Publications by authors named "Shintaro Akamoto"

32 Publications

Extraperitoneal colostomy in robotic surgery for rectal cancer using a tip-up fenestrated grasper.

Asian J Endosc Surg 2020 Oct 20. Epub 2020 Oct 20.

Department of Surgery, Sumitomo Besshi Hospital, Niihama-shi, Japan.

Introduction: Although extraperitoneal colostomy could reduce the risk for parastomal hernia formation, it is often technically demanding to dissect the extraperitoneal route laparoscopically. Here, we demonstrate our original surgical technique for extraperitoneal tunneling using a robotic instrument.

Materials And Surgical Technique: After total mesorectal excision (TME) and before specimen retrieval, the edge of the outer leaf of the parietal peritoneum was elevated by the grasper in the left hand and the tip-up fenestrated grasper (Tip-Up) in the right hand. The extraperitoneal tissue was opened using the scissor forceps (right hand). Then, extraperitoneal tunneling (inner tunnel) was performed using a Tip-Up with a width of approximately 4 cm that could reach adjacent to the lateral border of the abdominal rectus muscle. A round incision was made at a preoperatively marked site on the skin. The anterior rectal sheath was cut in a cruciate fashion. The abdominal rectus muscle was split, and then the posterior rectus sheath was cut longitudinally not just below the stoma marking site but also at a slant on the lateral side. The peritoneum was dissected with care to avoid opening the peritoneum. The outer side of the tunnel was broken through to the inner tunnel using an easy blunt dissection with two fingers. Kelly forceps were introduced through the extraperitoneal tunnel along with the fingers, and the stump of the sigmoid colon was grasped and exteriorized through this tunnel.

Discussion: Robotic retroperitoneal tunneling using a Tip-Up is easy and useful for preventing parastomal hernia.
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http://dx.doi.org/10.1111/ases.12880DOI Listing
October 2020

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

Surg Case Rep 2020 May 11;6(1):100. Epub 2020 May 11.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

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.
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http://dx.doi.org/10.1186/s40792-020-00858-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214569PMC
May 2020

A case of perihilar cholangiocarcinoma with bilateral ligamentum teres hepatis treated with hepatopancreatoduodenectomy.

Surg Case Rep 2020 Jan 30;6(1):32. Epub 2020 Jan 30.

Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan.

Background: Bilateral ligamentum teres (BLT) hepatis is a very rare anomaly defined as the connection of the bilateral fetal umbilical veins to both sides of the paramedian trunk, and it has never been reported in the English literature.

Case Presentation: A 72-year-old man who presented with obstructive jaundice was referred to our hospital. Contrast-enhanced computed tomography revealed that the patient had right-sided ligamentum teres (RSLT) and left-sided ligamentum teres (LSLT). The umbilical portion of the left portal vein, which the LSLT connected, became relatively atrophic in this patient. The RSLT attached to the tip of the right anterior pedicle and formed the umbilical portion of the right portal vein. The patient was diagnosed with perihilar cholangiocarcinoma which had invaded the root of the posterior branch of the bile duct, LHD, and intrapancreatic bile duct. The central bisectionectomy, in which the liver parenchyma was resected along the RHV on the right side and the LSLT on the left side, and caudate lobectomy combined with pancreatoduodenectomy were performed. The presence of the patient with BLT is important for ascertaining the mechanism of the development of RSLT. Two umbilical veins are present initially during the embryonic stage. In general, the right-sided vein disappears, and the atrophic left-sided vein remains connected to the left portal vein originating from the vitelline vein. Several papers on the mechanism of the development of RSLT have been published. Some authors have mentioned that a residue of the right umbilical vein and the disappearance of the left umbilical vein are the causes of RSLT. On the other hand, some authors have asserted that RSLT is the result of atrophy of the medial liver area. The presence of BLT in patients indicates that the mechanism of the development of RSLT is characterized by a residue of the right umbilical vein and the disappearance of the left umbilical vein.

Conclusions: The mechanism and origin of RSLT can be understood through cases of BLT, and surgeons must pay attention to anomalies of the portal and hepatic veins in patients with abnormal ligamentum teres.
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http://dx.doi.org/10.1186/s40792-020-0793-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992831PMC
January 2020

Local control of sphincter-preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis.

