Publications by authors named "Kensuke Fujii"

40 Publications

Collision Tumor Comprising Primary Malignant Lymphoma and Adenocarcinoma in the Ascending Colon.

Case Rep Gastroenterol 2021 Jan-Apr;15(1):379-388. Epub 2021 Mar 18.

Department of Surgery, Gastroenterological Center, Shunjukai Shiroyama Hospital, Osaka, Japan.

We describe the case of a 78-year-old man with collision tumor from the primary malignant lymphoma and adenocarcinoma in the ascending colon. He suffered anemia from sigmoid colon cancer, and colonoscopy revealed early-stage colorectal cancer with a diameter of 20 mm in the cecum, the biopsy specimen showed moderately differentiated adenocarcinoma. Contrast-enhanced computed tomography (CT) revealed bowel wall thickening with contrast enhancement at the cecum; however, no lymph node and organ metastases were found. As above, we performed laparoscopic ileocecal resection with D3 lymph node dissection. The postoperative course was uneventful, and he was discharged from the hospital on postoperative day 11. Histopathological findings were moderately differentiated adenocarcinoma which invaded the muscularis propria and serosa from the submucosa, while the adjacent serosa showed a highly diffuse proliferation of atypical cells with an irregular nuclear-to-cytoplasmic ratio. Besides, immunohistochemical staining findings were diffuse large B-cell lymphoma, and diffuse large B-cell lymphoma was coexistent with moderately differentiated adenocarcinoma. We treated the patient with cyclophosphamide, doxorubicin, vincristine, and prednisolone in combination with rituximab (R-CHOP therapy) during 3 months postoperatively. When the 8 courses had been completed, postoperative positron emission tomography-CT (PET-CT) confirmed complete response, and the disease control has been doing well. Malignant lymphoma of the colorectal region is relative rare, and the occurrence of synchronous lymphoma and adenocarcinoma of the colon is also rare. Furthermore, collision tumor by these different entities is very unusual. We presented here such a case. The accurate clinical determination of the dominant tumor and a close follow-up is required for proper treatment in these cases.
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http://dx.doi.org/10.1159/000513972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077522PMC
March 2021

Total pancreatectomy for pancreatic remnant carcinoma five years after pancreaticoduodenectomy: Report a case.

Int J Surg Case Rep 2021 Apr 20;81:105795. Epub 2021 Mar 20.

Department of Gastroenterological Center Surgery, Shunjukai Shiroyama Hospital, Osaka, Japan.

Introduction And Importance: The prognosis of non-invasive intraductal papillary mucinous neoplasma (IPMN) is better than that of pancreatic cancer. However, if the first surgical finding revealed an invasive IPMC, the risk of recurrence was found to be 7-21%.

Case Presentation: A 76-year-old Japanese man had undergone subtotal stomach-preserving pancreaticoduodenectomy for intraductal papillary mucinous carcinoma non-invasive type at our hospital. No signs of adenocarcinoma at the resection margin were found by pathological examination of frozen sections. Five years later, a blood analysis showed increased serum CA19-9 level. A contrast-enhanced computed tomography scan of the abdomen revealed a mass adjacent to the pancreaticogastrostomy anastomosis. The patient underwent a total pancreatectomy. The tumor was identified as a recurrent IPMC with subserosal invasion, but without nodal involvement. The resection margins were negative. The patient's postoperative course was uneventful, and he was discharged after 12 days. He is being followed up without adjuvant chemotherapy.

Discussion: The prognosis of IPMN is better than that of pancreatic cancer. However the risk of recurrence in invasive IPMC was found to be 7-21%. Therefore, IPMC must be surveilled every three months using tumor markers and imaging. Local recurrence in remnant pancreas is usually treated with systemic therapy. The median long-term survival after total pancreatectomy (range 7-24 months) was shown to be better than when chemotherapy alone was used (range 10-13 months).

Conclusion: We chose secondary surgery in term of survival time although there are quality of life drawbacks that currently make total pancreatectomy more inappropriate in patients than chemotherapy.
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http://dx.doi.org/10.1016/j.ijscr.2021.105795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024913PMC
April 2021

The Management of Recurrence of Hepatocellular Carcinoma Occurring Within 6 Months After Hepatic Resection: A Comparative Study Using a Propensity Score Matching Analysis.

J Gastrointest Cancer 2021 Jan 20. Epub 2021 Jan 20.

Department of General and Gastroenterological Surgery, Osaka Medical College Mishima-Minami Hospital, 8-1 Tamagawa-shinmachi, Takatsuki City, Osaka, 569-0856, Japan.

Background: Hepatectomy is currently recommended as the most reliable treatment for hepatocellular carcinoma. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial.

Methods: Three-hundred thirty-nine patients who underwent hepatectomy were retrospectively analyzed using a propensity score matching analysis for the risk factors and outcomes for early recurrences within 6 months. The remnant liver volumes and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after surgery. The Student's t test and chi-square test, the likelihood-ratio test, Fisher's exact test, Mann-Whitney U test, or Wilcoxon signed-rank test were used in the statistical analyses.

Results: Early recurrence developed in 41/312 patients (13.1%). Vascular invasion and non-curative resection were independent risk factors for the occurrence of early recurrence (P < 0.001 and < 0.001, respectively). Patients with early recurrence had a poorer prognosis than patients who developed later recurrences (P < 0.001). Patients who underwent surgery or other local treatments had better outcomes (P < 0.001). The changes in remnant liver volumes and laboratory data after postoperative month 2 were not significantly different between the two groups.

