Accurate ultrasound imaging based on range point migration method for the depiction of fetal surface.

PURPOSE: The purpose of this study is to evaluate the performance of a modified range point migration (RPM) method using a semi-broad transmit beam for fetal surface imaging. METHODS: The conventional RPM method depicts accurate images of target surfaces by estimating the reflection point on a target surface from the path length of plural transmit-and-receive element combinations. However, the conventional RPM method depicts false images when echoes from different targets are received simultaneously. For the elimination of false images in the employment of the RPM method, we propose a modified RPM method with a semi-broad transmit beam to decrease the number of targets in each measurement region. RESULTS: The modified RPM method depicted two acrylic cylinders of 2 cm in diameter with a root-mean-square error (RMSE) of 0.062 mm, where the RMSE of the migration method was 0.145 mm. The modified RPM method also succeeded in depicting a 7-month fetal phantom with a RMSE of 0.058 mm relative to a 3D image acquired using optical measurement. CONCLUSION: This study shows the potential of the modified RPM method in achieving accurate surface imaging of multiple targets using a semi-broad beam, indicating that the method is suitable for fetal surface imaging.

Totally laparoscopic pylorus-preserving gastrectomy for early gastric cancer in the middle stomach: technical report and surgical outcomes.

INTRODUCTION: The feasibility, safety, and improved quality of postoperative life following laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with a hand-sewn anastomosis via a mini-laparotomy for early gastric cancer (EGC) have been previously established. Here we describe the surgical procedure of totally laparoscopic pylorus-preserving gastrectomy (TLPPG) using an intracorporeal delta-shaped anastomosis technique, and the short-term surgical outcomes of 60 patients with EGC in the middle stomach are reported. METHODS: After lymphadenectomy and mobilization of the stomach, intraoperative gastroscopy was performed in order to verify the location of the tumor, and then the distal and proximal transecting lines were established, 5 cm from the pyloric ring and just proximal to Demel's line, respectively. Following transection of the stomach, a delta-shaped intracorporeal gastrogastrostomy was made with linear staplers. RESULTS: There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 259 min and 28 mL, respectively. Twelve patients (20.0%) experienced postoperative complications classified as grade II using the Clavien-Dindo classification, with the most frequent complication being gastric stasis (6 cases, 10.0 %). The incidence of severe complications classified as grade III or above was 1.7%; only one patient required reoperation and intensive care due to postoperative intraabdominal bleeding and subsequent multiple organ failure. CONCLUSION: TLPPG with an intracorporeal delta-shaped anastomosis was found to be a safe procedure, although it tended to require a longer operating time than the well-established LAPPG with a hand-sewn gastrogastrostomy.

Subtotal gastrectomy with limited lymph node dissection is a feasible treatment option for patients with early gastric stump cancer.

The de facto standard treatment for early gastric stump cancer (GSC) has been total gastrectomy combined with radical lymph node dissection. However, some patients could benefit if partial resection of the gastric stump is feasible. We investigated the feasibility of subtotal gastrectomy for early GSC as less invasive surgery. Subtotal gastrectomy was defined as a segmental resection of the gastric remnant including the anastomosis with limited lymph node dissection. A total of 66 patients with early GSC were enrolled and 24 patients (36.4 %) underwent subtotal gastrectomy (SG group). Clinicopathological characteristics were analyzed along with those of the other 42 patients (63.6 %) who underwent total gastrectomy (TG group). There were no significant differences between the two groups in the number of lymph nodes harvested (p = 0.880). Lymph node involvement was detected in 2 patients (8.3 %) in SG group and 5 patients (11.9 %) in TG group (p = 1.000). The previous disease (benign or malignant) and surgery (Billroth I or II) did not affect the rate of nodal involvement. The 5-year overall survival rate of SG group (94.7 %) was acceptable. Subtotal gastrectomy of the gastric remnant could be a feasible treatment option for patients with early gastric stump cancer when indicated.

Feasibility and nutritional impact of laparoscopy-assisted subtotal gastrectomy for early gastric cancer in the upper stomach.