Ann Gastroenterol Surg 2017 Sep 14;1(3):199-207. Epub 2017 Aug 14.

Department of Surgery Kyoto University Kyoto Japan.

Sphincter-preserving procedures (SPPs) for surgical treatment of low-lying rectal tumors have advanced considerably. However, their oncological safety for locally advanced low rectal cancer compared with abdominoperineal resection (APR) is contentious. We retrospectively analyzed cohort data of 1500 consecutive patients who underwent elective resection for stage II-III rectal cancer between 2010 and 2011. Patients with tumors 2-5 cm from the anal verge and clinical stage T3-4 were eligible. Primary outcome was 3-year local recurrence rate, and confounding effects were minimized by propensity score matching. The study involved 794 patients (456 SPPs and 338 APR). Before matching, candidates for APR were more likely to have lower and advanced lesions, whereas SPPs were carried out more often following preoperative treatment, by laparoscopic approach, and at institutions with higher case volume. After matching, 398 patients (199 each for SPPs and APR) were included in the analysis sample. Postoperative morbidity was similar between the SPPs and APR groups (38% vs 39%; RR 0.98, 95% CI 0.77-1.27). Margin involvement was present in eight patients in the SPPs group (one and seven at the distal and radial margins, respectively) and in 12 patients in the APR group. No difference in 3-year local recurrence rate was noted between the two groups (11% vs 14%; HR 0.77, 95% CI 0.42-1.41). In this observational study, comparability was ensured by adjusting for possible confounding factors. Our results suggest that SPPs and APR for locally advanced low rectal cancer have demonstrably equivalent oncological local control.
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http://dx.doi.org/10.1002/ags3.12032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881346PMC
September 2017

Global metabolic reprogramming of colorectal cancer occurs at adenoma stage and is induced by MYC.

Proc Natl Acad Sci U S A 2017 09 28;114(37):E7697-E7706. Epub 2017 Aug 28.

Institute for Advanced Biosciences, Keio University, Kakuganji, Tsuruoka 997-0052, Japan;

Cancer cells alter their metabolism for the production of precursors of macromolecules. However, the control mechanisms underlying this reprogramming are poorly understood. Here we show that metabolic reprogramming of colorectal cancer is caused chiefly by aberrant expression. Multiomics-based analyses of paired normal and tumor tissues from 275 patients with colorectal cancer revealed that metabolic alterations occur at the adenoma stage of carcinogenesis, in a manner not associated with specific gene mutations involved in colorectal carcinogenesis. expression induced at least 215 metabolic reactions by changing the expression levels of 121 metabolic genes and 39 transporter genes. Further, negatively regulated the expression of genes involved in mitochondrial biogenesis and maintenance but positively regulated genes involved in DNA and histone methylation. Knockdown of in colorectal cancer cells reset the altered metabolism and suppressed cell growth. Moreover, inhibition of MYC target pyrimidine synthesis genes such as , , and blocked cell growth, and thus are potential targets for colorectal cancer therapy.
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http://dx.doi.org/10.1073/pnas.1710366114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604037PMC
September 2017

Multiple gastric gastrointestinal stromal tumors treated by laparoscopic-endoscopic cooperative surgery: A case report.

Asian J Endosc Surg 2016 Nov 29;9(4):336-339. Epub 2016 Jul 29.

Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan.

The typical treatment of choice for gastrointestinal stromal tumors (GIST) is surgical resection. Here we report a case of three GIST lesions resected safely by laparoscopic-endoscopic cooperative surgery (LECS). A 78-year-old woman was referred to our hospital for further treatment of an enlarging gastric submucosal tumor. Esophagogastroduodenoscopy and endoscopic ultrasonography revealed two gastric submucosal tumors. Endoscopic ultrasonography-guided fine needle aspiration was subsequently performed. The patient underwent LECS in accordance with therapeutic guidelines for GIST. Assisted by a laparoscope and using three trocars, a full-thickness resection was performed endoscopically for the 3-cm lesion and its nearby submucosal tumor, which was newly detected intraoperatively. The other lesion was also resected with an autosuture device under laparoscopy. No intraoperative or postoperative complications were observed. In LECS, endoscopic observation and resection can minimize gastric deformation and preserve gastric function. To the best of our knowledge, this is the first case of LECS performed on multiple GIST.
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http://dx.doi.org/10.1111/ases.12307DOI Listing
November 2016

Influence of previous abdominal surgery on surgical outcomes between laparoscopic and open surgery in elderly patients with colorectal cancer: subanalysis of a large multicenter study in Japan.