Conclusion: Patients with early recurrence within 6 months had a poorer prognosis than patients who developed a later recurrence. However, patients who underwent repeat hepatectomy for recurrences had a better prognosis than did those who underwent other treatments, with good prospects for long-term survival.
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http://dx.doi.org/10.1007/s12029-021-00585-2DOI Listing
January 2021

Safety and Efficacy of Laparoscopic Liver Resection for Colorectal Liver Metastasis With Obesity.

Am Surg 2020 Dec 7:3134820952448. Epub 2020 Dec 7.

Department of Internal Medicine, Osaka Medical College Mishima-Minami Hospital, Japan.

Introduction: Laparoscopic liver resection (LLR) in obese patients has been reported to be particularly challenging owing to technical difficulties and various comorbidities.

Methods: The safety and efficacy outcomes in 314 patients who underwent laparoscopic or open nonanatomical liver resection for colorectal liver metastases (CRLM) were analyzed retrospectively with respect to the patients' body mass index (BMI) and visceral fat area (VFA).

Results: Two hundred and four patients underwent LLR, and 110 patients underwent open liver resection (OLR). The rate of conversion from LLR to OLR was 4.4%, with no significant difference between the BMI and VFA groups ( = .647 and .136, respectively). In addition, there were no significant differences in terms of operative time and estimated blood loss in LLR ( = .226 and .368; .772 and .489, respectively). The incidence of Clavien-Dindo grade IIIa or higher complications was not significantly different between the BMI and VFA groups of LLR ( = .877 and .726, respectively). In obese patients, the operative time and estimated blood loss were significantly shorter and lower, respectively, in LLR than in OLR ( = .003 and < .001; < .001 and < .001, respectively). There was a significant difference in the incidence of postoperative complications, organ/space surgical site infections, and postoperative bile leakage between the LLR and OLR groups ( = .017, < .001, and < .001, respectively).

Conclusion: LLR for obese patients with CRLM can be performed safely using various surgical devices with no major difference in outcomes compared to those in nonobese patients. Moreover, LLR has better safety outcomes than OLR in obese patients.
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http://dx.doi.org/10.1177/0003134820952448DOI Listing
December 2020

The Effects of Allogeneic Blood Transfusion in Hepatic Resection.

Am Surg 2021 Feb 15;87(2):228-234. Epub 2020 Sep 15.

13010 Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Takatsuki, Osaka, Japan.

Background: Hepatectomy has a high risk of perioperative bleeding due to the underlying disease. Here, we investigated the postoperative impact of allogeneic blood transfusion during hepatectomy.

Methods: The surgical outcomes in 385 patients who underwent hepatic resection for hepatocellular carcinoma were retrospectively reviewed. The association of allogeneic blood transfusion with surgical outcomes and remnant liver regeneration data was analyzed.

Results: Eighty-six patients (24.0%) received an allogeneic blood transfusion and 272 patients (76.0%) did not. After propensity score matching, the incidence rates of postoperative complication (Clavien-Dindo grade >IIIA), posthepatectomy liver failure, and massive ascites were significantly higher for the group that received a blood transfusion than for the group that did not receive blood transfusion ( < .001, = .001, and <.001, respectively). Postoperative measures of total bilirubin, albumin, platelet count, prothrombin time, aspartate aminotransferase, and alanine aminotransferase were significantly more favorable in patients without blood transfusion until day 7 after surgery. There were no correlations in the remnant liver regeneration at 7 days, and 1, 2, 5, and 12 months postoperatively between the 2 groups ( = .585, .383, .507, .261, and .430, respectively). Regarding prognosis, there was no significant difference in overall and recurrence-free survival between the 2 groups ( = .065 and .166, respectively).

Conclusion: Allogeneic transfusion during hepatectomy strongly affected remnant liver function in the early postoperative period; however, this was not related to the remnant liver regeneration volume. Despite that the allogeneic transfusion resulted in poorer postoperative laboratory test results and increased postoperative complication and mortality rates, it had no effect on the long-term prognosis.
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http://dx.doi.org/10.1177/0003134820950285DOI Listing
February 2021

Tachyarrhythmia improved by management of low back pain in a patient with delayed diagnosis of infective spondylodiscitis: A case report.

SAGE Open Med Case Rep 2020 23;8:2050313X20952996. Epub 2020 Aug 23.

Department of Emergency Medicine, Osaka Medical College, Takatsuki, Japan.

A 77-year-old man presented to the emergency room with a 1-month history of persistent low back pain with the absence of vital sign abnormalities. On several previous orthopedic surgery clinic visits, pathological back pain had not been considered and pain killers had been prescribed because he had low back pain due to lumbar spinal canal stenosis. He was admitted to the intensive care unit for infectious spondylodiscitis and infective endocarditis with disseminated abscess caused by methicillin-resistant . Shock refractory tachyarrhythmia could not be managed with antiarrhythmic agent in the intensive care unit. Intractable low back pain and persistent tachyarrhythmia were adequately managed by pain control with fentanyl in the intensive care unit. Infectious spondylodiscitis and infective endocarditis were effectively managed with anti-methicillin-resistant drugs, initially in rotational usage, but the patient died of extended-spectrum beta-lactamase-producing pneumonia on day 50 of hospitalization. Infectious spondylodiscitis should have been considered for persistent low back pain with hemodialysis, fever, and a history of device implantation. Pain management may be necessary for persistent tachycardia that proves unresponsive to usual antiarrhythmic medications.
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http://dx.doi.org/10.1177/2050313X20952996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448131PMC
August 2020

Successful multi-stage treatment of stoma limb perforation following Hartmann's operation report a case.

