Language：English   Publisher：Heliyon  

Background: The use of international telemedicine conferences for doctor-to-doctor education has increased following the coronavirus disease 2019 pandemic to ensure health and safety. Previous studies have shown that administrative tasks are an obstacle to promoting international telemedicine conferences but have not identified the type of system needed to alleviate this burden. Objective: The Asia-Pacific Advanced Network Medical Working Group (APAN-MWG) is an international telemedicine network that includes 1171 medical institutions and 3653 members as of July 21, 2021. The APAN-MWG has supported international telemedicine conferences since 2005 and implemented a program management system in 2014. The present study explores the conference organizers' tasks and evaluates the APAN-MWG management system through a survey of organizers. Methods: We developed a system called med-hok for managing conference programs, international medical institutions, and their members. We investigated all event programs using the med-hok system from June 3, 2015 to July 21, 2021. The target samples included 64 conference programs in 12 series hosted by 13 program organizers. The effectiveness of the system was evaluated using a four-point Likert scale (very good, good, poor, and very poor). The User Experience Questionnaire (UEQ) was used to assess user experience. Results: The survey response rate of the program organizers, who hosted 11 different program series in 7 Asian countries, was 92% (12/13). The administrative tasks for managing the programs were primarily handled by physicians (67%, 8/12), followed by technicians (17%, 2/12). The average program scope encompassed 7 countries, 10 institutions, and 44 members. The largest program comprised 194 members from 49 institutions in 25 countries and was managed by two physicians and one technician. Most program organizers (8/12, 67%) indicated that verifying member information was the most burdensome aspect of organizing teleconferences. Over 90% of respondents positively evaluated med-hok in the following areas: “Confirmation of institution information,” “Confirmation of member information,” “Confirmation of technical information,” “Maintaining the latest status of the program,” “Announcing and publicizing the event,” and “Formatting and correcting misspellings.” They rated user experience positively for all aspects (attractiveness: 1.22; practical quality: 1.42; and hedonic quality: 1.24). Conclusions: Many tasks of organizing casual international telemedicine conferences are handled by physicians and technicians with no operating funds or staff, unlike those in large academic conferences. The proposed system was found to help program organizers manage participants and communicate information effectively. These findings suggest that international telemedicine networks should implement an administrative support system to conduct program operations efficiently.

DOI： 10.1016/j.heliyon.2022.e11297

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：(一社)日本遠隔医療学会  

遠隔会議を用いた内視鏡ライブ配信は教育コンテンツとして人気が高い。その技術的な配信手法の検討や実際の準備には一定の知識や技能が必要である一方、新たにライブ配信を企画する医療施設は十分な技術参照情報を得られないのが現状の課題である。本研究では内視鏡ライブ配信に必要となる技術面での負担を明らかにするべく、過去の支援内容およびCOVID-19感染拡大前後での変化を評価する。2015年から2021年に行われた九州大学病院アジア遠隔医療開発センターによる内視鏡ライブ配信環境を持たない施設への技術支援を対象に、技術支援の件数、配信に用いたシステム、機材手配の内訳、技術支援者の現地立会いを年ごとに計上した。さらに各データは2019年までと2020年以降で比較を行った。配信に用いたシステムは2019年まではハードウェア型だったものが2020年以降はすべてソフトウェア型に置き換わった。機材手配については2020年以降に配信端末、カメラ、音声機器が有意に減少した(p<0.05)。また2020年以降は配信端末とカメラの手配が0件となった一方で、キャプチャーデバイスは全例で手配するようになった。技術支援者の立会いは、いずれの期間においても現地とオンラインの両方が見られた。全期間を通じて機材手配と技術支援者の立会いが見られたものの、COVID-19感染拡大以降に普及したソフトウェア型遠隔会議は内視鏡ライブ配信における技術面での負担の軽減が見込まれた。今後は熟練の術者による手技の配信に留まらず、地方や海外の医療施設の術者がエキスパートから指導を受けるなど新しい活用方法を見出すことが期待できる。(著者抄録)

Language：English   Publisher：(一社)日本遠隔医療学会  

Language：Japanese   Publisher：日本遠隔医療学会  

遠隔会議を用いた内視鏡ライブ配信は教育コンテンツとして人気が高い。その技術的な配信手法の検討や実際の準備には一定の知識や技能が必要である一方、新たにライプ配信を企画する医療施設は十分な技術参照情報を得られないのが現状の課題である。本研究では内視鏡ライプ配信に必要となる技術面での負担を明らかにするべく、過去の支援内容およぴCOVID-19感染拡大前後での変化を評価する。2015年から2021年に行われた九州大学病院アジア遠隔医療開発センターによる内視鏡ライプ配信環境を持たない施設への技術支援を対象に、技術支援の件数、配信に用いたシステム、機材手配の内訳、技術支援者の現地立会いを年ことに計上した。さらに各データは2019年までと2020年以降で比較を行った。配信に用いたシステムは2019年まではハードウェア型だったものが2020年以降はすべてソフトウェア型に置き換わった。機材手配については2020年以降に配信端末、カメラ、音声機器が有意に減少した(p< 0.05)。また2020年以降は配信端末とカメラの手配が0件となった一方で、キャプチャーデバイスは全例で手配するようになった。技術支援者の立会いは、いずれの期間においても現地とオンラインの両方が見られた。全期間を通じて機材手配と技術支援者の立会いが見られたものの、COVID-19感染拡大以降に普及したソフトウェア型遠隔会議は内視鏡ライプ配信における技術面での負担の軽減が見込まれた。今後は熟錬の術者による手技の配信に留まらず、地方や海外の医療施設の術者がエキスパートから指導を受けるなど新しい活用方法を見出すことが期待できる。

CiNii Research

Language：English   Publisher：Telemedicine and e-Health  

Introduction: Telemedicine conferencing is expected to become commonly used internationally. However, national reports on internationally related telemedicine are limited, and related activities and challenges in each country are unclear. In this study, we aimed to clarify the current status and barriers to international telemedicine conferencing in Japan. Methods: The questionnaire was sent to the Internationalization Project Team (I-PT) representatives in all 43 Japanese National University Hospitals. The total of 167 assigned staff comprised 86 medical staff in charge of internationalization (MI) and 81 technical staff in telemedicine (TT). Results: The response rate was 93% (40/43 universities) from 88 staff (44 MI and 44 TT). Most respondents (75%) stated that they had not been active in international telemedicine conferencing during the past 3 years, although a videoconferencing system was installed in 93% of universities. A total of 65% respondents felt that barriers to promoting telemedicine and conferencing existed. Most (43%) respondents reported staff shortage as the most serious barrier overall. Five TT (19%) felt that the most serious barrier was difficulty with English communication, although no MI selected this as a barrier. More MI than TT felt that technical issues were the most serious barrier (MI: 4/29, TT: 1/27). Conclusions: International telemedicine conferencing was found to be insufficiently active in I-PT of Japan, although the installed equipment and technical expertise of TT seemed adequate. This indicates that merely assigning MI and TT to an I-PT is not enough and that improved cooperation between both MI and TT at each university hospital is needed. Establishment of a structured international telemedicine center in each university hospital is to be suggested to accelerate the activities in Japan.

DOI： 10.1089/tmj.2021.0046

Web of Science

Scopus

PubMed

CiNii Research

Language：Japanese   Publisher：Japan Surgical Association  

DOI： 10.3919/jjsa.83.253

CiNii Research

CiNii Research

CiNii Research

CiNii Research

CiNii Research

Language：English  

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Language：English   Publishing type：Research paper (scientific journal)  

DOI： https://doi.org/10.9738/INTSURG-D-18-00011.1

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：English  

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DOI： 10.29086/JISfTeH.7.e16

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：Japanese  

Language：English  

Abstract
BACKGROUND/OBJECTIVES:
It is often difficult to determine an adequate resection line during pancreatectomy for intraductal papillary mucinous neoplasm involving the main pancreatic duct during partial pancreatectomy. The aim of this study was to evaluate the usefulness of improved peroral pancreatoscopy using SpyGlass-DStm in the preoperative assessment of intraductal papillary mucinous neoplasm involving the main pancreatic duct.
METHODS:
We collected and retrospectively analyzed clinicopathological data from seven consecutive patients who underwent preoperative assessment of intraductal papillary mucinous neoplasm involving the main duct using SpyGlass-DStm.
RESULTS:
Good imaging quality of the intraductal protruding lesion was obtained in all seven patients, and only one adverse event was noted wherein a patient had mild pancreatitis. Six patients underwent pancreatectomy. In one patient, masked-type concomitant pancreatic ductal adenocarcinoma and low-length dysplastic lesion was found near the surgical margin, which was not detected by preoperative imaging modalities including SpyGlass-DStm. The sensitivity of targeting biopsy during SpyGlass-DStm to diagnose high-grade dysplasia was 0%.
CONCLUSIONS:
SpyGlass-DStm can be safely performed in patients with intraductal papillary mucinous neoplasm involving the main duct, and has excellent visualization of the target lesion. However, challenges include poor diagnostic ability of targeting biopsy, and, therefore, intraoperative frozen section is still needed to obtain negative surgical margins

DOI： 10.1016/j.pan.2018.04.012

Language：English  

Abstract
PURPOSE:
Laparoscopic surgery as a treatment for congenital biliary dilatation is uncommon. We herein present a series of laparoscopic surgeries for congenital biliary dilatation performed in our institution and review our experience with this approach over a long period of time.

METHODS:
Medical records of 36 consecutive patients who underwent laparoscopic surgery for congenital biliary dilatation from 1996 to 2015 were retrospectively reviewed. Data on patient demographics, operative time, blood loss, hospital stay, and complications were evaluated. A comparison between the former period (Group A, 1996-2005) and the latter period (Group B, 2006-2015) was performed.

RESULTS:
The patients comprised 23 females and 13 males with a median age of 34 years. The median operative time, blood loss, and hospital stay was 493 min, 154 g, and 11 days, respectively. Total early and late complications occurred in 7 (19%) and 2 (5%) patients, respectively. A comparison between Groups A and B revealed no significant difference in operative time or complications, but operative blood loss, open conversion, and hospital stay were significantly lower in Group B than in Group A (P < 0.05).

CONCLUSION:
Laparoscopic surgery for congenital biliary dilatation is feasible and provides acceptable results. Further prospective studies of larger numbers of patients are needed.

DOI： 10.1007/s00595-017-1545-3

Language：English  

Language：English  

Abstract
The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with (n = 10) and without (n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer (P < 0.01) and blood loss significantly greater (P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent (P = 0.02) and postoperative hospital stay was significantly longer (P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study.

Language：English  

Language：English   Publishing type：Research paper (scientific journal)  

DOI： https://doi.org/10.9738/INTSURG-D-17-00137.1

Language：English  

Abstract
BACKGROUND:
Circumportal pancreas is a rare congenital pancreatic anomaly. The aim of this study was to clarify the clinical characteristics of patients with circumportal pancreases undergoing pancreatectomy.
METHODS:
The medical records of 508 patients who underwent pancreatectomy were retrospectively reviewed. The prevalence of circumportal pancreas and related anatomical variations were assessed. Surgical procedures and postoperative outcomes were compared in patients with and without circumportal pancreas.
RESULTS:
Circumportal pancreas was observed in 9 of the 508 patients (1.7%). In all nine patients, the portal vein was completely encircled by the pancreatic parenchyma above the level of the splenoportal junction, and the main pancreatic duct ran dorsal to the portal vein. The rate of variant hepatic artery did not differ significantly in patients with and without circumportal pancreas. Pancreatic fistula developed more frequently in patients with than without circumportal pancreas (44% vs. 14%, p = 0.03), but other clinical parameters did not differ significantly in these two groups.
CONCLUSIONS:
Despite being rare, circumportal pancreas may increase the risk of postoperative pancreatic fistula in patients undergoing pancreatectomy. However, a prospective, large-cohort study is necessary to determine the real incidence of relevant anatomical variations and the definitive clinical significance of this rare anomaly.

Language：Japanese   Publishing type：Research paper (scientific journal)  

DOI： 10.11477/mf.1407211678

Language：English  

Abstract
Background and study aims An Endoscopic Club E-conference (ECE) was set up in May 2014 to cater to increased demand for gastrointestinal endoscopy-related teleconferences in the Asia-Pacific region which were traditionally organized by the medical working group (MWG) of Asia-Pacific Advanced Network. This study describes how the ECE meeting was run, examines the group dynamics, outlines feedback and analyzes factors affecting the enthusiasm of participants. It is hoped that the findings here can serve as guidance for future development of other teleconference groups. Methods The preparation, running of and feedback on the ECE teleconference were evaluated and described. The country's economic situation, time zone differences, connectivity with a research and education network (REN) and engineering cooperation of each member were recorded and analyzed with regard to their association with participant enthusiasm, which was taken as participation in at least 50 % of the meetings since joining. Associations were calculated using 2-way table with chi-square test to generate odds ratio and P value. Results To date, ECE members have increased from 7 to 29 (increment of 314 %). Feedback received indicated a high level of satisfaction with program content, audiovisual transmission and ease of technical preparation. Upper gastrointestinal luminal endoscopy-related topics were the most favored program content. Those topics were presented mainly via case studies with a focus on management challenges. Time zone differences of more than 6 hours and poor engineering cooperation were independently associated with inactive participation (P values of 0.04 and 0.001 respectively). Conclusions Good program content and high-quality audiovisual transmission are keys to the success of an endoscopic medical teleconference. In our analysis, poor engineering cooperation and discordant time zones contributed to inactive participation while connectivity with REN and a country's economic situation were not significantly associated with participant enthusiasm.

DOI： 10.1055/s-0043-102935

Language：English  

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Abstract
BACKGROUND:
We previously reported the use of an inverted T-shaped method to obtain a suitable view for hand sewing to close the common entry hole when the linear stapler was fired for esophagojejunostomy after laparoscopic total gastrectomy (LTG). This conventional method involved insertion of the fixed cartridge fork to the Roux limb and the fine movable anvil fork to the esophagus to avoid perforation of the jejunum. However, insertion of the movable anvil fork to the esophagus during this procedure often requires us to strongly push down the main body of the stapler with the fixed cartridge fork to bring the direction of the anvil fork in line with the direction of the long axis of the esophagus while controlling the opening of the movable anvil fork. We therefore modified this complicated inverted T-shaped method using a linear stapler with a movable cartridge fork. This modified method involved insertion of the movable cartridge fork into the Roux limb followed by natural, easy insertion of the fixed anvil fork into the esophagus without controlling the opening of the movable cartridge fork.
METHODS:
We performed LTG in a total of 155 consecutive patients with gastric cancer from November 2007 to December 2015 in Kyushu University Hospital. After LTG, we performed the conventional inverted T-shaped method using a linear stapler with a fixed cartridge fork in 61 patients from November 2007 to July 2011 (fixed cartridge group). From August 2011, we used a linear stapler with a movable cartridge fork and performed the modified inverted T-shaped method in 94 patients (movable cartridge group). We herein compare the short-term outcomes in 94 cases of LTG using the modified method (movable cartridge fork) with those in 61 cases using the conventional method (fixed cartridge fork).
RESULTS:
We found no significant differences in the perioperative or postoperative events between the movable and fixed cartridge groups. One case of anastomotic leakage occurred in the fixed cartridge group, but no anastomotic leakage occurred in the movable cartridge group.
CONCLUSIONS:
Although there were no remarkable differences in the short-term outcomes between the movable and fixed cartridge groups, we believe that the modified inverted T-shaped method is technically more feasible and reliable than the conventional method and will contribute to the improved safety of LTG.

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：English   Publishing type：Research paper (scientific journal)  

Since its widespread acceptance for the treatment of early gastric cancer, laparoscopic gastrectomy has been gaining popularity as a treatment option for advanced gastric cancer. However, laparoscopic total gastrectomy (LTG) with splenectomy is seldom performed, because of its difficulty of removal of station 10 lymph nodes; splenectomy is technically essential for complete removal of these lymph nodes. The purpose of this study was to describe the details of the LTG procedure and to evaluate the short- and long-term outcomes of LTG with splenectomy.
Of 725 consecutive patients with gastric cancer who underwent laparoscopic gastrectomy with lymph node dissection in our institution from January 1996 to December 2012, 18 consecutive patients who underwent LTG with splenectomy were enrolled in this study.
No operative mortality occurred, and the pathological margins were free from cancer cells in all patients. The mean operation time was 388 min (range 324-566 min). The mean volume of blood loss was 45 ml (range 5-347 ml), and the mean number of dissected lymph nodes was 51 (range 40-105). Postoperative morbidity occurred in six patients (33.3 %) (each with grade B postoperative pancreatic fistula, postoperative bleeding, chylous ascites, atelectasis, ileus, and intra-abdominal infection). Five patients (27.8 %) developed recurrence (four in the peritoneum and one in the liver), and the overall 3- and 5-year survival rates were 83.0 and 72.6 %, respectively.
Considering the 0 % mortality rate and low rates of postoperative morbidity and locoregional recurrence, LTG with splenectomy is technically and oncologically acceptable. This procedure can be expanded to include advanced gastric cancer, which generally requires splenectomy for lymph node dissection.

DOI： 10.1007/s00464-014-3870-6

Language：Japanese   Publishing type：Research paper (other academic)  

Abstract：遠隔医療カンファレンスは発展途上国、先進国双方の医療従事者にとって有用であるが国を跨ぐ協力関係構築の困難さが活動の定着を阻んでいる。当院アジア遠隔医療開発センターは52ヶ国382施設と525回の遠隔医療カンファレンスイベントの実績があり、高品質なカンファレンス実現のための必要情報や手順を蓄積してきた。今後これらの情報項目や手順の標準化が必要である。本研究ではこれまで当センターが蓄積してきた情報項目を整理しそれらの一元管理および業務支援を目的としたデータベース構築を行った。遠隔医療カンファレンス運営には人物情報、イベントプログラム情報、イベント実績情報、施設情報の4種類の情報が必要であることがわかり情報項目を策定した。またイベント主催者、エンジニア、国際コーディネーターの各役割間で情報の同期が不十分であることがわかった。イベント実績情報、施設情報についてはデータベース構築しイベント運営を効率化できた。(著者抄録)

Language：Japanese   Publishing type：Research paper (other academic)  

Abstract：先天性心疾患の胎児診断の重要性は広く認識されるようになり、近年急速に普及している。重症心疾患の胎児スクリーニングには高いレベルの技術が必要とされる。遠隔地の産科医超音波技師が簡単に参加できる遠隔セミナーの必要性は高い。今回我々は学術ネットワーク(SINET)とH323テレビ会議システムを使って、遠隔セミナーを開催した。2日間にわたり、東京の一ツ橋記念講堂をメイン会場に、台湾大学を含む11の遠隔会場をつないで開催した。講演の一部はメイン会場ではなく遠隔会場から行い、メイン会場および他の遠隔会場に配信した。2日間の講演を通して、通信のトラブルは一度も発生せず、遠隔会場を含め全会場で、画質音質も高品質の配信を行うことができた。全国で428人が参加した。参加者の中心は、ある程度胎児心エコーの経験のある30～40代の産科医であった。終了後、参加者全員を対象としたアンケートを実施した。アンケートの回収率は23%であった。講演の内容に多くの参加者が満足されていたが、特に、今年初めて実施した診断テストに対しては高い評価をいただいた。また、遠隔会場の参加者から、全国どこにいても、容易に参加できるこの遠隔セミナーの意義を高く評価されていた。90%の参加者が次回も参加を希望されていた。アンケートの意見をできるだけ取り入れて、来年以降も遠隔セミナーを開催していきたい。(著者抄録)

Language：English  

Abstract
BACKGROUND/AIMS:
To review our treatment experience of gastrointestinal stromal tumors (GISTs) of the upper gastrointestinal tract and identify the prognostic factors that influence tumor recurrence.
METHODOLOGY:
Data of 46 consecutive patients with upper GI GISTs who underwent surgery from 1988 to 2011 were reviewed. The overall and disease-free survival rates and influence of clinicopathologic variables on disease-free survival rate were evaluated.
RESULTS:
The median age was 64 years (range, 20-86 years). R0 resections were performed in 43 (93.5%) patients. With a median follow-up time of 33 months (1-275 months), there were 5 (10.9%) recurrences and 2 mortalities in the high-risk group. The overall survival and recurrence-free survival rates at 5 years were 92.1% and 84.6%, respectively. Male gender, tumor size of >10 cm, high numbers of mitotic figures, R1 resection, high risk according to the Joensuu criteria, and a Ki-67 index of >10% were associated with a poor prognosis.
CONCLUSIONS:
Surgical resection of low- and intermediate-risk GISTs has excellent results. High counts of mitotic figures, male gender, incomplete resection, large tumor size, and a high Ki-67 index are associated with a poor prognosis.

Language：English  

Abstract
Live demonstration of endoscopy is one of the most attractive and useful methods for education and is often organized locally in hospitals. However, problems have been apparent in terms of cost, preparation, and potential risks to patients. Our aim was to evaluate a new approach to live endoscopy whereby remote hospitals are connected by the Internet for live endoscopic demonstrations. Live endoscopy was transmitted to the Congress of the Japan Gastroenterological Endoscopic Society by 13 domestic and international hospitals. Patients with upper and lower gastrointestinal diseases and with pancreatobiliary disorders were the subjects of a live demonstration. Questionnaires were distributed to the audience and were sent to the demonstrators. Questions concerned the quality of transmitted images and sound, cost, preparations, programs, preference of style, and adverse events. Of the audience, 91.2% (249/273) answered favorably regarding the transmitted image quality and 93.8% (259/276) regarding the sound quality. All demonstrators answered favorably regarding image quality and 93% (13/14) regarding sound quality. Preparations were completed without any outsourcing at 11 sites (79%) and were evaluated as 'very easy' or 'easy' at all but one site (92.3%). Preparation cost was judged as 'very cheap' or 'cheap' at 12 sites (86%). Live endoscopy connecting multiple international centers was satisfactory in image and sound quality for both audience and demonstrators, with easy and inexpensive preparation. The remote transmission of live endoscopy from demonstrators' own hospitals was preferred to the conventional style of locally organized live endoscopy.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society.
KEYWORDS:
education; international; internet; live demonstration; telemedicine

Language：English  

Abstract
INTRODUCTION:
We introduced a reduced-port procedure for laparoscopic restorative proctocolectomy without diverting ileostomy for patients with familial adenomatous polyposis and ulcerative colitis.
MATERIALS AND SURGICAL TECHNIQUE:
A multichannel port was inserted through a 2.5-cm umbilical incision. A 12-mm port in the right lower abdomen and a 3- or 5-mm port were also employed. A proctocolectomy was performed intracorporeally, and the entire colon and rectum were delivered through the umbilical incision. An ileal J-pouch was made extracorporeally following division of the mesenteric vessels. Ileal j-pouch-anal anastomosis was performed intracorporeally or transanally after rectal mucosectomy. A drain was inserted through the 12-mm port incision, and a transanal decompression tube was placed in the pouch. Two women and one man underwent this surgery, and their postoperative recovery was uneventful.
DISCUSSION:
Laparoscopic restorative proctocolectomy without a diverting stoma by a reduced-port technique is feasible and provides excellent cosmetic outcomes in selected patients.
© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
KEYWORDS:
One-stage operation; reduced-port surgery; restorative proctocolectomy

Language：English  

Abstract
Portable Healthcare Clinic (PHC) is a mobile healthcare system comprising of medical sensors and health assessment criteria. It has been applied in Bangladesh for the last two years as a pilot program to identify non-communicable diseases. In this study, we adapted PHC to fit post-disaster conditions. The PHC health assessment criteria are redesigned to deal with emergency cases and healthcare worker insufficiency. A new algorithm makes an initial assessment of age, symptoms, and whether the person is seeing a doctor. These changes will make the turn-around time shorter and will enable reaching the most affected patients better. We tested the operability and turn-around time of the adapted system at the debris flow disaster shelters in Hiroshima, Japan. Changing the PHC health assessment criteria and other solutions such as a list of medicine preparation makes the PHC system switch into an emergency mode more smoothly following a natural disaster.

Language：English  

Abstract
Portable Healthcare Clinic (PHC) is a mobile healthcare system comprising of medical sensors and health assessment criteria. It has been applied in Bangladesh for the last two years as a pilot program to identify non-communicable diseases. In this study, we adapted PHC to fit post-disaster conditions. The PHC health assessment criteria are redesigned to deal with emergency cases and healthcare worker insufficiency. A new algorithm makes an initial assessment of age, symptoms, and whether the person is seeing a doctor. These changes will make the turn-around time shorter and will enable reaching the most affected patients better. We tested the operability and turn-around time of the adapted system at the debris flow disaster shelters in Hiroshima, Japan. Changing the PHC health assessment criteria and other solutions such as a list of medicine preparation makes the PHC system switch into an emergency mode more smoothly following a natural disaster.

Language：English  

Abstract
BACKGROUND:
The prevalence of non-communicable diseases is increasing throughout the world, including developing countries.
OBJECTIVE:
The intent was to conduct a study of a preventive medical service in a developing country, combining eHealth checkups and teleconsultation as well as assess stratification rules and the short-term effects of intervention.
METHODS:
We developed an eHealth system that comprises a set of sensor devices in an attaché case, a data transmission system linked to a mobile network, and a data management application. We provided eHealth checkups for the populations of five villages and the employees of five factories/offices in Bangladesh. Individual health condition was automatically categorized into four grades based on international diagnostic standards: green (healthy), yellow (caution), orange (affected), and red (emergent). We provided teleconsultation for orange- and red-grade subjects and we provided teleprescription for these subjects as required.
RESULTS:
The first checkup was provided to 16,741 subjects. After one year, 2361 subjects participated in the second checkup and the systolic blood pressure of these subjects was significantly decreased from an average of 121 mmHg to an average of 116 mmHg (P<.001). Based on these results, we propose a cost-effective method using a machine learning technique (random forest method) using the medical interview, subject profiles, and checkup results as predictor to avoid costly measurements of blood sugar, to ensure sustainability of the program in developing countries.
CONCLUSIONS:
The results of this study demonstrate the benefits of an eHealth checkup and teleconsultation program as an effective health care system in developing countries.
KEYWORDS:
body area network; developing countries; preventive medicine; public health informatics; sensor; teleconsultation

Language：English   Publishing type：Research paper (scientific journal)  

Background/Aims: To review our treatment experience of gastrointestinal stromal tumors (GISTs) of the upper gastrointestinal tract and identify the prognostic factors that influence tumor recurrence. Methodology: Data of 46 consecutive patients with upper GI GISTs who underwent surgery from 1988 to 2011 were reviewed. The overall and disease-free survival rates and influence of clinicopathologic variables on disease-free survival rate were evaluated. Results: The median age was 64 years (range, 20-86 years). R0 resections were performed in 43 (93.5%) patients. With a median follow-up time of 33 months (1-275 months), there were 5 (10.9%) recurrences and 2 mortalities in the high-risk group. The overall survival and recurrence-free survival rates at 5 years were 92.1% and 84.6%, respectively. Male gender, tumor size of >10 cm, high numbers of mitotic figures, R1 resection, high risk according to the joensuu criteria, and a Ki-67 index of >10% were associated with a poor prognosis. Conclusions: Surgical resection of low- and intermediate-risk GISTs has excellent results. High counts of mitotic figures, male gender, incomplete resection, large tumor size, and a high Ki-67 index are associated with a poor prognosis.

DOI： 10.5754/hge12819

Language：English   Publishing type：Research paper (scientific journal)  

BackgroundMucinous cystic neoplasms (MCN) of the pancreas frequently develop in the distal pancreases of young women. Laparoscopic surgery can enhance cosmetic benefits and ease of surgery. This study assessed the feasibility of laparoscopic surgery for MCN.
MethodsThe medical records of 21 patients pathologically diagnosed with benign MCN after laparoscopic resection were reviewed. Clinical data were compared in the 11 patients with tumors 45mm (large tumor group) and the 10 patients with tumors <45mm (small tumor group).
ResultsLaparoscopic resection was completed in all patients, including distal pancreatectomy with (n = 9) and without (n = 11) spleen preservation and enucleation for pancreatic head lesion (n = 1). Operation time, blood loss, postoperative morbidity, and hospital stay were similar in the two groups. Spleen-preserving pancreatectomy could be more frequently completed in the small MCN group (P = 0.02). No recurrence was observed during a median follow-up period of 12 months.
ConclusionsLaparoscopic surgery can be completed in all patients with benign MCN, even those with large tumors, and patients with small MCN can get the additional benefit of spleen preservation.

DOI： 10.1002/jhbp.32

Language：English  

Abstract
BACKGROUND:
Moving images are often essential in medical education, to learn new procedures and advanced skills, but, in the past, high-quality movie transmission was technically much more challenging than transmitting still pictures because of technological limitations and cost.
MATERIALS AND METHODS:
We established a new system, taking advantage of two advanced technologies, the digital video transport system (DVTS) and the research and education network (REN), which enabled satisfactory telemedicine on a routine basis.
RESULTS:
Between 2003 and 2013, we organized 360 programs connecting 221 hospitals or facilities in 34 countries in Asia and beyond. The two main areas were endoscopy and surgery, with 113 (31%) and 106 (29%) events, respectively. Teleconferences made up 76% of the total events, with the remaining 24% being live demonstrations. Multiple connections were more popular (63%) than one-to-one connections (37%). With continuous technological development, new high-definition H.323 and Vidyo(®) (Hackensack, NJ) systems were used in 47% and 39% of events in 2011 and 2012, respectively. The evaluation by questionnaires was favorable on image and sound quality as well as programs.
CONCLUSIONS:
Remote medical education with moving images was well accepted in Asia with changing needs and developing technologies.
KEYWORDS:
Internet; digital video transport system; remote education; research and education network; telemedicine

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND:

Since its widespread acceptance for the treatment of early gastric cancer, laparoscopic gastrectomy has been gaining popularity as a treatment option for advanced gastric cancer. However, laparoscopic total gastrectomy (LTG) with splenectomy is seldom performed, because of its difficulty of removal of station 10 lymph nodes; splenectomy is technically essential for complete removal of these lymph nodes. The purpose of this study was to describe the details of the LTG procedure and to evaluate the short- and long-term outcomes of LTG with splenectomy.