J Gastroenterol 2017 Jun 20;52(6):695-704. Epub 2016 Sep 20.

Department of Surgery, Kitasato University Hospital, Sagamihara, Japan.

Background: The aim of the present study was to examine the technical and oncological feasibility of laparoscopic surgery (LAP) in elderly patients with a history of abdominal surgery.

Methods: We conducted a propensity score-matched case-control study of colorectal cancer (CRC) patients aged ≥80 years that were treated at 41 hospitals between 2003 and 2007. We included 601 patients who had a history of abdominal surgery and underwent curative and elective surgery for stage 0 to III CRC. After the matching procedure, 153 patients were included in each cohort. The surgical outcomes of LAP and open surgery (OS) were compared. P-values of <0.05 were considered statistically significant.

Results: LAP resulted in a significantly longer surgical time (220 vs. 170 min, p < 0.001), but significantly less intraoperative blood loss (39 vs. 100 ml, p < 0.001). A number of postoperative recovery-related parameters, including the length of the hospitalization period (12 vs. 14 days, p = 0.002), and the days to the resumption of fluid (2 vs. 3 days, p < 0.001) and solid food intake (4 vs. 5 days, p < 0.001), were significantly better in the LAP group. Moreover, the overall morbidity rate (43 vs. 66 %, p = 0.009) and the frequency of postoperative ileus (7 vs. 19 %, p = 0.023) were significantly lower in the LAP group, while the frequencies of other morbidities did not differ significantly between the groups. In the survival analyses, overall survival and disease-free survival did not differ between the two groups.

Conclusions: In this population, LAP can be performed safely in elderly CRC patients with a history of abdominal surgery, and LAP resulted in a lower postoperative morbidity rate than OS.
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http://dx.doi.org/10.1007/s00535-016-1262-5DOI Listing
June 2017

Follow-up of asymptomatic adult diaphragmatic hernia: should patients with this condition undergo immediate operation? A report of two cases.

Surg Case Rep 2016 Dec 9;2(1):95. Epub 2016 Sep 9.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

Background: Asymptomatic diaphragmatic hernia is generally thought to be rare among adults. We present two different types of asymptomatic diaphragmatic hernia diagnosed with computed tomography (CT) and discuss treatment strategies.

Case Presentation: Case 1: A 37-year-old woman was diagnosed with catamenial pneumothorax in the right diaphragm. Partial resection of the diaphragm and lung was performed using a linear stapler. She was asymptomatic after the operation and gave birth 2 years later. After delivery, she experienced recurrent pneumothorax, and CT revealed a right diaphragmatic defect with herniation of a part of the liver into the thorax. An iatrogenic diaphragmatic hernia was diagnosed. There has been no change in the size of the hernia and no symptoms due to the diaphragmatic hernia for more than 3 years after it was diagnosed. Case 2: A 75-year-old woman was previously diagnosed with rectal cancer and had undergone surgery after chemoradiotherapy. One year after surgery, herniation of a 3 × 1.3-cm section of retroperitoneal fat tissue into the left thoracic cavity was observed incidentally at a follow-up CT and was diagnosed as an adult Bochdalek hernia (BH). We reviewed the patient's past CT findings and confirmed that the same finding had been present since the first scan. A wait-and-see approach was chosen because there had been no change in the size of hernia, there were no symptoms, the patient was elderly, and there was a high risk of recurrence of the rectal cancer. She has had no symptoms to date, and careful follow-up has been performed.