Surg Case Rep 2020 May 14;6(1):102. Epub 2020 May 14.

Department of Surgery, Gastroenterological Center, Shunjukai Shiroyama Hospital, 2-8-1 Habikino, Habikino city, Osaka, 583-0872, Japan.

Background: Stoma-related complications are not rare, whereas the spontaneous perforation of the stoma limb is relatively rare. Herein, we report a case of stoma limb perforation which occurred after Hartmann's operation.

Case Presentation: A 50-year-old Japanese man presented to our Hospital with acute and severe abdominal pain. Abdominal computed tomography (CT) scan revealed that an abscess with free air was formed around the sigmoid colon. We performed Hartmann's operation, whereas he experienced redness, purulent discharge, and swelling around the colostomy at 10 days postoperatively. The contrast-enhanced CT scan of the abdomen revealed an abscess formation with air around the colostomy. He was diagnosed with an abdominal wall abscess due to perforation of the stoma limb. After the drainage, his symptoms were ameliorated by oral analgesics, anti-inflammatory drugs, and prophylactic antibiotic. Four months after the first operation, we performed a closedown of the sigmoid colostomy and fistula resection. The patient's postoperative course was uneventful, and he was discharged 14 days later.

Conclusions: This case depicts rare complications of Hartmann's operation. Operation is usually performed in patients with stoma limb perforation. However, if they are stable and the abscess is located in their abdominal wall, they may be treated successfully using a multi-stage approach of local drainage toward the stoma wall followed by stoma closure.
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http://dx.doi.org/10.1186/s40792-020-00827-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225223PMC
May 2020

Gastrointestinal Neurons Expressing HCN4 Regulate Retrograde Peristalsis.

Cell Rep 2020 03;30(9):2879-2888.e3

Department of Physiology, Osaka Medical College, Takatsuki, Japan. Electronic address:

Peristalsis is indispensable for physiological function of the gut. The enteric nervous system (ENS) plays an important role in regulating peristalsis. While the neural network regulating anterograde peristalsis, which migrates from the oral end to the anal end, is characterized to some extent, retrograde peristalsis remains unresolved with regards to its neural regulation. Using forward genetics in zebrafish, we reveal that a population of neurons expressing a hyperpolarization-activated nucleotide-gated channel HCN4 specifically regulates retrograde peristalsis. When HCN4 channels are blocked by an HCN channel inhibitor or morpholinos blocking the protein expression, retrograde peristalsis is specifically attenuated. Conversely, when HCN4(+) neurons expressing channelrhodopsin are activated by illumination, retrograde peristalsis is enhanced while anterograde peristalsis remains unchanged. We propose that HCN4(+) neurons in the ENS forward activating signals toward the oral end and simultaneously stimulate local circuits regulating the circular muscle.
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http://dx.doi.org/10.1016/j.celrep.2020.02.024DOI Listing
March 2020

The Relationship Between the Number of Ports and Surgical Outcomes in Laparoscopic Hepatectomy.

Surg Laparosc Endosc Percutan Tech 2020 Feb;30(1):85-90

Department of General and Gastroenterological Surgery.

Introduction: Reduced port surgery (RPS) has been garnering interest as a novel minimally invasive surgery lately.

Aim: The authors examined the relationship between the number of ports and surgical outcomes after laparoscopic hepatectomy (LH).

Materials And Methods: Between January 2012 and April 2019, 209 patients who underwent laparoscopic partial resection and lateral sectionectomy were retrospectively analyzed with respect to operative variables and surgical outcomes. Patients were divided into 5 groups by the number of ports used. Student's t test, the χ test, the likelihood-ratio test, Fisher exact test, or Mann-Whitney U test were used to analyze the data.

Results: Operative duration was significantly longer in patients with a larger number of ports than in those with a smaller number of ports. Chronological pain scores according to the visual analog scale (VAS) on postoperative days 1, 2, 4, and 7 were not associated with the number of ports and wound length in the umbilical region. The frequency of using additional analgesic agents was not significantly different between the groups. VAS scores and the number of additional analgesic agents used were smaller in patients in whom non-steroidal anti-inflammatory drugs were regularly administered postoperatively than in those in whom the drug was not regularly administered postoperatively. LH had a 3.4% complication rate (Clavien-Dindo classification >IIIA); however, this was not significantly different between the groups.

Conclusions: No significant difference in postoperative pain was observed between RPS and conventional methods, although operative durations were shorter with RPS. However, RPS for LH may be associated with excellent cosmetic results compared with conventional methods.
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http://dx.doi.org/10.1097/SLE.0000000000000750DOI Listing
February 2020

Usefulness of repair using Hem-o-lok™ for peritoneal tear as a complication of totally extraperitoneal repair: Case series.

Ann Med Surg (Lond) 2020 Jan 23;49:5-8. Epub 2019 Nov 23.

Division of Surgery Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan.

Introduction: Peritoneal tear (PT) is a frequent intraoperative event during totally extraperitoneal repair (TEP). We aimed to introduce our surgical technique for PT during TEP to avoid the more difficult TEP procedure.MethodsOne surgeon with 10 years of experience performed our TEP method in 147 TEP cases from January 2012 to June 2019. We investigated the repair time of each repair technique using endoscopic suturing (suturing group, SG) and endoscopic Hem-o-lok stapling (CG).

