Laparoscopic hand-sewn esophagojejunal anastomosis in laparoscopic proximal gastrectomy for early gastric cancer.

PURPOSE: In Asian countries, proximal gastrectomy is a standard treatment option for early primary gastric cancer located in the upper third of the stomach. However, laparoscopic proximal gastrectomy (LPG) is not widely employed due to the technical difficulty of laparoscopic esophagojejunal anastomosis. Therefore, we began performing laparoscopic hand-sewn esophagojejunal anastomosis. In this report, we describe the technique of this method and the short-term surgical outcomes. METHODS: Between February 2016 and June 2020, 18 patients underwent LPG with double-tract reconstruction at our institution. Laparoscopic hand-sewn esophagojejunal anastomosis was attempted for all patients. RESULTS: The median operative time for the 18 patients was 431 min (range: 301-549 min), and the estimated blood loss was 100 mL (range: 0-1524 mL). The median time for the hand-sewn esophagojejunostomy was 42 min (range: 26-81 min). Only one case was converted to open surgery after the reconstruction due to bleeding from an artery of the lesser curvature. No anastomotic leakage was observed in any patients (0/18, 0 %); however, two patients developed anastomotic stenosis (2/18, 11%). The mean length of postoperative hospital stay was 10 days (range: 8-28 days). CONCLUSION: The laparoscopic hand-sewn esophagojejunal anastomosis in LPG is a simple, cost-effective, and safe procedure. We believe that our method is a feasible choice. However, careful and longer follow-up of more patients is necessary to determine the advantages of our method.

Pure laparoscopic pancreas parenchymal dissection using CUSA for distal pancreatectomy.

Although stapler dissection and closure is commonly used for laparoscopic distal pancreatectomy (LDP), it is risky in patients with thick pancreatic parenchyma or titanium allergy. We performed laparoscopic pancreatic parenchymal dissection with cavitron ultrasonic surgical aspirator (CUSA) successfully in a patient with titanium allergy. Slinging the pancreas with nylon tape delineates the surgical plane. Pancreatic parenchyma was transected by CUSA in an almost bloodless field. Pancreatic duct branches and vessels were adequately exposed and dissected with a vessel sealing system. The main pancreatic duct was closed with Hem-O-lock. CUSA is an alternative to stapler dissection during LDP in select patients.

Novel approach of laparoscopic and endoscopic cooperative surgery (LECS) for cholecystectomy.

BACKGROUND: Endoscopic submucosal dissection (ESD) techniques, such as generating an artificial space between digestive tract layers for safer dissection, were thought to be safer for the resection of organs in cholecystectomy. We investigated whether combinations of endoscopic techniques and laparoscopic techniques could be performed more safely and rapidly. MATERIAL AND METHODS: Laparoscopic and endoscopic cooperative-cholecystectomy (LEC-chole) and conventional laparoscopic cholecystectomy (Lapa-chole) were performed in six dogs. Operation time was defined as the time from the creation of the first port to the retrieval of the resected gallbladder (GB); and GB bed dissection time was the time from local injection of natural saline to the clipping of the cystic duct. The main roles of the endoscope in LEC-chole were to obtain a sufficient cutting space via local injection of natural saline to the GB bed and to monitor the operative view without laparoscopic camera, thus omitting the umbilical port. RESULTS: The operation times were 60 ± 18.3 minutes for LEC-chole and 95 ± 7.0 for Lapa-chole (p = .036). The GB bed dissection times were 31 ± 8.54 minutes in LEC-chole and 50.6 ± 7.37 minutes in Lapa-chole (p = 0.048). There were significant differences in liver damage and bleeding (p = 0.116), but there were no significant differences in one-month survival. CONCLUSIONS: The application of LEC-chole may be expanded to cholecystectomy.

Predictors of postoperative complications in elderly and oldest old patients with gastric cancer.

BACKGROUND: The incidence of gastric cancer has been increasing among elderly persons in Japan. This study aimed to clarify risk factors for postoperative complications in oldest old patients with gastric cancer. METHODS: One-hundred ninety patients more than 75 years old with gastric cancer underwent gastrectomy between 2000 and 2011. Patients were classified into two groups: group A included 29 patients who were 85 years or older (oldest old patients), and group B included 161 patients who were 75-84 years of age. Perioperative parameters associated with complications were compared in each group. RESULTS: The preoperative estimated glomerular filtration rate was significantly lower in group A (p = 0.03). The two groups significantly differed in performance status (p = 0.018). Patients in group A received a lesser extent of lymph node dissection and had fewer lymph nodes excised. As a result, the duration of the operation was significantly shorter in group A. There were no significant differences in the frequency or grade of total complications or mortality between the two groups. Operative hemorrhage (>300 ml) and Hiroshima POSSUM (predicted morbidity risk >40) were risk factors in both groups A and B; the risk factors of preoperative serum albumin level and prognostic nutritional index (PNI) were specific to group A. CONCLUSIONS: Adjustments to the extent of surgery among oldest old patients most likely reduces the incidence of postoperative complications in this group. Preoperative serum albumin level and PNI are significant predictors of postoperative complications in oldest old patients with gastric cancer.