Conclusions: There are few reports of asymptomatic adult diaphragmatic hernia. Although symptomatic diaphragmatic hernia is generally treated surgically, there are cases in which a wait-and-see approach has been applied, such as our asymptomatic cases.
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http://dx.doi.org/10.1186/s40792-016-0220-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017960PMC
December 2016

Relationship between tissue tension and thermal diffusion to peripheral tissue using an energy device.

Asian J Endosc Surg 2016 Aug;9(3):226-30

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

The aim of the study was to assess the relationship between tissue tension and thermal diffusion to peripheral tissues using an electric scalpel, ultrasonically activated device, or a bipolar sealing system. The mesentery of pigs was excised with each energy device (ED) at three tissue tensions (0, 300, 600 g). The excision time and thermal diffusion area were monitored with thermography, measured for each ED, and then histologically examined. Correlations between tissue tension and thermal diffusion area were examined. The excision time was inversely correlated with tissue tension for all ED (electric scalpel, r = 0.718; ultrasonically activated device, r = 0.949; bipolar sealing system, r = 0.843), and tissue tension was inversely correlated with the thermal diffusion area with the electric scalpel (r = 0.718) and bipolar sealing system (r = 0.869). Histopathologically, limited deep thermal denaturation occurred at a tension of 600 g with all ED. We conclude that thermal damage can be avoided with adequate tissue tension when any ED is used.
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http://dx.doi.org/10.1111/ases.12283DOI Listing
August 2016

Perforation in an intestinal malignant lymphoma case.

BMC Res Notes 2016 Jun 13;9:308. Epub 2016 Jun 13.

Division of Hematology and Stem Cell Transplantation, Department of Internal Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

Background: The gastrointestinal tract is a relatively common involvement site in lymphoma and, in such cases, intestinal perforation is a concern before and during chemotherapy. The prediction of intestinal perforation prior to chemotherapy is difficult, and there is no standard strategy to minimize the frequency of severely adverse gastrointestinal events in lymphoma cases.

Case Presentation: The 61-year-old female patient had a history of primary central nervous system lymphoma (PCNSL), diagnosed histologically as diffuse large B cell lymphoma (DLBCL). We administered six courses of intensive chemotherapy consisting of high-dose methotrexate and sequential whole-brain irradiation (40.5 Gy). After a 3-year remission of the PCNSL, the patient's lymphoma recurred, involving the small intestine. (18)F-FDG-PET/CT upon the recurrence before chemotherapy showed multiple nodular lesions in the patient's gastrointestinal tract. Central nervous system lesions were not detected. We administered intensive salvage chemotherapy consisting of cyclophosphamide, high-dose AraC, methyl-prednisolone, etoposide, and rituximab. The response was a rapid partial response, but on day 10 after the initiation of salvage chemotherapy, she complained of abdominal pain with tenderness. The contrast-enhanced (CE)-CT revealed transmural ischemia of the intestine. On the 7th day after the onset of urgent abdominal symptoms, follow-up CE-CT showed that the ischemic lesion had become thin. We conducted elective surgery after waiting for the complete recovery of the patient's white blood cell count. The pathological findings of resected intestine confirmed the elimination of the majority of lymphoma cells and concomitant partial necrotic tissue.

Conclusions: We were able to avoid the neutropenic period and safely conducted the surgical treatment for the subclinical perforation by using CE-CT. The combination of (18)F-FDG-PET/CT before chemotherapy and CE-CT scanning for the targeted involvement site helped us evaluate the surgical indications and optimal timing of surgery in a lymphoma patient with gastrointestinal involvement.
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http://dx.doi.org/10.1186/s13104-016-2111-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4906586PMC
June 2016

Internal inguinal hernia on the transplant side after kidney transplantation: a case report.

