[Bronchial Stump Coverage Technique by da Vinci Xi].

da Vinci's greatest attractions are the fine images acquired with a high-resolution 3-dimensional( 3D) endoscope and the precise operation by forceps equipped with an articulated arm. We believed that complicated procedures can benefit from robot-assisted surgery. We have been actively performing collection and sewing of viable tissue using da Vinci Xi for the purpose of preventing bronchial stump fistulas. Of the 44 cases of lobectomy performed by the end of November 2019 using da Vinci Xi, 13 cases underwent bronchial stump covering. The covering procedure was intended for patients with conditions such as diabetes and a history of internal use of steroids. As the dressing, pedicled intercostal muscle was used in 4 cases, and free pericardial fat tissue was used in 9 cases. A good visual field was obtained by appropriately turning the oblique mirror upside down. The smoke emission effect of AirSeal was useful for securing the visual field. The dressing was sutured and fixed using 3-0 or 4-0 Prolene( SH) cut to a length of 10 to 12 cm. The postoperative course was good and bronchial stump fistula did not occur in all cases.

Impact of elemental diet on early recovery after laparoscopic colectomy: findings of a randomized controlled trial.

PURPOSE: An amino acid-containing elemental diet (ED) does not require digestion for nutritional absorption, making it a good option for patients with gastrointestinal malabsorption. We conducted a randomized trial to confirm that perioperative ED enhanced the recovery of patients undergoing laparoscopic colectomy. METHODS: Patients in the intervention arm received commercially available ED from the day prior to surgery until postoperative day (POD) 3, whereas patients in the control group received a conventional perioperative diet program. To verify the endpoints, "estimated minimum length of stay in hospital after surgery" (emLOS) was defined as the number of days necessary to reach all the five criteria; namely, "sufficient oral intake", "sufficient pain control", "withdrawal of intravenous alimentation", "no abnormal findings in routine examinations", and "no rise in fever". RESULTS: A total of 102 patients were randomized, 94 of whom were analyzed (ED 45, control 49). There was no morbidity or mortality. Shorter emLOS (POD 4 vs. POD 7; p = 0.018), earlier resumption of sufficient oral intake (POD 3 vs. POD 4; p = 0.034) and faster recovery to defecation (2.2 vs. 3.1 days; p = 0.005) were observed in the ED group vs. the control group. CONCLUSIONS: The perioperative ingestion of ED by patients undergoing laparoscopic colectomy is safe and can reduce the postoperative hospital stay by supporting the acceleration of oral intake.

Liquid-injection for preperitoneal dissection of transabdominal preperitoneal (TAPP) inguinal [corrected] hernia repair.

BACKGROUND: The creation of an adequate peritoneal flap during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, while avoiding injuring surrounding structures can be technically challenging. Liquid infiltration of the preperitoneal space can help facilitate dissection and avoid inadvertent injuries. We describe a novel technique for TAPP inguinal hernia repair using liquid-injection for preperitoneal [corrected] dissection and report our initial experience. METHODS: TAPP inguinal hernia repair using a liquid-injection technique during preperitoneal dissection was performed by a single surgical resident without prior TAPP repair experience from July 2013 to January 2014. After trocar placement, 60 mL of 0.3 % lidocaine with 1:300,000 dilution of epinephrine was injected percutaneously using a blunt needle under laparoscopic visualization into the preperitoneal space to assist with the dissection and parietalization of the vas deferens, spermatic vessels, and epigastric vessels. The initial peritoneal incision is performed at the lateral side of the inguinal canal, followed by blunt dissection of the preperitoneal space. RESULTS: Eleven patients (median age: 69; 8 male) with a total of 12 inguinal hernias underwent a TAPP repair using a liquid-injection preperitoneal dissection technique. Ten patients had unilateral hernias (4 indirect, 6 direct), and one patient had bilateral direct hernias. The median operative time, median injection time, and median dissection time were 116, 3.5, and 42 min, respectively. Estimated blood loss was less than 10 mL for all cases. No intraoperative injuries, conversions to open repair, or 30-day postoperative complications occurred. There were no hernia recurrences after a median follow-up of 143 days. CONCLUSION: Our preliminary experience suggests that liquid-injection to assist preperitoneal dissection during TAPP inguinal hernia repair appears to be safe and feasible. This novel method facilitates the dissection of spermatic cord structures, and can be used to minimize trauma to surrounding structures, especially when performed by trainees with limited operative experience.

Resected thymic large cell neuroendocrine carcinoma: report of a case.