Feasibility of pure EFTR using an innovative new endoscopic suturing device: the Double-arm-bar Suturing System (with video).

BACKGROUND: Endoscopic full-thickness resection (EFTR) requires a reliable full-thickness suturing device and an endoscopic counter-traction device to prevent the collapse of the digestive tract. OBJECTIVE: The present study aimed to assess the reliability of newly developed flexible endoscopy suturing devices and the feasibility of pure EFTR. METHODS: A total of 30 EFTRs were performed and allocated to three groups (N = 10 for each group). The full-thickness sutures were placed using over-the-scope clips (OTSCs), hand-sewn sutures, or the Double-arm-bar Suturing System (DBSS). Air leak tests were conducted in the three groups. The times required for the placement of one OTSC suture and single-stitch simple interrupted sutures (hand-sewn and DBSS sutures, respectively) were also compared. RESULTS: All 30 full-thickness sutures were completely and successfully placed. Regarding the air leak tests, the Mann-Whitney U test showed significant differences between OTSC and hand-sewn sutures (p = 0.003). There was also a significant difference between OTSC and DBSS sutures (p = 0.023). There was no significant difference between hand-sewn and DBSS sutures (p = 0.542). A significant difference was found in the suture time for single-stitch simple interrupted sutures among the OTSC, hand-sewn, and DBSS sutures. The Mann-Whitney U test revealed a significant difference between OTSC and hand-sewn sutures (p = 0.0001). There was no significant difference between OTSC and DBSS sutures (p = 0.533), while a significant difference was found between hand-sewn and DBSS sutures (p = 0.0001). CONCLUSIONS: Pure EFTR is feasible if the mechanical counter traction system is used to expand a small operative field and DBSS is used to make full-thickness sutures. The high safety of full-thickness resection and full-thickness suturing allows for clinical applications of this method.

Reconstruction for extensive groin hidradenitis suppurativa using a combination of inferior abdominal flap and medial thigh-lift: a case report.

UNLABELLED: Various methods for reconstructing hidradenitis suppurativa of the groin have been reported. However, it is difficult to attain favorable results both aesthetically and functionally. This report describes a case in which a defect was reconstructed using a combination of inferior abdominal flap and medial thigh-lift after radical excision of extensive groin hidradenitis suppurativa. A 37-year-old woman patient underwent radical excision of bilateral groin hidradenitis suppurativa. After the excision, an inferior abdominal flap and bilateral medial thigh flaps were created and advanced to close the defect. The operative procedure was simple and did not require a donor site. The postoperative scar coincided with the inguinal folds and was concealed by undergarments. No functional disorder remained. Reconstruction for extensive groin hidradenitis suppurativa using this method can attain good aesthetic and functional results. The combination of inferior abdominal flap and medial thigh-lift is potentially a useful option for reconstruction of extensive groin hidradenitis suppurativa. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Omental flap wrapping with fixation to the cut surface of the liver for reducing delayed gastric emptying after left-sided hepatectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication following left-sided hepatectomy. The goal of this study was to clarify the clinical implications of an omental flap wrapping procedure that includes fixation to the cut surface of the liver to reduce the incidence of DGE after left-sided hepatectomy. METHODS: The study included 50 consecutive patients who underwent left-sided hepatectomy between January 2000 and July 2011. Clinicopathologic risk factors for DGE after left-sided hepatectomy were identified using univariate and multivariate models. The incidence of DGE, digestive symptoms, and postoperative complications were compared between two groups: 25 patients treated with the omental flap wrapping and fixation procedure and 25 patients who did not receive such a flap. RESULTS: A univariate analysis revealed that a lack of the omental flap, the lymph node clearance, and use of left hemihepatectomy were associated with postoperative DGE. The multivariate analysis indicated that the lack of the omental flap was the only independent significant factor associated with the DGE (odds ratio, 21.23; p = 0.0002). There was a significant difference in the incidence of DGE between the patients with (4 %) and without an omental flap (36 %). The incidence of gastric distension and the use of prokinetic drugs were also significantly lower in patients with an omental flap than in patients without the flap, and patients with an omental flap resumed a solid diet significantly earlier. CONCLUSIONS: This retrospective single-center study revealed that it was possible to reduce the incidence of DGE using a procedure involving omental flap wrapping with fixation to the cut surface of the liver after left-sided hepatectomy.