METHODS:

Of 725 consecutive patients with gastric cancer who underwent laparoscopic gastrectomy with lymph node dissection in our institution from January 1996 to December 2012, 18 consecutive patients who underwent LTG with splenectomy were enrolled in this study.

RESULTS:

No operative mortality occurred, and the pathological margins were free from cancer cells in all patients. The mean operation time was 388 min (range 324-566 min). The mean volume of blood loss was 45 ml (range 5-347 ml), and the mean number of dissected lymph nodes was 51 (range 40-105). Postoperative morbidity occurred in six patients (33.3 %) (each with grade B postoperative pancreatic fistula, postoperative bleeding, chylous ascites, atelectasis, ileus, and intra-abdominal infection). Five patients (27.8 %) developed recurrence (four in the peritoneum and one in the liver), and the overall 3- and 5-year survival rates were 83.0 and 72.6 %, respectively.

CONCLUSIONS:

Considering the 0 % mortality rate and low rates of postoperative morbidity and locoregional recurrence, LTG with splenectomy is technically and oncologically acceptable. This procedure can be expanded to include advanced gastric cancer, which generally requires splenectomy for lymph node dissection.

Language：English   Publishing type：Research paper (scientific journal)  

Abstract
BACKGROUND/AIMS: This retrospective study was conducted to find preoperatively assessable risk factors for postoperative pancreatic fistula (POPF) in patients undergoing laparoscopic distal pancreatectomy (LDP) using a slow compression method with a stapler, which we call pen-firing compression (PFC).
METHODOLOGY: Fifty-two patients underwent LDP, of whom 42 underwent PFC for pancreatic division using a stapler. The relationship between preoperatively assessable factors and the incidence of clinical POPF was statistically analyzed.
RESULTS: Overall rate of POPF was 7.1% in 42 patients. Univariate analysis showed that greater BMI (p = 0.004) and thicker pancreatic stump (0.0022) were significant risk factors for POPF. BMI and stump thickness remained significant (P < 0.0001, P < 0.0001) by multivariate analysis. Cutoff points estimated by ROC curve were 27 kg/m2 for BMI and 27 mm for stump thickness.
CONCLUSIONS: High BMI value and thick pancreatic stump are significant risk factors for POPF after LDP. Alternative treatment of the pancreatic stump may prevent POPF in high-risk patients.

Language：English  

BACKGROUND:

The benefits and feasibility of laparoscopic surgery for remnant gastric cancer are still unclear. The purpose of this study was to describe the detailed procedure and to evaluate the clinical short-term outcomes of laparoscopic total gastrectomy (LTG) compared with open total gastrectomy (OTG) for remnant gastric cancer (RGC).

METHODS:

Of 1,247 consecutive patients who underwent gastrectomy for gastric cancer in our department at Kyushu University Hospital from January 1996 to May 2012, 22 patients who underwent successful curative resection of RGC with precise nodal dissection were enrolled in this study. Twelve patients underwent LTG and the remaining ten patients underwent OTG. We analyzed the clinical short-term outcomes of LTG and compared the results between LTG and OTG groups to evaluate the safety and feasibility of LTG.

RESULTS:

Twelve patients with RGC successfully underwent LTG without open conversion and morbidity. The mean operation time of LTG, 362.3 ± 68.4 min, was significantly longer than that of OTG (p = 0.0176), but the mean blood loss of LTG, 65.8 ± 62 g, was smaller than that of OTG (p < 0.01). The mean postoperative times to resumption of water and food intake were significantly shorter in the LTG group than in the OTG group (p < 0.01). The overall 3-year survival rate was comparable between the LTG and OTG groups (77.8 vs. 100 %; p = 0.9406).

CONCLUSIONS:

This study shows that LTG is a feasible and reliable procedure for the treatment of RGC in terms of short-term outcomes.

Language：English  

BACKGROUND:

Mucinous cystic neoplasms (MCN) of the pancreas frequently develop in the distal pancreases of young women. Laparoscopic surgery can enhance cosmetic benefits and ease of surgery. This study assessed the feasibility of laparoscopic surgery for MCN.

METHODS:

The medical records of 21 patients pathologically diagnosed with benign MCN after laparoscopic resection were reviewed. Clinical data were compared in the 11 patients with tumors ≥45 mm (large tumor group) and the 10 patients with tumors <45 mm (small tumor group).

RESULTS:

Laparoscopic resection was completed in all patients, including distal pancreatectomy with (n = 9) and without (n = 11) spleen preservation and enucleation for pancreatic head lesion (n = 1). Operation time, blood loss, postoperative morbidity, and hospital stay were similar in the two groups. Spleen-preserving pancreatectomy could be more frequently completed in the small MCN group (P = 0.02). No recurrence was observed during a median follow-up period of 12 months.

CONCLUSIONS:

Laparoscopic surgery can be completed in all patients with benign MCN, even those with large tumors, and patients with small MCN can get the additional benefit of spleen preservation.

Language：English  

Abstract
PURPOSE:
To compare the outcomes of laparoscopic surgery and open surgery for gastric gastrointestinal stromal tumors (GISTs) by size-matched analysis and evaluate whether laparoscopic surgery for lesions of >5 cm is feasible.
PATIENTS AND METHODS:
Data of 44 consecutive patients with gastric GIST who underwent surgery from 1988 to 2011 were reviewed. Twenty-three patients who underwent successful laparoscopic surgery were compared with 10 patients with similar tumor sizes who underwent open surgery. Among the 23 patients in the laparoscopic group, we compared postoperative results between GISTs of ≤5 cm and >5 cm.
RESULTS:
There were no differences in clinicopathological characteristics between the laparoscopic surgery group (LG) and the open surgery group (OG). The operation time was not different, but the blood loss (5.5 mL [range, 0-425 mL] in LG and 125 mL [range, 0-676 mL] in OG) (P=.008) and postoperative hospital stay (21 days in OG and 8 days in LG) (P<.001) were significantly less in the LG. Postoperative complications and recurrence were not different. Comparison between patients with lesions of >5 cm and patients with smaller lesions in the LG found that smaller lesions were associated with a shorter postoperative hospital stay (7.5 days versus 11 days) (P=.037).
CONCLUSIONS:
Laparoscopic resection of primary gastric GISTs is feasible even for tumors of >5 cm.

Language：English  

Language：English   Publishing type：Research paper (scientific journal)  

The benefits and feasibility of laparoscopic surgery for remnant gastric cancer are still unclear. The purpose of this study was to describe the detailed procedure and to evaluate the clinical short-term outcomes of laparoscopic total gastrectomy (LTG) compared with open total gastrectomy (OTG) for remnant gastric cancer (RGC).
Of 1,247 consecutive patients who underwent gastrectomy for gastric cancer in our department at Kyushu University Hospital from January 1996 to May 2012, 22 patients who underwent successful curative resection of RGC with precise nodal dissection were enrolled in this study. Twelve patients underwent LTG and the remaining ten patients underwent OTG. We analyzed the clinical short-term outcomes of LTG and compared the results between LTG and OTG groups to evaluate the safety and feasibility of LTG.
Twelve patients with RGC successfully underwent LTG without open conversion and morbidity. The mean operation time of LTG, 362.3 +/- A 68.4 min, was significantly longer than that of OTG (p = 0.0176), but the mean blood loss of LTG, 65.8 +/- A 62 g, was smaller than that of OTG (p < 0.01). The mean postoperative times to resumption of water and food intake were significantly shorter in the LTG group than in the OTG group (p < 0.01). The overall 3-year survival rate was comparable between the LTG and OTG groups (77.8 vs. 100 %; p = 0.9406).
This study shows that LTG is a feasible and reliable procedure for the treatment of RGC in terms of short-term outcomes.

DOI： 10.1007/s00464-013-3186-y

Language：Japanese   Publishing type：Research paper (scientific journal)  

膵神経内分泌腫瘍の治療の原則は切除術であり,従来は経過観察とされてきた小さな非機能性腫瘍も含め,すべての腫瘍を切除対象とするのが最近の世界的な流れである.術式は悪性度に応じて核出術,膵部分切除術,リンパ節郭清を伴う膵切除術を選択するが,術前の悪性度評価は必ずしも容易ではない.一方,多発性内分泌腫瘍症に伴う多発膵腫瘍に対しては膵全摘を回避する術式が望ましい.2012年4月に腹腔鏡下膵切除術が保険収載され,今後の普及が見込まれる.転移・再発巣も切除可能であれば切除を考慮する.切除不能肝転移でも90%以上の減量が可能であれば,減量術を含む集学的治療により長期予後が期待できる場合がある.(著者抄録)

Language：Japanese   Publishing type：Research paper (other academic)  

Language：English  

Abstract


PURPOSE:

The role of gastrectomy for patients with positive peritoneal cytology, but a negative macroscopic peritoneal implant (P-/cy+), remains unclear. The aim of this study was to evaluate laparoscopic gastrectomy for P-/cy+ patients.

METHODS:

This study reviewed a prospectively maintained gastric cancer database of gastric-cancer patients those underwent surgical resection. P-/cy+ gastric cancer that had invaded the subserosa, or deeper layers, of the stomach wall without distant organ metastases was considered operable in this institution. P-/cy+ patients underwent either open or laparoscopic gastrectomy with D2 lymphadenectomy. The short-term results were examined to assess differences in outcome between the two groups.

RESULTS:

Eighteen P-/cy+ patients without distant organ metastases underwent surgery between 2000 and 2010. Laparoscopic gastrectomy was performed in nine patients and open gastrectomy in nine patients. The estimated blood loss was significantly smaller, the resumption of food intake earlier, and the length of postoperative hospital stay shorter in the patients that underwent laparoscopic gastrectomy than in the patients that underwent open gastrectomy. There were no significant differences in the 2-year survival rates between the groups.

CONCLUSION:

Laparoscopic gastrectomy for P-/cy+ patients is a minimally invasive and safe oncologic procedure with good short-term results.

Language：English  

BACKGROUND:

Although laparoscopic distal gastrectomy has been widely accepted in clinical practice, laparoscopic total gastrectomy (LTG) is not yet familiar because of the difficulty in esophagojejunostomy. The purpose of this study was to evaluate perioperative and short-term outcomes of our procedure of intracorporeal gastrojejunostomy using linear staplers after LTG.

METHODS:

Of 98 consecutive patients who underwent LTG for gastric cancer in our department between August 2002 and December 2010, 94 patients underwent esophagojejunostomy with a linear stapling device. After October 2007, we modified the esophagojejunostomy; ie, the most recent 57 patients underwent transection of the esophagus in the ventrodorsal direction and insertion of a linear stapler from the anterior wall of the Roux limb to the posterior wall so as to make an inverted T-shaped anastomosis. We evaluated the results in these 57 patients (recent group) and compared them with the results in the earlier 37 patients (early group).

RESULTS:

The mean operative time in the recent group was 368 to 94.6 min, and the mean estimated blood loss was 57 to 33 g; both were comparable with those in the early group. Neither open conversion nor intraoperative complications were encountered. Two patients experienced anastomotic leakage in the earlier group, but anastomotic leakage did not occur in the recent group. No mortality was encountered.

CONCLUSION:

We herein report our procedure of intracorporeal gastrojejunostomy using linear staplers after LTG. Our procedure of esophagojejunostomy using linear staplers is safe and feasible and has acceptable morbidity.

Copyright © 2013 Mosby, Inc. All rights reserved.

Language：English  

Abstract


BACKGROUND/AIMS:

Telemedicine is a convenient and efficient tool for remote education in various fields. The telemedicine system can also be used to educate doctors and medical students. The aim of our study was to establish the effectiveness of the telemedical system for use in a live endoscopic multichannel demonstration conference and to test the effectiveness and usefulness of a multicenter-based live endoscopic demonstration through live, interactive, high resolution video transmission using advanced networks and the digital video transport system (DVTS).

METHODS:

This study is a prospective multicenter pilot study. A live demonstration of an endoscopic submucosal dissection (ESD) and an endoscopic retrograde cholangiopancreatography (ERCP) using advanced network technology was performed.

RESULTS:

The DVTS successfully transmitted uncompressed, high-resolution, digital lectures with endoscopy video during a multichannel endoscopic live demonstration of ESD and ERCP over multiple advanced networks. The overall satisfaction rating when the endoscopic lecture demonstration was performed by combining DVTS was generally good.

CONCLUSIONS:

We believe that a multicenter-based live endoscopic demonstration is a very effective conferencing method when using advanced networks and DVTS.

Language：English  

AIM: We sought to evaluate the feasibility of the lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy (LA-SVPDP).

BACKGROUND: Complete preservation of the splenic vessels is an ideal outcome in spleen-preserving distal pancreatectomy (SPDP). However, the preservation of the vessels is challenging in laparoscopic surgery because the splenic vein is often embedded in the pancreatic parenchyma. Herein we have described LA-SVPDP, the most feasible method for laparoscopic SPDP, and the outcome of our initial experience.

PATIENTS: Twenty-three patients underwent laparoscopic SPDP. Before we adopted LA-SVPDP, 8 patients underwent the Warshaw method and 6 underwent SVPDP. After the adoption of LA-SVPDP, 8 patients underwent LA-SVPDP and 1 donor underwent the Warshaw method.

RESULTS: None of patients undergoing LA-SVPDP required conversion to an open operation, whereas 2 patients undergoing the other procedures were converted to open operations. Five out of 8 patients who underwent the Warshaw method showed engorgement of the gastric veins, revealed by computed tomography. However, only 1 of the 5 patients showed mild gastric varices on endoscopy.

CONCLUSION: Although the Warshaw method is acceptable with a low incidence of gastric varices in our analysis, SVPDP is a feasible approach for SPDP. Our LA-SVPDP technique may contribute to safer and easier SVPDP in laparoscopic surgery.

Language：Japanese   Publishing type：Research paper (other academic)  

Abstract：九州大学病院では、2003年より高速国際学術ネットワーク網を活用した遠隔医療連携を行っており、2011年3月末までに27ヶ国149施設と253回のイベントを実施した。遠隔医療の発展のためには、活動における機器や接続手順等の標準化が重要である。著者らは活動当初に使用していた最小機器構成に加えて、活動を通じて培った経験と知識を集約して、2007年に標準的機器構成を提案した。今回、さらにその構成に改良を加えた機器構成を提案し、それに基づくパッケージを実証したので、旧構成との間の比較検討を行った。その結果、本パッケージは2つの旧構成の問題点を解決し、さらに機器の英語表記や国によって異なる電源や放送方式といった問題にも対応できた。本パッケージはDVTSだけでなく、大きな会場でのWeb会議システム等によるカンファレンスにも活用でき、高品質な遠隔医療を安価に実現する機器セットの基本形であると考える。

Language：English  

BACKGROUND: With the rapid and marked progress in gastrointestinal endoscopy, the education of doctors in many new diagnostic and therapeutic procedures is of increasing importance. Telecommunications (telemedicine) is very useful and cost-effective for doctors' continuing exposure to advanced skills, including those needed for hepato-pancreato-biliary diseases. Nevertheless, telemedicine in endoscopy has not yet gained much popularity. We have successfully established a new system which solves the problems of conventional ones, namely poor streaming images and the need for special expensive teleconferencing equipment.

METHODS: The digital video transport system, free software that transforms digital video signals directly into Internet Protocol without any analog conversion, was installed on a personal computer using a network with as much as 30 Mbps per channel, thereby providing more than 200 times greater information volume than the conventional system. Kyushu University Hospital in Japan was linked internationally to worldwide academic networks, using security software to protect patients' privacy.

RESULTS: Of the 188 telecommunications link-ups involving 108 institutions in 23 countries performed between February 2003 and August 2009, 55 events were endoscopy-related, 19 were live demonstrations, and 36 were gastrointestinal teleconferences with interactive discussions. The frame rate of the transmitted pictures was 30/s, thus preserving smooth high-quality streaming.

CONCLUSIONS: This paper documents the first time that an advanced tele-endoscopy system has been established over such a wide area using academic high-volume networks, funded by the various governments, and which is now available all over the world. The benefits of a network dedicated to research and education have barely been recognized in the medical community. We believe our cutting-edge system will be a milestone in endoscopy and will improve the quality of gastrointestinal education, especially with respect to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures.

Language：English  

BACKGROUND: Laparoscopic distal pancreatectomy (Lap-DP) is one of the most accepted laparoscopic procedures in the field of pancreatic surgery. However, pancreatic fistula remains a major and frequent complication in Lap-DP, as in open surgery. The aim of this retrospective study is to clarify the advantages of prolonged peri-firing compression (PFC) with a linear stapler for prevention of pancreatic fistula after laparoscopic distal pancreatectomy.

PATIENTS AND METHODS: Incidence of pancreatic fistula in clinical levels (equivalent to grades B and C defined by the International Study Group of Pancreatic Fistula (ISGPF)) was retrospectively compared between patients who underwent Lap-DP with PFC (PFC group, n = 17) and those who underwent Lap-DP without PFC (no-PFC group, n = 25).

RESULTS: Incidence of clinical pancreatic fistula was significantly lower in the PFC group than in the no-PFC group. Consistent with the results for pancreatic fistula, peritoneal drainage period and postoperative hospital stay were shorter in the PFC group than in the no-PFC group.

CONCLUSIONS: Our data show that PFC effectively prevents pancreatic fistula and shortens postoperative hospital stay after Lap-DP.

Language：English  

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) has been shown to be an effective surgical option for benign lesions in the body and tail of the pancreas. However, its advantages and disadvantages have not been well characterized. In this study, we compared the outcomes of LDP and open pancreatectomy performed in our clinic.

MATERIALS AND METHODS: Peri- and postoperative outcomes were retrospectively compared between patients with benign pancreatic disorders who underwent open distal pancreatectomy (ODP) (n = 35) and those who underwent LDP (n = 40). The peri- and postoperative factors analyzed included operative time, blood loss, hospital stay, postoperative recovery, biochemical findings, and complications.

RESULTS: LDP was associated with significantly less operative blood loss (363 versus 606 mL; P = 0.001) and shorter hospital stay (22 versus 27 day; P = 0.009), but longer operative time (342 versus 250 min; P = 0.000), compared with ODP. There were no significant differences between the two groups in complication rates or postoperative recovery, except for the significantly shorter duration of postoperative pain-killer intake and earlier improvement of the biochemical analysis in LDP than in ODP.

CONCLUSIONS: LDP appears to be a safe, desirable procedure for the management of benign pancreatic diseases, with outcomes similar to ODP

Language：English  

Language：English  

AbstractLaparoscopic gastrectomy is widely used as minimally invasive surgery for gastric carcinoma. Billroth I or Roux-en-Y reconstruction is commonly performed after laparoscopic distal gastrectomy (LDG). Roux-en-Y reconstruction after LDG is one of the best methods for reconstruction of the alimentary tract when Billroth I reconstruction is difficult. There are few reports of intracorporeal Roux-en-Y reconstruction after LDG because of the technical difficulties of such a procedure. In particular, in the case of a very small gastric remnant, gastrojejunostomy using endoscopic linear staplers becomes more complicated. We developed a new technique for intracorporeal Roux-en-Y reconstruction: a modified stapling technique to allow the gastrojejunostomy to be made on the stomach transecting line that is applicable even when the residual stomach is very small. Roux-en-Y reconstruction with our modified technique was performed in six patients. There was
no intraoperative complication or conversion to minilaparotomy or conventional celiotomy in any patient. Oral intake was easy and adequate after surgery. The present Roux-en-Y reconstruction procedure is feasible. Herein we describe an intraabdominal Roux-en-Y reconstruction with a modified stapling technique after LDG.

Language：English  

BACKGROUND: Teleteaching of endoscopy has been limited by the exorbitant cost and time inherent in high-quality digital endoscopy video transmission. The Digital Video Transport System (DVTS) transmitted over advanced networks, such as Internet2 and the Asia-Pacific Advanced Network (APAN), provides a unique infrastructure for sharing uncompressed digital videos of endoscopy. This may allow high-quality, real-time, international training of diagnostic and therapeutic endoscopy techniques at a low cost. OBJECTIVE: To test the proof of concept of long-distance teaching through live, interactive, high-resolution video transmission by using advanced networks and the DVTS. We used teleteaching of image-enhanced endoscopy techniques as a model. DESIGN: Prospective multicenter pilot study. SETTING AND PARTICIPANTS: Trainees, faculty, and staff at 3 international endoscopy units. INTERVENTION: An image-enhanced endoscopy video lecture with advanced-network technologies. MAIN OUTCOME MEASUREMENTS: We compared image-based prelecture and postlecture test scores and secondarily assessed technical feasibility and quality. RESULTS: The DVTS transmitted over advanced networks successfully transmitted uncompressed, high-resolution, digital lectures with endoscopic video (digital video format 720 x 480 pixels). Postsession scores improved. Participants highly rated the technical and informational quality. The majority reported a definite interest in participating in future sessions, with a mean rating (out of 5 [scale 1-5]) of 4.7 +/- 0.5. LIMITATIONS: Pilot study with a limited number of participants and sessions. CONCLUSION: The DVTS transmitted over advanced networks such as Internet2 and APAN can provide the infrastructure for transmission of high-resolution, uncompressed video endoscopy for the purpose of teleteaching endoscopy.

Language：English  

Language：English  

Language：English  

Traditional narrowband telemedicine cannot provide quality dynamic images. We conducted videoconferences of laparoscopic and endoscopic operations via an uncompressed video transmission technique. A superfast broadband Internet link was set up between Shanghai in the People's Republic of China and Fukuoka in Japan. Uncompressed dynamic video images of laparoscopic and endoscopic operations were transmitted by a digital video transfer system (DVTS). Seven teleconferences were conducted between June 2005 and June 2007. Of the 7 teleconferences, 5 were live surgical demonstrations and 3 were recorded video teleconsultations. Smoothness of the motion picture, sharpness of images, and clarity of sound were benefited by this form of telemedicine based upon DVTS. Telemedicine based upon DVTS is a superior choice for laparoscopic and endoscopic skill training across the borders.

Language：English  

Telecommunication is useful, but it is not widely accepted in medicine, partly because image quality is often inadequate for medical use and partly because an initial investment in special equipment is necessary. We conducted live multi-station teleconferences at the First Biennial Congress of the Asian-Pacific Hepato-Pancreato-Biliary Association (APHPBA), using a new telemedicine system which transmits original-quality images in a simple and economical manner. The venue in Japan was linked to Hong Kong, Singapore, and Manila for an endoscopic surgery session, and to Seoul, Beijing, and Taipei for a pancreas transplant session. A digital video transport system (DVTS), which transforms digital video signals directly to Internet protocol, was set up at each station. The presentations were smooth and clear, and were followed by interactive discussion between the four stations for each session. Although our system requires a broadband Internet connection of at least 30 Mbps, a high-speed academic network has been established already in many countries in the Asia-Pacific region and is readily used for research and educational purposes. Application of this high-performance but user-friendly system can make teleconferences more useful and exciting. Telecommunication based on DVTS and a high-speed academic network should revolutionize the future of such conferences as the APHPBA, as well as those in other fields and locations.


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Language：English  

BACKGROUND/AIMS: Telemedicine has opened the door to a wide range of learning experience and simultaneous feedback to doctors and students at various remote locations. However, there are limitations such as lack of approved international standards of ethics. The aim of our study was to establish a telemedical education system through the development of high quality images, using the digital transfer system on a high-speed network. METHODOLOGY: Using telemedicine, surgical images can be sent not only to domestic areas but also abroad, and opinions regarding surgical procedures can be exchanged between the operation room and a remote place. The Asia Pacific Information Infrastrucuture (APII) link, a submarine cable between Busan and Fukuoka, was used to connect Korea with Japan, and Korea Advanced Research Network (KOREN) was used to connect Busan with Seoul. Teleconference and video streaming between Hanyang University Hospital in Seoul and Kyushu University Hospital in Japan were realized using Digital Video Transfer System (DVTS) over Ipv4 network. RESULTS: Four endoscopic surgeries were successfully transmitted between Seoul and Kyushu, while concomitant teleconferences took place between the two throughout the operations. Enough bandwidth of 60 Mbps could be kept for two-line transmissions. The quality of transmitted video image had no frame loss with a rate of 30 images per second. The sound was also clear, and time delay was less than 0.3 sec. CONCLUSIONS: Our experience has demonstrated the feasibility of domestic and international telemedicine. We have established an international medical network with high-quality video transmission over Internet protocol, which is easy to perform, reliable, and economical. Our network system may become a promising tool for worldwide telemedical communication in the future.

Language：English  

BACKGROUND: Amid rapid changes in surgical techniques and patient care, education and training for the new generation of health care providers is of utmost importance. An international telesurgical system, which we established between Japan and Korea through super-fast broadband Internet without any loss of quality, was shown to be a powerful tool for this purpose. We attempted to expand our advanced system throughout the Asia-Pacific region and studied its usefulness. METHODS: Kyushu University Hospital (Fukuoka, Japan) was linked to 33 medical institutions and meeting venues in China, Taiwan, Thailand, Vietnam, Singapore, and Australia by academic optic fiber network. Digital video signals were directly converted into Internet protocol, and cipher security programs were used to protect patient privacy. RESULTS: Of 49 international surgical teleconferences conducted, 16 were real-time demonstrations of surgery, and 33 involved recorded videos. For 37 events, two stations were connected pier-to-pier, and for the remaining 12, multiple stations were connected. The network remained stable, and the time delay between stations was restricted to 0.3-1.0 seconds. Responding to questionnaires, 70.6% of participants rated the image quality as "very good," and 22.5% rated it "good." CONCLUSIONS: We succeeded in establishing a high-quality telesurgical system in a wide area of the Asia-Pacific region, and this is the first time high-speed Internet technology has been applied to surgery on such a large scale. Because it is not only of high quality but also economical and easy to set up, we believe this system will promote efficient remote surgical education and active academic exchange worldwide.

PMID: 17907987 [PubMed - in process]

Language：English  

Language：English  

Language：English  

OBJECTIVES: To promote the exchange of knowledge and standardization of medical procedures and medical systems in the Asia-Pacific region, we established a medical network with high-quality moving images over broadband Internet lines in February 2003. METHODS: Real-time teleconferences and live demonstrations with medical-quality videos, broadcast via the Digital Video Transport System, have been used to teach surgical techniques and other medical procedures across national borders. The Asia-Pacific Advanced Network (APAN) committee in August 2005 formally approved our proposal to establish a medical working group within APAN. The network was expanded by the launch of the Trans-Eurasia Information Network 2 in 2006. By the end of 2006, we had conducted 82 events, in 10 countries in the Asia-Pacific region. The multi-station event has increased every year. RESULTS: There have been no serious transmission problems or ethical conflicts so far. With these experiences and current achievements, we hope to extend this advanced network system to the entire Asia-Pacific. CONCLUSION: This system is a promising and very useful tool for the standardization of medical system and procedures across national borders. Drawing upon these experiences and current achievements, we hope to extend this advanced network system to the entire Asia-Pacific region.

Language：English  

PURPOSE: To assess the quality of sound and uncompressed images during an international broadcast of live surgery using the newly developed digital video transport system (DVTS). METHODS: Three networks connected hospitals in Seoul, Korea, and Fukuoka, Japan. A teleconference system with bidirectional transmission over the network was set up. DVTS was used to send and receive visual and audio signals during a live broadcast of a laparoscopic partial nephrectomy to viewers at the 94th annual meeting of the Japanese Urological Association. A questionnaire was used to assess the quality of images and sound. RESULTS: Of 713 questionnaires distributed, 418 were collected. The quality of image and voice was ranked very good or good by 95% and 92% of the audience, respectively. The quality of live surgery was considered high by 94% of the audience. CONCLUSION: Digital video images can be transformed directly to an Internet protocol without compression of the motion images using DVTS. Live surgery via teleconference using DVTS can help surgeons learn the skills of endoscopic surgery.

Language：English  

Language：English  

BACKGROUND/PURPOSE: The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated. METHODS: We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy. RESULTS: (1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05). CONCLUSIONS: Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.

Language：English  

Abstract

BACKGROUND:

Although telecommunication is increasing in popularity, poor-quality images sent through a narrowband network limit its use in the medical field.

METHODS:

Kyushu University Hospital in Japan and four hospitals in Korea were linked via superfast broadband Internet connection. The digital video transfer system, which can transmit digital videos without loss of image quality, was used, and the bandwidth was 30 Mbps per line.

RESULTS:

Of the 16 teleconferences conducted, 6 demonstrated real-time endoscopic surgery. In addition to the surgical images, preoperative diagnostic images, images of the operating room, and images of the staff in the conference room were transmitted to facilitate discussion. The network remained stable, and the sound delay was restricted to less than 0.3 s. In the other 10 teleconferences, recorded video images were used for discussion.

CONCLUSIONS:

The authors have established a high-quality, practical teleconference system that is economical and easy to use in clinical practice. This system shows promise for remote education beyond geographic borders.

Language：English   Publishing type：Research paper (scientific journal)  

Language：English   Publishing type：Research paper (scientific journal)  

Background: Laparoscopically assisted distal gastrectomy (LADG) with limited lymph node dissection (D1+alpha) has been used to treat a subset of patients with early gastric cancer. Technical advances have expanded indications for LADG to more advanced gastric cancers. However, little data are available on the feasibility or advantages of LADG with standard radical D2 lymph node dissection for patients with gastric cancer.
Methods: This study reviewed the clinical features of 37 patients who underwent LADG with D2 lymph node dissection for preoperatively diagnosed gastric carcinoma, then compared the results with the features of 31 patients who underwent conventional open distal gastrectomy (ODG) with D2 lymph node dissection.
Results: The laparoscopic procedure was not converted to laparotomy in any patient. There was no operative mortality and no serious morbidity among the patients who underwent LADG with D2 lymph node dissection. As compared with the ODG group, the LADG group had less operative blood loss (p < 0.001), earlier recovery of bowel activity (p = 0.012), and a shorter duration of fever after surgery (p = 0.015), despite the longer operation time (p = 0.007).
Conclusions: According to this study, LADG with D2 lymph node dissection is feasible and provides several advantages similar to those of limited lymph node dissection (D1+alpha). Depending on surgeons' technical proficiency, LADG can be used with standard radical lymph node dissection for patients with gastric cancers.