BACKGROUND: Laparoscopy-assisted total gastrectomy (LATG) is commonly performed for early gastric cancer (EGC) in the upper stomach; however, the incidence of anastomotic complications remains high, and postoperative nutritional status is not satisfactory. This study aimed to evaluate the feasibility and nutritional impact of a novel surgical procedure, laparoscopy-assisted subtotal gastrectomy (LAsTG). METHODS: This was a retrospective study of 167 patients with EGC in the upper stomach. Of these, 57 patients underwent LAsTG, while 110 patients underwent LATG. Postoperative change in body weight, and serum concentration of albumin (Alb) and total protein (TP) were compared between the LAsTG and LATG groups. Analysis of covariance (ANCOVA) was used to assess the influence of potential confounding factors. RESULTS: Frequency of anastomotic complications was significantly higher in the LATG group (16.3 %) than in the LAsTG group (5.3 %, P = 0.040). Postoperative recovery of body weight at 12 months after surgery was significantly better in the LAsTG group (89.8 ± 1.4 %) than in the LATG group (82.1 ± 1.0 %, P < 0.001). By ANCOVA, adjusted mean differences of Alb and TP at 12 months after surgery between the LAsTG and LATG groups were 0.226 g/dl (95 % CI 0.141-0.312; P < 0.001) and 0.380 g/dl (95 % CI 0.265-0.495; P < 0.001); thus, the surgical procedure was significantly associated with the postoperative Alb and TP levels. CONCLUSIONS: LAsTG could be a better choice than LATG for EGC in the upper stomach as a result of improvements in the incidence of anastomotic complications and postoperative nutritional status.

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.

Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy.

BACKGROUND: The safety of surgery for gastric cancer in the elderly has been shown previously. However, potentially fatal complications based on an established severity grading system were not well described, and associated risk factors have not been assessed. The present study sought to examine severity-dependent postoperative complications after laparoscopy-assisted distal gastrectomy (LADG) in elderly patients and risk factors of potentially fatal postoperative complications. METHODS: The study included 189 patients aged 70 years or older and who underwent LADG for early gastric cancer. Patient characteristics, perioperative outcomes, postoperative complications including severity assessment using the Clavien-Dindo classification, and risk factors related to postoperative complications were analyzed. RESULTS: The overall complication rate was 24.9 % (47/189). The most frequent complication was abdominal fluid collection (9 cases, 4.8 %). Severe complications classified as grade III or above in the Clavien-Dindo grading system were found in 20 (10.6 %) patients. Multivariate analysis identified preoperative serum albumin concentration (odds ratio, 5.200; 95 % CI, 1.706-15.850), Roux-en-Y reconstruction (odds ratio, 3.611; 95 % CI, 1.103-11.817), and simultaneous cholecystectomy (odds ratio, 5.008; 95 % CI, 1.378-18.201) as independent predictors of a higher rate of severe postoperative complications after LADG in elderly patients. CONCLUSION: The incidence of severe complications after LADG in the elderly was quite acceptable considering the risks associated with radical surgery with extensive lymphadenectomy. Preoperative serum concentrations of albumin (<4.0 g/dl), Roux-en-Y reconstruction, and simultaneous cholecystectomy are independent risk factors for severe postoperative complications in these patients.

The clinical safety of performing laparoscopic gastrectomy for gastric cancer by trainees after sufficient experience in assisting.

BACKGROUND: Laparoscopic gastrectomy (LAG) is increasingly performed to treat gastric cancer. However, the procedure remains complicated, and an optimal system for educating clinicians about LAG has not been established. METHODS: Our training system centers on understanding the anatomical appearance under laparoscopy and the standardized steps of LAG, including the roles of the scopist and the assistant. The trainees participated in LAG procedures as a scopist and an assistant in 30-35 cases, before conducting their first LAG case. The data of 788 consecutive patients with early gastric cancer who underwent LAG were also reviewed. RESULTS: During the study period, nine trainees performed a total of 215 LAG (27.3 %) with trainers, while 563 LAG were conducted by the two trainers (71.4 %). The surgical outcomes including operative time, blood loss, and retrieval of lymph nodes were almost equivalent for both the trainers and the trainees. The total experience among the trainees as scopist and as first assistant was 45.0 and 41.4 cases, respectively, and the trainees had experienced 33.8 cases as a scopist and 35.3 cases as an assistant before they performed their first LAG as an operator. After commencing experience as an operator, the average operation time of the trainees reached that of the trainers within six cases and their learning curve reached a plateau. CONCLUSIONS: Our training system based on attaining sufficient experience as an assistant and scopist in the simulation of a LAG procedure was effective for ensuring clinical safety for LAG performed by a trainee with experienced surgeons.