BACKGROUND: Thymic large cell neuroendocrine carcinoma (LCNEC) is extremely rare. The detailed clinical features of thymic LNCECs remain unknown. CASE PRESENTATION: A 90-year-old man with a history of diabetes mellitus, chronic renal failure, and an abdominal aortic aneurysm underwent computed tomography for follow-up, which showed an anterior mediastinal tumor, measuring 31 mm × 28 mm in diameter. Magnetic resonance imaging showed an iso-intensity mass on T1-weighted images and high intensity on T2-weighted images. 18F-Fluorodeoxyglucose-positron emission tomography showed marked uptake in the mass, which was diagnosed as invasive thymoma or thymic carcinoma. Video-assisted thoracic surgery through the left thoracic cavity was converted to median sternotomy due to severe adhesions between the left lung and the chest wall. Partial thymectomy and combined partial resection of left upper lobectomy and the first and the second costal cartilages were performed. The pathologic diagnosis was thymic LCNEC, Masaoka stage III. The patient developed pleural dissemination and left lung metastases in 5 months and died 12 months after surgery. CONCLUSIONS: Thymic LCNEC has high malignant potential. More cases need to be studied.

Tumor-associated antigen recognized by the 22-1-1 monoclonal antibody encourages colorectal cancer progression under the scanty CD8+ T cells.

PURPOSE: The receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is a novel tumor-associated antigen. Although evidence suggests that RCAS1 suppresses immunity by inducing tumor-infiltrating lymphocyte (TIL) apoptosis, RCAS1 function in humans is controversial. RCAS1 overexpression leads to the generation of the Tn glycan antigen (N-acetyl-D-galactosamine, GalNAc) recognized by the 22-1-1 monoclonal antibody. The objective of this study is to examine Tn glycan antigen function in colorectal cancer and to determine its relationship to CD8+ T cells and prognosis. EXPERIMENTAL DESIGN: Immunohistochemical analyses examined Tn expression in tumor cells and CD8 on TILs in 146 surgically resected colorectal cancer. RESULTS: Of 146 samples, 68 tumors (47%) were Tn+; 72 tumors (49%) were CD8+. Using Cox multivariate analysis and the Kaplan-Meier method, Tn and CD8 positivity were determined to be mutually independent prognostic factors (P = 0.0266 and 0.0210, respectively). Tn+ patients with CD8+ TILs exhibited better survival than Tn+/CD8- patients (P = 0.0129). For CD8- patients, Tn positivity was associated with decreased survival from that seen in Tn- patients (P = 0.0097), suggesting that Tn exerts a function independent of CD8+ T cells in tumor progression. In all patients and cases with synchronous liver metastases (n = 29), the Tn+/CD8- survival rate was significantly lower than that seen for other groups (P = 0.0001 and 0.0063, respectively). The average number of liver metastases in Tn+/CD8- cases also increased (mean, 8.2 tumors; P = 0.0032). Multivariate analysis identified Tn+/CD8- status and Dukes' staging as independent prognostic factors (P = 0.0016 and < 0.0001, respectively). CONCLUSIONS: Tn may encourage invasion and innidiation through a mechanism independent of CD8+ T cells. Thus, Tn+/CD8- status is a risk factor for multiple liver metastases development and an independent negative prognostic factor for colorectal cancer.

Long-term results following thoracoscopic surgery for esophageal leiomyoma in four patients.

For esophageal leiomyoma, surgical enucleation is accepted as the standard procedure when the tumor is symptomatic or large in size without malignant findings. The aim of this study is to clarify the long-term results following thoracoscopic surgery. Four patients with esophageal leiomyoma were subjected to thoracoscopic surgery. The indications for surgical resection of esophageal leiomyoma were as follows: 1) tumor size greater than 3cm or appearance of enlargement; 2) symptomatic patients. In one case of a larger tumor, hand-assisted thoracoscopic surgery was performed in order to ensure both minimal invasion and a wide operative area. There was no mortality and one postoperative complication. No local recurrence, port site recurrence, pleural dissemination or distant metastases were detected between 35 and 96 months after the operation. The advantages of thoracoscopic surgery for esophageal leiomyoma include its safety and long-term prevention of recurrence.

Resection of lung metastasis from gallbladder carcinoma: immunohistochemistry of RCAS1 and CD8+T cells in primary and metastatic tumors.