Surg Case Rep 2015 Dec 17;1(1):108. Epub 2015 Oct 17.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

The patient was a 52-year-old man who presented with right inguinal swelling and pain. He had undergone kidney transplantation in 2005 and bypass surgery using a vascular prosthesis from the left axillary artery to the bilateral femoral arteries in 2008. The vascular prosthesis had invaded the right inguinal canal ventrally. The transplanted ureter had a hazy appearance on a non-enhanced abdominal CT scan. A Lichtenstein operation was performed under a diagnosis of inguinal hernia. A skin incision with pulling of tissue and subcutaneous fat was devised to avoid exposure of the vascular prosthesis. The inguinal canal and spermatic cord were found to have coalesced. The hernia was diagnosed as a supravesical hernia, class II-1. This case shows that a Lichtenstein operation is a suitable procedure for avoidance of damage to the transplanted ureter in treatment of a transplant-side inguinal hernia in a kidney transplant recipient.
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http://dx.doi.org/10.1186/s40792-015-0094-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4609305PMC
December 2015

Morphological study of the neurovascular bundle to elucidate nerve damage in pelvic surgery.

Int J Colorectal Dis 2016 Mar 23;31(3):503-9. Epub 2015 Dec 23.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Mikicho, Kitagun, Kagawa, 761-0793, Japan.

Purpose: Postoperative sexual and urinary dysfunction may occur after rectal cancer surgery involving the pelvis, but this problem cannot be solved. The aim of this study was to examine the nerve morphology of the neurovascular bundle in cadavers to determine possible causes of nerve damage during surgery.

Methods: Twenty-two formalin-fixed cadavers were used in the study. The cadavers were donated to the Tokyo Medical University. The study comprised histological evaluation of paraffin-embedded bilateral neurovascular bundle specimens from the cadavers. Four slides of 3-cm thick were made every 1 cm in a plane perpendicular to the rectum towards the pelvic floor from the peritoneal reflection in bilateral neurovascular bundles in 22 cadavers. The number of nerves, the mean nerve area, and the mean nerve diameter were measured in each slide.

Results: The results were categorized into cases with high (group H) and low (group L) positions of the pelvis 1 cm above and 2 cm below the peritoneal reflection, respectively. There was no significant difference in the number of nerves between these groups. The nerve area and nerve diameter were significantly smaller in group L, and these characteristics were more marked in males.

Conclusions: Our results show that the nerves of the neurovascular bundle became smaller in the deep pelvis. This may cause these nerves to be more susceptible to injury, resulting in nerve damage in the deep pelvis that leads to postoperative dysfunction. Particularly, this type of nerve damage may be a cause of postoperative sexual dysfunction in males.
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http://dx.doi.org/10.1007/s00384-015-2470-9DOI Listing
March 2016

Beneficial effect of D-allose for isolated islet culture prior to islet transplantation.

J Hepatobiliary Pancreat Sci 2016 Jan 26;23(1):37-42. Epub 2015 Nov 26.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

Background: Pretransplant restoration of islets damaged during isolation remains to be solved. In this study, we examined the effect of D-allose on islets isolated from rat pancreata prior to islet transplantation.

Methods: Rat islets isolated from fresh pancreata were cultured overnight in Roswell Park Memorial Institute 1640 solution in the absence (group 1) or presence (group 2) of D-allose. Then we assessed stimulation index of insulin, and cure rate after islet transplantation to diabetic nude mice. We also measured malondialdehyde level and caspase 3 activity of islets after the overnight culture for assessment of the oxidative stress and the apoptosis.

Results: D-allose significantly improved insulin secretion of islets. The stimulation index in group 2 was significantly higher than in group 1. Cure rate after transplantation in group 2 was higher than in group 1 especially in the first week. The malondialdehyde level in group 2 was significantly lower than in group 1. But the caspase 3 activities in both groups did not differ.

Conclusions: D-allose treatment of isolated islet culture prior to transplantation restored islet function and increased successful transplant rate. The results of this study suggested that D-allose improved function of damaged islets through its anti-oxidative activity.
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http://dx.doi.org/10.1002/jhbp.298DOI Listing
January 2016

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

Gastric Cancer 2015 Jul 30;18(3):653-61. Epub 2014 May 30.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

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.
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http://dx.doi.org/10.1007/s10120-014-0387-6DOI Listing
July 2015

A woman with pruritus ani.