DOI： 10.1007/s00464-005-0175-9

Language：English  

BACKGROUND: Laparoscopically assisted distal gastrectomy (LADG) with limited lymph node dissection (D1+alpha) has been used to treat a subset of patients with early gastric cancer. Technical advances have expanded indications for LADG to more advanced gastric cancers. However, little data are available on the feasibility or advantages of LADG with standard radical D2 lymph node dissection for patients with gastric cancer. METHODS: This study reviewed the clinical features of 37 patients who underwent LADG with D2 lymph node dissection for preoperatively diagnosed gastric carcinoma, then compared the results with the features of 31 patients who underwent conventional open distal gastrectomy (ODG) with D2 lymph node dissection. RESULTS: The laparoscopic procedure was not converted to laparotomy in any patient. There was no operative mortality and no serious morbidity among the patients who underwent LADG with D2 lymph node dissection. As compared with the ODG group, the LADG group had less operative blood loss (p < 0.001), earlier recovery of bowel activity (p = 0.012), and a shorter duration of fever after surgery (p = 0.015), despite the longer operation time (p = 0.007). CONCLUSIONS: According to this study, LADG with D2 lymph node dissection is feasible and provides several advantages similar to those of limited lymph node dissection (D1+alpha). Depending on surgeons' technical proficiency, LADG can be used with standard radical lymph node dissection for patients with gastric cancers.

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：English  

Language：English   Publishing type：Research paper (scientific journal)  

A 37-year-old woman with a history of syncope was hospitalized with a diagnosis of hypoglycemia due to insulinoma. Computed tomography (CT) and magnetic resonance imaging revealed an enhanced solid mass, 1.5 cm in diameter, at the tail of the pancreas. Angiography via the splenic artery revealed a hypervascular mass. Because the tumor was located deep in the pancreatic parenchyma, laparoscopic distal. pancreatectomy was performed. The pancreas was exposed by dissecting the greater omentum, and the tumor was located by intraoperative ultrasonography. After division of the splenic artery, the pancreas, main pancreatic duct, and splenic vein were transected with an endoscopic linear stapler. The pancreatic pedicle was divided at the splenic hilum to preserve the spleen. The postoperative course was uneventful except for the appearance of splenic infarction on a CT scan 2 weeks after surgery but without any overt symptoms. Spleen-preserving laparoscopic distal pancreatectomy by division of splenic vessels is a feasible treatment option for benign pancreatic disease.

Language：English   Publishing type：Research paper (scientific journal)  

Background: Infrasternal mediastinoscopic surgery is a new alternative to the thoracoscopic approach for patients with anterior mediastinal masses.
Methods: We applied this technique to 18 thymectomies, one thymomectomy, and one cystectomy in a total of 20 patients with anterior mediastinal masses and then assessed the surgical results.
Results: Infrasternal mediastinoscopic surgery was accomplished in 18 of the 20 patients (90%). The pathological diagnoses included 13 Masaoka stage I thymomas, one stage II thymoma, two stage III thymomas, one thymic cyst, one pericardial cyst, one thymic granuloma, and one mature teratoma. Two patients with stage III thymoma required conversion to sternotomy, one for invasion into the innominate vein and the other for invasion into the pericardium. There was no surgically related mortality or complications in any patients.
Conclusion: Infrasternal mediastinoscopic surgery is safe and feasible for stage I thymoma and other benign tumors in the anterior mediastinum.

DOI： 10.1007/s00464-003-8191-0

Language：English  

Language：Japanese   Publishing type：Research paper (scientific journal)  

膵疾患に対し腹腔鏡下手術を施行した症例のうち,膵体尾部切除術(DP)5例と膵嚢胞胃吻合術(CG)5例を対象に腹腔鏡下手術の適応と手術成績について検討した.CGの症例は全て仮性嚢胞であり,自動縫合器を用いて嚢胞と胃壁に内瘻を形成した.その結果,膵周囲の高度な炎症のため,各術式で各々1例が開腹術に移行した.開腹術に移行した症例を除いた症例の平均手術時間はDP 283±66分,CG 204±50分であり,出血量は各々248±263g,38±48gであった.膵液瘻や縫合不全等の合併症は認められず,経口摂取開始は平均6±1日,術後在院日数は17±4日であった.慢性膵炎に対する腹腔鏡下手術の有用性が示唆された

Language：Japanese   Publishing type：Research paper (other academic)  

Language：English  

BACKGROUND/AIMS: The growth of technology based on internet protocol has affected on the informatics and automatic controls of medical fields. The aim of this study was to establish the telemedical educational system by developing the high quality image transfer using the DVTS (digital video transmission system) on the high-speed internet network. METHODS: Using telemedicine, we were able to send surgical images not only to domestic areas but also to international area. Moreover, we could discuss the condition of surgical procedures in the operation room and seminar room. The Korean-Japan cable network (KJCN) was structured in the submarine between Busan and Fukuoka. On the other hand, the Korea advanced research network (KOREN) was used to connect between Busan and Seoul. To link the image between the Hanyang University Hospital in Seoul and Kyushu University Hospital in Japan, we started teleconference system and recorded image-streaming system with DVTS on the circumstance with IPv4 network. RESULTS: Two operative cases were transmitted successfully. We could keep enough bandwidth of 60 Mbps for two-line transmission. The quality of transmitted moving image had no frame loss with the rate 30 per second. The sound was also clear and the time delay was less than 0.3 sec. CONCLUSIONS: Our study has demonstrated the feasibility of domestic and international telemedicine. We have established an international medical network with high-quality video transmission over internet protocol. It is easy to perform, reliable, and also economical. Thus, it will be a promising tool in remote medicine for worldwide telemedical communication in the future.

Language：English  

BACKGROUND: Although minimally invasive surgery has achieved worldwide acceptance in various fields, laparoscopic surgery for pancreatic diseases has been reported only rarely. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery. METHODS: Fifteen patients, comprising eight men and seven women with an average age of 54 years, underwent laparoscopic pancreatic surgery. Distal pancreatectomy was indicated for solid tumors ( n = 4), cystic lesions ( n = 3), and chronic pancreatitis ( n = 2). Cystogastrostomy was performed for pseudocysts ( n = 4) and enucleation for insulinomas ( n = 2). The lesions varied in size from 1 to 9 cm (2.9 +/- 2.4 cm) and were located in the pancreatic head ( n = 2), body ( n = 3), or tail ( n = 10). For distal pancreatectomy, the splenic artery was divided and the parenchyma was transected with a linear stapler. Laparoscopic ultrasonography was used to determine the distance between the tumor and the main pancreatic duct for enucleation as well as to localize the lesion for distal pancreatectomy. Cystogastrostomy, 4.5 cm in length, was also performed with the linear stapler through the window of the lesser omentum. RESULTS: Mean operation time was 249 +/- 70 min (293 +/- 58 min in distal pancreatectomy, 185 +/- 14 min in enucleation, 204 +/- 50 min in cystogastrostomy), and mean blood loss was 138 +/- 184 g (213 +/- 227 g, 75 +/- 35 g, 38 +/- 48 g, respectively). Two distal pancreatectomies (13%) were converted to open surgery due to severe peripancreatic inflammation. There was no related mortality, but there were two cases (15%) of pancreatic fistula, one in a distal pancreatectomy case and the other in an enucleation case, and both were treated conservatively. CONCLUSIONS: Laparoscopic pancreatic surgery is safe and feasible for patients with benign tumors and cystic lesions.

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Infrasternal mediastinoscopic surgery is a new alternative to the thoracoscopic approach for patients with anterior mediastinal masses. METHODS: We applied this technique to 18 thymectomies, one thymomectomy, and one cystectomy in a total of 20 patients with anterior mediastinal masses and then assessed the surgical results. RESULTS: Infrasternal mediastinoscopic surgery was accomplished in 18 of the 20 patients (90%). The pathological diagnoses included 13 Masaoka stage I thymomas, one stage II thymoma, two stage III thymomas, one thymic cyst, one pericardial cyst, one thymic granuloma, and one mature teratoma. Two patients with stage III thymoma required conversion to sternotomy, one for invasion into the innominate vein and the other for invasion into the pericardium. There was no surgically related mortality or complications in any patients. CONCLUSION: Infrasternal mediastinoscopic surgery is safe and feasible for stage I thymoma and other benign tumors in the anterior mediastinum.

Language：English   Publishing type：Research paper (scientific journal)  

Background: Although minimally invasive surgery has achieved worldwide acceptance in various fields, laparoscopic surgery for pancreatic diseases has been reported only rarely. The purpose of this study was to evaluate the outcomes and feasibility of laparoscopic pancreatic surgery.
Methods: Fifteen patients, comprising eight men and seven women with an average age of 54 years, underwent laparoscopic pancreatic surgery. Distal pancreatectomy was indicated for solid tumors (n = 4), cystic lesions (n = 3), and chronic pancreatitis (n = 2). Cystogastrostomy was performed for pseudocysts (n = 4) and enucleation for insulinomas (n = 2). The lesions varied in size from 1 to 9 cm (2.9 +/- 2.4 cm) and were located in the pancreatic head (n = 2), body (n = 3), or tail (n = 10). For distal pancreatectomy, the splenic artery was divided and the parenchyma was transected with a linear stapler. Laparoscopic ultrasonography was used to determine the distance between the tumor and the main pancreatic duct for enucleation as well as to localize the lesion for distal pancreatectomy. Cystogastrostomy, 4.5 cm in length, was also performed with the linear stapler through the window of the lesser omentum.
Results: Mean operation time was 249 +/- 70 min (293 +/- 58 min in distal pancreatectomy, 185 +/- 14 min in enucleation, 204 +/- 50 min in cystogastrostomy), and mean blood loss was 138 +/- 184 g (213 +/- 227 g, 75 35 g, 38 +/- 48 g, respectively). Two distal pancreatectomies (13%) were converted to open surgery due to severe peripancreatic inflammation. There was no related mortality, but there were two cases (15%) of pancreatic fistula, one in a distal pancreatectomy case and the other in an enucleation case, and both were treated conservatively.
Conclusions: Laparoscopic pancreatic surgery is safe and feasible for patients with benign tumors and cystic lesions.

DOI： 10.1007/s00464-003-8164-3

Language：English   Publishing type：Research paper (scientific journal)  

Objective: In this retrospective review, we evaluated the advantages and disadvantages of LADG for patients of heavier weight with early gastric cancer.
Summary Background Data: LADG has been used to treat early gastric cancer. We and others have reported less operative blood loss, less pain, early recovery of bowel activity, early restart of oral intake, and a shorter hospital stay with LADG compared with a conventional open method. There is, however, little information on the advantages of LADG for obese patients with early gastric cancer.
Methods: Between January 1996 and March 2002, 76 patients with preoperatively diagnosed early gastric carcinoma underwent LADG in our department. We classified these patients into 2 groups on the basis of body mass index (BMI). Nineteen patients had a high-BMI (greater than or equal to 24.2 kg/m(2)), and 57 patients had a normal-BMI (< 24.2 kg/m(2)). We collected data by retrospectively reviewing the medical charts.
Results: Extension of the minilaparotomic incision or conversion to laparotomy was needed in 6 (32%) of the 19 patients in the high-BMI group, whereas only 3 (5%) of 57 patients in the normal-BMI group required either. In the high-BMI group, Roux-en-Y anastomosis rather than Billroth I anastomosis was adopted more often than in the normal-BMI group, due to the difficulty of the reconstruction (58% versus 4%, P = 0.001). Significantly longer operative time (370 +/- 61 minutes versus 317 +/- 58 minutes, P = 0.015) and prolonged recovery of bowel activity (3.5 +/- 1.0 days versus 2.6 +/- 1.0 days, P = 0.007) were observed in the patients in the high-BMI group.
Conclusions: In the current study, LADG in patients of heavier weight was accompanied by more technical difficulties, and the disadvantages of longer operative time and delayed recovery of bowel activity was observed in patients of heavier weight. Heavier weight appears to be an ominous factor in the successful completion of LADG and should be considered in the decision to use LADG. There are still benefits of a decreased incidence of serious wound and hernia complications in successful cases.

DOI： 10.1097/01.sla.0000094302.51616.2a

Language：English  

BACKGROUND: Although endoscopic surgical procedures are popular in various fields, reports on its use in gastric surgical procedures are limited. This study was designed to review our initial experience with laparoscopic gastric surgical techniques to evaluate indications and surgical results.
STUDY DESIGN: We undertook a retrospective analysis of 100 patients (66 men and 34 women, mean age 63 years) who underwent laparoscopic gastric surgical procedures between 1995 and 2001. Procedures performed were distal gastrectomy (n = 76), wedge resection (n = 20), and intragastric surgical procedures (n = 4). Patients were divided into two groups according to the date of the procedure, from the earliest to the most recent.
RESULTS: There were 85 patients with gastric cancers, 14 submucosal tumors, and 1 duodenal ulcer. In 8 cases conversion was made to an open surgical procedure. Operation times required for distal gastrectomy, wedge resection, and intragastric surgical procedures were 330 +/- 69, 144 +/- 34, and 298 +/- 106 min, and blood loss was 354 +/- 251, 56 +/- 94, and 33 +/- 58 g, respectively. Complications included transient anastomotic stenosis (n = 5), leakage (n = 4), and bleeding (n = 1) after distal gastrectomy, and bleeding (n = 1) after intragastric surgical procedures. There were no complications after wedge resection. Comparing the first and second halves of the series, the percentage of distal gastrectomy significantly increased from 66% to 86% (p = 0.02) and the number of dissected lymph nodes at this procedure increased from 20 +/- 13 to 33 +/- 17 (p < 0.01).
CONCLUSIONS: Laparoscopic gastric surgical procedures are safe and feasible for early gastric cancers and submucosal tumors. Technical advances in lymph node dissection have made distal gastrectomy a leading and increasingly popular laparoscopic procedure for early gastric cancer. (C) 2003 by the American College of Surgeons.

DOI： 10.1016/S1072-7515(03)00419-8

Language：English  

BACKGROUND: Although endoscopic surgical procedures are popular in various fields, reports on its use in gastric surgical procedures are limited. This study was designed to review our initial experience with laparoscopic gastric surgical techniques to evaluate indications and surgical results.
STUDY DESIGN: We undertook a retrospective analysis of 100 patients (66 men and 34 women, mean age 63 years) who underwent laparoscopic gastric surgical procedures between 1995 and 2001. Procedures performed were distal gastrectomy (n = 76), wedge resection (n = 20), and intragastric surgical procedures (n = 4). Patients were divided into two groups according to the date of the procedure, from the earliest to the most recent.
RESULTS: There were 85 patients with gastric cancers, 14 submucosal tumors, and 1 duodenal ulcer. In 8 cases conversion was made to an open surgical procedure. Operation times required for distal gastrectomy, wedge resection, and intragastric surgical procedures were 330 +/- 69, 144 +/- 34, and 298 +/- 106 min, and blood loss was 354 +/- 251, 56 +/- 94, and 33 +/- 58 g, respectively. Complications included transient anastomotic stenosis (n = 5), leakage (n = 4), and bleeding (n = 1) after distal gastrectomy, and bleeding (n = 1) after intragastric surgical procedures. There were no complications after wedge resection. Comparing the first and second halves of the series, the percentage of distal gastrectomy significantly increased from 66% to 86% (p = 0.02) and the number of dissected lymph nodes at this procedure increased from 20 +/- 13 to 33 +/- 17 (p < 0.01).
CONCLUSIONS: Laparoscopic gastric surgical procedures are safe and feasible for early gastric cancers and submucosal tumors. Technical advances in lymph node dissection have made distal gastrectomy a leading and increasingly popular laparoscopic procedure for early gastric cancer. (C) 2003 by the American College of Surgeons.

DOI： 10.1016/S1072-7515(03)00419-8

Language：English   Publishing type：Research paper (scientific journal)  

Laparoscopic cholecystectomy is sometimes difficult due to complicated biliary anatomy including gallbladder duplication, a rare anomaly of the biliary tract. We report a case of duplicated gallbladder successfully removed under laparoscopy using endoscopic nasobiliary (ENB) tube cholangiography. A 61-year-old Japanese woman presented us with right upper abdominal pain. Ultrasonography revealed two cystic structures lying in the gallbladder fossa, and the upper one contained multiple stones. Endoscopic retrograde cholangiography showed two gallbladders, each of which has a cystic duct draining into the common bile duct separately. Laparoscopic cholecystectomy was planned under the preoperative diagnosis of double gallbladder with gallstones in the accessory gallbladder. The ENB tube was inserted just before the operation. Laparoscopic removal of the double gallbladder was successfully done using the ENB tube to identify the biliary tree anatomy and to close the stump of the cystic duct. In this communication, we would like to stress the usefulness of the ENB tube at the time of laparoscopic biliary surgery in patients with biliary anomalies including gallbladder duplication.

DOI： 10.1007/s00464-002-4523-8

Language：English  

Background/Aims: The outcome of advanced gallbladder carcinoma is dismal despite aggressive surgery. The aim of this study was to evaluate the surgical outcome and prognostic factors for patients with gallbladder carcinoma and to identify patients who may benefit from radical surgery.
Methodology: Fifty-six patients who underwent surgical resection of gallbladder carcinoma were retrospectively reviewed. Their tumor markers, operative management, pathological factors and survival were analyzed.
Results: The serum carcinoembryonic antigen level was elevated in 9 of 51 patients (18%) with data available as was the serum carbohydrate antigen 199 level in 14 of 47 patients (30%). Univariate analysis showed that jaundice, serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels, the number, size, macroscopic type, and histological grade of the tumor, the depth of tumor invasion (pT), pathological stage, lymph node metastasis (pN), lymphatic invasion, vascular invasion, perineural infiltration, curability of lymph node dissection and surgical margins have prognostic significance for survival. Multivariate analysis revealed jaundice, high histological grade, pT3 or pT4, and surgical margins were independent prognostic factors for survival.
Conclusions: Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels are potential predictors and informative for survival There are still difficulties to treat gallbladder carcinoma infiltrating beyond subserosa or revealing jaundice.

Language：English  

Background/Aims: The outcome of advanced gallbladder carcinoma is dismal despite aggressive surgery. The aim of this study was to evaluate the surgical outcome and prognostic factors for patients with gallbladder carcinoma and to identify patients who may benefit from radical surgery.
Methodology: Fifty-six patients who underwent surgical resection of gallbladder carcinoma were retrospectively reviewed. Their tumor markers, operative management, pathological factors and survival were analyzed.
Results: The serum carcinoembryonic antigen level was elevated in 9 of 51 patients (18%) with data available as was the serum carbohydrate antigen 199 level in 14 of 47 patients (30%). Univariate analysis showed that jaundice, serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels, the number, size, macroscopic type, and histological grade of the tumor, the depth of tumor invasion (pT), pathological stage, lymph node metastasis (pN), lymphatic invasion, vascular invasion, perineural infiltration, curability of lymph node dissection and surgical margins have prognostic significance for survival. Multivariate analysis revealed jaundice, high histological grade, pT3 or pT4, and surgical margins were independent prognostic factors for survival.
Conclusions: Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels are potential predictors and informative for survival There are still difficulties to treat gallbladder carcinoma infiltrating beyond subserosa or revealing jaundice.

Language：English  

BACKGROUND/AIMS: The outcome of advanced gallbladder carcinoma is dismal despite aggressive surgery. The aim of this study was to evaluate the surgical outcome and prognostic factors for patients with gallbladder carcinoma and to identify patients who may benefit from radical surgery. METHODOLOGY: Fifty-six patients who underwent surgical resection of gallbladder carcinoma were retrospectively reviewed. Their tumor markers, operative management, pathological factors and survival were analyzed. RESULTS: The serum carcinoembryonic antigen level was elevated in 9 of 51 patients (18%) with data available as was the serum carbohydrate antigen 19-9 level in 14 of 47 patients (30%). Univariate analysis showed that jaundice, serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels, the number, size, macroscopic type, and histological grade of the tumor, the depth of tumor invasion (pT), pathological stage, lymph node metastasis (pN), lymphatic invasion, vascular invasion, perineural infiltration, curability of lymph node dissection and surgical margins have prognostic significance for survival. Multivariate analysis revealed jaundice, high histological grade, pT3 or pT4, and surgical margins were independent prognostic factors for survival. CONCLUSIONS: Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels are potential predictors and informative for survival. There are still difficulties to treat gallbladder carcinoma infiltrating beyond subserosa or revealing jaundice.

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：English  

Language：English  

OBJECTIVE: In this retrospective review, we evaluated the advantages and disadvantages of LADG for patients of heavier weight with early gastric cancer. SUMMARY BACKGROUND DATA: LADG has been used to treat early gastric cancer. We and others have reported less operative blood loss, less pain, early recovery of bowel activity, early restart of oral intake, and a shorter hospital stay with LADG compared with a conventional open method. There is, however, little information on the advantages of LADG for obese patients with early gastric cancer. METHODS: Between January 1996 and March 2002, 76 patients with preoperatively diagnosed early gastric carcinoma underwent LADG in our department. We classified these patients into 2 groups on the basis of body mass index (BMI). Nineteen patients had a high-BMI (>/= 24.2 kg/m2), and 57 patients had a normal-BMI (<24.2 kg/m2). We collected data by retrospectively reviewing the medical charts. RESULTS: Extension of the minilaparotomic incision or conversion to laparotomy was needed in 6 (32%) of the 19 patients in the high-BMI group, whereas only 3 (5%) of 57 patients in the normal-BMI group required either. In the high-BMI group, Roux-en-Y anastomosis rather than Billroth I anastomosis was adopted more often than in the normal-BMI group, due to the difficulty of the reconstruction (58% versus 4%, P = 0.001). Significantly longer operative time (370 +/- 61 minutes versus 317 +/- 58 minutes, P = 0.015) and prolonged recovery of bowel activity (3.5 +/- 1.0 days versus 2.6 +/- 1.0 days, P = 0.007) were observed in the patients in the high-BMI group. CONCLUSIONS: In the current study, LADG in patients of heavier weight was accompanied by more technical difficulties, and the disadvantages of longer operative time and delayed recovery of bowel activity was observed in patients of heavier weight. Heavier weight appears to be an ominous factor in the successful completion of LADG and should be considered in the decision to use LADG. There are still benefits of a decreased incidence of serious wound and hernia complications in successful cases.

Language：English  

BACKGROUND: Although endoscopic surgical procedures are popular in various fields, reports on its use in gastric surgical procedures are limited. This study was designed to review our initial experience with laparoscopic gastric surgical techniques to evaluate indications and surgical results. STUDY DESIGN: We undertook a retrospective analysis of 100 patients (66 men and 34 women, mean age 63 years) who underwent laparoscopic gastric surgical procedures between 1995 and 2001. Procedures performed were distal gastrectomy (n = 76), wedge resection (n = 20), and intragastric surgical procedures (n = 4). Patients were divided into two groups according to the date of the procedure, from the earliest to the most recent. RESULTS: There were 85 patients with gastric cancers, 14 submucosal tumors, and 1 duodenal ulcer. In 8 cases conversion was made to an open surgical procedure. Operation times required for distal gastrectomy, wedge resection, and intragastric surgical procedures were 330 +/- 69, 144 +/- 34, and 298 +/- 106 min, and blood loss was 354 +/- 251, 56 +/- 94, and 33 +/- 58 g, respectively. Complications included transient anastomotic stenosis (n = 5), leakage (n = 4), and bleeding (n = 1) after distal gastrectomy, and bleeding (n = 1) after intragastric surgical procedures. There were no complications after wedge resection. Comparing the first and second halves of the series, the percentage of distal gastrectomy significantly increased from 66% to 86% (p = 0.02) and the number of dissected lymph nodes at this procedure increased from 20 +/- 13 to 33 +/- 17 (p < 0.01). CONCLUSIONS: Laparoscopic gastric surgical procedures are safe and feasible for early gastric cancers and submucosal tumors. Technical advances in lymph node dissection have made distal gastrectomy a leading and increasingly popular laparoscopic procedure for early gastric cancer.

Language：English  

During the last 3 years, 59 patients underwent endoscopic neck surgery. We started the video-assisted neck surgery with the gasless skin-lifting method for benign thyroid and parathyroid diseases to avoid complications of carbon dioxide (CO2) insufflation. Hemithyroidectomy was performed for benign thyroid tumors and subtotal thyroidectomy was selected for Graves' disease. Parathyroid adenomas were extirpated for primary hyperparathyroidism with precise preoperative localization by imaging modalities. In order to obtain a better visual field and to improve the cosmetic results, we have adopted the complete endoscopic method via breast approach with low CO2 insufflation pressure since August 2001. An intraoperative parathormone assay was introduced recently to confirm the complete removal of parathyroid adenomas. Both gasless and insufflation methods are feasible for endoscopic neck surgery with excellent cosmetic results. (C) 2002 Editions scientifiques et medicales Elsevier SAS. All rights reserved.

Language：English  

BACKGROUND/AIMS: Association of cholangiocellular carcinoma in patients with hepatolithiasis has been reported. However, its incidence depending on the kind of stones is obscure. The aim was to examine the association rate of cholangiocellular carcinoma in patients with hepatolithiasis with a special reference to the kind of intrahepatic stones. METHODOLOGY: One hundred and thirty-nine patients with hepatolithiasis who have been treated from 1973 to 1997 were retrospectively reviewed to examine the characteristics of cholangiocellular carcinoma. The type and location of intrahepatic calculi were analyzed. RESULTS: Cholangiocellular carcinoma was found in 8 of 139 patients, the incidence being 5.8%. The incidence of carcinoma was more than twice in patients whose stones were located in intrahepatic bile duct only (9.3%; 5/54) than in those located in both intrahepatic and extrahepatic bile duct (3.5%; 3/85). Of 121 patients excluding 18 whose calculi were not available for classification, the kind of intrahepatic calculi was brown pigment in 106 patients (87.6%), cholesterol in 10 (8.3%), black pigment in 4, and fatty acid calcium in one. Cholangiocellular carcinoma was associated in 3 (2.8%) of 106 patients with brown pigment stones, 3 (30%) of 10 with cholesterol stones, in one with fatty acid calcium stones, and one patient whose stone was not available for analysis. The association rate of cancer was significantly (P < 0.01) higher in patients with cholesterol stones than those with brown pigment stones. One patient survived for 24 months after left lobectomy but the others died within six months. CONCLUSIONS: An early and attentive evaluation for the possible presence of cholangiocellular carcinoma is mandatory not only in patients with brown pigment stones but also in those with intrahepatic cholesterol stones.

Language：English  

BACKGROUND/AIMS: The purpose of this study was to evaluate the clinical utility of laparoscopic surgery for gastric submucosal tumor. METHODS: The records of 11 patients who underwent laparoscopic wedge resection (LR group) for gastric submucosal tumors were reviewed and compared with those of 8 patients who underwent open surgery (OS group). RESULTS: Mean operation time was 145 +/- 43 min in the LR group and 127 +/- 33 min in the OS group (p = 0.301). Mean blood loss was 97 +/- 107 and 107 +/- 47 g, respectively (p = 0.387). Patients in the LR group began walking 1.4 +/- 0.7 days after surgery, which was significantly earlier than those in the OS group (2.7 +/- 1.3 days, p = 0.021). The first flatus (1.5 +/- 0.5 vs. 3.1 +/- 0.6 days, respectively, p = 0.0004) and resumption of oral food intake (3.0 +/- 1.7 vs. 4.3 +/- 0.9 days, respectively, p = 0.020) were also earlier in the LR group. White blood cell count on the first postoperative day was lower (7,000 +/- 2,100 vs. 11,900 +/- 3,580/mm(3), respectively, p = 0.004) in the LR group than in the OS group, and the duration of fever (>38.0 degrees C; 0.1 +/- 0.3 vs. 0.9 +/- 0.8 days, respectively, p = 0.014) and the period of postoperative hospitalization (13.2 +/- 3.7 vs. 20.8 +/- 6.1 days, respectively, p = 0.014) were significantly shorter in the LR group than in the OS group. No complications occurred in either group. CONCLUSION: Laparoscopic surgery was superior to open surgery in terms of postoperative recovery time with comparable operation time and blood loss. Laparoscopic wedge resection is a promising surgical alternative for the treatment of gastric submucosal tumors. Copyright 2002 S. Karger AG, Basel

Language：English  

Language：English  

During the last 3 years, 59 patients underwent endoscopic neck surgery. We started the video-assisted neck surgery with the gasless skin-lifting method for benign thyroid and parathyroid diseases to avoid complications of carbon dioxide (CO2) insufflation. Hemithyroidectomy was performed for benign thyroid tumors and subtotal thyroidectomy was selected for Graves' disease. Parathyroid adenomas were extirpated for primary hyperparathyroidism with precise preoperative localization by imaging modalities. In order to obtain a better visual field and to improve the cosmetic results, we have adopted the complete endoscopic method via breast approach with low CO2 insufflation pressure since August 2001. An intraoperative parathormone assay was introduced recently to confirm the complete removal of parathyroid adenomas. Both gasless and insufflation methods are feasible for endoscopic neck surgery with excellent cosmetic results.