Results: Twenty-three (15.6%) PT cases occurred as TEP complication. The mean repair times (with standard deviation) of the PT were 16.2 ± 13 and 7.6 ± 7.0 min in the SG and CG, respectively, indicating a significant difference (P = 0.043). The repair time of the PT using Hem-o-lok (Teleflex, Wayne, PA, USA) stapling was shorter than that using endoscopic suturing, which was significantly different despite the length of the PT.

Conclusion: Hem-o-lok stapling is feasible in case of PT during TEP.
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http://dx.doi.org/10.1016/j.amsu.2019.11.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911983PMC
January 2020

The Management of Recurrence within Six Months after Hepatic Resection for Colorectal Liver Metastasis.

Dig Surg 2020 9;37(4):282-291. Epub 2019 Oct 9.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Takatsuki, Osaka, Japan.

Background: Hepatectomy is currently recommended as the most reliable treatment for colorectal liver metastases. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial.

Methods: Two-hundred ninety-five patients who underwent hepatectomy were retrospectively analyzed for the risk factors and the outcomes for early recurrence within 6 months. The remnant liver volumes (RLVs) and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after the operation.

Results: Early recurrence developed in 88/295 patients (29.8%). Colorectal cancer lymph node metastasis, synchronous liver metastasis, and multiple liver metastases were independent risk factors for the occurrence of early recurrence (p < 0.001, 0.032, and 0.019, respectively). Patients with early recurrence had a poorer prognosis than did patients who developed later recurrence (p < 0.001). Patients who underwent surgery or other local treatment had better outcomes. The changes in RLV and laboratory data after postoperative month 2 were not significantly different between the 2 groups.

Conclusion: Patients with early recurrence within 6 months had a poorer prognosis than did patients who developed later recurrence. However, patients who underwent repeat hepatectomy for recurrence had a better prognosis than did those who underwent other treatments, with good prospects for long-term survival.
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http://dx.doi.org/10.1159/000503420DOI Listing
April 2021

Laparoscopic Repeat Hepatic Resection for the Management of Liver Tumors.

J Gastrointest Surg 2019 11 16;23(11):2314-2321. Epub 2019 Jul 16.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan.

Background: Laparoscopic hepatic resection has been developed as a minimally invasive surgery; however, laparoscopic repeat minor hepatic resection (LRH) carries a higher risk of damage to other organs because of postoperative changes to and losses of anatomical landmarks. The current standard approach at many facilities has been to perform open repeat minor hepatic resection (ORH). This paper describes the surgical outcomes, procedure safety, and utility of ORH versus LRH, as well as the laparoscopic techniques used in LRH.

Methods: Between February 2010 and May 2018, the data of 142 patients who underwent LRH or ORH at a single institution were retrospectively reviewed. Surgical outcomes, procedure safety, and procedure utility data were analyzed.

Results: Forty-five patients underwent LHR and 97 patients underwent ORH. The conversion rate from LHR to OHR was 13.3%. After propensity score matching (PSM), the estimated blood loss was significantly lower in the LRH group than in the ORH group (50 mL vs. 350 mL; P < 0.001). The LRH group had an 8.1% complication rate, while the ORH group had a complication rate of 24.3% (P = 0.044). The postoperative length of stay was significantly shorter in the LHR group than in the OHR group (9 days vs. 11 days) (P = 0.024).

Conclusion: LRH can be performed safely using various surgical devices. More favorable results are achieved with LRH than with ORH in terms of surgical outcomes including intraoperative bleeding, postoperative complications, and postoperative lengths of stay.
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http://dx.doi.org/10.1007/s11605-019-04276-zDOI Listing
November 2019

Laparoscopic omentectomy in primary torsion of the greater omentum: report of a case.

Surg Case Rep 2019 May 9;5(1):76. Epub 2019 May 9.

Department of Surgery, Gastroenterological Center, Shunjukai Shiroyama Hospital, 2-8-1 Habikino Habikino-city, Osaka, 583-0872, Japan.

Background: Torsion of the greater omentum is a rare cause of acute abdominal pain in adults and children. It is very difficult to make a correct diagnosis of torsion clinically because it mimics other acute pathologies; however, the preoperative diagnosis can be easily confirmed with the use of computed tomography (CT). Herein, we report a case of laparoscopic omentectomy for primary torsion of the omentum, which was not improved by conservative treatment.

Case Presentation: A 50-year-old Japanese man presented to our hospital with acute right lower quadrant abdominal pain of a few hours' duration. Routine blood tests showed a white blood cell count of 8900/mm, and the C-reactive protein (CRP) level was 8.13 mg/dl. Contrast-enhanced CT scan of the abdomen revealed twisting of the omentum with a local mass of fat density and fluid distributed in a whirling oval-shaped mass pattern at the right flank and iliac fossa. Therefore, the patient was admitted to our hospital based on a diagnosis of omental torsion. The patient was treated with conservative treatment with analgesics, anti-inflammatories, and antibiotics. Although his symptoms were ameliorated, his laboratory and radiological findings worsened. We performed laparoscopic omentectomy 6 days after admission. The resected omentum was 24 cm × 22 cm in size and was twisted and dark red in color, suggesting infarction. Histological analysis revealed that the specimen was ischemic and hemorrhagic omentum, accompanied by inflammatory infiltration. The patient's postoperative course was uneventful, and he was discharged 9 days later.

Conclusion: This is a rare case of primary torsion of the greater omentum that was treated successfully with laparoscopic omentectomy. Considering the increase in surgical difficulty due to inflammation from prolonged torsion and the limited efficacy of conservative treatment, we conclude that surgical intervention is warranted as early as possible when torsion of the greater omentum is suspected.
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http://dx.doi.org/10.1186/s40792-019-0618-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509293PMC
May 2019

Laparoscopic Total Devascularization of the Upper Stomach and Splenectomy (Hassab's Procedure) Under Indocyanine Green Fluorescence Imaging: Initial Experience.