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a laparoscopic retractor.

Although extraperitoneal colostomy is often performed to prevent postoperative parastomal hernia formation following an open abdominoperineal resection of lower rectal cancer, it has not been widely employed laparoscopically because of the difficulty associated with the extraperitoneal route. This paper describes a laparoscopic extraperitoneal sigmoid colostomy using the Endo Retract™ Maxi instrument. This surgical technique is easy, and helps to prevent the development of parastomal hernias.

Free hemiback flap with surgical delay for reconstruction of extensive soft tissue defect: a case report.

A delay procedure allows for reliable tissue transfer in random pattern flaps and axial pattern flaps. However, delay procedures have not been studied in free flaps. In this report, we present a case involving the use of a free extended latissimus dorsi musculocutaneous flap (hemiback flap) that included half of the total back skin and was based on thoracodorsal vessels for reconstruction of an extensive soft tissue defect of the flank and waist. The flap was tailored in combination with a delay procedure. Intraoperative indocyanine green fluorescence angiography indicated profuse perfusion except for the most inferomedial part of the flap, which was discarded. The flap survived. A free hemiback flap may offer a valuable option for reconstruction of extensive soft tissue defects. To our knowledge, this is the first report to demonstrate a free flap made in combination with a delay procedure.

Delayed distally based sural flap with temporary venous supercharging.

The distally based sural flap has become popular for reconstruction of the foot and leg. However, this flap often fails due to venous congestion. In this report, we developed a new modification of the distally based sural flap. The procedure comprised three stages. In the first stage, the flap was raised cephalad to the midpoint of the posterior aspect of the leg, involving reanastomosis of the short saphenous vein (SSV) at the proximal end of the flap. In the second stage, ligature of the SSV was performed. In the third stage, the entire flap was raised. We treated eight patients with the flap. All flaps survived completely. Duplex scanning indicated that venous drainage of the flap was provided by the tenuous venae comitantes (VCs) surrounding the SSV. Reanastomosis of the SSV may prevent rapid venous overloading of the VCs. Our new modification may be useful to avoid venous congestion.

Reading man flap: application to plantar defects.

The plantar surface of the foot has highly specialized, densely adherent, glabrous skin, making functional replacement difficult. Glabrous skin defects should be replaced with similar skin to restore function and aesthetics. An innovative technique, the "reading man flap," was developed for closure of circular skin defects. At locations such as the face, trunk, thigh, and calf, the "reading man" procedure provides tension-free closure with minimal additional healthy skin excision, and it does not cause "dog ear" formation. The potential exists for replacement of plantar defects with skin of the same quality using this procedure. In the present study, we report on 2 clinical cases in which intermediate-size plantar defects were reconstructed using the reading man flap. This method can provide tissue as durable, yet as sensitive, as skin that matches the unique characteristics of the plantar skin.

Hemiforehead flap for reconstruction of composite facial defects.

Composite defects overlap 2 or more facial units. It is difficult to reconstruct composite defects with adequate shape, color, and texture. Because it is non-hair bearing, is relatively thin, and has a color and texture similar to that of the rest of the face, the skin of the forehead possesses excellent characteristics for nasal reconstruction and repair of other facial areas. The authors developed an extended thin forehead flap (hemiforehead flap) that includes half of the total forehead skin and is based on supratrochlear vessels. In the patient reported here, a hemiforehead flap was used to reconstruct composite defects of the lower lid, cheek, nose, and upper lip. Acceptable aesthetic and functional results were achieved. This flap may serve as an alternative for reconstruction of composite facial defects.

Slow parenchymal flattening technique for distal pancreatectomy using an endopath stapler: simple and safe technical management.