Successful application of laparoscopic and endoscopic cooperative surgery (LECS) for a lateral-spreading mucosal gastric cancer.

In the current era of endoscopic submucosal dissection (ESD) for early gastric cancer, which carries a negligible risk of lymph node metastasis, local resection of the stomach remains an option for these lesions. This is particularly so for a large intramucosal lesion or a lesion with a strong ulcer scar, for which ESD becomes a difficult option. Here, we describe a case of lateral-spreading intramucosal gastric cancer of 6-cm diameter located at the fornix of the stomach, which was successfully treated by laparoscopic and endoscopic cooperative surgery (LECS) because of the expected risk of complications during ESD. In the LECS procedure, the resection margin was appropriately determined by the endoscopic evaluation in detail and by the ESD technique. If early gastric cancer fits the criteria for endoscopic resection but would present difficulty if performing ESD, this is a good indication for the LECS procedure.

Different features of complications with Billroth-I and Roux-en-Y reconstruction after laparoscopy-assisted distal gastrectomy.

BACKGROUND: This study investigated differences in the features of postoperative complications between Billroth-I (B-I) and Roux-en-Y (R-Y) reconstructions after laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer. MATERIAL AND METHODS: The study included 424 patients who underwent LADG for cT1, cN0 gastric cancer. Patient characteristics, surgical outcomes, postoperative complications including severity assessment using the Clavien-Dindo classification, and risk factors related to postoperative complications were analyzed. RESULTS: B-I and R-Y were performed in 329 and 95 patients, respectively. Total time in hospital was longer in R-Y (15.2 ± 10.5 days) than in B-I (12.8 ± 6.4 days; P = 0.034). The incidence of severe complications was higher in R-Y (13.7%) than in B-I (5.2%; P = 0.009). Three cases of internal hernia and three cases of duodenal stump leakage were observed in R-Y. Univariate analysis revealed the method of reconstruction was a risk factor for severe postoperative complications after LADG (P = 0.006). CONCLUSIONS: The features of postoperative complications are quite different between B-I and R-Y after LADG. Complications after R-Y were more severe than those after B-I. To avoid these severe complications in R-Y, it is necessary to understand these different features.

Three-step esophagojejunal anastomosis with atraumatic anvil insertion technique after laparoscopic total gastrectomy.

BACKGROUND: Esophagojejunostomy during laparoscopic total gastrectomy (LATG) using a circular stapler is a difficult procedure for which there remains no widely accepted standard technique. Based upon our experience with esophagogastrostomy during laparoscopic proximal gastrectomy, we have applied a modified lift-up method to LATG. MATERIAL AND METHODS: Esophagojejunostomy using a modified lift-up method was performed during LATG in 41 patients with early gastric cancer, from July 2005 to June 2010. The lift-up technique comprises three steps, which together reduce the difficulty of anvil insertion by lifting up the nasogastric tube connected to the anvil head. RESULTS: During the early stages of the present study, some patients who underwent LATG with the modified lift-up method developed anastomotic leakage, with stenosis occurring in two cases (4.9%) and three cases (7.3%), respectively. All patients who developed complications showed improvement following conservative treatment with no surgical procedure. The anastomotic leaks occurred during the later periods of the study. There was no mortality in the present study. CONCLUSIONS: Our modified lift-up technique facilitates circular-stapled esophagojejunostomy in LATG and could provide a more feasible and safe option for an established procedure, especially for preventing anastomotic leak.