Surg Innov 2019 Aug 8;26(4):432-435. Epub 2019 Feb 8.

1 Medico Shunju Shiroyama Hospital, Osaka, Japan.

The use of surgical treatment for refractory isolated gastric varices has decreased owing to the development of endoscopic and radiologic procedures, although surgeries are sometimes required as the final method. A 75-year-old Japanese woman was diagnosed with solitary gastric varices. Initially, intraoperative splenic artery embolization was performed using the balloon transcatheter technique under general anesthesia. Laparoscopic splenectomy was performed safely owing to preoperative splenic artery embolization. Intraoperative indocyanine green (ICG) fluorescence angiography was performed following the injection of 5 mL of ICG; the remnant stomach was observed using laparoscopic equipment with an ICG imaging system, and blood flow from the remnant gastric artery was confirmed. The blood did not pool or wash out immediately, which confirmed successful devascularization of the stomach. The total operative time was 269 minutes, and the intraoperative blood loss was 500 mL. The patient's postoperative course was good, and at 21 days after the last operation, she was discharged from our hospital in remission. Real-time fluorescence angiography with ICG is a reliable and objective technique of assessing blood flow of the stomach. Accurate, extensive devascularization in the lower esophagus and upper stomach was performed using Hassab's procedure in combination with ICG imaging.
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http://dx.doi.org/10.1177/1553350619828912DOI Listing
August 2019

Laparoscopic Excisional Cholecystectomy with Full-Thickness Frozen Biopsy in Suspected Gallbladder Carcinoma.

Case Rep Gastroenterol 2018 Sep-Dec;12(3):747-756. Epub 2018 Dec 13.

Division of Surgery, Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan.

Owing to the advantages of a laparoscopic approach, laparoscopic cholecystectomy (LC) is thought to be the treatment of choice in gallbladder disease, even in cases of suspected malignancy. However, it is difficult to differentiate between cholecystitis and gallbladder carcinoma (GBC). We performed radical hepatectomy in patients with pT2 GBC diagnosed by full-thickness frozen biopsy. A 75-year-old Japanese man presented to our hospital with discomfort in the right upper quadrant of the abdomen. This patient was diagnosed with suspected GBC and was scheduled to undergo LC and intraoperative histological examination. Following the procedure, we made a diagnosis of GBC with negative invasion of the cystic duct stump. We converted the laparoscopic procedure to an open surgery involving wedge liver resection with lymphadenectomy. The patient was discharged from our hospital in remission 14 days following the radical hepatectomy. Histological examination showed that the GBC had invaded the liver (T3a), but there was no lymph node metastasis (N0): stage IIIA. Between April 2009 and September 2018, 580 patients underwent cholecystectomy for gallbladder disease at our hospital. Among these, 8 (1.4%) were suspected to have GBC preoperatively and underwent laparoscopic excisional cholecystectomy. We performed elective surgery in the early stage in two patients and second-look surgery in two patients recently. We were able to perform what we termed a laparoscopic excisional cholecystectomy, involving LC with a full-thickness frozen biopsy, even in situations where intraoperative histological examination was not available. Altogether, laparoscopic excisional cholecystectomy is an effective surgical treatment for suspected early GBC.
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http://dx.doi.org/10.1159/000495603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341341PMC
December 2018

Combination of electrohydraulic lithotripsy and laparoscopy for gallbladder access in type III Mirizzi syndrome.

Asian J Endosc Surg 2019 Apr 13;12(2):227-231. Epub 2018 Dec 13.

Division of Surgery, Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan.

Introduction: A 50-year-old Japanese man presented with obstructive jaundice. We performed endoscopic retrograde biliary drainage before biliary decompression. CT showed a thickened gallbladder wall with low-density areas and a 35-mm gallstone; the stone was impacted in the gallbladder neck and cystic duct. The patient was therefore diagnosed with Mirizzi syndrome (type II or III) and scheduled for laparoscopic treatment. We performed subtotal cholecystectomy and intraoperative choledochoscopy because we recognized a fistula between the gallbladder and common bile duct preoperatively.

Materials And Surgical Technique: We opened the ductus choledochus, and a choledochoscope was introduced under laparoscopic guidance. An electrohydraulic lithotripsy probe with irrigation was passed through the choledochoscope to extract the gallstone.

Discussion: This fragmentation technique is effective for impacted large stones observed in Mirizzi syndrome. Therefore, electrohydraulic lithotripsy with laparoscopy is effective in cases of difficult gallbladder access such as that that occurs in type II or III Mirizzi syndrome.
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http://dx.doi.org/10.1111/ases.12602DOI Listing
April 2019

The utility of the subcuticular suture in hepatic resection.

Contemp Oncol (Pozn) 2018 30;22(3):184-190. Epub 2018 Sep 30.

Osaka Medical College Hospital, Takatsuki, Osaka, Japan.

Aim Of The Study: Despite recent technical progress and advances in the perioperative management of liver surgery, postoperative surgical site infection (SSI) is still one of the most common complications that extends hospital stays and increases medical expenses following hepatic surgery.

Material And Methods: From 2001 to 2017 a total of 1180 patients who underwent hepatic resection for liver tumours were retrospectively analysed with respect to the predictive factor of superficial incisional SSI, using a propensity score matching by procedure (subcuticular or mattress suture).