BACKGROUNDS/AIMS: The appropriate closure of the pancreatic remnant after a distal pancreatectomy remains controversial. To describe a safer and simple distal pancreatectomy using an endopath stapler, with special emphasis on the slow parenchymal flattening technique. METHODOLOGY: The slow parenchymal flattening technique (SFT) for a distal pancreatectomy using an endopath stapler (Echelon 60) was applied to avoid a destruction of pancreas capsule and parenchyma for a soft friable pancreas. In this technique, the pancreas was gently compressed with an atraumatic intestinal clamp for a few minutes prior to the stapling dissection. Then, the closure jaw of endopath stapler was closed carefully and slowly taking more than 5 minutes at the fixed speed before dissection. RESULTS: SFT using the Echelon 60 was performed for 22 consecutive patients who required a distal pancreatectomy. Only one patient (4.5%) developed a symptomatic pancreatic fistula (ISGPF classification grade B). There were no mortalities or severe pancreatic fistula (ISGPF classification grade C) in this series. CONCLUSIONS: The SFT using the Echelon 60 can be performed easily, which enables surgeons to achieve confident pancreas stump without any tissue injury.

Spontaneous regression of advanced transverse colon cancer with remaining lymph node metastasis.

BACKGROUND: The observation of spontaneous regression (SR) has been well documented for many cancer types, including renal cell carcinoma, non-Hodgkin's lymphoma, leukemia, neuroblastoma, and malignant melanoma. However, the SR frequency in colorectal cancer is very rare. Therefore, the accumulation of SR colorectal cancer cases might contribute to find the regression mechanism. CASE PRESENTATION: A 67-year-old woman received colonoscopy due to being positive for fecal occult blood testing and was diagnosed as having a transverse colon cancer at a local hospital. She was admitted to our institution for surgical treatment of the colon cancer. The colonoscopy revealed a type 2 tumor of 13 mm in diameter at the hepatic flexure of the transverse colon. The enhanced computed tomography (CT) showed an enlarged lymph node in the intermediate lymph node region. The 18F-fluorodeoxyglucose positron emission tomography/CT showed no abnormal accumulation on the transverse colon; however, an abnormal accumulation was found at the enlarged lymph node. The patient was preoperatively diagnosed as having advanced transverse colon cancer with lymph node metastasis and underwent laparoscopic right hemicolectomy with D3 lymph node dissection. Pathological examination showed only a scar-like tissue and no cancerous lesion in the transverse colon, while a metastatic lymph node was histologically confirmed in the intermediate lymph node region. Loss of MLH1 and PMS2 expression was observed in the cancer cells of both biopsy specimens and resected lymph nodes. No recurrence was seen for 5 years after surgery. CONCLUSIONS: We reported a rare case of SR of the primary transverse colon cancer without regression of the metastatic regional lymph node. We considered that colorectal cancer with SR should be resected because even if SR of the primary lesion occurs, lymph node metastasis might have an inconsistent behavior as shown in the present case.

Prefabricated scalping forehead flap with skeletal support.

It is difficult to reconstruct a nose with adequate shape, color, and texture in patients who have full-thickness nasal defects with extensive loss of skeletal support. The scalping forehead flap is a reliable technique for nasal reconstruction. To our knowledge, however, there have been no reports about a prefabricated scalping forehead flap with a bone graft as skeletal support. In the case reported here, a prefabricated scalping forehead flap combined with an iliac bone graft as skeletal support was used to successfully reconstruct a full-thickness defect of the nose associated with partial frontal bone loss and complete loss of the nasal bones. Acceptable functional and aesthetic results were achieved. This method may be a good alternative for reconstruction of full-thickness nasal defects with extensive loss of skeletal support.

A case of venous varix of the volar digit and review of the literature.

Venous varix of the volar digit (VVVD) is a rare condition that is usually described as a firm, blue, and painful mass. However, the clinical features of VVVD are still unclear. We treated a patient who had a firm, normal-skin-colored, and painless mass on the volar aspect of a digit. The mass was removed and was diagnosed as VVVD by histological examination. Magnetic resonance imaging was useful for assisting with the pre-operative diagnosis. We also review 11 previously reported cases.

Delayed wraparound abdominal flap reconstruction for a totally degloved hand.

Resurfacing a totally degloved hand is one of the most difficult management problems in hand surgery. It is difficult to cover the entire hand by using flaps. Although early coverage can be achieved, secondary amputation is often required due to an inadequate blood supply. We devised a delayed wraparound abdominal flap (DWAF) that was well-vascularised and could cover the whole hand. Here we report on a patient with a totally degloved hand, in whom reconstruction was performed using a DWAF and good functional results were achieved despite late surgery. Reconstruction with a DWAF may be a useful option for the totally degloved hand.

Lymphatic transit rate as a predictive parameter for nodal metastasis in primary limb malignant melanoma.