Language：Others  

DOI： 10.1159/000064209

Language：English  

Background/Aims: Association of cholangiocellular carcinoma in patients with hepatolithiasis has been reported. However, its incidence depending on the kind of stones is obscure. The aim was to examine the association rate of cholangiocellular carcinoma in patients with hepatolithiasis with a special reference to the kind of intrahepatic stones.
Methodology: One hundred and thirty-nine patients with hepatolithiasis who have been treated from 1973 to 1997 were retrospectively reviewed to examine the characteristics of cholangiocellular carcinoma. The type and location of intrahepatic calculi were analyzed.
Results: Cholangiocellular carcinoma was found in 8 of 139 patients, the incidence being 5.8%. The incidence of carcinoma was more than twice in patients whose stones were located in intrahepatic bile duct only (9.3%; 5/54) than in those located in both intrahepatic and extrahepatic bile duct (3.5%; 3/85). Of 121 patients excluding 18 whose calculi were not available for classification, the kind of intrahepatic calculi was brown pigment in 106 patients (87.6%), cholesterol in 10 (8.3%), black pigment in 4, and fatty acid calcium in one. Cholangiocellular carcinoma was associated in 3 (2.8%) of 106 patients with brown pigment stones, 3 (30%) of 10 with cholesterol stones, in one with fatty acid calcium stones, and one patient whose stone was not available for analysis. The association rate of cancer was significantly (P<0.01) higher in patients with cholesterol stones than those with brown pigment stones. One patient survived for 24 months after left lobectomy but the others died within six months.
Conclusions: An early and attentive evaluation for the possible presence of cholangiocellular carcinoma is mandatory not only in patients with brown pigment stones but also in those with intrahepatic cholesterol stones.

Language：English  

Background. Infrasternal mediastinoscopic surgery is a new approach to resection of the anterior mediastinal mass.
Methods. We evaluated this new approach in 23 patients with myasthenia gravis who underwent total thymectomy assisted by infrasternal mediastinoscopy between 1998 and 2000. The results were analyzed with special reference to morbidity and short-term improvement of the disease severity determined according to quantitative myasthenia gravis (QMG) scores.
Results. Complete removal of the thymic gland with the pericardial adipose tissue was accomplished through an infrasternal mediastinoscopic approach in 21 of the 23 (91.3%) patients. The remaining 2 patients required conversion to sternotomy, the one for insufficient sternal lifting with vascular tape and the other for invasion of a thymoma to the innominate vein. There was no related mortality and only one complication, a phrenic nerve injury in 1 patient (4.3%). Significant clinical improvement of disease was achieved in the short term and several advantages were apparent.
Conclusions. Infrasternal mediastinoscopic thymectomy is safe and feasible for patients with myasthenia gravis. (C) 2001 by The Society of Thoracic Surgeons.

DOI： 10.1016/S0003-4975(01)03210-6

Language：English   Publishing type：Research paper (scientific journal)  

Objectives Pancreaticobiliary maljunction, an anomalous union of the pancreatic duct with the common bile duct, is a risk factor for biliary carcinoma. We hypothesized that, in patients with pancreaticobiliary maljunction, persistent regurgitation of pancreatic juice into the biliary tract induces oxidative DNA damage. We assessed the expression of an oxidative DNA base-modified product, 8-hydroxy-2'-deoxyguanosine, in gallbladder epithelium.
Design Eleven noncancerous gallbladders from patients with pancreaticobiliary maljunction, 12 gallbladder carcinomas from patients without pancreaticobiliary maljunction and 14 noncancerous gallbladders from patients without pancreaticobiliary maljunction (control) were studied.
Methods Immunohistochemistry was performed for 4-hydroxy-2-nonenal-modified protein (as a marker for lipid peroxidation), 8-hydroxy-2'-deoxyguanosine and p53 gene product.
Results Stronger cytoplasmic staining of 4-hydroxy-2-nonenal-modified protein was observed in the gallbladder epithelium from patients with pancreaticobiliary maljunction than in epithelium from gallbladder cancer patients or from control subjects with normal gallbladders. Clear, strong nuclear staining of 8-hydroxy-2'-deoxyguanosine was observed in the gallbladder epithelial cells from patients with pancreaticobiliary maljunction. Densitometric quantitation revealed significantly higher expression of 8-hydroxy-2'-deoxyguanosine in gallbladder epithelial cells from patients with pancreaticobiliary maljunction (index 27.3 +/- 3.1) than in cells from patients with gallbladder carcinoma (11.4 +/- 1.5; P < 0.05) or from control subjects with normal gallbladder (6.4 +/- 1.0; P < 0.05). Positivity of p53 was 27% in gallbladder epithelium associated with pancreaticobiliary maljunction, 75% ih gallbladder carcinoma epithelium and 0% in control epithelium.
Conclusions These results suggest that reactive oxygen species are produced in the gallbladder of patients with pancreaticobiliary maljunction and that oxidative DNA injury is related to carcinogenesis in these patients. (C) 2001 Lippincott Williams & Wilkins.

Language：English  

Background: Recent advances have allowed the performance of parathyroidectomy as an endoscopic procedure. Carbon dioxide (CO2) insufflation can be used to create a working space in the anterior neck, but it has been associated with a number of complications. We have devised a skin-lifting method to overcome these problems.
Methods: Eleven consecutive patients underwent video-assisted parathyroidectomy. Preoperative imaging revealed a solitary adenoma in all 11 cases. A 3-cm oblique incision was made below the clavicle, and a 5-mm. incision was made on the lateral neck. After the skin was lifted, video-assisted parathyroidectomy was performed.
Results: Surgery required 186 +/- 50 min. No conversions to conventional cervicotomy were needed. Levels of serum calcium and intact parathormone decreased significantly in all patients on postoperative day 1. Laryngeal recurrent nerve paresis and seroma were noted in one patient each.
Conclusions: Our procedure eliminates any potential CO2 problems and offers the advantages of direct manipulation and improved cosmesis. Endoscopic parathyroidectomy should be considered a viable option for the surgical treatment of a solitary adenoma.

DOI： 10.1007/s004640080049

Language：English   Publishing type：Research paper (scientific journal)  

A 61-year-old man was admitted to our hospital with right lateral abdominal pain. The patient had chronic hepatitis type B and type C and was diagnosed as hepatocellular carcinoma in the anterior-superior segment of the liver by ultrasonography and abdominal computed tomography. Although laboratory examinations were within normal limits, the indocyanine green retention rate at 15min was as high as 72.0% and the bromosulfophtalein retention rate at 45min 17.3%. We additionally performed technetium-99m-galactosyl human serum albumin liver scintigraphy and liver biopsy, both of which indicated only mild chronic liver damage, indicating that the liver function is adequate for surgery. After partial hepatectomy, a pathological examination revealed well to moderately differentiated hepatocellular carcinoma with only mild chronic inflammation in adjacent liver tissue. The indocyanine green retention rate at 15min is the best discriminating preoperative test for evaluating hepatic functional reserve, but when marked retention of both indocyanine green and bromosulfophtalein show the discrepancy with normal routine liver function tests, technetium-99m-galactosyl human serum albumin liver scintigraphy and liver biopsy are helpful diagnostic methods for assessing the preoperative hepatic function.

Language：English  

Laparoscopic surgery for a congenital choledochal cyst was accomplished in five of eight adult patients for whom it was attempted (63%). Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure.
Background: Congenital choledochal cyst is a good indication for laparoscopic surgery. However, only two case reports are available at this writing.
Methods: Eight adult patients, ages 19 to 61 years (mean, 32.6 years), underwent laparoscopically assisted resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy.
Results: The whole procedure was accomplished in five patients (63%). The duration of the procedure ranged from 525 to 680 min (average. 616 min). Open conversion in three patients was necessitated by severance of a small common hepatic duct because of disorientation caused by previous laparoscopic cholecystectomy, electrocautery injury to the common channel distal to the anomalous pancreaticobiliary junction, or heavy adhesion around the cyst secondary to recent severe cholangitis. Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure.
Conclusions: Laparoscopically assisted resection of the choledochal cyst and hepaticojejunostomy are technically feasible and deserve further clinical trials.

DOI： 10.1007/s004640000380

Language：English  

To evaluate the benefits and safety of laparoscopic cholecystectomy (LC) in patients with cardiac valve replacement (which frequently leads to cholelithiasis), 12 patients with cholelithiasis associated with cardiac valve replacement were studied. The patients were divided into two groups, of 6 patients each, according to the type of operation performed, open cholecystectomy (OC) or LC. The postoperative course was monitored with respect to laboratory data on postoperative days (POD) 1, 3, and 7. The mean duration of operation, blood loss, days to food resumption, length of hospital stay, and morbidity were compared between the two groups. Significant differences (P < 0.05) were found between the OC and LC groups in white blood cell counts on POD 1 (12 980 +/- 3040/mm3 vs 8300 +/- 1590/mm3), days to food resumption (2.7 +/- 0.4 days vs 1.0 +/- 0.7 days), and length of postoperative stay (15.8 +/- 1.0 days vs 10.8 +/- 1.6 days). There were no complications in the LC group, but 1 patient in the OC group had heart failure postoperatively. Our findings indicate the efficacy and safety of LC in patients with cardiac valve replacement. "

Language：Others  

DOI： 10.1007/s005340170040

Language：English   Publishing type：Research paper (other academic)  

DOI： 10.1097/00042737-200111000-00016

Language：English  

BACKGROUND: Recent advances have allowed the performance of parathyroidectomy as an endoscopic procedure. Carbon dioxide (CO2) insufflation can be used to create a working space in the anterior neck, but it has been associated with a number of complications. We have devised a skin-lifting method to overcome these problems. METHODS: Eleven consecutive patients underwent video-assisted parathyroidectomy. Preoperative imaging revealed a solitary adenoma in all 11 cases. A 3-cm oblique incision was made below the clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted, video-assisted parathyroidectomy was performed. RESULTS: Surgery required 186 +/- 50 min. No conversions to conventional cervicotomy were needed. Levels of serum calcium and intact parathormone decreased significantly in all patients on postoperative day 1. Laryngeal recurrent nerve paresis and seroma were noted in one patient each. CONCLUSIONS: Our procedure eliminates any potential CO2 problems and offers the advantages of direct manipulation and improved cosmesis. Endoscopic parathyroidectomy should be considered a viable option for the surgical treatment of a solitary adenoma.
OBJECTIVE: The use of endoscopic surgical procedures has rapidly spread to abdominal and thoracic surgeries and subsequently to surgeries of the neck region. Several surgeons initiated endoscopic parathyroidectomy using CO2 insufflation to create the working space; however, they reported various complications. We describe here a skin-lifting method that may have few complications. METHODS: A 65-year-old man was diagnosed with primary hyperparathyroidism due to a solitary adenoma of the left inferior parathyroid gland. A 3-cm oblique incision was made below the left clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted up, we performed video-assisted parathyroidectomy. RESULTS: Parathyroid extirpation took 2 hours and blood loss was minimal. The patient had minimal pain and no complications postoperatively. Serum concentrations of calcium and intact parathyroid hormone were normalized on the next day. CONCLUSION: Using the skin-lifting method, we obtained a sufficient operative view and encountered no complications. This procedure is cosmetically desirable, and we consider it a feasible alternative for the treatment of parathyroid adenoma.

Language：English  

Laparoscopic surgery for a congenital choledochal cyst was accomplished in five of eight adult patients for whom it was attempted (63%). Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure. BACKGROUND: Congenital choledochal cyst is a good indication for laparoscopic surgery. However, only two case reports are available at this writing. METHODS: Eight adult patients, ages 19 to 61 years (mean, 32.6 years), underwent laparoscopically assisted resection of the choledochal cyst and Roux-en-Y hepaticojejunostomy. RESULTS: The whole procedure was accomplished in five patients (63%). The duration of the procedure ranged from 525 to 680 min (average, 616 min). Open conversion in three patients was necessitated by severance of a small common hepatic duct because of disorientation caused by previous laparoscopic cholecystectomy, electrocautery injury to the common channel distal to the anomalous pancreaticobiliary junction, or heavy adhesion around the cyst secondary to recent severe cholangitis. Creation of a Roux-en-Y jejunal limb by midline minilaparotomy and hepaticojejunostomy using a laparoscopic sewing instrument facilitated the procedure. CONCLUSIONS: Laparoscopically assisted resection of the choledochal cyst and hepaticojejunostomy are technically feasible and deserve further clinical trials.

Language：English  

BACKGROUND: Infrasternal mediastinoscopic surgery is a new approach to resection of the anterior mediastinal mass. METHODS: We evaluated this new approach in 23 patients with myasthenia gravis who underwent total thymectomy assisted by infrasternal mediastinoscopy between 1998 and 2000. The results were analyzed with special reference to morbidity and short-term improvement of the disease severity determined according to quantitative myasthenia gravis (QMG) scores. RESULTS: Complete removal of the thymic gland with the pericardial adipose tissue was accomplished through an infrasternal mediastinoscopic approach in 21 of the 23 (91.3%) patients. The remaining 2 patients required conversion to sternotomy, the one for insufficient sternal lifting with vascular tape and the other for invasion of a thymoma to the innominate vein. There was no related mortality and only one complication, a phrenic nerve injury in 1 patient (4.3%). Significant clinical improvement of disease was achieved in the short term and several advantages were apparent. CONCLUSIONS: Infrasternal mediastinoscopic thymectomy is safe and feasible for patients with myasthenia gravis.

Language：English  

BACKGROUND:

Bilirubin oxidative metabolites (BOMs) are generated from bilirubin as a result of its scavenging action against free radicals. During sepsis, excess amounts of free radicals are produced, and they play an important role in the pathophysiological process. We studied whether urinary excretion of BOMs would increase under septic conditions in humans and compared BOM levels with other well-established clinical parameters of inflammation.

METHODS:

In 19 septic patients and 28 nonseptic control patients, the BOM concentrations in urine were measured by enzyme-linked immunosorbent assay with an anti-bilirubin antibody.

RESULTS:

Urinary BOM levels in septic patients were much higher than those in control patients (21.6 +/- 2.5 vs 1.4 +/- 0.4 micromol/g creatinine, P < 0.001). Although there was a linear correlation between urinary BOM and serum total bilirubin levels (r = 0.392, P = 0.008), serum bilirubin levels were not significantly higher in the septic group than in the control group (P = 0.072). BOM levels correlated with body temperature (r = 0.801, P < 0.001), white blood cell counts in the peripheral blood (r = 0.590, P < 0.001), serum C-reactive protein (r = 0.653, P < 0.001), and the acute physiological and chronic health evaluation (APACHE II) score (r = 0.467, P = 0.003).

CONCLUSIONS:

These results demonstrated a urinary increase in BOMs in septic patients. This increase indicates that urinary BOM level is a possible marker for continuous monitoring of sepsis severity in clinical practice.

Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVES: Pancreaticobiliary maljunction, an anomalous union of the pancreatic duct with the common bile duct, is a risk factor for biliary carcinoma. We hypothesized that, in patients with pancreaticobiliary maljunction, persistent regurgitation of pancreatic juice into the biliary tract induces oxidative DNA damage. We assessed the expression of an oxidative DNA base-modified product, 8-hydroxy-2'-deoxyguanosine, in gallbladder epithelium. DESIGN: Eleven noncancerous gallbladders from patients with pancreaticobiliary maljunction, 12 gallbladder carcinomas from patients without pancreaticobiliary maljunction and 14 noncancerous gallbladders from patients without pancreaticobiliary maljunction (control) were studied. METHODS: Immunohistochemistry was performed for 4-hydroxy-2-nonenal-modified protein (as a marker for lipid peroxidation), 8-hydroxy-2'-deoxyguanosine and p53 gene product. RESULTS: Stronger cytoplasmic staining of 4-hydroxy-2-nonenal-modified protein was observed in the gallbladder epithelium from patients with pancreaticobiliary maljunction than in epithelium from gallbladder cancer patients or from control subjects with normal gallbladders. Clear, strong nuclear staining of 8-hydroxy-2'-deoxyguanosine was observed in the gallbladder epithelial cells from patients with pancreaticobiliary maljunction. Densitometric quantitation revealed significantly higher expression of 8-hydroxy-2'-deoxyguanosine in gallbladder epithelial cells from patients with pancreaticobiliary maljunction (index 27.3 +/- 3.1) than in cells from patients with gallbladder carcinoma (11.4 +/- 1.5; P < 0.05) or from control subjects with normal gallbladder (6.4 +/- 1.0; P < 0.05). Positivity of p53 was 27% in gallbladder epithelium associated with pancreaticobiliary maljunction, 75% in gallbladder carcinoma epithelium and 0% in control epithelium. CONCLUSIONS: These results suggest that reactive oxygen species are produced in the gallbladder of patients with pancreaticobiliary maljunction and that oxidative DNA injury is related to carcinogenesis in these patients.

Language：English  

Background. Bilirubin oxidative metabolites (BOMs) are generated from bilirubin as a result of its scavenging action against free radicals. During sepsis, excess amounts of free radicals are produced, and they play an important role in the pathophysiological process. We studied whether urinary excretion of BOMs would increase under septic conditions in humans and compared BOM levels with other well-established clinical parameters of inflammation.
Methods. In 19 septic patients and 28 nonseptic control patients, the BOM concentrations in urine were measured by enzyme-linked immunosorbent assay with an anti-bilirubin antibody.
Results. Urinary BOM levels in septic patients were much higher than those in control patients (21.6 +/- 2.5 vs 1.4 +/- 0.4 mu mol/g creatinine, P < 0.001). Although there was a linear correlation between urinary BOM and serum total bilirubin levels (r = 0.392, P = 0.008), serum bilirubin levels were not significantly higher in the septic group than in the control group (P = 0.072). BOM levels correlated with body temperature (r = 0.801, P < 0.001), white blood cell counts in the peripheral blood (r = 0.590, P < 0.001), serum C-reactive protein (r = 0.653, P < 0.001), and the acute physiological and chronic health evaluation (APACHE II) score (r = 0.467, P = 0.003).
Conclusions. These results demonstrated a urinary increase in BOMs in septic patients. This increase indicates that urinary BOM: level is a possible marker for continuous monitoring of sepsis severity in clinical practice. (C) 2001 Academic Press.

DOI： 10.1006/jsre.2000.6036

Language：English  

Heme oxygenase (HO)-1, the rate-limiting enzyme in heme degradation, is induced by oxidative stress and its major end product, bilirubin, is a potent physiological antioxidant. We studied the induction of HO-1 and bilirubin production in intestinal mucosa using a rat model of sepsis. E. coli lipopolysaccharide was administered intraperitonealy to male Wistar rats and intestinal mucosa was harvested. Intestinal lipid peroxides increased significantly at 1 hy and peaked at 170% of the control value at 5 hr. GSH significantly decreased at 3 hr, reaching the nadir of 50% of the control value at 5 hr. HO-1 mRNA was maximally induced fivefold at 3 hr and HO-1 protein maximally increased to 10 times the control value at 7.5 hr. Both bilirubin and bilirubin oxidative metabolites were maximally increased at 10 hr, to 4.3 and 3.7 times the control value, respectively. These data suggest that oxidative stress in sepsis quickly induces HO-1 in intestinal mucosa and that subsequent production of bilirubin works as an antioxidant. The small intestinal mucose is an active participant in the general response to sepsis.

DOI： 10.1023/A:1005626622203

Language：English  

Heme oxygenase (HO)-1, the rate-limiting enzyme in heme degradation, is induced by oxidative stress and its major end product, bilirubin, is a potent physiological antioxidant. We studied the induction of HO-1 and bilirubin production in intestinal mucosa using a rat model of sepsis. E. coli lipopolysaccharide was administered intraperitonealy to male Wistar rats and intestinal mucosa was harvested. Intestinal lipid peroxides increased significantly at 1 hr and peaked at 170% of the control value at 5 hr. GSH significantly decreased at 3 hr, reaching the nadir of 50% of the control value at 5 hr. HO-1 mRNA was maximally induced fivefold at 3 hr and HO-1 protein maximally increased to 10 times the control value at 7.5 hr. Both bilirubin and bilirubin oxidative metabolites were maximally increased at 10 hr, to 4.3 and 3.7 times the control value, respectively. These data suggest that oxidative stress in sepsis quickly induces HO-1 in intestinal mucosa and that subsequent production of bilirubin works as an antioxidant. The small intestinal mucosa is an active participant in the general response to sepsis.

Language：English  

Out of 63 Japanese patients with pancreatic carcinoma who underwent surgical resection, 8 short-term survivors who died within 3 months after resection and 6 long-term survivors who were alive for more than 3 years after resection were compared regarding 26 clinicopathological parameters. The 8 short-term survivors were significantly older than the 6 long-term survivors (63.7 versus 47.8 years, P = 0.0099). The mean peripheral lymphocyte count was significantly smaller in the short-term survivors than in the long-term survivors (1,212 versus 2,115 /microl, P = 0.0459). Operative blood loss was significantly larger in the short-term survivors than in the long-term survivors (2,393 versus 1,043 g, P = 0.0157). The surgical margin was affected by malignant cells in 7 of the 8 short-term survivors, but in only 2 of the 6 long-term survivors (P = 0.0362). Of the 8 short-term survivors, 5 were in comprehensive stage IV and 3 in stage III, while 3 of the 6 long-term survivors were in stage III, two in stage II, and one in stage I (P = 0.0487). All the 8 short-term survivors were of the comprehensive curability C, while 3 of the 6 long-term survivors were of A, one B and the other two C (P = 0.0239). Multiple regression analysis of these 6 profound factors showed that the peripheral lymphocyte count was an independent significant parameter to differentiate the short-term and long-term survivors. These findings suggest that, although the aggressive nature of pancreatic cancer has been accepted, the clinical course after pancreatectomy would also depend upon the immunological state of the patient.

Language：English  

BACKGROUND: The purpose of this study was to compare clinical outcomes between laparoscopically assisted and open distal gastrectomy for early gastric cancer. METHODS: The records of 21 patients who underwent laparoscopically assisted distal gastrectomy (LG) for preoperative diagnosis of intramucosal gastric carcinoma between January 1996 and August 1998 were reviewed and compared with those of 31 open distal gastrectomy patients during the same period. RESULTS: Age, gender, and size and histologic differentiation of the lesions were matched. Those located at the body of the stomach (p = 0.011) and those macroscopically depressed (p = 0.049) were subjected more frequently to open surgery. Laparoscopically assisted gastrectomy required significantly longer operative time (p < 0.001) with less extensive lymph node dissection (p < 0.001). However, time to start of walking (p = 0.032), time to flatus (p = 0.002), duration of postoperative fever (p = 0.027), and postoperative hospital stay (p = 0.001) were significantly shorter in the LG group, and this group had a lower white blood cell count on the first postoperative day (p = 0.010). Blood loss and time to oral intake were comparable between the groups. Complications included one conversion to open surgery, one leakage, and one stenosis in the LG group, and two leakages and an atelectasis in the OG group. CONCLUSIONS: Although LG requires longer surgical time, this retrospective study suggests that it is superior to open surgery in terms of faster postoperative recoveries, shorter hospital stays, and cosmetic outcomes.

Language：English  

Background: The purpose of this study was to compare clinical outcomes between laparoscopically assisted and open distal gastrectomy for early gastric cancer.
Methods: The records of 21 patients who underwent laparoscopically ;assisted distal gastrectomy (LG) for preoperative diagnosis of intramucosal gastric carcinoma between January 1996 and August 1998 were reviewed and compared with those of 31 open distal gastrectomy patients during the same period.
Results: Age, gender, and size and histologic differentiation of the lesions were matched. Those located at the body of the Stomach (p = 0.011) and those macroscopically depressed (p = 0.049) were subjected more frequently to open surgery. Laparoscopically assisted gastrectomy required significantly longer operative time (p < 0.001) with less extensive lymph node dissection (p < 0.001). However, time to start of walking (p = 0.032), time to flatus (p = 0.002), duration of postoperative fever (p = 0.027), and postoperative hospital stay (p = 0.001) were significantly shorter in the LG group, and this group had a lower white blood cell count on the first postoperative day (p = 0.010). Blood loss and time to oral intake were comparable between the groups, Complications included one conversion to open surgery, one leakage, and one stenosis in the LG group, and two leakages and an atelectasis in the OG group.
Conclusions: Although LG requires longer surgical time, this retrospective study suggests that it is superior to open surgery in terms of faster postoperative recoveries, shorter hospital stays, and cosmetic outcomes.

DOI： 10.1007/s004649900005

Language：English  

Out of 63 Japanese patients with pancreatic carcinoma who underwent surgical resection, 8 short-term survivors who died within 3 months after resection and 6 long-term survivors who were alive for more than 3 years after resection were compared regarding 26 clinicopathological parameters. The 8 short-term survivors were significantly older than the 6 long-term survivors (63.7 versus 47.8 years, P = 0.0099). The mean peripheral lymphocyte count was significantly smaller in the short-term survivors than in the longterm survivors (1,212 versus 2,115/mu l, P = 0.0459). Operative blood loss was significantly larger in the short-term survivors than in the long-term survivors (2,393 versus 1,043 g, P = 0.0157). The surgical margin was affected by malignant cells in 7 of the 8 short-term survivors, but in only 2 of the 6 long-term survivors (P = 0.0362). Of the 8 short-term survivors, 5 were in comprehensive stage IV and 3 in stage III, while 3 of the 6 long-term survivors were in stage III, two in stage II, and one in stage I (P = 0.0487). All the 8 shortterm survivors were of the comprehensive curability C, while 3 of the 6 long-term survivors were of A, one B and the other two C (P = 0.0239). Multiple regression analysis of these 6 profound factors showed that the peripheral lymphocyte count was an independent significant parameter to differentiate the short-term and long-term survivors. These findings suggest that, although the aggressive nature of pancreatic cancer has been accepted, the clinical course after pancreatectomy would also depend upon the immunological state of the patient.

Language：English  

BACKGROUND/AIMS: Even with the recent advances of diagnostic and therapeutic modalities, the clinical course of patients with pancreatic cancer remains dismal. Five-year survivors are rare, cure is exceptional, and the operative mortality rate is significant. In this study, univariate and multivariate retrospective analyses were performed with regard to the prognostic parameters to clarify the problems in order to improve survival rates after surgical resection.
METHODOLOGY: Clinical courses of 60 Japanese patients with pancreatic cancer who underwent surgical resection in one Japanese University Hospital were reviewed to scrutinize the influence of 22 prognostic (9 host-side, 5 operative and 8 tumor-side) factors. A special reference was made on intraoperative radiation therapy, portal vein resection, lymph node dissection around the aorta, and conventional pancreatoduodenectomy versus pylorus-preserving pancreatoduodenectomy in pancreatic head cancer.
RESULTS: Univariate analysis showed that operation time, comprehensive stage, comprehensive curability, histopathologic grade of differentiation and histopathologic venous invasion were statistically significant factors. Multivariate Cox regression analysis regarding the 5 profound factors showed that histopathologic grade of differentiation and histopathologic venous invasion were independently significant factors. The 1- and 3-year survival rates of 18 patients with intra-operative radiation therapy were 56% and 39%, while those of 36 patients without intra-operative radiation therapy were 54% and 18%. The 1- and 3-year survival rates of 43 patients with PV0,1 were 58% and 28%, while those of 17 with PV2,3 were 50% and 10%. Three patients with PV2 in I and PV3 in 2 underwent a portal vein resection. Two of the 3 patients were dead from liver metastasis 3 and 5 months after a surgical resection of liver metastasis. The 1- and 3-year survival rates of 17 with radical lymph node dissection including the para-aortic area were 61% and 26%, while those of 27 without para-aortic lymph node dissection were 66% and 25%. Of the 17 patients, the para-aortic lymph node was metastasized in 1 patient. The 1- and 3-year survival rates of 31 with pancreatoduodenectomy were 53% and 18%, while the 1- and 3-year survival rates with pylorus preserving pancreatoduodenectomy were 68% and 28%, respectively.
CONCLUSIONS: These findings suggest that the clinical outcome after surgical resection of pancreatic carcinoma depends on tumor-side factors not operative parameters or host-side parameters. The clinical course seems to rely upon the nature of pancreatic cancer not upon the operative procedure.

Language：English  

Background: Hepatic resection and percutaneous transhepatic cholangioscopic lithotomy (PTCSL) are the two main approaches to the treatment of hepatolithiasis, but comparisons of longterm followup results have not been adequately reported.
Study Design: Of 86 patients with hepatolithiasis admitted to our institution between 1980 and 1996, we reviewed 54 patients: 26 who underwent hepatic resection and 28 who underwent PTCSL. Five patients who underwent postoperative cholangioscopic lithotomy were included in the former group. The remainder of the hepatolithiasis patients were not treated by hepatic resection or PTCSL and, therefore, were excluded from this study. Hepatic resections were mainly indicated for left-sided localized intrahepatic calculi, atrophic liver, and possible presence of cholangiocellular carcinoma. PTCSL was performed for right-sided, bilateral or recurrent stones at an average of 6 treatments (rang 1 to 20 treatments) for each patient. There were no differences between the two groups in terms of gender or age. The recurrence rate of stones and longterm prognosis were analyzed using the Kaplan-Meier method, and other clinical factors listed below were statistically compared.
Results: The rate of complete removal of stones was similarly high in each group (96.2% in the hepatic resection group versus 96.4% in the PTCSL group). The complication (38.5% versus 21.4%) and 5-year survival (85.6% versus 100%) rates were comparable. Remaining bile duct stricture (18.2% versus 60.9%, p < 0.01) and 5-year recurrence rates (5.6% versus 31.5%, p < 0.05) were statistically lower in the hepatic resection group than in the PTCSL group.
Conclusions: Hepatic resection, when combined with postoperative cholangioscopic lithotomy, is a preferable treatment for left-sided stones with strictures and bilateral stones. (J Am Coll Surg 1999;189:177-182. (C) 1999 by the American College of Surgeons).