Results: The incidence of superficial and deep incisional SSIs was found to be 7.1% (84/1180). By propensity score matching (PSM), 121 of the 577 subcuticular suture group patients could be matched with 121 of the 603 mattress suture group patients. Multivariate analysis demonstrated wound closure technique as the only independent risk factor that correlated significantly with the occurrence of superficial incisional SSIs ( = 0.038). C-reactive protein (CRP) levels on postoperative day 4 were significantly higher in patients with incisional SSIs than in those without ( < 0.001).

Conclusions: Wound closure technique with subcuticular continuous spiral suture using absorbable suture should be considered to minimise the incidence of incisional SSIs. Moreover, wounds should be carefully checked when CRP levels are high on postoperative day 4.
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http://dx.doi.org/10.5114/wo.2018.78940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238092PMC
September 2018

Volumetric and Functional Regeneration of Remnant Liver after Hepatectomy.

J Gastrointest Surg 2019 05 27;23(5):914-921. Epub 2018 Sep 27.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan.

Background: Post-hepatectomy liver regeneration is of great interest to liver surgeons, and understanding the process of regeneration could contribute to increasing the safety of hepatectomies and improving prognoses.

Methods: Five hundred thirty-eight patients who underwent hepatectomy were retrospectively analyzed. Postoperative outcomes were evaluated, with a focus on the effects of portal vein resection and resected liver volume on remnant liver regeneration in patients with liver tumors. Remnant liver volumes (RLVs) and laboratory data were measured postoperatively using multidetector computed tomography on day 7 and months 1, 2, 5, 12, and 24 after the operation.

Results: Liver regeneration speed peaked at 1 week postoperatively and gradually decreased. Regeneration with large resections was longer than that with small resections, with the remnant liver regeneration rate being significantly lower in the former at all time points. Remnant liver regeneration plateaued around 5 months postoperatively, when regeneration is almost complete. Up to 1 month postoperatively, laboratory data were significantly worse when more portal veins was resected. After 2 months postoperatively, these data recovered to near normal levels.

Conclusion: The speed and rate of remnant liver regeneration primarily showed a strong correlation with the number of resected portal veins and the amount of removed liver parenchyma. The larger the resection ratio, the longer it took the liver to regenerate. We confirmed that recovery of the liver's functional aspects accompanies recovery of the RLV.
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http://dx.doi.org/10.1007/s11605-018-3985-5DOI Listing
May 2019

Surgical strategy for suspected early gallbladder carcinoma including incidental gallbladder carcinoma diagnosed during or after cholecystectomy.

Ann Med Surg (Lond) 2018 Sep 2;33:56-59. Epub 2018 Aug 2.

Division of Surgery Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan.

Purpose: This paper presents an overview of the surgical strategy for patients with suspected gallbladder carcinoma (GBC), including incidental GBC cases, preoperatively or intraoperatively, as well as their outcomes.

Methods: Between April 2009 and December 2017, 529 patients underwent cholecystectomy for gallbladder disease at our hospital. Both intraoperative and postoperative histological examinations of the excised gallbladder facilitated the diagnosis of GBC. Surgery-related variables and surgical approaches were evaluated according to the extent of tumor invasion.

Results: Of 529 patients, eight were diagnosed with GBC during/after cholecystectomy, including four women and four men. Mean age was 75.4 (range, 59-89) years. Five patients had gallbladder stones and three had cholecystitis. Three patients with stages T1b and T2 underwent additional liver bed wedge resections with or without prophylactic common bile duct excision. Five of the eight patients are still alive and two of the remaining three died from other diseases; one patient with pT3 died of recurrent GBC (peritonitis carcinomatosa).

Conclusion: Because of the ability to obtain full-thickness frozen biopsies during laparoscopic cholecystectomy, we could diagnose GBC intraoperatively, allowing for rapid diagnosis and tumor resection. We recommend developing a surgical treatment strategy for suspected early GBC in advance of cholecystectomy.
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http://dx.doi.org/10.1016/j.amsu.2018.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6127871PMC
September 2018

The Relationship Between Postoperative Chemotherapy and Remnant Liver Regeneration and Outcomes After Hepatectomy for Colorectal Liver Metastasis.

J Gastrointest Surg 2019 10 5;23(10):1973-1983. Epub 2018 Sep 5.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.

Background: Postoperative chemotherapy for treating colorectal liver metastasis (CLM) has been introduced with the aim of improving therapeutic outcomes. However, there is no consensus on the utility of multidisciplinary treatments with postoperative chemotherapy. Therefore, we evaluated surgical outcomes in patients with CLMs who underwent hepatectomy, while focusing on the effects of post-hepatectomy chemotherapy on remnant liver regeneration.

Methods: Two hundred ninety patients who underwent hepatectomy were retrospectively analyzed using propensity score matching. Postoperative outcomes were evaluated with a focus on the effects of post-hepatectomy chemotherapy on regeneration of the remnant liver in patients with CLM. The remnant liver volumes (RLVs) were measured postoperatively using multi-detector computed tomography on day 7 and months 1, 2, 5, and 12 after the operation.

Results: RLV regeneration and postoperative blood laboratory data did not differ significantly between patients who received postoperative chemotherapy and those who did not receive postoperative chemotherapy immediately after surgery or at any time point from postoperative day 7 to postoperative month 12. The recurrence rates, including same and other segmental intrahepatic recurrences, as well as the resection frequency of the remnant liver were not significantly different between the two groups.