BACKGROUND: The status of sentinel lymph node (SLN) is one of the most predictive prognostic factors in patients with clinically localized malignant melanomas (MMs). However, since the positive SLN metastatic rate is as low as 20%, it is desirable to minimize SLN biopsy performance with imaging. By dynamic lymphoscintigraphy, we have proposed the lymphatic transit rate (LTR), the value that the distance between the primary lesion and SLN is divided by scintigraphic saturation time. LTR represents the scintigraphic saturation velocity and can be used for evaluation of metastasis of skin cancers. METHODS: Dynamic lymphoscintigraphy data from 36 lymph nodes in 36 patients with primary MM on the limb were analyzed. The initial sites of the MMs were the lower limb in 24 patients and the upper limb in 12 patients. Histopathologically, nodal metastasis was found in 10 patients. RESULTS: In the lower limb MM, the mean LTRs were 3.49 cm/min in histologically non-metastatic SLNs and 4.49 cm/min in histologically metastatic SLNs (P = 0.0056). In the upper limb MM, the mean LTRs were 2.59 cm/min in non-metastatic SLNs and 3.94 cm/min in metastatic SLNs (P = 0.0162). Thus, significantly higher LTRs were obtained in the metastatic SLNs. All SLNs with LTR < 4.0 cm/min in the lower limb MM and those with LTR < 3.0 cm/min in the upper limb MM were non-metastatic. CONCLUSION: LTR is a useful predictive indicator for nodal metastasis and SLN biopsy performance in MMs.

Esophageal cancer associated with a sarcoid-like reaction and systemic sarcoidosis in lymph nodes: supportive findings of [18F]-fluorodeoxyglucose positron emission tomography-computed tomography during neoadjuvant therapy.

BACKGROUND: In patients with esophageal cancer, differentiation between lymph node metastasis and lymphadenopathies from sarcoidosis or sarcoid-like reactions of lymph nodes is clinically important. Herein, we report two esophageal cancer cases with lymph node involvement of sarcoid-like reaction or sarcoidosis. CASE PRESENTATION: One patient received chemotherapy and the other chemoradiotherapy as initial treatments. In both cases, [18F]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) was performed before and after chemo(radio)therapy. After the treatment, FDG uptake was not detected in the primary tumor, but it was slightly reduced in the hilar and mediastinal lymph nodes in both cases. These non-identical responses to chemo(radio)therapy suggest the presence of sarcoid-like reaction of lymph nodes associated with squamous cell carcinoma of the esophagus. Curative surgical resection was performed as treatment. CONCLUSIONS: These FDG-PET/CT findings may be helpful to distinguish between metastasis and sarcoidosis-associated lymphadenopathy in esophageal cancer.

Fas-mediated upregulation of vascular endothelial growth factor and monocyte chemoattractant protein-1 expression in cultured dermal fibroblasts: role in the inflammatory response.

The Fas-Fas ligand interaction is the most important pathway in starting apoptosis. In addition, several recent reports have emerged documenting non-apoptotic roles for Fas. However, a non-apoptotic role of Fas in dermal fibroblasts remains unknown. The present study investigated whether Fas stimulation not only promotes apoptosis but also stimulates elements of the inflammatory response such as angiogenesis and macrophage infiltration. Fas stimulation was performed by treating cultured human dermal fibroblasts with an agonistic anti-Fas monoclonal antibody (mAb). Anti-Fas mAb-treated fibroblasts showed a significantly greater increase of caspase-3 and caspase-8 activity compared with control fibroblasts. Addition of the anti-Fas mAb induced DNA fragmentation, as confirmed by the DNA ladder assay. Terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate nick end labeling (TUNEL) staining showed that treatment with the anti-Fas mAb induced an increase of apoptotic fibroblasts in a time-dependent manner. At both mRNA and protein levels, anti-Fas mAb-treated fibroblasts showed significantly higher expression of vascular endothelial growth factor (VEGF) and monocyte chemoattractant protein (MCP)-1 compared with control fibroblasts. A pan-caspase inhibitor (Z-VAD-FMK) significantly inhibited VEGF and MCP-1 expression. After transplantation of fibroblasts into mice with severe combined immunodeficiency, the nodules derived from anti-Fas mAb-treated fibroblasts showed more abundant neovascularization, increased macrophage infiltration, and more apoptotic cells in comparison with nodules derived from control fibroblasts. The results of both in vitro and in vivo studies confirmed significantly higher angiogenic activity and macrophage chemotactic activity of anti-Fas mAb-treated fibroblasts compared with control fibroblasts.