DOI： 10.1016/S1072-7515(99)00109-X

Language：English  

Background: Despite recent progress in diagnosis and therapy, the clinical course: of patients with pancreatic carcinoma remains dismal. There have been several approaches to improve the clinical course of patients with pancreatic carcinoma, namely: (i) detection of small pancreatic carcinoma; (ii) radical resection with retroperitoneal clearance and portal vein resection; (iii) multidisciplinary therapy including chemoradiation; and so forth.
Methods: In this series, eight Japanese patients with small pancreatic carcinoma measuring less than 2 cm in diameter (including two with non-invasive carcinoma and one with minimally invasive carcinoma) and 53 with larger pancreatic carcinoma were reviewed to find the diagnostic and therapeutic clues to improve the clinical course of patients with pancreatic carcinoma.
Results: Lymphatic (ly) and perineural (pn) permeation was significantly more frequent and extensive in the 53 patients with large pancreatic carcinoma than in the eight with small pancreatic carcinoma (ly 0/1/2/3:3/24/18/8 versus 5/2/1/0, P = 0.0284; pn 0/1/2/3:4/29/14/6 versus 3/2/3/0, P = 0.0491). The surgical margin was affected by malignant cells in 18 (34%) of the 53 patients with large carcinoma but none (0%) of the eight with small carcinoma (P = 0.0004). The comprehensive stage was significantly earlier in the eight with small carcinoma than in the 53 with large carcinoma (comprehensive stage I/II/III/IV:4/0/3/1 versus 0/3/26/24, P < 0.0001). Comprehensive curability of the eight small carcinoma cases was significantly higher than that of the 53 large carcinoma cases (comprehensive curability A/B/C:5/3/0 versus 9/5/39; P = 0.0003). 1-year and 9-year cumulative survival rates of the eight patients with small carcinoma were 100% and 82%, whereas those of the 53 with large carcinoma were 51% and 17%, respectively (P = 0.0207). However, the eight small carcinoma cases already showed frequent invasion to the vascular (v), lymphatic (ly) and perineural (pn) structure [v(+): 3/8, ly(+): 5/8, pn(+):5 /8] and lymph node metastasis (n) [n(+): 3/8]. Out of the eight small pancreatic carcinomas, one minimally invasive carcinoma and two non-invasive carcinomas showed no vascular, lymphatic or perineural invasion or lymph node metastasis. All the three patients have been doing well 19, 32 and 44 months after the operation. The diagnostic dues in the three patients were dilatation of the main pancreatic duct in one and of the branch duet in the other two.
Conclusions: These findings suggest that surgical resection frequently cures patients with small pancreatic carcinoma but more effective adjuvant therapy should be developed to control lymphatic permeation, venous invasion or perineural infiltration in surgical resection of large pancreatic carcinoma. The supreme goal is to detect noninvasive or minimally invasive pancreatic carcinoma with a dilatation of the main or branch pancreatic duct as a diagnostic aid.

Language：English  

BACKGROUND: Bilirubin has been recognized as an anti-oxidant. The purpose of this study was to examine whether bilirubin would act as an antioxidant for surgical stress in humans. MATERIALS AND METHODS: Serum bilirubin and urinary bilirubin oxidative metabolites (BOM) were measured in 96 patients who underwent surgery. The antioxidant activity of bilirubin was assessed using BOM measured by enzyme-linked immunosorbent assay with an anti-bilirubin monoclonal antibody. RESULTS: Serum bilirubin levels increased after surgery in all 96 patients (p < 0.01), but did not correlate with operation time or blood loss (p = 0.53 and p = 0.28, respectively). BOM increased only in patients with major surgeries (p = 0.048). Significant correlations between BOM and operation time and blood loss were found (p < 0.01). CONCLUSIONS: Bilirubin appears to act as an antioxidant for invasive surgery in humans. Urinary BOM could be a reliable marker for the degree of surgical stress."

Language：English  

To evaluate the efficacy of percutaneous transhepatic abscess drainage (PTAD) as an initial choice of treatment for liver abscess, the medical records of 28 patients with liver abscess were retrospectively analyzed. The patients were predominantly men (23 of 28) with a mean age of 59 years (range, 19-86 years). Their chief complaints were fever (86%), right hypochondralgia (32%), and jaundice (11%). Fifteen of the 28 patients (54%) had hepatobiliary and pancreatic carcinoma, and 31% had postoperative liver abscess. PTAD was performed in 23 patients and surgical drainage in 5. The overall success rate for PTAD was 83%. The success rate for PTAD for patients with multiple abscesses was 83% (5 of 6), compared with a success rate of 82% (14 of 17) for patients with solitary abscess. The prognostic factors for survival were cancer and sepsis and the mortality rate for patients with cancer was 40% (6 of 15) while the mortality rate for patients with sepsis was 56% (5 of 9). As a complication of drainage, 1 patient (4%) in the PTAD group had pleural abscess due to the transpleural puncture. Our findings support the use of PTAD as the primary treatment for liver abscess, as it is safe and effective irrespective of the number of abscesses and the patient's condition."

Language：English  

BACKGROUND: Although peritoneal washing cytology has been widely used in the field of gynecology, it has not been performed so frequently in patients with pancreatic cancer. Only a few papers have reported surgical implications of peritoneal washing cytology. MATERIALS AND METHODS: We reviewed results of peritoneal washing cytology performed immediately after laparotomy in 50 Japanese patients with pancreatic cancer. The 50 patients were divided into two groups according to the results of cytology. Clinicopathological findings were compared between these two groups. RESULTS: Cytology of peritoneal washing was positive in 13 (26%) of the 50 patients. Nine of the 13 patients had no visible peritoneal dissemination. There were no significant differences regarding the age, tumor size and serum level of the carcinoembryonic antigen. Moderately to poorly differentiated adenocarcinoma and perineural invasion (ne3) and lymphatic permeation (ly3) of marked degree were more frequent in the positive group than in the negative group (p < 0.01). The survival curve of the 37 patients with negative cytology was significantly better than that of the 13 with positive cytology (p < 0.01). Four of 13 patients with positive cytology underwent a potentially curative resection but died within 12 months. Three of these four patients died of peritonitis carcinomatosa with massive malignant ascites and one died of local recurrence. CONCLUSIONS: Positive peritoneal washing cytology is not rare in patients with pancreatic cancer and indicates a contraindication of pancreatectomy.

Language：English  

BACKGROUND/AIMS: Even with the recent advances of diagnostic and therapeutic modalities, the clinical course of patients with pancreatic cancer remains dismal. Five-year survivors are rare, cure is exceptional, and the operative mortality rate is significant. In this study, univariate and multivariate retrospective analyses were performed with regard to the prognostic parameters to clarify the problems in order to improve survival rates after surgical resection. METHODOLOGY: Clinical courses of 60 Japanese patients with pancreatic cancer who underwent surgical resection in one Japanese University Hospital were reviewed to scrutinize the influence of 22 prognostic (9 host-side, 5 operative and 8 tumor-side) factors. A special reference was made on intra-operative radiation therapy, portal vein resection, lymph node dissection around the aorta, and conventional pancreatoduodenectomy versus pylorus-preserving pancreatoduodenectomy in pancreatic head cancer. RESULTS: Univariate analysis showed that operation time, comprehensive stage, comprehensive curability, histopathologic grade of differentiation and histopathologic venous invasion were statistically significant factors. Multivariate Cox regression analysis regarding the 5 profound factors showed that histopathologic grade of differentiation and histopathologic venous invasion were independently significant factors. The 1- and 3-year survival rates of 18 patients with intra-operative radiation therapy were 56% and 39%, while those of 36 patients without intra-operative radiation therapy were 54% and 18%. The 1- and 3-year survival rates of 43 patients with PV0,1 were 58% and 28%, while those of 17 with PV2,3 were 50% and 10%. Three patients with PV2 in 1 and PV3 in 2 underwent a portal vein resection. Two of the 3 patients were dead from liver metastasis 3 and 5 months after a surgical resection of liver metastasis. The 1- and 3-year survival rates of 17 with radical lymph node dissection including the para-aortic area were 61% and 26%, while those of 27 without para-aortic lymph node dissection were 66% and 25%. Of the 17 patients, the para-aortic lymph node was metastasized in 1 patient. The 1- and 3-year survival rates of 31 with pancreatoduodenectomy were 53% and 18%, while the 1- and 3-year survival rates with pylorus preserving pancreatoduodenectomy were 68% and 28%, respectively. CONCLUSIONS: These findings suggest that the clinical outcome after surgical resection of pancreatic carcinoma depends on tumor-side factors not operative parameters or host-side parameters. The clinical course seems to rely upon the nature of pancreatic cancer not upon the operative procedure."

Language：English  

BACKGROUND:

Despite recent progress in diagnosis and therapy, the clinical course of patients with pancreatic carcinoma remains dismal. There have been several approaches to improve the clinical course of patients with pancreatic carcinoma, namely: (i) detection of small pancreatic carcinoma; (ii) radical resection with retroperitoneal clearance and portal vein resection; (iii) multidisciplinary therapy including chemoradiation; and so forth.

METHODS:

In this series, eight Japanese patients with small pancreatic carcinoma measuring less than 2 cm in diameter (including two with non-invasive carcinoma and one with minimally invasive carcinoma) and 53 with larger pancreatic carcinoma were reviewed to find the diagnostic and therapeutic clues to improve the clinical course of patients with pancreatic carcinoma.

RESULTS:

Lymphatic (ly) and perineural (pn) permeation was significantly more frequent and extensive in the 53 patients with large pancreatic carcinoma than in the eight with small pancreatic carcinoma (ly 0/1/2/3:3/24/18/8 versus 5/2/1/0, P = 0.0284; pn 011/2/3:4/29/14/6 versus 3/2/3/0, P = 0.0491). The surgical margin was affected by malignant cells in 18 (34%) of the 53 patients with large carcinoma but none (0%) of the eight with small carcinoma (P = 0.0004). The comprehensive stage was significantly earlier in the eight with small carcinoma than in the 53 with large carcinoma (comprehensive stage I/II/II/IV:4/0/3/1 versus 0/3/26/24, P < 0.0001). Comprehensive curability of the eight small carcinoma cases was significantly higher than that of the 53 large carcinoma cases (comprehensive curability A/B/C:5/3/0 versus 9/5/39; P = 0.0003). 1-year and 3-year cumulative survival rates of the eight patients with small carcinoma were 100% and 82%, whereas those of the 53 with large carcinoma were 51% and 17%, respectively (P = 0.0207). However, the eight small carcinoma cases already showed frequent invasion to the vascular (v), lymphatic (ly) and perineural (pn) structure [v(+): 3/8, ly(+): 5/8, pn(+):5 /8] and lymph node metastasis (n) [n(+): 3/8]. Out of the eight small pancreatic carcinomas, one minimally invasive carcinoma and two non-invasive carcinomas showed no vascular, lymphatic or perineural invasion or lymph node metastasis. All the three patients have been doing well 19, 32 and 44 months after the operation. The diagnostic clues in the three patients were dilatation of the main pancreatic duct in one and of the branch duct in the other two.

CONCLUSIONS:

These findings suggest that surgical resection frequently cures patients with small pancreatic carcinoma but more effective adjuvant therapy should be developed to control lymphatic permeation, venous invasion or perineural infiltration in surgical resection of large pancreatic carcinoma. The supreme goal is to detect non-invasive or minimally invasive pancreatic carcinoma with a dilatation of the main or branch pancreatic duct as a diagnostic aid.

Language：English  

OBJECTIVE: To assess of the grade of malignancy of intraductal papillary neoplasm of the pancreas (IPNP). DESIGN: Retrospective analysis. SETTING: University hospital, Japan. PATIENTS: 8 men and 9 women, mean age 67 years, with IPNP. RESULTS: 12 lesions were in the head of the pancreas, two in the body and three in the tail. There were no differences in the age and sex of the patients, the presence of diabetes mellitus or history of pancreatitis, serum concentrations of carcinoembryonic antigen, and CA 19-9, pancreatic function test, and the site of origin of benign and malignant IPNP. The mean diameter of the main pancreatic duct was 16 mm in the four malignant tumours, but 6 mm in the 13 benign IPNP (p < 0.05). 10 of the 13 benign IPNP were located in the branch duct, two in the main pancreatic duct, and another in both the main and branch ducts, while all four malignant IPNP were situated in the main duct (p < 0.01). Mural nodules were detectable preoperatively in all four malignant IPNP but in only 5 of the 13 benign tumours (39%). The mean diameter of the mural nodules in the five benign IPNPs was 3 mm, whereas that in the four malignant ones was 24 mm (p < 0.01). All but one patient (who had a malignant IPNP) were alive for one to 36 months (mean 16 months) after resection. CONCLUSIONS: IPNP is a unique variant of pancreatic exocrine neoplasm with a good prognosis after resection. The diameter of the main pancreatic duct, size of the mural nodule, and site of the tumour (main pancreatic duct or branch duct) differ significantly between benign and malignant tumours."

Language：English  

A successful resection rate for diffuse bile duct carcinoma is low. Major hepatectomy combined with pancreatoduodenectomy is a possible choice for curative resection, but the post-operative mortality rate after such an extensive surgery has been reported to be high. The main reason for post-operative death is liver failure. With the aid of pre-operative portal vein embolization, major hepatectomy (left lobectomy and extended right lobectomy with caudate lobectomy) and pylorus-preserving pancreatoduodenectomy was successfully applied to 2 patients with diffuse bile duct carcinoma as a one-stage surgery. We herein report these 2 cases discussing the usefulness of pre-operative portal vein embolization.

Language：English  

BACKGROUND: Hepatic resection and percutaneous transhepatic cholangioscopic lithotomy (PTCSL) are the two main approaches to the treatment of hepatolithiasis, but comparisons of longterm followup results have not been adequately reported. STUDY DESIGN: Of 86 patients with hepatolithiasis admitted to our institution between 1980 and 1996, we reviewed 54 patients: 26 who underwent hepatic resection and 28 who underwent PTCSL. Five patients who underwent postoperative cholangioscopic lithotomy were included in the former group. The remainder of the hepatolithiasis patients were not treated by hepatic resection or PTCSL and, therefore, were excluded from this study. Hepatic resections were mainly indicated for left-sided localized intrahepatic calculi, atrophic liver, and possible presence of cholangiocellular carcinoma. PTCSL was performed for right-sided, bilateral or recurrent stones at an average of 6 treatments (range 1 to 20 treatments) for each patient. There were no differences between the two groups in terms of gender or age. The recurrence rate of stones and longterm prognosis were analyzed using the Kaplan-Meier method, and other clinical factors listed below were statistically compared. RESULTS: The rate of complete removal of stones was similarly high in each group (96.2% in the hepatic resection group versus 96.4% in the PTCSL group). The complication (38.5% versus 21.4%) and 5-year survival (85.6% versus 100%) rates were comparable. Remaining bile duct stricture (18.2% versus 60.9%, p < 0.01) and 5-year recurrence rates (5.6% versus 31.5%, p < 0.05) were statistically lower in the hepatic resection group than in the PTCSL group. CONCLUSIONS: Hepatic resection, when combined with postoperative cholangioscopic lithotomy, is a preferable treatment for left-sided stones with strictures and bilateral stones."

Language：English  

Objective: To assess of the grade of malignancy of intraductal papillary neoplasm of the pancreas (IPNP).
Design: Retrospective analysis.
Setting: University hospital, Japan.
Patients: 8 men and 9 women, mean age 67 years, with IPNP.
Results: 12 lesions were in the head of the pancreas, two in the body and three in the tail. There were no differences in the age and sex of the patients, the presence of diabetes mellitus or history of pancreatitis, serum concentrations of carcinoembryonic antigen, and CA 19-9, pancreatic function test, and the site of origin of benign and malignant IPNP. The mean diameter of the main pancreatic duct was 16 mm in the four malignant tumours, but 6 mm in the 13 benign IPNP (p < 0.05). 10 of the 13 benign IPNP were located in the branch duct, two in the main pancreatic duct, and another in both the main and branch ducts, while all four malignant IPNP were situated in the main duct (p < 0.01). Mural nodules were detectable preoperatively in all four malignant IPNP but in only 5 of the 13 benign tumours (39%). The mean diameter of the mural nodules in the five benign IPNPs was 3mm, whereas that in the four malignant ones was 24 mm (p < 0.01). All but one patient (who had a malignant IPNP) were alive for one to 36 months (mean 16 months) after resection.
Conclusions: IPNP is a unique variant of pancreatic exocrine neoplasm with a good prognosis after resection. The diameter of the main pancreatic duct, size of the mural nodule, and site of the tumour (main pancreatic duct or branch duct) differ significantly between benign and malignant tumours.

DOI： 10.1080/110241599750007081

Language：Others  

Background Bilirubin has been recognized as an antioxidant.
The purpose of this study was to examine
whether bilirubin would act as an antioxidant for
surgical stress in humans. Materials and Methods
Serum bilirubin and urinary bilirubin oxidative
metabolites (BOM) were measured in 96 patients
who underwent surgery. The antioxidant activity
of bilirubin was assessed using BOM measured
by enzyme-linked immunosorbent assay with an
anti-bilirubin monoclonal antibody. Results Serum
bilirubin levels increased after surgery in all 96
patients (p<0.01), but did not correlate with operation
time or blood loss (p=0.53 and p=0.28, respectively).
BOM increased only in patients with major
surgeries (p=0.048). Significant correlations between
BOM and operation time and blood loss were found
(p<0.01). Conclusions Bilirubin appears to act as an
antioxidant for invasive surgery in humans. Urinary
BOM could be a reliable marker for the degree of
surgical stress.

DOI： 10.1155/1999/16374

Language：English  

Exocrine and endocrine functions of the pancreas were assessed in 44 Japanese patients who underwent pancreatic head resection. Functions were analyzed comparing levels before surgery, at a short-term follow-up (<2 months), and at a long-term follow-up (12-31 months), The N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) excretion test, fasting blood sugar (FBS) level, and oral glucose tolerance test (OGTT) were used to determine pancreatic function. The patients were divided into three groups according to the size of the main pancreatic duct: group 1, 15 patients with a normal sized duct (less than or equal to 3 mm); group 2, 20 with a moderately dilated duct (>3 mm, <10 mm); and group 3, 9 with a markedly dilated duct (greater than or equal to 10 mm). The mean BT-PABA value (6-hr urinary PABA recovery rate) in group showed no change during the postoperative period. In contrast, the BT-PABA values in groups 2 and 3 had dropped by the short-term follow-up and returned to the preoperative level by the long-term examination. FBS and 120-min OGTT levels were not different between the three groups preoperatively. Although these values showed no change in all the three groups at the short-term measurements, the FBS in group 3 and 120-min levels in all the three groups had increased at the long-term. These findings suggest that exocrine pancreatic function shows a short-term deterioration in patients with a dilated pancreatic duct but recovers to the preoperative level over the long term after pancreatic head resection. Endocrine insufficiency, however, may occur at a long-term point after surgery irrespective of the preoperative pancreatic ductal dilatation.

DOI： 10.1023/A:1026686824173

Language：English  

Language：English  

Background. The objective of this study was to clarify the relationship between preoperative exocrine pancreatic function and pancreatic anastomotic leakage after pancreatectomy.
Methods. Fifty-five patients who underwent proximal pancreatectomy with pancreaticojejunostomy were reviewed with regard to preoperative exocrine pancreatic function, size of the main pancreatic duct, post operative pancreatic juice output, and pancreaticojejunostomy leakage.
Results. There were 32 patients with a normal value at the preoperative N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) excretion lest (> 70 %) and 23 with a low BT-PABA value (less than or equal to 70 %). The greatest diameter of the main pancreatic duct in the group with normal BT-PABA results was significantly smaller than that in the group with low, BT-PABA results (4.6 +/- 2.7 mm vs 7.1 +/- 4.2 mm; P < .05). The output of pancreatic juice during a 10-day period (from postoperative days 5 through 14) in the group with normal BT-PABA results was significantly higher than that in the group with lour BT-PABA results (1738 +/- 898 mL vs 1072 +/- 1174 mL; P < .05). Pancreatic leakage occurred in 8 (25 %) of the 32 patients in the group with normal BT-PABA results and in none of the 23 patients in the group with low BT-PABA results (P < .01).
Conclusions. Patients with normal exocrine pancreatic function produce a larger amount of pancreatic juice than those with low exocrine pancreatic function and have a potential risk of anastomotic leakage after pancreatectomy.

Language：English  

Objective: To evaluate the efficacy of early angiography in the diagnosis and treatment of delayed arterial hemorrhage as a significant complication following pancreatectomy.
Design: Retrospective case series.
Setting: University hospital; 6-year period between January 1992 and December 1997.
Patients and Intervention: Of a total of 81 patients undergoing pancreatic head resection, 10 (12%) developed massive arterial hemorrhage after surgery. All 10 patients underwent an emergency angiography and 8 of these were managed by transcatheter arterial embolization.
Results: Before onset of major bleeding, 9 patients (90%) had developed intra-abdominal abscess resulting from pancreatic fistula or other anastomotic leak, and all 10 patients had had preliminary minor bleeding. The angiogram demonstrated an exact site of bleeding as a pseudoaneurysm in all 10 patients. Transcatheter arterial embolization achieved temporary control of bleeding in all 8 patients for whom embolization was attempted and complete hemostasis in 5 of the 8 subsequently, yielding a success rate of 63%. Overall, 4 patients (40%) died of complications related directly to the major hemorrhage or the transcatheter arterial embolization technique.
Conclusions: An emergency angiography should be considered in all patients who develop either a sentinel or massive gastrointestinal bleed following pancreatectomy irrespective of suspected intra-abdominal sepsis. Transcatheter arterial embolization allows temporary control of massive hemorrhage and hemodynamic stabilization in most cases, and prevents the need for high-risk emergency surgery.

DOI： 10.1001/archsurg.133.10.1099

Language：English  

Language：English  

Background. Delta-bilirubin is a bilirubin covalently bound with albumin, which is nontoxic and excreted neither in urine nor in bile. We previously reported that the percentage of delta-bilirubin increased after biliary drainage and that the rapidly excretable bilirubin fraction (total minus delta-bilirubin) was a better parameter to predict the effectiveness of biliary decompression in the dog model. The aim of the present study was to elucidate whether it is applicable to humans.
Materials and Methods. The serum bilirubin concentration was measured and its fractions were analyzed by high-performance liquid chromatography in 22 patients with obstructive jaundice before and after biliary drainage. In addition, the patients were subgrouped into good and poor drainage groups according to the decline index of serum bilirubin to examine the significance of delta-bilirubin.
Results. The concentration of total bilirubin decreased from 14.1 mg/dl before biliary drainage to 5.4 mg/dl 28 days after drainage. During this period, the percentage of conjugated bilirubin steeply declined from 47.1 to 8.8% and that of excretable bilirubin from 63.4 to 28.6%. In contrast, the proportion of serum delta-bilirubin increased from 36.6 to 71.4%. There was an inverse correlation between percentage of delta-bilirubin and total bilirubin concentration (r = -0.69, P < 0.01). In the good drainage group, the percentage of delta-bilirubin increased above 60% within 7 days after biliary drainage, but it did not reach 60% by 28 days in the poor drainage group. A decreasing rate of total bilirubin minus delta-bilirubin, the excretable bilirubin fraction, was a better index than that of total bilirubin to assess the efficacy of biliary drainage (P < 0.01).
Conclusions. The increase in the percentage of serum delta-bilirubin indicates an effectiveness of biliary drainage in man. An analysis of serum delta-bilirubin for 7 days can distinguish the good drainage patients from the poor drainage patients. (C) 1998 Academic Press.

DOI： 10.1006/jsre.1998.5357

Language：English  

BACKGROUND: The objective of this study was to compare the alterations in pancreatic function after pancreatoduodenectomy between malignant and benign diseases.
METHODS: In 34 patients who underwent pancreatoduodenectomy for pariampullary cancer (malignant group; n = 18) and benign pancreatic disorders (benign group; n = 16), exocrine and endocrine functions were analyzed before surgery, at a short-term period (less than or equal to 2 months), and at a long-term period (>12 months) after surgery. Assessment was based on the BT-PABA excretion test, fasting blood sugar level, and oral glucose tolerance test.
RESULTS: Compared with the preoperative level, urinary PABA excretion rate in the malignant group significantly decreased on short-term follow-up but recovered on long-term follow-up. However, that in the benign group increased on long-term follow-up without showing a shortterm decline. Diabetes mellitus was present in 11 (61 %) of the 18 patients in the malignant group and 6 (38%) of the 16 in the benign group before surgery. Glucose tolerance improved in 6 (55%) of the 11 patients in the malignant group but in only 1 (17%) of the 6 in the benign group shortly after surgery. In the benign group, 3 (30%) of 10 patients with normal preoperative glucose tolerance became diabetic after surgery, while no patient in the malignant group developed diabetes on short-term follow-up.
CONCLUSIONS: Surgeons should pay attention to exocrine pancreatic function in patients with a periampullary cancer and to glucose metabolism in patients with benign disease over the shortterm period after pancreatoduodenectomy. (C) 1998 by Excerpta Medica, Inc.

DOI： 10.1016/S0002-9610(98)00105-6

Language：English  

BACKGROUND: Extended cholecystectomy is the common operation for gallbladder carcinoma. When extended cholecystectomy is performed, the liver bed can be generously resected from the fundus to the body of the gallbladder; however, the thickness of the liver parenchyma to be removed is limited to the neck of the gallbladder. There have been few reports providing convincing data with regard to how thick the liver can be anatomically resected by extended cholecystectomy. METHODS: The thickness of the liver tissue actually resected at the time of extended cholecystectomy and that potentially resected by extended cholecystectomy were measured in 24 clinical and 25 autopsy cases, respectively, to assess the anatomical limit of extended cholecystectomy. RESULTS: The mean anatomical distances from the neck of the gallbladder to the right hepatic duct and to the bifurcation of the anterior and posterior branch of the right hepatic duct were only 1.6 and 5.9 mm, respectively. The distance from the gallbladder to the bifurcation of the superior and inferior branch of the right anterior hepatic duct, and to the root of the right anterior inferior hepatic duct were 11.2 mm2, and 12.8 mm3, respectively (123:p < 0.05). The actual width of the liver excised by extended cholecystectomy was 5.2 mm at the neck, 11.7 mm at the body, and 8.1 mm at the fundus of the gallbladder, respectively. These results indicate that the neck of the gallbladder is anatomically close to the hepatic hilum including the right hepatic duct and portal vein. CONCLUSIONS: Surgical strategy for gallbladder carcinoma should be considered to rely not only upon the depth of invasion but also upon the site of gallbladder tumor. When gallbladder carcinoma involves the muscle layer or further at the neck of the organ, more extensive hepatectomy than extended cholecystectomy should be considered."

Language：English  

Background. Despite the increasing number of long-term survivors after pancreatoduodenectomy, little is known about morphological appearance of the remnant pancreas or the biliary system after surgery.
Methods. To evaluate long-term morphological changes of the remnant pancreas and biliary tree after pancreatoduodenectomy, computed tomograms obtained at the time of surgery and more than 2 years after operation were reviewed in 19 Japanese patients.
Results. Two to three years after surgery, parenchymal atrophy of the remnant pancreas occurred in 9 (56%) of 16 patients without atrophy at the time of surgery, Three patients who had had parenchymal atrophy preoperatively showed no change after surgery. Of 10 patients with a dilated pancreatic duct preoperatively, 8 (80%) patients demonstrated a decline in ductal size, while the other 2 showed persistent ductal dilatation, Of 9 patients with a normal-sized pancreatic duct preoperatively, 2 patients (22%) developed ductal dilatation after surgery, and the other 7 showed no change. In 4 (57%) of 7 patients,vith a dilated hepatic duct preoperatively dilatation was reduced after surgery, whereas it persisted in the remaining 3, Only one (8%) of 12 patients with a nondilated biliary tree preoperatively showed ductal dilatation 6 months following surgery. Pneumobilia was revealed in 13 (68%) of 19 patients by the follow-up examinations.
Conclusions. Surgeons should be aware of these changes in morphology of the remnant pancreas and biliary tree after pancreatectoduodenectomy.

Language：English  

Background. Cholangioscopic lithotomy (CSL) for hepatolithiasis, a minimally invasive procedure, has a place in complicated or recurrent hepatolithiasis. CSL itself, however, carries inherent risk for recurrence. We analyzed follow-up data after CSL for primary or repeat hepatolithiasis to determine the frequency of recurrence.
Methods. This retrospective analysis includes 21 patients with hepatolithiasis admitted to the hospital from September 1992 to December 1995 who underwent CSL. Through a percutaneous biliary drainage route cholangioscopy was inserted to remove calculi with basket forceps or electrohydraulic lithotripter. Stenotic ducts, defined as less than 2 mm in diameter were dilated with silicone rubber stenting of a balloon dilator:
Results. Ten patients were treated for primary hepatolithiasis and 11 for repeat hepatolithiasis. Of the patients With primary hepatolithiasis, one died of complications and the other nine patients underwent complete lithotomy. Among 11 patients who had repeat hepatolithiasis, four had undergone hepatectomy for hepatolithiasis and two previous CSLs; 10 patients (91 %) underwent complete lithotomy. During the follow-up, four (40 %) of the 10 patients with biliary stenosis at the time of cholangioscopic treatment showed recurrent calculi, whereas all eight patients without stricture had uneventful courses. Of the 19 patients who underwent complete lithotomy, calculi recurred in four (21 %), three cases of which recurred less than 1 year after CSL.
Conclusions. Against hepatolithiasis of primary and postoperative repeat cases, CSL can allow complete lithotomy. The bile duct stricture however, carries a high risk for recurrent calculi; hence, permanent relief of stricture is mandatory.