Conclusion: Postoperative chemotherapy may be of small significance for patients with CLM in terms of the remnant liver volume regeneration and functional recovery.
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http://dx.doi.org/10.1007/s11605-018-3952-1DOI Listing
October 2019

Surgical technique of laparoscopic hybrid approach for recurrent inguinal hernia: Report a case.

Int J Surg Case Rep 2018 7;50:13-16. Epub 2018 Jul 7.

Division of Surgery Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan.

Introduction: Currently, laparoscopic surgery (LS) is a widely accepted surgical treatment for inguinal hernias, and it has major advantages, especially for recurrent cases.

Presentation Of Case: We diagnosed the recurrent inguinal hernia after wound infection and performed the laparosocopic approach. We would like to introduce our method. We distinguished between the presence and absence of bilateral inguinal hernia with an intra-abdominal scope using the transabdominal preperitoneal inguinal hernia repair (TAPP) technique, which we call laparoscopic examination. Thus, we can distinguish between the types of inguinal hernias and whether they are bilateral or not. We dissected the Retzius space on the inside of an epigastric arteriovenous fistula as part of TEP part A, and dissection was performed without a balloon. We separated and dissected the Retzius space. We also performed lateral dissection of the preperitoneal space. We made an incision in the peritoneum at the inner groin ring (hernia sac). We isolated the cord structures (parietalization) using TAPP. We finally checked this operation from the abdominal space (TAPP filed) and determined whether the repair was satisfactorily completed or not.

Discussion: Our hybrid method is not special but the conventional laparoscopic approach adapted each merits both TAPP and TEP.

Conclusion: Our method is effective for difficult recurrent inguinal hernias.
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http://dx.doi.org/10.1016/j.ijscr.2018.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083376PMC
July 2018

Surgical Outcome and Hepatic Regeneration after Hepatic Resection for Hepatocellular Carcinoma in Elderly Patients.

Dig Surg 2019 14;36(4):289-301. Epub 2018 May 14.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan.

Introduction: The rising proportion of elderly patients (aged 80 yearsor above) in our population means that more elderly patients are undergoing hepatectomy.

Methods: Five-hundred and thirty patients who underwent hepatectomy for hepatocellular carcinoma (HCC) were retrospectively analyzed with respect to their preoperative status and perioperative results, including remnant liver regeneration. The remnant liver volume was postoperatively measured with multidetector CT on postoperative day 7 and 1, 2, 5, and 12 months after surgery. An elderly group (aged 80 or older) was compared with a non-elderly group (aged less than 80 years).

Results: Underlying diseases of the cardiovascular system were significantly more common in the elderly group (57.8%, p = 0.0008). The postoperative incidence of Clavien-Dindo Grade IIIa or higher complications was 20.0% in the elderly group and 24.3% in the non-elderly group, and this difference was not significant. As for regeneration of the remnant liver after resection, this was not morphologically delayed compared to the non-elderly group.

Conclusions: In this study, we have demonstrated that safe, radical hepatectomy, similar to procedures performed on non-elderly patients, can be performed on patients with HCC aged 80 and older with sufficient perioperative care.
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http://dx.doi.org/10.1159/000488327DOI Listing
January 2020

Short- and Long-Term Results of Laparoscopic Parenchyma-Sparing Hepatectomy for Small-Sized Hepatocellular Carcinoma: A Comparative Study Using Propensity Score Matching Analysis.

Am Surg 2018 Feb;84(2):230-237

The aim of this study was to evaluate the degree of invasiveness and the clinical outcomes of laparoscopic parenchyma-sparing hepatectomy (LPSH) for a maximum hepatocellular carcinoma (HCC) size ≤5 cm. Sixty-one LPSHs and 175 open parenchyma-sparing hepatectomies (OPSHs) for small-sized HCC were analyzed using a propensity score matching analysis. The median operative time was significantly shorter in the LPSH group (194 min) than in the OPSH group (275 minutes) (P < 0.0001). The estimated blood loss was significantly lower in the LPSH group (100 mL) than in the OPSH group (380 mL) (P < 0.0001). The incidences of superficial incisional surgical site infections and respiratory complications were significantly lower in the LPSH group than in the OPSH group (P = 0.0161 and 0.0285, respectively). During the postoperative course, the white blood cell counts and C-reactive protein levels were significantly lower in the LPSH group. There were no differences in overall survival and disease-free survival (P = 0.1293 and 0.4039, respectively), and no significant differences in terms of type of recurrence and site of intrahepatic recurrence (P = 0.1410). The data from the present series suggest the lesser invasiveness and safety of LPSH even for small-sized HCC patients.
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February 2018

Preoperative Chemotherapy May Not Influence the Remnant Liver Regenerations and Outcomes After Hepatectomy for Colorectal Liver Metastasis.

World J Surg 2018 10;42(10):3316-3330

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan.

Background: Various chemotherapy regimens have been shown to improve outcomes when administered before tumor excision surgery. However, there is no consensus on the utility of multidisciplinary treatment with preoperative chemotherapy for treating colorectal liver metastasis (CLM).

Materials And Methods: Two hundred-fifty patients who underwent hepatectomy were retrospectively analyzed using propensity score matching. Postoperative outcomes were evaluated with a focus on the effect of pre-hepatectomy chemotherapy on regeneration of the remnant liver in patients with CLM. The remnant liver volumes (RLVs) were postoperatively measured with multidetector computed tomography on days 7 and months 1, 2, 5, and 12 after the operation.

