nation-wide scientific network to support the surgical routine by the necessary evidence with a focus on Korea.

Laparoscopic sleeve gastrectomy: More than a restrictive bariatric surgery procedure?

Sleeve gastrectomy (SG) is a restrictive bariatric surgery technique that was first used as part of restrictive horizontal gastrectomy in the original Scopinaro type biliopancreatic diversion. Its good results as a single technique have led to a rise in its use, and it is currently the second most performed technique worldwide. SG achieves clearly better results than other restrictive techniques and is comparable in some aspects to the Roux-en-Y gastric bypass, the current gold standard in bariatric surgery. These benefits have been associated with different pathophysiologic mechanisms unrelated to weight loss such as increased gastric emptying and intestinal transit, and activation of hormonal mechanisms such as increased GLP-1 hormone and decreased ghrelin. The aim of this review was to highlight the salient aspects of SG regarding its historical evolution, pathophysiologic mechanisms, main results, clinical applications and perioperative complications.

The first successful gastrectomy.

In the latter part of the 19th century safe and effective elective abdominal surgery seemed to be, at last, more than just a dream. This possibility followed two vital advances. First, the introduction of anaesthesia, heralded by the use of ether by William Morton in Boston in 1845 and then of chloroform by J.Y. Simpson in Edinburgh a couple of years later, and second the work of Joseph Lister on the antiseptic method of surgery, following his publication on this subject in the Lancet in 1867. (Interestingly enough, as far as I know, Lister himself never performed a laparotomy--if anything he was principally an orthopaedic surgeon.) The major elective abdominal problem facing the surgeon at that time was the surgical management of carcinoma of the stomach--then the commonest killing cancer.

Ever-changing endoscopic treatment for early gastric cancer: yesterday-today-tomorrow.

Endoscopic resection has been an optimal treatment for selected patients with early gastric cancer (EGC) based on advances in endoscopic instruments and techniques. As endoscopic submucosal dissection (ESD) has been widely used for treatment of EGC along with expanding ESD indication, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis (LNM). Recently, new techniques including ESD or endoscopic full-thickness resection combined with sentinel node navigation enable minimal tumor resection and a laparoscopic lymphadenectomy in cases of EGC with high risk of LNM. This review covers the development and challenges of endoscopic treatment for EGC. Moreover, a new microscopic imaging and endoscopic techniques for precise endoscopic diagnosis and minimally invasive treatment of EGC are introduced.

Surgical treatment of gastric cancer in Japan, trend from standardization to individualization.

Japan has a huge number of patients with gastric cancer and has developed various surgical treatments for this disease.This paper intends to introduce our strategies against gastric cancer. The Japanese Gastric Cancer Association was established in 1962. Its major purposes are promotion of basic and clinical researches and popularization of the latest knowledge and technologies. For the purposes, the association organized the annual scientific meeting and the nationwide registry by member hospitals, and published the Japanese Classification of Gastric Cancer (1) and the Treatment Guide Line (2). The nationwide registry reported that proportion of Stage-I cancer was 22.5% in 1963-66,which increased to 59.3% in 2008 (3,4,5). 11,261 patients with gastric resection were registered by 187 hospitals in 2008. 63 patients were died within 30 postoperative days and the direct death rate was 0.55%. 5 year survival rate (5YSR) was 37.5% for resected cases in 1963-66, which was improved to 70.1% in 2008. 5YSR was improved from 55.1% to 74.1% for Stage-II, and from 39.1% to 48.8% for Stage-III in the period. According to remarkable increase of early stage cancer, principle of surgical treatments was shifted from "€œextended and standardized surgery for radicality" €to "€œreasonable and individual surgery considering safety and quality of life"€. This trend produced a large variation in surgical treatments; namely 1) minimally invasive surgeries,2) function preserving surgeries, 3) optimal extent of lymph node dissection, and 4) aggressive but safe surgeries.Intention of this paper is to explain these procedures, the intentions, the indications, and the treatment results.

[Ludwig von Riediger (Ludwik Rydygier). A great surgeon forgotten in Germany]. / Ludwig von Riediger (Ludwik Rydygier). Ein großer, in Deutschland vergessener Chirurg.

Riediger was born in West Prussia and studied medicine in Greifswald under Carl Hueter. Having accomplished his surgical training in Gdansk, Greifswald and Jena in 1879 he built an outstanding private hospital in Chelmno where he wrote important publications in the Polish language. In 1887 he polonized his name to Rydygier to obtain Bavarian citizenship and succeeded Johann von Mikulicz as the chair of surgery at the Jagiellonian University. In 1897 he was given the chair in surgery at the University of Lviv and in 1901/02 he became rector. In World War I he served in the Austrian and Polish Armies. In the Polish-Soviet War (1920) he played an active role against the invading Bolshevic (Soviet) army as head of the medical service for the Polish army in Pomerania. After 23 years in Lviv he became professor emeritus. Before returning to West Prussia he lost his fortune due to the stock market crash in 1920 and died at 70 years old. Riediger founded the Polish Society of Surgeons and was cofounder of the German Association of Urology. His descendents formed a dynasty of surgeons in Brazil.