DOI： 10.1016/S0039-6060(98)70163-1

Language：English   Publishing type：Research paper (other academic)  

Language：Japanese  

1995年迄の11年間の肝切除を施行した原発性肝細胞癌症例51例の累積生存率は5年生存率42.6%,10年生存率37.3%であった.有意な予後因子は臨床病期,肉眼的進行度,門脈浸潤,腫瘍最大径,手術根治度,肝内転移であった.臨床病期Iの5年生存率は68.0%であったが,IIは 23.6%で,また門脈浸潤のない5年生存率は62.0%,浸潤のある症例では30.9%であった.Coxの比較ハザードモデルによる多変量解析では臨床病期と門脈浸潤が有意な因子であったほか,C型肝炎の有無が有意な独立因子となった

Language：English  

BACKGROUND: Delta-bilirubin is a bilirubin covalently bound with albumin, which is nontoxic and excreted neither in urine nor in bile. We previously reported that the percentage of delta-bilirubin increased after biliary drainage and that the rapidly excretable bilirubin fraction (total minus delta-bilirubin) was a better parameter to predict the effectiveness of biliary decompression in the dog model. The aim of the present study was to elucidate whether it is applicable to humans. MATERIALS AND METHODS: The serum bilirubin concentration was measured and its fractions were analyzed by high-performance liquid chromatography in 22 patients with obstructive jaundice before and after biliary drainage. In addition, the patients were subgrouped into good and poor drainage groups according to the decline index of serum bilirubin to examine the significance of delta-bilirubin. RESULTS: The concentration of total bilirubin decreased from 14.1 mg/dl before biliary drainage to 5.4 mg/dl 28 days after drainage. During this period, the percentage of conjugated bilirubin steeply declined from 47.1 to 8.8% and that of excretable bilirubin from 63.4 to 28.6%. In contrast, the proportion of serum delta-bilirubin increased from 36.6 to 71.4%. There was an inverse correlation between percentage of delta-bilirubin and total bilirubin concentration (r = -0.69, P < 0.01). In the good drainage group, the percentage of delta-bilirubin increased above 60% within 7 days after biliary drainage, but it did not reach 60% by 28 days in the poor drainage group. A decreasing rate of total bilirubin minus delta-bilirubin, the excretable bilirubin fraction, was a better index than that of total bilirubin to assess the efficacy of biliary drainage (P< 0.01). CONCLUSIONS: The increase in the percentage of serum delta-bilirubin indicates an effectiveness of biliary drainage in man. An analysis of serum delta-bilirubin for 7 days can distinguish the good drainage patients from the poor drainage patients. Copyright 1998 Academic Press."

Language：English  

Exocrine and endocrine functions of the pancreas were assessed in 44 Japanese patients who underwent pancreatic head resection. Functions were analyzed comparing levels before surgery, at a short-term follow-up (<2 months), and at a long-term follow-up (12-31 months). The N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) excretion test, fasting blood sugar (FBS) level, and oral glucose tolerance test (OGTT) were used to determine pancreatic function. The patients were divided into three groups according to the size of the main pancreatic duct: group 1, 15 patients with a normal sized duct (< or =3 mm); group 2, 20 with a moderately dilated duct (>3 mm, <10 mm); and group 3, 9 with a markedly dilated duct (> or =10 mm). The mean BT-PABA value (6-hr urinary PABA recovery rate) in group 1 showed no change during the postoperative period. In contrast, the BT-PABA values in groups 2 and 3 had dropped by the short-term follow-up and returned to the preoperative level by the long-term examination. FBS and 120-min OGTT levels were not different between the three groups preoperatively. Although these values showed no change in all the three groups at the short-term measurements, the FBS in group 3 and 120-min levels in all the three groups had increased at the long-term. These findings suggest that exocrine pancreatic function shows a short-term deterioration in patients with a dilated pancreatic duct but recovers to the preoperative level over the long term after pancreatic head resection. Endocrine insufficiency, however, may occur at a long-term point after surgery irrespective of the preoperative pancreatic ductal dilatation."

Language：English  

BACKGROUND: The objective of this study was to clarify the relationship between preoperative exocrine pancreatic function and pancreatic anastomotic leakage after pancreatectomy. METHODS: Fifty-five patients who underwent proximal pancreatectomy with pancreaticojejunostomy were reviewed with regard to preoperative exocrine pancreatic function, size of the main pancreatic duct, postoperative pancreatic juice output, and pancreaticojejunostomy leakage. RESULTS: There were 32 patients with a normal value at the preoperative N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) excretion test (> 70%) and 23 with a low BT-PABA value (< or = 70%). The greatest diameter of the main pancreatic duct in the group with normal BT-PABA results was significantly smaller than that in the group with low BT-PABA results (4.6 +/- 2.7 mm vs 7.1 +/- 4.2 mm; P < .05). The output of pancreatic juice during a 10-day period (from postoperative days 5 through 14) in the group with normal BT-PABA results was significantly higher than that in the group with low BT-PABA results (1738 +/- 898 mL vs 1072 +/- 1174 mL; P < .05). Pancreatic leakage occurred in 8 (25%) of the 32 patients in the group with normal BT-PABA results and in none of the 23 patients in the group with low BT-PABA results (P < .01). CONCLUSIONS: Patients with normal exocrine pancreatic function produce a larger amount of pancreatic juice than those with low exocrine pancreatic function and have a potential risk of anastomotic leakage after pancreatectomy."

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Leakage of pancreatoenterostomy remains as a serious and fatal complication after pancreatectomy. Several risk factors have been reported, ie, normal pancreatic parenchyma, small pancreatic duct, a large amount of intraoperative blood loss, management of the cut surface of the pancreas, and the presence of preoperative jaundice. Transected pancreatic ductules on the cut surface of the pancreas that are not drained into the main pancreatic duct after pancreatectomy are one of the risks. The pancreatic juice is alkaline and turns red litmus to blue. METHODS: In order to detect the transected pancreatic ductules on the cut surface of the pancreas, red litmus paper is applied to the cutting surface of the pancreas after stimulation of secretin. RESULTS: Nondrained, transected pancreatic ductules on the cut surface of the pancreas can be detected as blue spots on the red litmus paper. The corresponding areas to the blue spots can be transfixed with sutures to close the nondrained and transected pancreatic ductules. CONCLUSION: Litmus paper can be expected to detect pancreatoenterostomy leakage after pancreatectomy."

Language：English  

BACKGROUND: Cholangioscopic lithotomy (CSL) for hepatolithiasis, a minimally invasive procedure, has a place in complicated or recurrent hepatolithiasis. CSL itself, however, carries inherent risk for recurrence. We analyzed follow-up data after CSL for primary or repeat hepatolithiasis to determine the frequency of recurrence. METHODS: This retrospective analysis includes 21 patients with hepatolithiasis admitted to the hospital from September 1992 to December 1995 who underwent CSL. Through a percutaneous biliary drainage route, cholangioscopy was inserted to remove calculi with basket forceps or electrohydraulic lithotripter. Stenotic ducts, defined as less than 2 mm in diameter, were dilated with silicone rubber stenting or a balloon dilator. RESULTS: Ten patients were treated for primary hepatolithiasis and 11 for repeat hepatolithiasis. Of the patients with primary hepatolithiasis, one died of complications and the other nine patients underwent complete lithotomy. Among 11 patients who had repeat hepatolithiasis, four had undergone hepatectomy for hepatolithiasis and two previous CSLs; 10 patients (91%) underwent complete lithotomy. During the follow-up, four (40%) of the 10 patients with biliary stenosis at the time of cholangioscopic treatment showed recurrent calculi, whereas all eight patients without stricture had uneventful courses. Of the 19 patients who underwent complete lithotomy, calculi recurred in four (21%), three cases of which recurred less than 1 year after CSL. CONCLUSIONS: Against hepatolithiasis of primary and postoperative repeat cases, CSL can allow complete lithotomy. The bile duct stricture, however, carries a high risk for recurrent calculi; hence, permanent relief of stricture is mandatory."

Language：English  

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a newly developing noninvasive examination of the biliopancreatic trees. Roles of MRCP in the diagnosis of pancreatic diseases have not been scrutinized. METHODS: Endoscopic retrograde cholangiopancreatography (ERCP) and MRCP were reviewed in 52 Japanese patients with various pancreatic diseases and 6 patients with normal pancreas to compare their diagnostic usefulness and limitation. RESULTS: In those with normal pancreas, only the main pancreatic duct was visualized by MRCP, while both the main pancreatic and branch ducts were clearly delineated by ERCP. In 3 patients with serous cystadenoma, the tumor was not visualized by ERCP, whereas it was visible as a high-intensity mass on MRCP. Of 18 patients with a ""mucin hypersecreting"" tumor of the branch type, MRCP demonstrated cystically dilated branch ducts in all, while ERCP failed to visualize the dilated ducts in 6 patients. However, the details of the cystic lesions (mural nodule, communication with the main pancreatic duct) were more exactly demonstrated by ERCP than MRCP. In 5 patients with a mucin hypersecreting tumor of the main pancreatic duct type, the dilated main pancreatic duct and the presence of mural nodules were similarly demonstrated both by ERCP and MRCP. In 12 patients with pancreatic adenocarcinoma, indirect findings were similarly demonstrated both by ERCP and MRCP, ie, stenosis (4 patients) and obstruction (8) together with dilation of the main pancreatic duct (9). In 3 patients, the center of the mass showed high intensity on MRCP, suggesting the secondary change of pancreatic carcinoma. In 8 patients with obstruction of the main pancreatic duct due to carcinoma, the distal pancreatic duct was visualized by MRCP but not by ERCP. In 9 patients who had undergone pylorus-preserving or standard pancreatoduodenectomy, follow-up MRCP was obtainable in all examined and displayed the main pancreatic duct. CONCLUSIONS: MRCP plays a complementary role in the surgical diagnosis of pancreatic disorders and is especially useful to examine the pancreatic duct after pancreatoduodenectomy."

Language：English  

OBJECTIVE:

To evaluate the efficacy of early angiography in the diagnosis and treatment of delayed arterial hemorrhage as a significant complication following pancreatectomy.

DESIGN:

Retrospective case series.

SETTING:

University hospital; 6-year period between January 1992 and December 1997.

PATIENTS AND INTERVENTION:

Of a total of 81 patients undergoing pancreatic head resection, 10 (12%) developed massive arterial hemorrhage after surgery. All 10 patients underwent an emergency angiography and 8 of these were managed by transcatheter arterial embolization.

RESULTS:

Before onset of major bleeding, 9 patients (90%) had developed intra-abdominal abscess resulting from pancreatic fistula or other anastomotic leak, and all 10 patients had had preliminary minor bleeding. The angiogram demonstrated an exact site of bleeding as a pseudoaneurysm in all 10 patients. Transcatheter arterial embolization achieved temporary control of bleeding in all 8 patients for whom embolization was attempted and complete hemostasis in 5 of the 8 subsequently, yielding a success rate of 63%. Overall, 4 patients (40%) died of complications related directly to the major hemorrhage or the transcatheter arterial embolization technique.

CONCLUSIONS:

An emergency angiography should be considered in all patients who develop either a sentinel or massive gastrointestinal bleed following pancreatectomy irrespective of suspected intra-abdominal sepsis. Transcatheter arterial embolization allows temporary control of massive hemorrhage and hemodynamic stabilization in most cases, and prevents the need for high-risk emergency surgery.

Language：English  

BACKGROUND: The objective of this study was to compare the alterations in pancreatic function after pancreatoduodenectomy between malignant and benign diseases. METHODS: In 34 patients who underwent pancreatoduodenectomy for pariampullary cancer (malignant group; n = 18) and benign pancreatic disorders (benign group; n = 16), exocrine and endocrine functions were analyzed before surgery, at a short-term period (< or = 2 months), and at a long-term period (>12 months) after surgery. Assessment was based on the BT-PABA excretion test, fasting blood sugar level, and oral glucose tolerance test. RESULTS: Compared with the preoperative level, urinary PABA excretion rate in the malignant group significantly decreased on short-term follow-up but recovered on long-term follow-up. However, that in the benign group increased on long-term follow-up without showing a short-term decline. Diabetes mellitus was present in 11 (61%) of the 18 patients in the malignant group and 6 (38%) of the 16 in the benign group before surgery. Glucose tolerance improved in 6 (55%) of the 11 patients in the malignant group but in only 1 (17%) of the 6 in the benign group shortly after surgery. In the benign group, 3 (30%) of 10 patients with normal preoperative glucose tolerance became diabetic after surgery, while no patient in the malignant group developed diabetes on short-term follow-up. CONCLUSIONS: Surgeons should pay attention to exocrine pancreatic function in patients with a periampullary cancer and to glucose metabolism in patients with benign disease over the short-term period after pancreatoduodenectomy."

Language：English  

We report two cases of carcinoma of the pancreas with anomalous junction of the pancreaticobiliary tracts. A 71-year-old Japanese woman had obstructive jaundice. Ultrasonography showed a hypoechoic mass in the pancreatic head and computed tomography demonstrated a low-density nodule in the pancreatic head. Endoscopic retrograde cholangiopancreatography displayed a double duct sign and an anomalous junction of the pancreaticobiliary tracts. The patient underwent a pancreatoduodenectomy. The histopathologic diagnosis of the resected specimen was adenocarcinoma of the pancreatic head. A 56-year-old Japanese man also developed obstructive jaundice. Ultrasonography and computed tomography showed a huge mass almost replacing the whole pancreas and involving the superior mesenteric artery, splenic artery, splenic vein, and portal vein. Multiple hepatic metastases and peritoneal dissemination were present. Endoscopic retrograde cholangiopancreatography demonstrated an anomalous junction of the pancreaticobiliary tracts. The patient died of hemorrhage from esophageal varices. We discuss the relationship between the anomalous junction of the pancreaticobiliary tracts and pancreatic carcinoma.

Language：English  

Comparison of laparoscopic versus open cholecystectomy in patients with cardiac valve replacement.
J Hepatobiliary Pancreat Surg. 2001;8(2):158-60.

Language：English  

BACKGROUND: Magnetic resonance chorangiopancreatography (MRCP) is a newly developing noninvasive examination of the biliopancreatic trees. Roles of MRCP in the diagnosis of pancreatic diseases have not been scrutinized.
METHODS: Endoscopic retrograde cholangiopancreatography (ERCP) and MRCP were reviewed in 52 Japanese patients with various pancreatic diseases and 6 patients with normal pancreas to compare their diagnostic usefulness and limitation.
RESULTS: In those with normal pancreas, only the main pancreatic duct was visualized by MRCP, while both the main pancreatic and branch ducts were clearly delineated by ERCP. In 3 patients with serous cystadenoma, the tumor was not visualized by ERCP, whereas it was visible as a high-intensity mass on MRCP. Of 18 patients with a "mucin hypersecreting" tumor of the branch type, MRCP demonstrated cystically dilated branch ducts in all, while ERCP failed to visualize the dilated ducts in 6 patients. However, the details of the cystic lesions (mural nodule, communication with the main pancreatic duct) were more exactly demonstrated by ERCP than MRCP. In 5 patients with a mucin hypersecreting tumor of the main pancreatic duct type, the dilated main pancreatic duct and the presence of mural nodules were similarly demonstrated both by ERCP and MRCP. In 12 patients with pancreatic adenocarcinoma, indirect findings were similarly demonstrated both by ERCP and MRCP, ie, stenosis (4 patients) and obstruction (8) together with dilation of the main pancreatic duct (9). In 3 patients, the center of the mass showed high intensity on MRCP, suggesting the secondary change of pancreatic carcinoma. In 8 patients with obstruction of the main pancreatic duct due to carcinoma, the distal pancreatic duct was visualized by MRCP but not by ERCP. In 9 patients who had undergone pylorus-preserving or standard pancreatoduodenectomy, follow-up MRCP was obtainable in all examined and displayed the main pancreatic duct.
CONCLUSIONS: MRCP plays a complementary role in the surgical diagnosis of pancreatic disorders and is especially useful to examine the pancreatic duct after pancreatoduodenectomy. (C) 1998 by Excerpta Medica, Inc.

Language：English  

BACKGROUND: Leakage of pancreatoenterostomy remains as a serious and fatal complication after pancreatectomy. Several risk factors have been reported, ie, normal pancreatic parenchyma, small pancreatic duct, a large amount of intraoperative blood loss, management of the cut surface of the pancreas, and the presence of preoperative jaundice. Transected pancreatic ductules on the cut surface of the pancreas that are not drained into the main pancreatic duct after pancreatectomy are one of the risks. The pancreatic juice is alkaline and turns red litmus to blue.
METHODS: In order to detect the transected pancreatic ductules on the cut surface of the pancreas, red litmus paper is applied to the cutting surface of the pancreas after stimulation of secretin.
RESULTS: Nondrained, transected pancreatic ductules on the cut surface of the pancreas can be detected as blue spots on the red litmus paper. The corresponding areas to the blue spots can be transfixed with sutures to close the non-drained and transected pancreatic ductules.
CONCLUSION: Litmus paper can be expected to detect pancreatoenterostomy leakage after pancreatectomy. (C) 1998 by Excerpta Medica, Inc.

DOI： 10.1016/S0002-9610(97)00290-0

Language：English  

Background, Extended cholecystectomy is the common operation for gallbladder carcinoma. When extended cholecystectomy is performed, the liver bed can be generously resected from the fundus to the body of the gallbladder; however, the thickness of the liver parenchyma to be removed is limited to the neck of the gallbladder. There have been few reports providing convincing data with regard to how thick the liver can be anatomically resected by extended cholecystectomy.
Methods, The thickness of the liver tissue actually resected at the time of extended cholecystectomy and that potentially resected by extended cholecystectomy were measured in 24 clinical and 25 autopsy cases, respectively, to assess the anatomical limit of extended cholecystectomy,
Results. The mean anatomical distances from the neck of the gallbladder to the right hepatic duct and to the bifurcation of the anterior and posterior branch of the right hepatic duct were only 1.6(1 2 3) and 5.9(1) mm, respectively. The distance from the gallbladder to the bifurcation of the superior and inferior branch of the right anterior hepatic duct, and to the root of the right anterior inferior hepatic duct were 11.2 mm(2) and 12.8 mm(3), respectively ((1 2 3): p<0.05). The actual width of the liver excised hy extended cholecystectomy was 5.2 mm at the neck, 11.7 mm at the body, and 8.1 mm at the fundus of the gallbladder, respectively. These results indicate that the neck of the gallbladder is anatomically close to the hepatic hilum including the right hepatic duct and portal vein.
Conclusions. Surgical strategy for gallbladder carcinoma should be considered to rely not only upon the depth of invasion but also upon the site of gallbladder tumor. When gallbladder carcinoma involves the muscle layer or further at the neck of the organ, more extensive hepatectomy than extended cholecystectomy should be considered.

Language：Others  

DOI： 10.1007/bf02488978

Language：English  

Background: Phosphoenolpyruvate (PEP) is a high-energy metabolite in the final step of glycolysis. PEP is converted into pyruvate by pyruvate kinase. One molecule of adenosine triphosphate (ATP) is generated from one molecule of PEP. The aim of this study was to examine the effects of PEP on hepatic energy metabolism at an early phase after ischemia and reperfusion were examined in rats. Materials and methods: Male Wistar rats (250-350 g) were divided into two groups; after two 15-min periods of ischemia with 2 min reperfusion in between, either PEP or glucose solution (400 mmol/liter, pH 7.4) was infused into the portal vein (2.5 ml/300 g body wt/5 min). Before and 0, 5, 10, and 30 min after ischemia, arterial blood and liver tissue were collected for analyses. Results: During the two ischemic periods, ATP and total adenine nucleotide (TAN) of the liver decreased from 9.10 +/- 0.50 and 14.06 +/- 0.29 to 0.99 +/- 0.50 and 10.86 +/- 0.42 mmole/g liver, respectively (P < 0.05), while adenosine monophosphate (AMP) increased from 1.18 +/- 0.15 to 8.47 +/- 0.66 mmole/g liver (P < 0.05). Hepatic energy charge (EC) significantly decreased from 0.78 +/- 0.02 to 0.16 +/- 0.03 (P < 0.05). Serum concentrations of pyruvate and lactate were elevated from 1.18 +/- 0.15 and 18.4 +/- 0.52 to 3.29 +/- 0.52 and 72.6 +/- 4.8 mg/dl, respectively (P < 0.05). After a 5-min infusion of PEP or glucose solution, the ATP concentration was significantly higher in the PEP group than in the glucose group (4.08 +/- 0.58 mu mole/g liver vs 2.20 +/- 0.45 mu mole/g liver, P < 0.01), whereas AMP concentration was significantly lower in the PEP group than in the glucose group (4.26 +/- 0.66 mu mole/g liver vs 7.02 +/- 0.71 mu mole/g liver, P < 0.01). EC in the PEP group was significantly higher than that in the glucose group (0.493 +/- 0.051 vs 0.293 +/- 0.042, P < 0.01), Ten minutes after ischemia, the ATP, TAN, and EC levels were still higher in the PEP group than in the glucose group, but the difference did not reach statistical significance. At 30 min after ischemia, these values became similar in both groups. At 5, 10, and 30 min after ischemia, serum pyruvate concentrations were higher in the PEP group than in the glucose group. Conclusion: These findings suggest that PEP recovers hepatic energy from liver cell damage at an early phase after ischemia and reperfusion by prompt ATP production through the degradation of PEP into pyruvate in the liver. (C) 1997 Academic Press.

DOI： 10.1006/jsre.1997.5177

Language：English  

Background/Aims: The postoperative course of patients with bile duct carcinoma after surgical resection remains dismal. The purpose of this study was to examine the mode of spread from the original site of the carcinoma and its prognostic significance.
Methodology: A total of 46 Japanese patients with extrahepatic bile duct carcinoma who underwent surgical resection from January 1976 to August 1995 were retrospectively reviewed.
Results: Out of 24 patients with upper bile duct carcinoma, 16 (67%) were papillary or well differentiated tubular adenocarcinoma of the polypoid or nodular type on gross configuration, whereas 7 of 11 patients (64%) with lower bile duct carcinoma had moderately differentiated tubular adenocarcinoma or poorly differentiated adenocarcinoma of the annular constrictive or diffusely infiltrating type (p<0.01). A noteworthy feature was perineural invasion (18/24, 75%) in the former group. Lymphatic permeation. and venous invasion. were seen in 50% and 38% of the former group and these were present in 73%, and in 73% of the latter (p<0.01). Lymph node metastasis was most frequent in patients with lower bile duct carcinoma (5/11, 45%). Periductal spread along the bile duct toward the liver was more frequent and extensive in the infiltrating type than in the polypoid, nodular, or annular constrictive type. Carcinoma of the polypoid type often extended along the mucosa and rarely through the periductal layer. The mean distance between the edge of carcinoma invasion estimated by cholangiography and that proved by histology on the resected specimens was 6.1 +/- 6.1 mm in the hepatic and 6.2 +/- 9.1 mm in the duodenal direction. In all 11 patients with lower bile duct carcinoma, surgical margins were free of cancer cells, while they were affected by malignant cells in 17 of 24 patients with upper bile duct carcinoma. Univariate log-rank analysis showed that venous invasion, perineural infiltration, and the presence or absence of cancer cells at the cut edge of the bile duct in the hepatic direction. and at the resection margins in the transverse direction were significant prognostic factors. Multivariate Cox regression analysis revealed that cancer cells at the edge of the bile duct in, the hepatic direction constitute a significant and independent prognostic variant.
Conclusions: Extrahepatic bile duct carcinoma should be excised to a distance of 1.5 cm from the edge of the carcinoma as estimated on cholangiography to achieve cancer-free margins, especially at the resected margins in the hepatic direction.

Language：English  

Background: An accurate frozen section diagnosis is important when deciding the surgical strategy against a gallbladder tumor intraoperatively. Little has been reported on the accuracy of frozen section diagnosis of the gallbladder.
Patients and Methods: In a total of 86 consecutive patients with gallbladder tumor, the accuracy of the frozen section diagnosis was examined. There were 32 patients with polypoid lesions and 54 with nonpolypoid tumors.
Results: The frozen tissue diagnosis and final diagnosis were identical in 82 of the 86 cases, that is, benign in 65 and malignant in 17. The other four cases had different diagnoses, that is, conversion from benign to malignant in two and from malignant to benign in two. The overall accuracy of frozen diagnosis was 95.3% (97.0% for benign and 94.7% For malignant). In 32 polypoid lesions, the accuracy of frozen section diagnosis was 91% (93% for benign; 89% for malignant). In 54 nonpolypoid lesions, the accuracy of diagnosis was 98% (100% for benign; 93% for malignant). The diagnosis of depth of invasion was identical only in 7 (70%) of the 10 carcinoma cases examined, while it was diverse in the remaining 3, that is, conversion from adenocarcinoma invading the subserosa to that limiting to the mucosa in one, from carcinoma within the mucosa to that infiltrating the muscle coat in one, and from carcinoma affecting the muscle layer to that invading the subserosa in the other. Alterations of frozen section diagnosis about being benign or malignant and about the depth of invasion were encountered in seven patients, five of whom had a polypoid tumor.
Conclusions: The intraoperative frozen tissue diagnosis is fairly reliable as to whether lesions are malignant or benign; however, accuracy is low in patients with polypoid lesions of the gallbladder. Also, frozen section diagnosis does not reliably measure the depth of invasion of gallbladder carcinoma. (C) 1997 Wiley-Liss, Inc.

Language：English  

BACKGROUND/AIMS: The postoperative course of patients with bile duct carcinoma after surgical resection remains dismal. The purpose of this study was to examine the mode of spread from the original site of the carcinoma and its prognostic significance. METHODOLOGY: A total of 46 Japanese patients with extrahepatic bile duct carcinoma who underwent surgical resection from January 1976 to August 1995 were retrospectively reviewed. RESULTS: Out of 24 patients with upper bile duct carcinoma, 16 (67%) were papillary or well differentiated tubular adenocarcinoma of the polypoid or nodular type on gross configuration, whereas 7 of 11 patients (64%) with lower bile duct carcinoma had moderately differentiated tubular adenocarcinoma or poorly differentiated adenocarcinoma of the annular constrictive or diffusely infiltrating type (p < 0.01). A noteworthy feature was perineural invasion (18/24, 75%) in the former group. Lymphatic permeation and venous invasion were seen in 50% and 38% of the former group and these were present in 73%, and in 73% of the latter (p < 0.01). Lymph node metastasis was most frequent in patients with lower bile duct carcinoma (5/11, 45%). Periductal spread along the bile duct toward the liver was more frequent and extensive in the infiltrating type than in the polypoid, nodular, or annular constrictive type. Carcinoma of the polypoid type often extended along the mucosa and rarely through the periductal layer. The mean distance between the edge of carcinoma invasion estimated by cholangiography and that proved by histology on the resected specimens was 6.1 +/- 6.1 mm in the hepatic and 6.2 +/- 9.1 mm in the duodenal direction. In all 11 patients with lower bile duct carcinoma, surgical margins were free of cancer cells, while they were affected by malignant cells in 17 of 24 patients with upper bile duct carcinoma. Univariate log-rank analysis showed that venous invasion, perineural infiltration, and the presence or absence of cancer cells at the cut edge of the bile duct in the hepatic direction and at the resection margins in the transverse direction were significant prognostic factors. Multivariate Cox regression analysis revealed that cancer cells at the edge of the bile duct in the hepatic direction constitute a significant and independent prognostic variant. CONCLUSIONS: Extrahepatic bile duct carcinoma should be excised to a distance of 1.5 cm from the edge of the carcinoma as estimated on cholangiography to achieve cancer-free margins, especially at the resected margins in the hepatic direction.Unique Identifier 98019684PubMed Identifier 9356836Authors Yamaguchi K Chijiiwa K Saiki S Shimizu S Takashima M Tanaka MInstitution Department of Surgery I, Kyushu University Faculty of Medicine, Japan.Title Carcinoma of the extrahepatic bile duct: mode of spread and its prognostic implications.Source Hepato-Gastroenterology. 44(17):1256-61, 1997 Sep-Oct.Abbreviated Source Hepatogastroenterology. 44(17):1256-61, 1997 Sep-Oct.Serials Code 00004104NLM Journal Code ga7, 8007849Journal Subset AIM JournalsCountry of Publication GreeceMeSH Subject Headings Bile Duct Neoplasms/mo [Mortality] *Bile Duct Neoplasms/pa [Pathology] Bile Duct Neoplasms/su [Surgery] Bile Ducts, Extrahepatic/pa [Pathology] Bile Ducts, Extrahepatic/su [Surgery] *Bile Ducts, Extrahepatic Cholangiocarcinoma/mo [Mortality] *Cholangiocarcinoma/pa [Pathology] Cholangiocarcinoma/sc [Secondary] Cholangiocarcinoma/su [Surgery] Female Follow-Up Studies Human Male Middle Age Prognosis Proportional Hazards Models Risk Factors Survival Rate Time FactorsAbstract BACKGROUND/AIMS: The postoperative course of patients with bile duct carcinoma after surgical resection remains dismal. The purpose of this study was to examine the mode of spread from the original site of the carcinoma and its prognostic significance. METHODOLOGY: A total of 46 Japanese patients with extrahepatic bile duct carcinoma who underwent surgical resection from January 1976 to August 1995 were retrospectively reviewed. RESULTS: Out of 24 patients with upper bile duct carcinoma, 16 (67%) were papillary or well differentiated tubular adenocarcinoma of the polypoid or nodular type on gross configuration, whereas 7 of 11 patients (64%) with lower bile duct carcinoma had moderately differentiated tubular adenocarcinoma or poorly differentiated adenocarcinoma of the annular constrictive or diffusely infiltrating type (p < 0.01). A noteworthy feature was perineural invasion (18/24, 75%) in the former group. Lymphatic permeation and venous invasion were seen in 50% and 38% of the former group and these were present in 73%, and in 73% of the latter (p < 0.01). Lymph node metastasis was most frequent in patients with lower bile duct carcinoma (5/11, 45%). Periductal spread along the bile duct toward the liver was more frequent and extensive in the infiltrating type than in the polypoid, nodular, or annular constrictive type. Carcinoma of the polypoid type often extended along the mucosa and rarely through the periductal layer. The mean distance between the edge of carcinoma invasion estimated by cholangiography and that proved by histology on the resected specimens was 6.1 +/- 6.1 mm in the hepatic and 6.2 +/- 9.1 mm in the duodenal direction. In all 11 patients with lower bile duct"

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BACKGROUND: An accurate frozen section diagnosis is important when deciding the surgical strategy against a gallbladder tumor intraoperatively. Little has been reported on the accuracy of frozen section diagnosis of the gallbladder. PATIENTS AND METHODS: In a total of 86 consecutive patients with gallbladder tumor, the accuracy of the frozen section diagnosis was examined. There were 32 patients with polypoid lesions and 54 with nonpolypoid tumors. RESULTS: The frozen tissue diagnosis and final diagnosis were identical in 82 of the 86 cases, that is, benign in 65 and malignant in 17. The other four cases had different diagnoses, that is, conversion from benign to malignant in two and from malignant to benign in two. The overall accuracy of frozen diagnosis was 95.3% (97.0% for benign and 94.7% for malignant). In 32 polypoid lesions, the accuracy of frozen section diagnosis was 91% (93% for benign; 89% for malignant). In 54 nonpolypoid lesions, the accuracy of diagnosis was 98% (100% for benign; 93% for malignant). The diagnosis of depth of invasion was identical only in 7 (70%) of the 10 carcinoma cases examined, while it was diverse in the remaining 3, that is, conversion from adenocarcinoma invading the subserosa to that limiting to the mucosa in one, from carcinoma within the mucosa to that infiltrating the muscle coat in one, and from carcinoma affecting the muscle layer to that invading the subserosa in the other. Alterations of frozen section diagnosis about being benign or malignant and about the depth of invasion were encountered in seven patients, five of whom had a polypoid tumor. CONCLUSIONS: The intraoperative frozen tissue diagnosis is fairly reliable as to whether lesions are malignant or benign; however, accuracy is low in patients with polypoid lesions of the gallbladder. Also, frozen section diagnosis does not reliably measure the depth of invasion of gallbladder carcinoma."