Results: RLV regeneration and blood test results did not significantly differ between patients who underwent preoperative chemotherapy versus those who did not immediately after surgery or at any time point from postoperative day 7 to postoperative month 12. The 1-, 2-, and 3-year overall survival (OS) rates for all patients were 94.6, 86.2, and 79.9%, respectively; the corresponding disease-free survival (RFS) rates were 49.3, 38.6, and 33.7%, respectively. There were no significant differences in OS and RFS between the two groups after hepatic resection. The recurrence rates, including marginal and intrahepatic recurrences, as well as resection frequency of the remnant liver were not significantly different between the two groups.

Conclusion: Preoperative chemotherapy may have no appreciable benefit for patients with CLM in terms of perioperative and long-term outcomes.
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http://dx.doi.org/10.1007/s00268-018-4590-1DOI Listing
October 2018

Laparoscopic Hepatic Resection Using Extracorporeal Pringle Maneuver.

J Laparoendosc Adv Surg Tech A 2018 Apr 3;28(4):452-458. Epub 2017 Nov 3.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital , Takatsuki City, Japan .

Background: Laparoscopic hepatic resection (LHR) has been developed as a novel minimally invasive surgery. However, despite improvements in equipment and procedures, intraoperative hemorrhage remains an issue that requires great precaution. To reduce the amount of intraoperative blood loss, we perform the Pringle maneuver, aimed at occluding the inflow of blood into the liver during LHR. This article describes our experience performing LHR using the Pringle maneuver, including postoperative results, and discusses the safety and effectiveness of the Pringle maneuver.

Methods: Data from 83 patients who underwent laparoscopic partial right hepatic resection with or without the Pringle maneuver were retrospectively analyzed with respect to surgical outcomes, safety, and utility.

Results: In LHR, the amount of bleeding was significantly lower in cases that included the Pringle maneuver (P = .0314). However, there were no differences in the duration of surgery, surgical margin, rate of curative resections, and incidence of postoperative complications. Laboratory data collected after surgery showed no significant difference between the two groups regardless of whether blood flow was occluded or not.

Conclusions: The Pringle maneuver may be effective in reducing the amount of intraoperative blood loss during laparoscopic partial right hepatic resection, although the difference is not clinically significant. Rather, the reduction in bleeding can reduce the stress experienced by the operator while keeping the transection stump of the liver dry. Particularly, the extracorporeal Pringle maneuver using cotton tape is simple and convenient and can be carried out within a short amount of time.
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http://dx.doi.org/10.1089/lap.2017.0196DOI Listing
April 2018

Comparison of Regeneration of Remnant Liver After Hemihepatectomy with or Without the Middle Hepatic Vein.

World J Surg 2018 04;42(4):1100-1110

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan.

Background: There is no consensus about remnant liver regeneration associated with middle hepatic vein (MHV) resecting.

Methods: Seventy-five patients who underwent hemihepatectomy were retrospectively analysed with respect to remnant liver regeneration. The liver remnant volume (LRV) and each sectional volume were postoperatively measured with multidetector computed tomography at day 7 and months 1, 2, 5, and 12 after the operation.

Results: In right hemihepatectomy cases, the regeneration rate of LRV in the MHV preservation group was significantly higher than that of the MHV resection group at months 5 and 12. In particular, the regeneration rate of remnant segment IV peaked at day 7 and was shrunk after 1 month, and was significant higher in the MHV preservation group. In left hemihepatectomy cases, the regeneration rate of LRV at month 12 was significantly higher in the MHV preservation group. The regeneration rate of the remnant anterior section peaked at 1 month and was shrunk.

Conclusion: In this study, the MHV should be preserved or reconstructed whenever possible during hepatic hemihepatectomy. Hepatic regeneration in the MHV perfusion region becomes poor within 7 days to 1 month after surgery (UMIN000023714).
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http://dx.doi.org/10.1007/s00268-017-4225-yDOI Listing
April 2018

Laparoscopic Liver Resection Using the Lateral Approach from Intercostal Ports in Segments VI, VII, and VIII.

J Gastrointest Surg 2017 Dec 31;21(12):2135-2143. Epub 2017 Jul 31.

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan.

Background: Laparoscopic liver resection (LLR) has been developed as a minimally invasive surgery. However, challenges such as difficulty securing visibility and limited control of forceps make it difficult to complete LLR in hepatic segments VI, VII, and VIII. To overcome these challenges, we devised a surgical technique using intercostal ports. We termed this approach the lateral approach. This work describes our experience performing LLR using this approach and discusses the safety and effectiveness of this approach.

Methods: Between April 2011 and December 2016, data from 91 patients who underwent LLR with or without the intercostal port at a single institution were retrospectively analyzed regarding surgical outcomes, safety, and utility.

Results: LLR was performed for 32 patients with the intercostal port and for 59 patients without the intercostal port. The conversion rates to open surgery with and without intercostal ports were 3.1 and 25.4% (P = 0.008). In hepatic segments VII and VIII, the rates of conversion to open surgery were significantly lower for cases involving intercostal ports (6.7 vs. 42.9 and 0 vs. 38.9%; P = 0.035 and 0026, respectively); however, there were no differences in hepatic segment VI (0 vs. 7.4%; P = 0.563). There were no differences in operative time, blood loss volume, surgical margin, curative resection rate, or postoperative complication rate for LLR in all segments (VI, VII, and VIII). No adverse events due to placement of the intercostal port were observed in this set of patients.

Conclusion: LLR using the lateral approach and intercostal ports for hepatic segments VII and VIII resulted in a significant decrease in conversion rates to open surgery.
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http://dx.doi.org/10.1007/s11605-017-3516-9DOI Listing
December 2017
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