Advanced Gallbladder cancer has an extremely poor prognosis. We examined a patient with resectable gallbladder cancer with associated lung metastasis. A 64-year-old female patient, diagnosed with gallbladder cancer and a solitary benign lung tumor by imaging, was subjected to extensive cholecystectomy and extrahepatic bile duct resection. After one year, a follow-up CT indicated enlargement of the lung tumor; video-assisted right middle lobectomy was then performed. The lung tumor was diagnosed as a metastasis derived from the gallbladder cancer by pathology and immunohistochemistry. Expression of RCAS1, an independent unfavorable prognostic indicator in gallbladder cancer, was observed in both the gallbladder and lung tumors. However, infiltration of CD8+T cells was only seen in the lung metastatic tumor. She has remained free of any evidence of recurrence in the 10 months and 4 years after the first surgery. The results that metastasis is solitary and infiltrated by CD8+T cells correspond with the present clinical history.

Radical operation for recurring gastric carcinoma.

BACKGROUND/AIMS: The effectiveness of surgical treatment for recurring gastric carcinoma is unclear. We conducted a retrospective review of our results with a radical surgical approach to the treatment of gastric cancer metastases. METHODOLOGY: Nine patients who underwent radical resection of recurring gastric cancer between 1990 and 2003 were examined and follow-up was completed by March 2003. RESULTS: The surgically removed recurring sites included local lesions (4 patients), as well as metastases in the liver (4 patients) and ovary (1 patient). There were no major complications or operative deaths. The mean operative time was 380 minutes; the mean intraoperative blood loss was approximately 525mL and the mean volume of transfused blood was 178mL. Re-recurrence appears in 8 patients between 1.5 and 26 months (average 8.5 months) following surgical resection. The sites of re-recurrence included the peritoneum, liver, lymph nodes, bone, as well as local lesions. One patient currently shows no evidence of disease more than 6 years after resection of the local recurrence. Two other patients remain alive, but presented with re-recurrence at 4 and 10 months postoperatively. The remaining 6 patients died of cancer between 2 and 28 months after surgery for recurring lesions. CONCLUSIONS: Radical surgery for recurring gastric cancer both liver and extrahepatic lesions is a safe treatment with a good prognosis for long-term survival in a select patient subpopulation.

Anicteric early bile duct carcinoma detection with magnetic resonance cholangiopancreatography.

The poor prognosis of extrahepatic bile duct carcinoma makes early detection and diagnosis essential for positive patient outcomes. We describe 2 cases of jaundice-free early extrahepatic bile duct carcinoma detected by magnetic resonance cholangiopancreatography. Extrahepatic bile duct carcinoma was discovered incidentally in patient 1 by magnetic resonance cholangiopancreatography during evaluation of a gallbladder stone. In patient 2, extrahepatic bile duct carcinoma was found during a routine health maintenance exam. Both patients underwent radical surgical intervention. Both patient 1 and 2 have remained in good health for over one year, 3.5 and one year, respectively, and have not exhibited any signs or symptoms of relapse or cancer recurrence. Based on these cases, it appears that magnetic resonance cholangiopancreatography can play a significant role in the early detection of extrahepatic bile duct carcinoma and improve disease prognosis.

Mesenteric lymph nodes status influencing survival and recurrence pattern after hepatectomy for colorectal liver metastases.

BACKGROUND/AIMS: We retrospectively reviewed our results with curative hepatic resection of metastases from colorectal carcinoma, and analyzed several factors of the primary tumor and liver metastases. METHODOLOGY: From 1988 to 1995, 90 patients underwent curative resection of colorectal liver metastases. The total mortality rate was 1.1%. Overall 5-year survival rate after hepatectomy was 37.9%. RESULTS: Mesenteric lymph node metastases from the primary tumor and the prehepatectomy serum carcinoembryonic antigen level were significant. In multivariate analysis, positive mesenteric lymph node was an independent prognostic factor. In the recurrent patterns, mesenteric lymph node metastases were associated with extrahepatic recurrence after hepatectomy. CONCLUSIONS: The prehepatectomy carcinoembryonic antigen level and mesenteric lymph node metastases of the primary tumor were the most important predictive factors for long survival after hepatectomy. Patients with these risk factors should be closely followed up with regard not only to the remnant liver but also extrahepatic organs.

Surgical treatment of pulmonary recurrence after hepatectomy for colorectal liver metastases.