Gastroenterology 2013 May 22;144(5):887, 1160-1. Epub 2013 Mar 22.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

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http://dx.doi.org/10.1053/j.gastro.2012.12.036DOI Listing
May 2013

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

Surg Today 2013 Dec 8;43(12):1425-32. Epub 2012 Dec 8.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan,

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.
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http://dx.doi.org/10.1007/s00595-012-0446-8DOI Listing
December 2013

Spontaneous perforation in collagenous colitis.

Surgery 2014 Jan 4;155(1):198-9. Epub 2012 Dec 4.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

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http://dx.doi.org/10.1016/j.surg.2012.10.008DOI Listing
January 2014

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a laparoscopic retractor.

Surg Today 2013 May 4;43(5):580-2. Epub 2012 Nov 4.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.

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.
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http://dx.doi.org/10.1007/s00595-012-0403-6DOI Listing
May 2013

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler.

Surg Today 2013 Feb 11;43(2):141-7. Epub 2012 Jul 11.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.

Purpose: No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler.

Methods: A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses.

Results: Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %.

Conclusion: Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.
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http://dx.doi.org/10.1007/s00595-012-0235-4DOI Listing
February 2013

Hand-assisted laparoscopic partial splenectomy using an endopath monopolar sealer.

Surg Laparosc Endosc Percutan Tech 2011 Dec;21(6):e291-4

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

A partial splenectomy is a good way to prevent postsplenectomy infections by preservation of the immune role of the spleen for select patients. Although a laparoscopic total splenectomy is a safe and feasible treatment modality, the laparoscopic approach has not been generally adopted for a partial splenectomy because of technical difficulties. The hand-assisted technique provides an excellent means to explore, to retract safely, and to apply immediate hemostasis in solid organ resection. The hand-assisted laparoscopic partial splenectomy using an endopath monopolar sealer (Salient EndoSH2.0 Monopolar Sealer) was performed successfully. The segmental arteries and veins were isolated and divided using a tactile feedback. Splenic parenchyma was dissected and sealed using an endopath monopolar sealer. The surgical field was almost bloodless during the parenchymal transection and the transection time was around 15 minutes. The hand-assisted laparoscopic approach allows partial splenectomy as a safe and bloodless surgery for select patients.
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http://dx.doi.org/10.1097/SLE.0b013e3182311ee4DOI Listing
December 2011

Surgical approach for extrahepatic metastasis of HCC in the abdominal cavity.

Hepatogastroenterology 2011 Nov-Dec;58(112):2067-70

Department of Surgery, Takamatsu Hospital, Kagawa, Japan.

Background/aims: Despite recent development of therapeutic strategies for intrahepatic lesions, standard guidelines for treatment of extrahepatic metastases of hepatocellular carcinoma have not been established.

Methodology: Surgical resection for intra-abdominal extrahepatic metastases of hepatocellular carcinoma was performed on 10 patients at our institution between 1992 and 2008. We retrospectively examined the clinicopathologic features and significance of a surgical approach in these patients.

Results: Nine of the 10 patients received treatment for primary hepatocellular carcinoma before surgery for intra-abdominal extrahepatic metastasis. A simultaneous intrahepatic lesion was detected in half of the patients when the extrahepatic metastasis was resected. Extrahepatic recurrent organs included adrenal glands, lymph nodes, abdominal wall, stomach and diaphragm. The mean survival period after resection was 36.1 months. Two patients are still alive without further recurrence. One patient died of retroperitoneal recurrence and 7 died of intrahepatic recurrence or liver failure after resection.

Conclusions: With careful case selection, considering that not all extrahepatic metastases suggest systemic spread of hepatocellular carcinoma, surgical treatment for metastatic lesions in the abdominal cavity can provide a relatively good prognosis.
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http://dx.doi.org/10.5754/hge11188DOI Listing
March 2012

Persisting ratio of total amylase output in drain fluid can predict postoperative clinical pancreatic fistula.

J Hepatobiliary Pancreat Sci 2011 Nov;18(6):815-20

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.

Background/purpose: A consistent predictor for pancreatic fistula (PF) development in the early period after pancreatic resection is still lacking.