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BACKGROUND: Phosphoenolpyruvate (PEP) is a high-energy metabolite in the final step of glycolysis. PEP is converted into pyruvate by pyruvate kinase. One molecule of adenosine triphosphate (ATP) is generated from one molecule of PEP. The aim of this study was to examine the effects of PEP on hepatic energy metabolism at an early phase after ischemia and reperfusion were examined in rats. MATERIALS AND METHODS: Male Wistar rats (250-350 g) were divided into two groups; after two 15-min periods of ischemia with 2 min reperfusion in between, either PEP or glucose solution (400 mmol/liter, pH 7.4) was infused into the portal vein (2.5 ml/300 g body wt/5 min). Before and 0, 5, 10, and 30 min after ischemia, arterial blood and liver tissue were collected for analyses. RESULTS: During the two ischemic periods, ATP and total adenine nucleotide (TAN) of the liver decreased from 9.10 +/- 0.50 and 14.06 +/- 0.29 to 0.99 +/- 0.50 and 10.86 +/- 0.42 mmole/g liver, respectively (P < 0.05), while adenosine monophosphate (AMP) increased from 1.18 +/- 0.15 to 8.47 +/- 0.66 mmole/g liver (P < 0. 05). Hepatic energy charge (EC) significantly decreased from 0.78 +/- 0.02 to 0.16 +/- 0.03 (P < 0.05). Serum concentrations of pyruvate and lactate were elevated from 1.18 +/- 0.15 and 18.4 +/- 0. 52 to 3.29 +/- 0.52 and 72.6 +/- 4.8 mg/dl, respectively (P < 0.05). After a 5-min infusion of PEP or glucose solution, the ATP concentration was significantly higher in the PEP group than in the glucose group (4.08 +/- 0.58 micromole/g liver vs 2.20 +/- 0.45 micromole/g liver, P < 0.01), whereas AMP concentration was significantly lower in the PEP group than in the glucose group (4.26 +/- 0.66 micromole/g liver vs 7.02 +/- 0.71 micromole/g liver, P < 0. 01). EC in the PEP group was significantly higher than that in the glucose group (0.493 +/- 0.051 vs 0.293 +/- 0.042, P < 0.01). Ten minutes after ischemia, the ATP, TAN, and EC levels were still higher in the PEP group than in the glucose group, but the difference did not reach statistical significance. At 30 min after ischemia, these values became similar in both groups. At 5, 10, and 30 min after ischemia, serum pyruvate concentrations were higher in the PEP group than in the glucose group. CONCLUSION: These findings suggest that PEP recovers hepatic energy from liver cell damage at an early phase after ischemia and reperfusion by prompt ATP production through the degradation of PEP into pyruvate in the liver. Copyright 1997 Academic Press."

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Alkylation of DNA at the O(6)-position of guanine is one of the most critical events leading to induction of mutation as well as to cancer. The enzyme O(6)-methylguanine-DNA methyltransferase repairs this and related lesions in DNA. By means of gene targeting, we established mouse lines deficient in the methyltransferase gene and tissues from these mice contained no methyltransferase activity. Administration of methylnitrosourea to these gene-targeted mice led to early death, and normal mice treated in the same manner showed no untoward effects. In mice given methylnitrosourea treatment, the bone marrow became hypocellular and there was a drastic decrease in the number of leukocytes and platelets, thereby indicating an impaired reproductive capacity of hematopoietic stem cells. Methyltransferase apparently protected these mice from the pancytopenia caused by the alkylating agent. "

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The effect of alpha-tocopherol on the hypocholesterolemic action of sesamin was examined in rats given a cholesterol-enriched diet. When different levels (0.05 and 0.2%) of sesamin were fed, the supplementation of 1% alpha-tocopherol significantly accentuated the hypocholesterolemic action of sesamin, particularly with the higher sesamin level, although alpha-tocopherol alone did not affect the concentration of serum cholesterol. The dose-dependent promoting effect of alpha-tocopherol on the hypocholesterolemic action of sesamin was confirmed by supplementing different levels (0.2 and 1%) of alpha-tocopherol to a fixed level of sesamin (0.2%). alpha-Tocopherol was still effective at the 0.2% level. The metabolism of sesamin in the liver S9 fraction appeared to be interfered with alpha-tocopherol in vitro, suggesting a possible role of alpha-tocopherol in maintenance of the availability of sesamin. "

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The effects of sesamin, a potent inhibitor of delta 5-desaturase in polyunsaturated fatty acid biosynthesis, on the fatty acid compositions of tissue lipids and liver functions were examined in rodents. When a mixture of sesamin and episesamin (51.1:48.2, w/w) was given to rats at a dietary level of 0.5% for 13 days, the proportions of dihomo-gamma-linolenic acid significantly increased not only in the liver but also in plasma and hemocytes, suggesting an interference with delta 5-desaturation by these lignans. The sesamin preparation at the dietary level of 1% improved changes in various blood parameters of the mouse, such as aspartate aminotransferase and alanine aminotransferase activities, and the concentrations of total cholesterol, triglyceride and total bilirubin, caused by continuous inhalation of ethanol. In addition, sesamin showed a significant protective effect against the accumulation of fat droplets and vacuolar degeneration in the mouse liver, as confirmed on histological examination. Sesamin, at the level of 100 mg/kg body weight, also tended to prevent liver lipid accumulation by carbon tetrachloride in mice. These results indicate that sesamin and a related lignan compound have an ability to improve liver function.

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Biliary amphipathic anionic polypeptide (APF) the major protein of the pigment-lipoprotein complex in bile, and calcium-binding protein (CBP) from gallstones are both small (<10 kDa), highly acidic, amphipathic proteins present in bile and closely associated also with pigmented areas in human gallstones. Polyclonal antibodies against APF have shown cross-reactivity with plasma high density lipoproteins (HDL). This study examines the hypothesis that APF and CBP might be closely related or even identical, and might also share common epitopes with the larger apoA-I (23 kDa). To assess this, immunoreactivity of the three delipidated, highly purified proteins was determined against a panel of 12 monoclonal antibodies (MAbs) prepared against APF and a panel of 4 MAbs against apoA-I. APF was isolated from bile by zonal ultracentrifugation. CBP was isolated from proteins precipitated from bile by CaCl2, as well as from the calcium bilirubinate shells of cholesterol gallstones, by extraction successively with methyl-t-butyl ether, methanol, and Na2EDTA, followed by Sephadex G-25 chromatography and two-stage preparative SDS-PAGE. ApoA-I was prepared by two types of chromatography: Sephacryl S200 chromatography and heparin-chromatographic immunoaffinity. Specific polyclonal antibodies to APF and apoA-I were prepared from immunized rabbits. MAbs to APF and apoA-I were prepared by immunization of mice, using standard hybridoma technique. Western blotting of APF and CBP in 15% SDS-PAGE yielded one band with an apparent molecular weight of 6.5 kDa, which, along with apoA-I, was immunostained by polyclonal antibodies to APF and apoA-I. Using 12 MAbs against APF with three types of ELISA (direct antigen binding, competitive antigen displacement, and epitope competition between antibodies), it was shown that APF and delipidated apoA-I shared six epitopes, three of which were detected also on the surface of intact HDL particles. Six other epitopes were present in APF but not apoA-I, four of which were exposed on the surface of HDL. Four MAbs against apoA-I reacted with APF and CBP. Amino acid analyses of APF and CBP were similar with 20-23% acidic and 7-11% basic amino acids and low contents of cysteine, methionine, and tyrosine; both differed from apoA-I in containing isoleucine and cysteine. Using ELISA and one MAb (no. 32) against APF, this polypeptide was detected in human plasma HDL, the pigment-lipoprotein complex in the bile of humans, dogs, and rats, and in both pigment and cholesterol gallstones. Like CBP, APF contained tightly bound bile pigments and arrested the precipitation of calcium carbonate from a supersaturated solution in vitro. These common properties and immunological cross-reactivity between APF and CBP suggest that the two proteins may be identical, and likely play a role in both transport of cholesterol and precipitation of calcium salts in bile, and therefore in the formation of both cholesterol and calcium/pigment-containing gallstones. APF/CBP also shares some epitopes with apoA-I and plasma HDL. The presence of amino acids in APF/CBP not found in apoA-I, however, renders it probable that APF is a true minor apolipoprotein of HDL, distinct from apoA-I, that binds tightly to the surface of HDL.

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We have previously isolated from 13 cholesterol gallstones a low molecular weight acidic bili-protein that inhibited the precipitation of calcium carbonate in vitro. We now report the isolation of a similar protein from seven black pigment gallstones. Cholesterol was removed from the stones by Soxhlet apparatus with methyl t-butyl ether, and bile acids were extracted with methanol. The protein was purified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis after demineralization of the stones with ethylenediaminetetraacetate. Structural and functional properties of the protein from the black stones that were similar to the protein from the cholesterol stones included the following: (a) an apparent molecular weight of about 5 kD; (b) a high content of acidic (19.8%) and hydrophobic (50.1%) amino acids with a low content of basic residues (8.4%) and little sulfide-containing amino acids (1.9%); (c) an inhibitory effect on both the initiation and growth of calcium carbonate crystals in vitro; and (d) very tight (possibly covalent) binding of a diazo-positive yellow pigment, presumably bilirubin, with maximum spectral absorbance at 410 nm. The structural and functional similarities of these bili-proteins from black pigment and cholesterol gallstones and their striking effects on calcium carbonate precipitation in vitro suggest that they play a common role in the regulation of precipitation of calcium salts during the formation of both types of gallstones.

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Thirty-two benign hepatic lesions, which were resected because of a diagnosis of malignancy, were reviewed to demonstrate the characteristics of the problem and to consider the best course of management. The preoperative diagnoses included 21 hepatocellular carcinomas, six metastases and five others. As the final diagnosis, hemangioma and focal nodular hyperplasia were the two major lesions mimicking malignancy, accounting for seven and six patients, respectively. Four Of seven hemangiomas were atypical, with a considerable amount of fibrosis. Focal nodular hyperplasia and adenoma were misdiagnosed as hepatocellular carcinoma among other malignancies. Two instances each of necrotic tissue and hemangioma were diagnosed as metastatic carcinoma. The lesions that were studied had main features, including a diameter of less than 4 centimeters in 23 patients, evident discrepancy among the roentgenologic diagnoses in 25 patients and no rapid increase in size in 28 patients. Four of nine needle biopsies performed gave false-positive results and did not always provide adequate information. It was concluded that 15 of the 32 patients, who satisfied the aforementioned three criteria, could have been observed more carefully. However, in the other 1 7 patients, surgical intervention was considered justified because of an indication of a higher likelihood of a real malignancy.

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Thirty-two benign hepatic lesions, which were resected because of a diagnosis of malignancy, were reviewed to demonstrate the characteristics of the problem and to consider the best course of management. The preoperative diagnoses included 21 hepatocellular carcinomas, six metastases and five others. As the final diagnosis, hemangioma and focal nodular hyperplasia were the two major lesions mimicking malignancy, accounting for seven and six patients, respectively. Four of seven hemangiomas were atypical, with a considerable amount of fibrosis. Focal nodular hyperplasia and adenoma were misdiagnosed as hepatocellular carcinoma among other malignancies. Two instances each of necrotic tissue and hemangioma were diagnosed as metastatic carcinoma. The lesions that were studied had main features, including a diameter of less than 4 centimeters in 23 patients, evident discrepancy among the roentgenologic diagnoses in 25 patients and no rapid increase in size in 28 patients. Four of nine needle biopsies performed gave false-positive results and did not always provide adequate information. It was concluded that 15 of the 32 patients, who satisfied the aforementioned three criteria, could have been observed more carefully. However, in the other 17 patients, surgical intervention was considered justified because of an indication of a higher likelihood of a real malignancy.

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The effects of dietary supplementation of sesamin on 7,12-dimethylbenz[a]anthracene (DMBA)-induced mammary carcinogenesis in female Sprague-Dawley rats were studied. Experimental diets containing 0.2% sesamin (an equiweight mixture of sesamin and episesamin) or 0.2% alpha-tocopheryl acetate were given to rats starting 1 week before intragastric administration of DMBA (10 mg/rat). Sesamin significantly (p less than 0.05) reduced the cumulative number of palpable mammary cancers by 36% at 12 weeks post-DMBA administration compared with animals on a control diet. Alpha-tocopheryl acetate inhibited both the incidence and the cumulative number of mammary tumors by 20% and 45%, respectively. Concentrations of lipid peroxides in plasma, liver and tumors were all decreased in both sesamin and alpha-tocopheryl acetate groups. The activity of peripheral blood mononuclear cells (PBMC) increased in rats fed sesamin (140 to 150% of the control and alpha-tocopheryl acetate groups). Fatty acid compositions of plasma, liver and tumor phosphatidylcholine showed a decreased tendency of the metabolism of linoleic acid to arachidonic acid and hence of the plasma concentration of prostaglandin E2 in the sesamin group. The inhibitory effect of sesamin on DMBA-induced mammary carcinogenesis may be ascribed, at least in part, to immunopotentiation and increased antioxidative activity.

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We have previously isolated from 13 cholesterol gallstones a low molecular weight acidic bili-protein that inhibited the precipitation of calcium carbonate in vitro. We now report the isolation of a similar protein from seven black pigment gallstones. Cholesterol was removed from the stones by Soxhlet apparatus with methyl t-butyl ether, and bile acids were extracted with methanol. The protein was purified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis after demineralization of the stones with ethylenediaminetetraacetate. Structural and functional properties of the protein from the black stones that were similar to the protein from the cholesterol stones included the following: (a) an apparent molecular weight of about 5 kD; (b) a high content of acidic (19.8%) and hydrophobic (50.1%) amino acids with a low content of basic residues (8.4%) and little sulfide-containing amino acids (1.9%); (c) an inhibitory effect on both the initiation and growth of calcium carbonate crystals in vitro; and (d) very tight (possibly covalent) binding of a diazo-positive yellow pigment, presumably bilirubin, with maximum spectral absorbance at 410 nm. The structural and functional similarities of these bili-proteins from black pigment and cholesterol gallstones and their striking effects on calcium carbonate precipitation in vitro suggest that they play a common role in the regulation of precipitation of calcium salts during the formation of both types of gallstones.

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The aim of the present study was to analyse bile samples from cases with gallstones by high performance liquid chromatography according to the type of stones present, with special reference to the glucoside and xyloside conjugates of bilirubin, and to investigate their deconjugation. The composition of bilirubin conjugates in bile was similar between cholesterol and black pigment stones except that the total bilirubin concentration was about 5 times higher in black pigment stone cases with haemolysis. Unconjugated bilirubin was higher in brown pigment stone cases than in cholesterol stone cases, although total bilirubin concentration was lower in the former. In addition, in brown pigment stone cases, bile contained statistically less bilirubin diglucuronide and more bilirubin diglucoside and monoglucoside than in bile with cholesterol stones (P < 0.05). Glucoside and xyloside conjugates are also major components, regardless of the types of gallstones present, accounting for as much as 18 to 25%. Incubation experiment revealed that bilirubin diglucuronide was more readily deconjugated than bilirubin diglucoside or bilirubin monoglucoside monoxyloside. Therefore, glucuronide conjugates were likely to be the main source of unconjugated bilirubin in the formation of pigment gallstones.

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Previous studies have strongly suggested that human bile contains a substance(s) that interferes with the precipitation of calcium phosphate and carbonate from solution. These studies, however, did not distinguish between calcium binding by biliary constituents resulting in decreased calcium carbonate saturation (alterations in solution thermodynamics) and true inhibition of calcium salt precipitation by kinetic factors. Because our recent studies have shown that canine common duct bile is always supersaturated with calcium carbonate (thermodynamically at risk for precipitation), we hypothesized that it must contain kinetic factors that inhibit formation and/or growth of calcium carbonate crystals. Effects of canine bile, bovine albumin and the bile salt taurocholate on calcium carbonate precipitation were studied in highly supersaturated solutions of calcium carbonate that spontaneously undergo rapid precipitation. Measured free ionized calcium concentrations, [Ca++], and calculated calcium carbonate saturation indices were compared in test solutions and controls to evaluate the thermodynamic effects of test solutions on the degree of saturation in the assay system. It is shown that addition of only 0.2 ml of normal canine gallbladder bile to the assay system (a 1:101 dilution of biliary components) abolished precipitation. A lesser inhibitory effect (a decrease in the rate of precipitation) was observed when gallbladder bile was diluted but was lost after 10-fold dilution. Canine common duct bile caused a decrease in the rate of precipitation similar to diluted gallbladder bile. In contrast, sodium taurocholate (250 mmol/L), the major bile salt in the dog, and albumin (1.5 gm/L), the most abundant protein in bile, had only a minimal inhibitory effect. We conclude that normal bile contains kinetic factors that inhibit calcium carbonate precipitation and protect against calcium-containing gallstones. These effects are not due to changes in calcium carbonate saturation but rather to alterations in precipitation kinetics.

Language：English   Publishing type：Research paper (other academic)  

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Language：English   Publishing type：Research paper (other academic)  

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DOI： 10.3109/00313028409059097

Responsible for pages：図説・日本遠隔医療,35-36   Language：Japanese  

Responsible for pages：Gold book［digital book］：Technological Inｎovation in Education and Health,552-572   Language：English  

Responsible for pages：Global Telemedicine and eHealth Updates: Knowledge Resources,310-313   Language：English  

Responsible for pages：Advanced in Telemedicine: Enabling Facots and Scenarios,87-110   Language：English  

Responsible for pages：Telemedicine in the 21st Century,143-164   Language：English  

Responsible for pages：インフォームド・コンセント,181-183   Language：Japanese  

Responsible for pages：インフォームド・コンセント,184-186   Language：Japanese  

Responsible for pages：エクセルナース(検査編）,432-437   Language：Japanese  

Responsible for pages：エクセルナース(検査編）,296-297   Language：Japanese  

Responsible for pages：内視鏡・検査・治療・ケアがよくわかる本,78-83   Language：Japanese  

Responsible for pages：臨床医のための膵炎,131-133   Language：Japanese  

Responsible for pages：消化器外科周術期管理のすべて,244-247   Language：Japanese  

Responsible for pages：（ｴﾝﾄﾞｽｺﾋﾟｽﾄとﾗﾊﾟﾛｽｺﾋﾟｽﾄのための）最新消化器内視鏡治療,360-364   Language：Japanese  

Responsible for pages：ナーシング・フォーカスシリーズ,   Language：Japanese  

Responsible for pages：消化器外科周術期管理のすべて,316-319   Language：Japanese  

Responsible for pages：消化器外科周術期管理のすべて,298-302   Language：Japanese  

Responsible for pages：消化器癌の外科治療 専門医にきく最新の臨床,278-279   Language：Japanese  

Responsible for pages：消化器癌の外科治療 専門医にきく最新の臨床,280-281   Language：Japanese  

Responsible for pages：胆石症：診断治療の最前線,71-76   Language：Japanese  

Responsible for pages：外科手術のコツと落とし穴「肝臓」,110-111   Language：Japanese  

Event date： 2021.4 - 2022.4

Language：English   Presentation type：Oral presentation (general)  

Venue：Abu Dhabi (online)   Country：United Arab Emirates  

Event date： 2020.12

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Venue：和歌山市   Country：Japan  

Event date： 2020.12

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Venue：和歌山市   Country：Japan  

Event date： 2020.12

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Venue：和歌山市   Country：Japan  

Event date： 2020.12

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Venue：徳島市   Country：Japan  

Event date： 2020.12

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Venue：徳島市   Country：Japan  

Event date： 2020.11

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Venue：神戸市   Country：Japan  

Event date： 2020.11

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Venue：神戸市   Country：Japan  

Event date： 2020.9

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Venue：福岡市   Country：Japan  

Event date： 2020.8

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Venue：横浜市   Country：Japan  

Event date： 2020.8

Venue：横浜市   Country：Japan  

【背景】胃癌手術における系統的リンパ節郭清は、胃切除術式によりその郭清範囲が定義されているため、術前のリンパ節転移の有無を評価が重要である。しかし、肉眼的にはリンパ節腫大がなくても病理学的に転移があるものも多く、その評価は難しいことがある。また、リンパ節転移多数例(N3)の予後は不良であるが、N3症例における術後化学療法について決まった見解はない。【目的】胃癌N3症例の治療成績を検討し、そのリスク因子や適切な術後化学療法について検討する。【対象】2007年4月から2017年3月の10年間に当科で施行した胃癌手術のうち、病理学的リンパ節転移７個以上(pN3)の74例について検討した。観察期間中央値は25か月、施行術式は胃全摘42例(57%)、幽門側胃切除32例(43%)であった。深達度はT2が7例(9%)、T3が33例(45%)、T4aが27例(36%)、T4bが4例(5%)であったが、T1b(早期癌)にも3例(4%)認められた。【結果】N3症�� c$N$&$A!"=Q8e5年無再発生存例は10例（13.5%）に認められた（N3a：９例、N3b：１例）。その全てで術後化学療法を開始され、術後S-1+CDDP療法施行例や術後１年を超えて化学療法を施行した例で長期生存を認めた。しかし、副作用等のため短期間で中止となったものでも３例は予後良好であった。一方、再発例においては、化学療法を行った結果、術後8年以上の生存例がみられたものあった。【結論】胃癌リンパ節転移多数例は予後不良であるが、術後化学療法によって長期生存が可能になる場合があり、今後も症例の蓄積と治療法の検討が必要である。

Event date： 2020.7

Language：Japanese  

Venue：横浜市   Country：Japan  

Event date： 2020.3

Venue：横浜市   Country：Japan  

Event date： 2019.12

Venue：福岡市   Country：Japan  

Event date： 2019.12

Language：English  

Venue：Abu Dhabi   Country：United Arab Emirates  

Event date： 2019.12

Venue：横浜市   Country：Japan  

当科では1996年に腹腔鏡補助下胃切除術を導入して以降、様々な術式を行ってきた。完全鏡視下胃切除を開始してからは主にRoux-en-Y再建を行ってきたが、2009年からは完全鏡視下幽門側胃切除Billroth-I再建法として、デルタ吻合を導入し、現在は本法が再建の第一選択となっている。また、近年、当施設では十二指腸切離の際にEndo GIA Tri-Staple 60リンフォース（以下、リンフォース）を用いている。当初は、Roux-en-Y再建における十二指腸断端部の縫合強度改善および止血目的でリンフォースを使用していたが、デルタ吻合時にもリンフォースによる十二指腸切離を行うことで、吻合の際に十二指腸をリニアステープラーにかぶせる操作が非常にスムーズになることが分かった。最近、吻合口形成にリンフォースを使用する学会報告は散見されるが、十二指腸切離にリンフォースを用いてデルタ吻合を行う方法は報告がなく、今回その手技を供覧する。また、カートリッジの挿入方向や角度の調節も合わせて工夫することで、吻合の際の過度な緊張による十二指腸損傷リスクを低減できるものと考えている。"

Event date： 2019.12

Venue：横浜市   Country：Japan  

Event date： 2019.11

Venue：神戸市   Country：Japan  

【目的】腹腔鏡下胃切除において、金谷らが考案したデルタ吻合は、完全鏡視下Billroth- I法再建の代表的な手技であり、広く普及している。一方、不用意なリニアステイプラー挿入による過度な緊張などによって、十二指腸損傷を来すリスクがある。そこで、これまで我々の施設で行ってきたデルタ吻合における、リニアステイプラー挿入の安全性を明らかにすることを目的として、術中・術後成績の検討を行った。【方法】当科においては、2009年7月にデルタ吻合を導入し、以降の腹腔鏡下幽門側胃切除（LDG）における完全鏡視下Billroth-I法再建時は全例にデルタ吻合を行っている。2019年2月末までに施行したデルタ吻合症例157例について、その治療成績を検討した。一般的なデルタ吻合では、リニアステイプラーのカートリッジ側を胃に挿入し、アンビルフォーク側（金属側）を十二指腸に挿入することが多いが、我々は十二指腸損傷のリスク軽減を目的として、逆に金属側を胃に挿入し、カートリッジ側を十二指腸に挿入して行った。【成績】上記挿入法で施行した157例において、術中・�� =Q8e$N==Fs;XD2B;=}$dK%9gITA4$O#1Nc$b$J$/!"J-9gIt69:u$dDL2a>c32$J$I$NCfD94|9gJ;>I$b#1Nc$bG'$a$J$+$C$?!#%j%K%"%9%F%$%W%i!<$N%7%c%U%H<4J}8~$K8GDj$5$l$F$$$k6bB0B&$r0_$KA^F~$9$k$3$H$K$h$j!"<4$rJ];}$7$?>uBV$G;D0_$r==Fs;XD2B&$KF0$+$9$3$H$,$G$-!"$=$N0lJ}$G==Fs;XD2$XA^F~$9$kB&!J%+!<%H%j%C%8!K$K$O2DF0@-$rM?$(!"$+$D@hC<$,F_$G$"$k$?$a$K!"==Fs;XD2A^F~!J<B:]$O==Fs;XD2$r$+$V$;$k!K$N:]$K==Fs;XD2JI$X$N2aEY$J6[D%$rKI$.!"0&8nE*$JJ-9g$,$G$-$?$H9M$($i$l$k!#

Event date： 2019.11

Venue：神戸市   Country：Japan  

Event date： 2019.11

Venue：Fukuoka   Country：Japan  

Event date： 2019.11

Venue：高知市   Country：Japan  

腹腔鏡下胃切除術は、開腹手術と比較した場合の優位性を背景に、その普及と手技の定型化が進んでいる。当科では現在、腹腔鏡下胃切除術を予定する患者さん全てに対して術前1mmスライスで造影CTを撮像し、VINCENT(FUJI)を用いて3D構築を行っている。通常、臍部にカメラポートを挿入し、そこを基準点として気腹下に他ポートを挿入していくが、術前3DCTの検討を行うと、臍部から膵上縁の高さ、6番郭清の目標となる右胃大網静脈合流部の相対的位置関係にはかなりの個人差があり、臍部を基準点としてポート位置を決定すると、膵上縁までの距離が遠く、郭清に難渋する症例があることがわかってきた。今回我々は、2015年3月以降からポートシミュレーションを開始するまでの127例の腹腔鏡下胃切除（6番郭清を伴う胃全摘、もしくは幽門側胃切除術）と2017年4月以降、ポートシミュレーションを術前に行って手術を施行した82例の周術期データを用いてシミュレーションの効果を検討した。両群において、手術時間に有意差はなかったが(P=0.30)、術中出血�� L$OM-0U$K8:>/$7$F$$$?!JP=0.03）。さらに、膵液瘻の指標となる術後腹水アミラーゼ値において、POD1では減少の傾向があり(P=0.053)、POD3においては有意に減少していた(P=0.003)。当科におけるポートシミュレーションの取り組みを実際の手術ビデオともに発表する。

Event date： 2019.11

Venue：高知市   Country：Japan  

Event date： 2019.11

Language：English  

Venue：Macau   Country：Macao  

Event date： 2019.10

Venue：Thimphu   Country：Bhutan  

Event date： 2019.10

Venue：Manila   Country：Philippines  

Event date： 2019.9

Venue：朝倉市   Country：Japan  

Event date： 2019.8

Venue：Thimphu   Country：Bhutan  

Event date： 2019.7

Venue：東京都   Country：Japan  

【背景】胃切除後にしばしば胆石が発生することが知られており、胃切除術の際に予防的胆嚢摘出術を行うべきかどうか長らく議論されてきた。一方、近年は胆嚢摘出術だけでなく胃癌手術も腹腔鏡手術が普及してきており、以前議論されてきた開腹手術の時とは状況が異なる可能性がある。【目的】今回、胃癌に対する腹腔鏡下胃切除術後胆石症の発生を検討し、予防的胆嚢摘出術の必要性を検討する。【対象】2000年4月から201７年3月の間に当科で胃癌に対する腹腔鏡下幽門側胃切除術を施行した696例について検討した。そのうち31例(4.5%)で、胃切除術以前に胆嚢摘出術が行われていた。また、胃切除術の時点で胆石を有していた54 例(7.8%)に対しては、同時に胆嚢摘出術を施行した。これらに加えて開腹移行例12例、Billroth-II再建6例を除き、最終的にBillroth-I再建(B-I)284例、Roux-en-Y法(R-Y)310例について、術後胆石症発生の有無およびその治療を後ろ向きに検討した。観察期間中央値はB-I 61.7か月、R-Y 60.9か月であっ�� $?!#!Z7k2L![=Q8eC@@P>I!JC@G97k@P>I!"AmC@4I7k@P>I!K$NH/@8$r52例（全体の8.8%）に認めた。再建形式別では、B-1群12例（4.2%）、R-Y群40例（12.9%）でR-Y再建群の方が有意に多かった（p=0.0002）、術後胆石を認めるまでの期間（中央値）はB-I群38.1か月、R-Y群31.4か月であり、それぞれ継時的に増加していた。そのうち36例は無症状であり、治療を要したものは16例(全体の2.7%)で、そのうち15例はR-Y群であった。なお、総胆管結石症をB-I群1例（0.4%）、R-Y群11例（3.6%）に認め、総胆管結石の発生割合もR-Y群で高かった(p=0.0056)。【結語】胆石の発生はR-Y群の方がB-I群よりも有意に多く、R-Y群では総胆管結石の発生率も高かった。治療を要した術後胆石は全体の2.7%、さらに開腹胆嚢摘出を要したものは0.5%に留まるため、胆石を認めない予防的胆嚢摘出は不要と思われるが、Roux-en-Y再建後の胆石発生には注意が必要である。