BACKGROUND/AIMS: Although pulmonary recurrence is frequent among the extrahepatic recurrences after hepatectomy, the efficacy of surgical treatment for pulmonary recurrence after hepatectomy has not been confirmed. Surgical resection of pulmonary recurrence after hepatectomy for colorectal metastases was reviewed retrospectively to evaluate the survival benefit. METHODOLOGY: From 1990 to 1995, 10 of the 17 patients with pulmonary recurrence after hepatectomy for colorectal metastases underwent surgical treatment. Ten patients underwent resection of pulmonary recurrence. RESULTS: Operative mortality was 0%, and a postoperative complication was observed in 1 patient after pulmonary metastasectomy. The overall 5-year survival rate after pulmonary metastasectomy was 10.0%, and the median survival was 21.7 (range: 2.4-77.9) months. One patient underwent resection two times for remnant lung recurrence after first lung metastasectomy, and is alive with no evidence of recurrence 77.9 months after the first pulmonary resection, and 50.7 months after the third pulmonary resection. In 3 patients with well-differentiated adenocarcinoma, the median survival time was 6.2 months (range: 2.4-9.7). The other hands, 7 patients with moderately differentiated adenocarcinoma have a longer median survival time of 29.2 months (range: 16.0-77.9). CONCLUSIONS: Pulmonary metastasectomy after hepatectomy for metastases from colorectal cancer is a safe treatment, and might offer prolonged survival for highly selected patients.

Single incision laparoscopic approach for esophageal achalasia: A case report.

INTRODUCTION: Esophageal achalasia is an uncommon, benign, neurodegenerative disease that induces a transit disorder characterized by incomplete lower esophageal sphincter relaxation. PRESENTATION OF CASE: A 56-year-old woman with dysphagia was admitted to our hospital. An esophagography revealed flask-type achalasia. Endoscopy revealed a dilated esophagus and some resistance at the esophagogastric junction. We used a capped wound protector, common straight forceps, and hook-type electrocautery to perform transumbilical single incision laparoscopic Heller myotomy with Dor fundoplication (SILHD). The left liver lobe and cardia were pulled by a thread. A 6-cm Heller myotomy of the esophagus was performed with an additional 2-cm myotomy of the gastric wall. Dor fundoplication was performed to cover the exposed submucosa. Intraoperative endoscopy confirmed the adequacy of the myotomy and Dor fundoplication. There were no postoperative complications. An esophagography and an endoscopic examination did not reveal stenosis or reflux at 1-year follow-up, and the patient has been satisfactorily symptom free. DISCUSSION: LHD is the most accepted surgical treatment for achalasia and has low invasiveness and long-term efficacy. SILHD for achalasia is a new approach and may provide improved cosmetics and less invasiveness compared with those by conventional LHD. The 1-year follow-up results in the present case are the longest reported to date. The evaluation of long-term results in a large-scale study is necessary in future. CONCLUSION: SILHD can be safe, widely accepted, mid-term minimal invasive and cosmetically superior surgical procedure for achalasia.

Surgical treatment of liver metastases from pancreatic cancer.

Pancreatic cancer is a disease with a poor prognosis. Most patients are diagnosed at an advanced and unresectable stage. Even if the primary cancer is radically removed, postoperative recurrence frequently occurs. Generally, metastatic liver tumors from pancreatic cancer are not indicated for surgical treatment. Here we evaluate the results of performing hepatectomy for liver metastases of pancreatic cancer. In our institute, six patients with liver metastases from pancreatic cancer were treated by partial hepatectomy. Overall 1-, 3- and 5-year survival rates of six patients after hepatectomy were 66.7%, 33.3% and 16.7%, respectively, and one patient was alive for 65.4 months. Performing a hepatectomy for liver metastases of pancreatic cancer, when combined with a pancreas resection, was recently considered to be a safe operation, and one that might offer prolonged survival for highly selected patients with curative resection of liver metastases. In the future, it will be necessary to develop new multi-modality therapies to improve the prognosis of pancreatic cancer.

Reconstructed beta-catenin/TCF4 signaling in yeast applicable to functional evaluation of APC mutations.

In human genetics and molecular oncology, mutation research is necessary not only to identify mutations in nucleic acid sequences, but also to analyze the loss of function caused by mutant proteins. We reconstructed a protein-protein network system of human beta-catenin and TCF4, in Saccharomyces cerevisiae. beta-Catenin and TCF4 proteins form a complex and transactivate reporter genes. Co-expressed wild-type APC with beta-catenin and TCF4 inhibit the transcriptional activity of the beta-catenin/TCF4 complex in yeast, as well as in mammals. This unique method in which the beta-catenin/TCF4 signaling pathway is reconstructed in vivo may prove useful for the functional evaluation of APC mutants, including a type of APC truncated and missense mutants influenced to the ability of binding to beta-catenin.