Patients And Methods: A total of 54 consecutive patients undergoing pancreatic resection were enrolled between June 2007 and April 2010. Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) were performed in 38 and 16 patients, respectively. For the purpose of finding an early predictor for PF development, we investigated drain amylase levels (d-Amy, IU/mL), drain output volume (d-Vol, mL/day) and drain amylase output (Amy-V, IU/day) on postoperative days (POD) 1 and 3. Amy-V was calculated as the product of d-Amy and d-Vol, and was expressed as the sum of values obtained from all drains. In addition, the ratio of d-Amy or Amy-V on POD3 to that on POD1 was calculated as the persisting ratio in each patient.

Results: The overall incidence of clinical PF (International Study Group on Pancreatic Fistula Grade B and C) was 16.7%, occurring in 13.1% after PD and 25% after DP. All PF occurred in cases with a remnant pancreas of soft texture. There was no significant difference in d-Amy, d-Vol, or Amy-V on POD1 and POD3 between patients with and without clinical PF. The persisting ratio of Amy-V was significantly lower in patients without clinical PF compared to those with clinical PF (p = 0.029). Furthermore, the persisting ratio of Amy-V was significantly lower in patients with Grade A PF compared to those with Grade B PF (p = 0.03).

Conclusion: The persisting ratio of drain amylase output is a new significant predictive factor for clinical PF development.
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http://dx.doi.org/10.1007/s00534-011-0393-6DOI Listing
November 2011

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

Hepatogastroenterology 2010 Sep-Oct;57(102-103):1309-13

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Kita-gun, Miki-cho, Kagawa 761-0793, Japan.

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.
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April 2011

18F-fluorodeoxyglucose positron emission tomography in the diagnosis of small pancreatic cancer.

World J Gastroenterol 2011 Jan;17(2):231-5

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan.

Aim: To investigate the role of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in the diagnosis of small pancreatic cancer.

Methods: This study involved 31 patients with proven invasive ductal cancer of the pancreas. The patients were divided into 3 groups according to the maximum diameter of the tumor: TS1 (maximum tumor size ≤ 2.0 cm), TS2 (> 2.0 cm and ≤ 4.0 cm) or TS3-4 (> 4.0 cm). The relationships between the TS and various diagnostic tools, including FDG-PET with dual time point evaluation, were analyzed.

Results: The tumors ranged from 1.3 to 11.0 cm in diameter. Thirty of the 31 patients (97%) had a positive FDG-PET study. There were 5 patients classified as TS1, 15 as TS2 and 11 as TS3-4. The sensitivity of FDG-PET, computed tomography (CT) and magnetic resonance imaging (MRI) were 100%, 40%, 0% in TS1, 93%, 93%, 89% in TS2 and 100%, 100%, 100% in TS3-4. The sensitivity of FDG-PET was significantly higher in comparison to CT and MRI in patients with TS1 (P < 0.032). The mean standardized uptake values (SUVs) did not show a significant difference in relation to the TS (TS1: 5.8 ± 4.5, TS2: 5.7 ± 2.2, TS3-4: 8.2 ± 3.9), respectively. All the TS1 tumors (from 13 to 20 mm) showed higher SUVs in FDG-PET with dual time point evaluation in the delayed phase compared with the early phase, which suggested the lesions were malignant.

Conclusion: These results indicate that FDG-PET with dual time point evaluation is a useful modality for the detection of small pancreatic cancers with a diameter of less than 20 mm.
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http://dx.doi.org/10.3748/wjg.v17.i2.231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020378PMC
January 2011

[A case of Stage IV AFP producing gastric cancer with long-term survival treated by adjuvant chemotherapy with S-1].

Gan To Kagaku Ryoho 2010 Mar;37(3):521-6

Dept. of Gastroenterological Surgery, Faculty of Medicine, Kagawa University.