Event date： 2019.7

Venue：東京都   Country：Japan  

Event date： 2019.7

Venue：東京都   Country：Japan  

Event date： 2019.7

Venue：福岡市   Country：Japan  

Event date： 2019.6

Venue：Bishkek   Country：Other  

Event date： 2019.6

Venue：福岡市   Country：Japan  

症例は50歳代、男性。胸部食道癌に対して鏡視下食道切除・後縦隔経路胃管再建を施行した。術後4年経過後に喀血を来し、胃管肺瘻の診断で右肺上葉切除、広背筋弁による瘻孔閉鎖術を施行したが、瘻孔が開存し膿胸となったため、緊急開窓ドレナージ術を施行した。その後、炎症の波及により気管支断端瘻も併発し、胃管と右気管支それぞれの瘻孔が近接して併存する状態となった。その後もステント治療や肋間筋被覆、心膜パッチなどを試みたが瘻孔閉鎖に至らず、長期間の絶食・入院加療を要した。保存的治療では改善なく、かつ胃管瘻からの消化液流出を食い止めることが困難になったため、胃管の口側、肛門側を切離し、回結腸による消化管再建術を行い（胸骨前経路）、残存した胃管にはドレナージチューブを留置した。その結果、食事が可能になり、頻回の通院を要するもののフルタイム勤務できるまでに社会復帰を果たすことができた。今回、再建胃管末端部（盲端部）の虚血により肺瘻を形成したと考えられる。胸部食道癌手術における後縦隔経路再建は、他の再建経路に比べて距離が短く生理的であり、縫合不全率も低いが、一�� }$G:F7z0_4I$N6;9PFbL~Ce$,LdBj$H$5$l!"5)$G$O$"$k$,:#2s$N$h$&$JGYaq7A@.$d0_4I4b<#NE$X$N1F6A$,Bg$-$$!#$7$?$,$C$F!"<j=Q;~$K:F7z0_4I$N7lN.$K==J,Cm0U$9$k$3$H$O$b$A$m$s!"$I$N:F7z7PO)$rA*Br$9$k$+$K$D$$$F$O!"8D!9$N>u67$K1~$8$?H=CG$r$9$Y$-$G$"$k$H9M$($i$l$k!#

Event date： 2019.5

Venue：Thimphu   Country：Bhutan  

Event date： 2019.4

Venue：名古屋市   Country：Japan  

Event date： 2019.4

Venue：Hanoi   Country：Viet Nam  

Event date： 2019.4

Venue：大阪市   Country：Japan  

【背景】高齢患者は基礎疾患および加齢に伴う身体機能低下によって術後合併症が重篤化する危険性があり、胃の切除範囲や郭清範囲の縮小が望ましいという意見がある。また、周術期化学療法についても忍容性の問題等で施行されないことも多く、患者のQOL保持と癌の予後を考慮した治療戦略が求められる。【目的】80歳以上の高齢胃癌患者に対して、術式、郭清範囲、化学療法の有無からみた至適治療戦略に関する検討を行った。【対象】2007年4月から2017年3月の10年間に当科で腹腔鏡下胃癌手術（バイパス、部分切除を除く）を施行した腹腔鏡下胃癌手術（審査腹腔鏡、バイパスを除く）796例のうち、80歳以上の高齢患者94例（80-90歳）について、後ろ向きに検討した。観察期間中央値は29.2か月（5.9-71.3か月）、施行術式は胃全摘21例(22.3%)、噴門側胃切除14例(14.9%)、幽門側胃切除55例(58.5%)などであり、3例(3.2%)で開腹移行がなされた。最終病期はStage I 62例(66.0%)、Stage II 18
例(19.1%)、Stage III(8.5%)、Stage IV (6.3%)であった。【結果】進行癌43例のうちD2リンパ節郭清は26例（60.5%）に施行され、17例（39.5%）で郭清範囲の縮小がなされた。また、術後化学療法が施行されたのはわずか5例に留まった。縮小手術や化学療法の有無による予後への悪影響は明らかでなかった。なお、観察期間内の死亡例は35例(37.2%)に認めたが、原病死(16例)よりも他病死(19例)の方が多かった。また、術後合併症を認めた群は、合併症を認めなかった群に比べて術後在院日数が長く(中央値13日、9日、p&LT;0.001)、予後不良であった(5年生存率36%、72%、p=0.048)。また、胃全摘患者の予後は幽門側胃切除や噴門側胃切除の患者よりも悪かった。【結語】高齢患者では郭清度や化学療法の有無については差を認めなかったが、胃全摘患者の予後は悪く、可能な限り胃全摘を避けた方が望ましいと考えられた。

Event date： 2019.4

Venue：大阪市   Country：Japan  

これまで、我々は臓器変形モデルや３Dプリンターを用いた硬性/軟性/透過型モデル、スコープの位置情報を光学式センサーにより取得し、リアルタイムに仮想腹腔鏡画像を提供する術中ナビゲーションなど３次元モデルに基づいた手法を報告してきた。しかし、これらは個別の症例に日常診療として実用化しするには、コストや人員の確保などの面で問題があった。現在、我々は胃癌、食道癌の術前にルーチンとして1mmCTを複数相で撮像し３D画像を作成し、血管走行や関連臓器の形状、その相対的な位置関係などを把握している。当院ではこの作業を電子カルテに組み込まれたソフトで10分で行える。３D画像には２Dでは把握できない血管走行の向きや角度、長さ、周囲臓器との相対的な位置関係といった３Dでのみ特異的に把握できる立体解剖情報が含まれる。これまで、食道癌や胃癌の300症例以上の３D画像を取得し、それぞれの手術の難易度に関わる因子を複数同定してきた。たとえば、腹腔動脈の走行の向きや各分岐までの距離、膵実質との位置関係は個人差があり、手技の難易度�� $H?<$/4X$o$k!#2f!9$O$3$l$i$N#3D特異的因子を考慮して、ポート配置と郭清のアプローチ法を適切かつ個別に選択した。これにより３D導入前胃癌300症例と比較して導入後150症例で有意に出血量と膵液瘻が減少した。また、我々はロボット手術でも関節機能がないデバイスを用いるが、この際のポート配置にも術前３Dは有効であった。また、食道癌手術においては３D画像で評価可能な縦隔の広さが郭清/再建の両方においてその難易度や合併症のリスク因子となった。現在も鏡視下手術は進化しており、同じ術式でも複数のアプローチ法が確立されている。３次元モデルは単なる解剖把握による有用性だけではなく、その特有の解剖学的特徴を認識することで、適切な手技を選択し周術期の合併症を減らし、郭清精度を向上させうると考える。

Event date： 2019.2 - 2019.3

Venue：沼津市   Country：Japan  

[Background and Aim] It is widely known that cholelithiasis often occurs after gastrectomy, however, the consensus is not established about the differences of its incidence by reconstruction. In this study, it is examined the incidence of cholelithiasis after laparoscopic gastrectomy by the reconstruction.[Methods] 707 patients who underwent laparoscopic distal gastrectomy for gastric cancer since 2000 to 2017, were retrospectively examined, and were divided Roux-en-Y (R-Y) group (n=371) and Billroth-1 (B-1) group (n=319). The median follow-up was 60.7 months and 61.3 months in each. [Results] 49 cases (6.9%) of cholelithiasis were recognized, 12 cases (3.8%) in B-1 and 37 cases (10.0%) in R-Y (p=0.0016). The median postoperative intervals of cholelithiasis incidence were 27.0 months in B-1 and 31.4 months in R-Y (p=0.65). The incidence of choledocholithiasis has two cases (0.6%) in B-1, and 11 cases (3.0%) in R-Y (p=0.026). [Conclusion] The incid
ence of the cholelithiasis significantly had more in R-Y than in B-1, and was also at high incidence of the choledocholithiasis in R-Y. It is necessary to pay attention to the incidence of cholelithiasis after R-Y, and it is suggested that cholecystectomy be considered as early as possible when cholelithiasis is recognized.

Event date： 2019.2 - 2019.3

Venue：沼津市   Country：Japan  

Previously, we introduced 3 approaches, such as medial, right, left sided approaches and reported the utility of 3D simulation for its selection depending on the personalized anatomy. In 453 laparoscopic cases, blood loss and pancreatic fistula were reduced after 3D simulation. In Japan, for robotic suprapancreatic LN dissection, articulated instrument are often used because the articulation is one of most important advantages in robotic surgery. On the other hand, surgeons with experience of laparoscopic surgery are familiar with the use of ultrasonic scalpel, which is a non-articulated device even in robotic surgery. Therefore, such surgeons are not familiar with the robotic procedures without the ultrasonic scalpel. Recently, we introduced the preoperative 3D simulation for robotic LN dissection using ultrasonic scalpel. Based on the position of pancreas and major vessels, we decided the port site for the ultrasonic scalpel and the camera arms
and then safely and appropriately performed robotic LN dissection using the ultrasonic scalpel. Here, we will report about the utility of preoperative 3D simulation for robotic gastrectomy using ultrasonic scalpel.

Event date： 2019.2

Venue：鹿児島市   Country：Japan  

＜目的＞当科ではこれまで進行胃癌を含めて1000例を超える腹腔鏡下胃切除術を施行している。郭清を伴う胃癌に対して、双孔式、単孔式胃切除術が報告されているが、その遂行には高度な技術が要求される。当科では従来の手術手順は踏襲しNeedle 鉗子を用いた腹腔鏡下胃切除術を行ってきた。今回、Needle鉗子に焦点をおいて行ったD2郭清を伴う胃切除術に関して報告する。＜手技＞細径鉗子は2.1mm BJ Needle鉗子もしくは3mm鉗子を使用し、組織の展開を行う際は組織損傷予防の為にガーゼを介して行っている。臍部に30mmの切開を置き、マルチチャンネルポートを挿入、同ポートに12mmトロッカーおよび5mmトロッカーを挿入する。D2郭清の場合、術者は左手用に右季肋部に5mmポートを、また、右手用に12mmポートを右側腹部に挿入する。助手は右手用に左季肋部に細径鉗子を挿入し、左手用にマルチチャンネルポートに挿入した5mmポートを利用する。上腹部正中に肝圧排鈎用に3mmの切開を置く。ガーゼを12㎜ポートからあらかじめ数枚挿入しておく。�� _@ZN%$N:]$K$O%^%k%A%A%c%s%M%k$N12㎜ポートからリニアーステープラーを挿入する。＜結果＞#11pリンパ節郭清の際には膵臓の十分な転がしおよび胃膵ヒダの腹側への牽引が重要となるが、症例を選択すれば、助手は上記ポート配置で充分に展開することが可能であり細径鉗子でも胃膵ヒダの把持に問題はなかった。また、通常のポート配置に比べて助手の左手が臍部から挿入されているため、カメラポートとの干渉で若干操作性が窮屈となったが、助手の両手の角度が大きくなり、膵上縁の視野展開にはより有効な側面もあった。＜まとめ＞これまでの手術手技を生かして、Needle鉗子を用いた腹腔鏡下胃切除術でも適切な郭清が可能であった。Needle鉗子は、内臓脂肪が多い症例では術野の展開に問題が生じる可能性もあるが、症例を選択すれば、適切に膜を把持することにより術野の展開が可能になると考える。

Event date： 2019.1

Venue：Dagupan   Country：Philippines  

Event date： 2018.12

Venue：Yangon   Country：Myanmar  

Event date： 2018.12

Venue：東京都   Country：Japan  

Event date： 2018.12

Venue：福岡市   Country：Japan  

Event date： 2018.12

Venue：福岡市   Country：Japan  

Event date： 2018.12

Venue：福岡市   Country：Japan  

Event date： 2018.12

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：Puerto Varas   Country：Chile  

Event date： 2018.11

Venue：東京都   Country：Japan  

我々は2013年にロボットを導入したが、その後定着しなかった。この1因は鏡視下で親しんだ超音波凝固切開装置を用いない手技の導入であった。現在も、超音波凝固切開装置はロボットの利点である関節機能がないため膵上縁郭清ではその使用は限定されている。国外では患者右側に2本のアームをセットし、超音波凝固切開装置による膵上縁郭清が行われているが、国内のポートセッティングの多くは患者左側に2本のアームがあり、通常、超音波凝固切開装置での膵上縁郭清が困難である。これまで鏡視下手術において我々は３Dシミュレーションから主要血管や膵臓の相対的な位置関係を把握し、ポート位置や膵上縁郭清のアプローチを適切に決定し、安全な郭清が行えることを報告してきた。また、この手法は膵の変形や回転を伴うものの３D導入以前300症例に比較して、導入後150症例での術後膵液瘻が有意に減少していた。再度ロボットを導入するにあたって、国内で多い患者左側に2本のアームを挿入するセッティングと慣れたデバイスである超音波凝固切開装置の使用を優先し、術前３D$
B%7%_%e%l!<%7%g%s$+$i%+%a%i%]!<%H$d45<T1&B&%]!<%H$N0LCV$r87L)$K7hDj$9$k$3$H$Gg9>e1o3T@6$r4^$`0BA4$J<j5;$r?7$?$KDj7?2=$7$?!#:#8e!"#3�Dで把握できる主要血管の走行角度や膵との位置関係から手術の難易度を予測し、進行度によらず、安全確実な郭清を担保したロボット手術の導入をすすめていく。

Event date： 2018.11

Venue：Merida   Country：Mexico  

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：福岡市   Country：Japan  

BackgroundThe number of surgeons in Japan has declined more than 25% in the last 20 years. Another problem faced in Japan is the limited English communication skills of Japanese students. As an attempt to address these problems, international tele-education involving live surgery for second-year medical students was undertaken.MethodsA lecture was designed to introduce students to telemedicine as well as devices and instruments for laparoscopic surgery. After the class, students were given questionnaires for evaluation purposes. The class required a connection between Japan and Korea with live surgeries annually from 2008 to 2017. ResultsA total of 96% of medical students had a favorable impression of the class. A total of 88.3% were positive about the class being performed in English, and 96.1% thought it important for promoting international exchange and improving their English skills. The percentage of students indicating interest in general su
rgery was 86.6%, and 94.5% of them were interested in laparoscopic surgery. Finally, three quarters of students had a more favorable impression of surgery after the class than before.ConclusionOur tele-education class is an effective approach for encouraging medical students in the early years of training to become interested in surgery and international exchanges.

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：福岡市   Country：Japan  

Event date： 2018.11

Venue：Fukuoka   Country：Japan  

Event date： 2018.11

Venue：神戸市   Country：Japan  

Event date： 2018.11

Venue：神戸市   Country：Japan  

Event date： 2018.11

Venue：神戸市   Country：Japan  

Event date： 2018.10

Venue：Dushanbe, Tajikistan   Country：Other  

Event date： 2018.10

Venue：Dushanbe, Tajikistan   Country：Other  

招待講演（Invited lecture）です。

Event date： 2018.10

Venue：横浜市   Country：Japan  

Event date： 2018.10

Venue：横浜市   Country：Japan  

Event date： 2018.9

Venue：Santiago   Country：Chile  

Event date： 2018.9

Venue：福岡市   Country：Japan  

Event date： 2018.9

Venue：Riyadh  

Event date： 2018.7

Venue：鹿児島市   Country：Japan  

高齢化に伴い、80歳以上の高齢患者にも胃癌手術を行う機会が増えている。しかし、高齢者は身体機能の衰えや併存疾患のため、術後合併症の発生には若年者以上に注意を払う必要がある。そこで、今回当科で手術を行った80歳以上の胃癌患者における術後合併症について検討を行った。　2008年1月から2014年12月の間に当科で胃癌手術（バイパス、部分切除を除く）を施行した574例のうち、80歳以上の高齢患者67例（80-90歳）について後ろ向きに検討した。観察期間中央値は47か月（5-60か月）、施行術式は胃全摘11例、噴門側胃切除13例、幽門側胃切除43例であり、そのうち66例（98.5%）に腹腔鏡手術を施行した。　　80歳以上の高齢患者67例のうちClavien-Dindo分類Grade 2以上の術後合併症は15例(22.3%)にみられた。内訳は、縫合不全が１例、イレウス１例、肺炎・無気肺７例、尿路感染症１例、心不全１例などで、在院死は１例もなかった。術後合併症の有無と、術式・手術時間・出血量との間��K$OM-0U$JAj4X$rG'$a$J$+$C$?$,!"=Q8e9gJ;>I$rG'$a$?72(n=15)は、合併症を認めなかった群(n=52)に比べて有意に術後在院日数が長く(中央値13日、9日、p&LT;0.001)、予後不良であった(5年生存率36%、72%、p=0.048)。　また、術前栄養状態についても検討を行い、小野寺らが報告した予後栄養指数PNI(血清アルブミン値x10+血中リンパ球数x0.005)およびBMIを用いて評価を行った。PNI中央値は45.9 (36.1-63.1)、BMI中央値は22.3(17.4-32.4)であり、術後合併症の有無と術前PNIあるいはBMIとの間にも有意差はみられなかった。　以上より、高齢者における胃癌術後合併症の有無は予後に影響を及ぼすため、安全な手術を遂行するための十分な評価が必要と考えられた。

Event date： 2018.7

Venue：鹿児島市   Country：Japan  

Event date： 2018.7

Venue：鹿児島市   Country：Japan  

Event date： 2018.6

Venue：宇都宮市   Country：Japan  

食道癌手術後の５年全生存率は55.9%、根治手術後の再発は28-47%に認められ、根治切除を行ってもその再発率の高さが問題となっている。再発形式としてはリンパ節、局所再発、遠隔臓器への転移（肺、肝、骨、脳など）があり、それぞれの病態に応じた治療が求められる。そこで、当科で1987年１月から2016年12月の間に当科で食道癌根治手術（食道切除術）を行った335例を対象として、手術時点での臨床病理学的所見と術後再発形式(術後再発が判明した時点での再発部位)との関係を後ろ向きに検討した。術後再発は92例(27.5%)に認められ、手術から再発までの期間は10.8か月(中央値)であった。判明時点での再発形式は、局所再発または縦隔リンパ節再発41例(全手術例の12.2%)、頚部リンパ節再発23例(6.9%)、腹腔内リンパ節再発13例(3.9%)、肺転移23例(6.9%)、肝転移15例(4.5%)、骨転移8例(2.4%)、その他19例(5.7%)であった(重複あり)。病変の位置��K$h$k8!F$$G$O!"6;It?)F;4b286例中86例(30.1%)、腹部食道癌24例中6例(25.0%)に術後再発を認め、肺転移は胸部中部食道癌(Mt)における割合が最も高く(再発48例中14例; 29.2%)、肝転移は腹部食道(Ae)における割合が最も高い(再発6例中4例; 66.7%)などの結果が得られた。また、再発形式別の検討や手術時のリンパ節転移部位との関連なども検討を行った。これらの結果を踏まえて、術後の再発予防をいかに行うかが今後の検討課題であると考えられる。

Event date： 2018.6

Venue：宇都宮市   Country：Japan  

Event date： 2018.6

Venue：北九州市   Country：Japan  

Event date： 2018.4

Venue：Ho Chi Minh City   Country：Viet Nam  

Event date： 2018.4

Venue：東京都   Country：Japan  

Event date： 2018.4

Venue：東京都   Country：Japan  

Event date： 2018.4

Venue：東京都   Country：Japan  

Event date： 2018.4

Venue：東京都   Country：Japan  

胃癌に対する腹腔鏡下胃切除術は、開腹手術と比較した非劣性の報告の増加を背景に、その普及と手技の定型化が進んでいる。当科では、同手術を開始当初より、術者がすべての手技を患者右側より行う方法で技術を確立しており、500例を超える症例の蓄積がある。さらに近年、3DCTによるシミュレーションが発達しており、郭清時に切離する動静脈の分岐やその位置、郭清すべき膵上縁の解剖学的位置関係などの腹腔内状況が、術前より想定し得るようになった。しかし、腹腔内における膵臓の位置には個人差があり、通常行うように臍部にカメラポートを挿入し、そこを中心として他ポートを挿入していく手順では、術者右手ポートが目標とする右胃大網動脈根部/静脈合流部や膵上縁へのアクセスルートから外れる場合がある。今回我々は、上部消化管手術症例41例について、腹腔内の解剖学的位置関係の差異を、3Dシミュレーションを用いて詳細に検討した。男性30:女性11、年齢中央値68歳（50-85）、BMI中央値22(16.9-34.8)で、原疾患は胃癌29例、食道癌6例、胃粘��l2<<pag3例、食道裂孔ヘルニア1例、十二指腸癌1例、卵巣癌腹腔内リンパ節転移1例であった。臍部から膵上縁までの高さは中央値110.3mmであるが、その範囲は67.5-154.6mmと大きな個体差があった。また、右胃大網動脈根部の高さも、中央値72mmであるが、こちらも範囲は19.3-114.9mmと非常に大きな個体差を認めた。ただし、膵上縁の高さと右胃大網動脈根部の高さそれぞれの間には相関があり(P&LT;0.01, rs=0.90: Spearman検定)、右胃大網動脈根部/静脈合流部を基準に右下腹部ポート(術者右手)を挿入することは妥当と思われた。これらのデータを基に、当科では最適な右手ポートを術前より想定する方法を確立したので報告する。

Event date： 2018.4

Venue：東京都   Country：Japan  

Event date： 2018.3

Venue：横浜市   Country：Japan  

Event date： 2018.3

Venue：横浜市   Country：Japan  

Event date： 2018.3

Venue：横浜市   Country：Japan  

Event date： 2018.3

Venue：Sao Paulo   Country：Brazil  

Event date： 2017.12

Venue：Kuala Lumpur   Country：Malaysia  

Event date： 2017.12

Venue：京都市   Country：Japan  

Event date： 2017.12

Venue：京都市   Country：Japan  

Event date： 2017.12

Venue：京都市   Country：Japan  

Event date： 2017.11

Venue：Coquimbo   Country：Chile  

Event date： 2017.11

Venue：東京都   Country：Japan  

Event date： 2017.11

Venue：Tokyo   Country：Japan  

Event date： 2017.11

Venue：Cebu   Country：Philippines  

Event date： 2017.11

Venue：Cebu   Country：Philippines  

Event date： 2017.10

Venue：福岡市   Country：Japan  

Event date： 2017.10

Venue：福岡市   Country：Japan  

Event date： 2017.10

Venue：福岡市   Country：Japan  

Event date： 2017.10

Venue：福岡市   Country：Japan  

Event date： 2017.9

Venue：名古屋市   Country：Japan  

Event date： 2017.9

Venue：札幌市   Country：Japan  

Event date： 2017.9

Venue：福岡市   Country：Japan  

Event date： 2017.9

Venue：福岡市   Country：Japan  

Event date： 2017.8 - 2018.9

Venue：Dalian   Country：China  

Event date： 2017.7

Venue：金沢市   Country：Japan  

Event date： 2017.7

Venue：金沢市   Country：Japan  

Event date： 2017.7

Venue：金沢市   Country：Japan  

Event date： 2017.7

Venue：金沢市   Country：Japan  

Event date： 2017.7

Venue：金沢市   Country：Japan  

Event date： 2017.6

Venue：Colombo  

Event date： 2017.6

Venue：軽井沢町   Country：Japan  

Event date： 2017.6

Venue：軽井沢町   Country：Japan  

Event date： 2017.6

Venue：軽井沢町   Country：Japan  

Event date： 2017.6

Venue：Manila   Country：Philippines  

Event date： 2017.6

Venue：Manila   Country：Philippines  

Event date： 2017.5

Venue：名古屋市   Country：Japan  

Event date： 2017.5

Venue：名古屋市   Country：Japan  

Event date： 2017.5

Venue：福岡市   Country：Japan  

Event date： 2017.5

Venue：福岡市   Country：Japan  

Event date： 2017.5

Venue：Chicago  

Event date： 2017.4

Venue：横浜市   Country：Japan  

Event date： 2017.4

Venue：横浜市   Country：Japan  

Event date： 2017.4

Venue：横浜市   Country：Japan  

Event date： 2017.4

Venue：Bishkek   Country：Other  

Event date： 2017.4

Venue：Fukuoka   Country：Japan  

Event date： 2016.12

Venue：横浜市   Country：Japan  

Event date： 2016.12

Venue：横浜市   Country：Japan  

Event date： 2016.12

Venue：横浜   Country：Japan  

Event date： 2016.12

Venue：Mexico city   Country：Mexico  

Event date： 2016.11

Venue：東京都   Country：Japan  

Event date： 2016.11

Venue：東京都   Country：Japan  

Event date： 2016.11

Venue：東京都   Country：Japan  

Event date： 2016.11

Venue：Bangkok   Country：Thailand  

Event date： 2016.11

Venue：神戸市   Country：Japan  

Event date： 2016.11

Venue：神戸市   Country：Japan  

Event date： 2016.11

Venue：神戸市   Country：Japan  

Event date： 2016.10

Venue：福岡市   Country：Japan  

Event date： 2016.10

Venue：米子市   Country：Japan  

Event date： 2016.10

Venue：米子市   Country：Japan  

Event date： 2016.10

Venue：米子市   Country：Japan  

Event date： 2016.10

Venue：福岡市   Country：Japan  

Event date： 2016.9

Venue：Mexico city   Country：Mexico  

Event date： 2016.9

Venue：Santiago   Country：Chile  

Event date： 2016.9

Venue：Kathmandu   Country：Nepal  

Event date： 2016.9

Venue：福岡市   Country：Japan  

Event date： 2016.7

Venue：徳島市   Country：Japan  

Event date： 2016.7

Venue：徳島市   Country：Japan  

Event date： 2016.7

Venue：Santiago   Country：Chile  

Event date： 2016.7

Venue：東京都   Country：Japan  

Event date： 2016.6

Venue：佐賀市   Country：Japan  

Event date： 2016.4

Venue：Dhaka   Country：Bangladesh  

Event date： 2016.4

Venue：大阪市   Country：Japan  

Event date： 2016.4

Venue：大阪市   Country：Japan  

Event date： 2016.4

Venue：大阪市   Country：Japan  

Event date： 2016.4

Venue：大阪市   Country：Japan  

Event date： 2016.4

Venue：大阪市   Country：Japan  

Event date： 2016.3

Venue：別府市   Country：Japan  

Event date： 2016.3

Venue：別府市   Country：Japan  

Event date： 2016.3

Venue：別府市   Country：Japan  

Event date： 2016.3

Venue：東京都   Country：Japan  

Event date： 2016.1

Venue：福岡市   Country：Japan  

Event date： 2015.12

Venue：東京都   Country：Japan  

Event date： 2015.12

Venue：大阪   Country：Japan  

Event date： 2015.12

Venue：大阪市   Country：Japan  

Event date： 2015.12

Venue：大阪市   Country：Japan  

Event date： 2015.12

Venue：大阪市   Country：Japan  

Event date： 2015.11

Venue：福岡市   Country：Japan  

Event date： 2015.11

Venue：福岡市   Country：Japan  

Event date： 2015.10

Venue：仙台市   Country：Japan  

Event date： 2015.10

Venue：仙台市   Country：Japan  

Event date： 2015.10

Venue：東京都   Country：Japan  

Event date： 2015.9

Venue：Mazatlan   Country：Mexico  

Event date： 2015.9

Venue：Daegu   Country：Korea, Republic of  

Event date： 2015.8

Venue：Sao Paulo   Country：Brazil  

Event date： 2015.7

Venue：飯塚市   Country：Japan  

Event date： 2015.7

Venue：浜松   Country：Japan  

Event date： 2015.7

Venue：浜松市   Country：Japan  

Event date： 2015.7

Venue：浜松市   Country：Japan  

Event date： 2015.7

Venue：横浜市   Country：Japan  

Event date： 2015.6

Venue：名古屋市   Country：Japan  

Event date： 2015.6

Venue：Porto   Country：Portugal  

Event date： 2015.6

Venue：東京   Country：Japan  

Event date： 2015.6

Venue：東京都   Country：Japan  

Event date： 2015.4

Venue：名古屋市   Country：Japan  

Event date： 2015.4

Venue：名古屋市   Country：Japan  

Event date： 2015.4

Venue：名古屋市   Country：Japan  

Event date： 2015.4

Venue：名古屋市   Country：Japan  

Event date： 2015.4

Venue：名古屋   Country：Japan  

Event date： 2015.3

Venue：広島市   Country：Japan  

Event date： 2015.3

Venue：広島市   Country：Japan  

Event date： 2015.3

Venue：広島市   Country：Japan  

Event date： 2014.12

Venue：大分   Country：Japan  

Event date： 2014.11

Venue：Cancun   Country：Mexico  

Event date： 2014.11

Venue：Hawaii  

Event date： 2014.10

Venue：Yangon   Country：Myanmar