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.

New technique for rectal division in laparoscopic anterior resection--with video.

BACKGROUND: A new technique for performing laparoscopic anterior resection is described. Main differences from the standard technique are (1) pneumoperitoneum to improve exposure of the rectum, even in a narrow pelvis; (2) rectal division performed using a conventional linear stapler inserted via a 4.5 cm suprapubic incision; and (3) eversion of the rectum for tumors close to the anal verge, with transection performed under direct vision. METHODS: Results in 78 patients who underwent transabdominal transection and in 7 patients requiring rectal eversion were compared retrospectively with those in 61 consecutive patients who had undergone standard laparoscopic resection. RESULTS: The duration of the operation and estimated blood loss were greater with rectal eversion, and more staple cartridges were used for the conventional technique; however, the incidence of complications was similar for all three groups. Five patients in the conventional group required conversion to an open procedure. CONCLUSION: The new technique should improve the safety of resection.

Intracorporeal Billroth 1 reconstruction by triangulating stapling technique after laparoscopic distal gastrectomy for gastric cancer.

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patient's figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The "triangulating stapling technique" (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patient's figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

Laparoscopic hemicolectomy in a patient with situs inversus totalis.

As among persons with normal anatomy, occasional patients with situs inversus develop malignant tumors. Recently, several laparoscopic operations have been reported in patients with situs inversus. We describe laparoscopic hemicolectomy with radical lymphadenectomy in such a patient. Careful consideration of the mirror-image anatomy permitted safe operation using techniques not otherwise differing from those in ordinary cases. Thus, curative laparoscopic surgery for colon cancer in the presence of situs inversus is feasible and safe.

Respiratory function after laparoscopic distal gastrectomy--an index of minimally invasive surgery.

BACKGROUND: As the techniques of laparoscopic surgery have improved, various institutions have performed laparoscopic gastrectomies with regional lymph node dissection, as well as open surgery. Although alleviation of postoperative pain and prompt recovery have been reported in the literature, objective indexes of the minimal invasiveness of laparoscopic procedures are as yet very few. METHODS: We performed distal gastrectomy with regional lymph node dissection for gastric cancer patients using three kinds of procedures, namely, open gastrectomy, hand-assisted laparoscopic surgery (HALS), and totally laparoscopic gastrectomy. Ablation of the stomach, lymph node dissection, and reconstruction of the digestive tract were all carried out intracorporeally with or without HALS in the laparoscopic procedures. The ordinary respiratory function test was performed pre- and postoperatively for 50 patients operated on by each procedure, and the reduced percentages of the measured values were calculated. RESULTS: Postoperative respiratory function was consistently excellent, with minimal loss of vital capacity and forced expiratory volume per second in the totally laparoscopic group compared to HALS or open cases. CONCLUSIONS: Although it may be a complicated technique, totally laparoscopic distal gastrectomy is considered a minimally invasive procedure for gastric cancer from the viewpoint of postoperative respiratory function.

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer.

Recently, a minimally invasive operation for gastric malignancies has been developed, and this laparoscopic operation is seen as a technique that will raise quality of life for patients. Previously, we reported this technique, as well as the results of a distal gastrectomy with regional lymph node dissection using hand-assisted laparoscopic surgery (HALS) for gastric cancer located in the middle or lower third of the stomach. This paper describes total or proximal gastrectomy with regional lymph node dissection by HALS on 28 cases of gastric cancer located in the upper portion of the stomach. After the mobilization of stomach and lymph node dissection via HALS, an anastomosis of the esophagus was performed intracorporeally with a conventional circular stapling device (PCEEA), whereas jejunojejunostomy and jejunogastrostomy were carried out extracorporeally with a conventional hand-sewn procedure through a HALS wound. The operation time and the amount of blood loss in all the patients were considered to be satisfactory, and the average number of dissected lymph nodes per patient was similar to that in open surgery. The patients had minimal morbidity and quick recovery after their operation. This technique was thought to be not only less invasive, but also similarly curative compared with open gastrectomy.