Acid secretion and gastric surgery.

It was long believed that there were major differences in the pathophysiology between the three major categories of peptic ulcers. The unifying feature was that all peptic ulcers occurred in a mucosal compartment exposed to acid-pepsin secretions. All ulcers tended to heal more rapidly when acid secretion was more readily neutralized or inhibited. Decreased local resistance was considered to be present in primarily acute and chronic gastric ulcer. Surgery for peptic ulcer intended to reduce acid secretion, which also resulted in a diminished pepsin enzyme activity. The corresponding reduction could be accomplished either by gastric resection, different vagotomies or a combination of resections and vagotomies. Most of the procedures were basically abandoned at the time of introduction of modern medical therapeutic strategies. For duodenal ulcer and prepyloric ulcer diseases, various vagotomies were generally recommended or combined with antrectomy. Partial gastrectomy or antrectomy with gastroduodenostomy was the standard procedure for treatment of type 1 gastric ulcer. The great caveat associated with surgical procedures for elective treatment of uncomplicated peptic ulcer disease is confined to operative mortality, postoperative morbidity, and late postoperative metabolic sequelae. The only remaining indication today of remedial gastric surgery for peptic ulcer disease is when there is a defined risk for gastric cancer in an unhealed gastric ulcer and very seldom in a case with recurrent or therapy-resistant peripyloric ulcer.

Esophagoplasty using previously resected stomach proposed by A.A. Rusanov: history and the current state.

To perform esophageal reconstruction in patients after distal gastrectomy colonic or jejunal transplant is usually used. But the use of remnant stomach in esophagoplasty appears to be an interesting idea. This method preserves some advantages of esophagogastroplasty as such. It is possible to pull-up the remnant stomach to the needed level, using mobilization with the spleen and pancreatic tail and its transposition into the left pleural cavity. This type of esophageal replacement, currently widely adopted in China, was proposed and first performed in 1958 by Professor A.A. Rusanov from Russia (former USSR). Different aspects of this method including historical are discussed in the literature review.

[Old and new concepts in surgical therapy of gastroduodenal ulcers complicated or resistant to treatment]. / Concepte vechi si noi in terapia chirurgicala a ulcerelor gastroduodenale complicate sau rebele la tratament.

This article presents the old and the new therapeutic protocols in the gastroduodenal ulcer. In our opinion, subtotal gastric resection and bilateral subdiafragmatic vagotomy must be considered "historical" without having theoretical support in the era of the antisecretory and anti Helicobacter pylori medication, with similar or superior effects. Is considered as complete the era of the gastric large crippling resection of Péan and Billroth, as the era of Dragstedt's vagotomy and applied the new methods nonaggressive and miniminvasive.

[150 years since the birth of Thomas Ionescu (1860-1926)]. / Thoma Ionescu (1860-1926): 150 de ani de la mastere.

One of the most important surgeons of the 1900 period was the Romanian-born Thomas Jonnesco. He became a surgeon in Paris (1885-1890) under the guidance of D.M. Bourneville and J. Peyrot (Bicatre), P. Berger (Tenon), A. Le Dentu (St. Louis) and A. Verneuil (Pitié-Salpétrire). In 1894, he gained at the Paris Faculty of Medicine the title of professor of anatomy. In the same year he was selected by the professors Poirier, Charpy and Nicolas to be their collaborator in a treatise of anatomy, published in 1894. In 1895, he returned to Bucharest to lead the Institute of Topographic Anatomy and Experimental Surgery, especially created for him. He also accepted the Chair of the Clinical Surgery of Coltzea Hospital in Bucharest. In 1896 he founded in Paris the French periodical "Archives des Sciences Medicales'". Jonnesco was a prolific surgeon in the field of experimental surgery, especially cervical sympathectomy, general spinal anaesthesia but also in surgical oncology and genito-urinary field. He also drew clinical correlations on surgical techniques of gastrectomy for cancer, on total abdominal genital ablation as treatment for septic conditions of the uterus and the adnexa or on the large abdominal hysterectomy with complete ilio-lumbo-pelvic lymph node dissection in uterine cancer, which refined Wertheim's hysterectomy method. Thomas Jonnesco is now considered the founder of the modem Romanian school of