A 66-year-old woman underwent a total gastrectomy for advanced gastric cancer of cardia. The histological diagnosis was moderately-differentiated tubular adenocarcinoma and the pathological Stage was IV: T4 (diaphragm), N2, M0. Microscopically, there were findings of severe lymphatic and venous invasions with intravenous tumor thrombus around the splenic hilum. Immunohistochemical staining confirmed AFP production of the tumor. The risk of recurrence was considered very high and her prognosis very poor. The patient received adjuvant chemotherapy with S-1. There was no finding of recurrence in the series of postoperative follow-up examinations. Previous reports describe the prognosis of AFP producing gastric cancer as very poor. In several cases, however, aggressive treatments for AFP producing gastric cancer may result in a better prognosis. This is a long survival case of AFP producing gastric cancer successfully treated with S-1 after surgery.
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March 2010

The discrepancy in thymidylate synthase and dihydropyrimidine dehydrogenase expression depending on measurement methodologies in stage 4 gastric cancer.

Hepatogastroenterology 2008 Sep-Oct;55(86-87):1882-6

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

Background/aims: Thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) are reported to be a major determinant of variations in the sensitivity for fluoropyrimidines in gastric cancer. The aim of this study was to investigate whether there is a discrepancy in the TS and DPD expression depending on measuring method.

Methodology: The protein levels and mRNA level of TS and DPD were estimated in primary gastric cancer tissue specimens after a non-curative resection. The protein levels were determined by ELISA from frozen tissue specimens. The gene expressions were measured using real-time reverse transcriptional polymerase chain reaction (RT-PCR). For the extraction of RNA, laser-captured microdissection (LCM) was performed in formalin-fixed paraffin-embedded (FFPE) specimens.

Results: There was no correlation between the protein levels and mRNA levels of TS and DPD. The protein levels and mRNA expression levels were not correlated with survival. High levels of TS mRNA showed a trend toward reduced survival (p=0.074).

Conclusions: The discrepancy in TS and DPD expressions depending on the measurement methodologies utilized should thus be emphasized in these far advanced gastric cancer patients.
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January 2009

Localized malignant mesothelioma in the middle mediastinum: report of a case.

Surg Today 2008 9;38(7):635-8. Epub 2008 Jul 9.

Department of Surgery, Jyuzen General Hospital, Ehime, Japan.

Localized malignant mesothelioma in the mediastinum is rare and most known cases have been reported as "localized malignant pericardial mesothelioma." We report a case of a middle mediastinal tumor, which we were able to resect completely. Histopathological examination of the tumor confirmed that it was a malignant epithelial lymphohistiocytoid mesothelioma. We assumed that the tumor was derived from the pericardium. Local recurrence was detected 1 year after resection, and the patient died of the disease about 2 years later.
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http://dx.doi.org/10.1007/s00595-007-3679-1DOI Listing
December 2008

Neutrophil elastase inhibitor (sivelestat) preserves antitumor immunity and reduces the inflammatory mediators associated with major surgery.

Surg Today 2007 30;37(5):359-65. Epub 2007 Apr 30.

Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita, Kagawa 761-0793, Japan.

Purpose: To examine the effects of the administration of perioperative sivelestat, a selective neutrophil elastase inhibitor, on tumor immunity and inflammatory mediators in patients who undergo major surgery.

Methods: Thirteen patients admitted to the hospital for elective surgery were equally randomized into one of two groups: the Sivelestat group (n = 6) and the control group (n = 7). Thereafter, the immunosuppressive acidic protein (IAP), serum interleukin-6 (IL-6), and type 1/type 2 T-helper cell balance were all assessed at several time points before and after surgical intervention.

Results: The serum IL-6 values at 1 and 12 h after surgery and on postoperative days 1 and 3 were all significantly lower in the sivelestat group than in the control group. The IAP values at postoperative days 7 and 28 in the sivelestat group were also significantly lower than those in the control group. There was a significant correlation between the IL-6 level at 1 h after surgery and the IAP level at postoperative days 7 and 28.

Conclusions: In this preliminary study, the perioperative administration of sivelestat was thus suggested to reduce surgical stress by decreasing the cytokine release and preserving the antitumor immunity.
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http://dx.doi.org/10.1007/s00595-006-3409-0DOI Listing
July 2007

(18)F-FDG accumulations in primary malignant melanoma of the esophagus.

Surgery 2006 Jul;140(1):118-9

Department of Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.

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http://dx.doi.org/10.1016/j.surg.2005.06.039DOI Listing
July 2006