伊藤 綾香

BACKGROUND: This study aimed to investigate the laparoscopic gastrectomy (LG) performance of non-Endoscopic Surgical Skill Qualification System (ESSQS)-qualified surgeons under the ESSQS-qualified surgeon guidance and compare oncological outcomes of gastric cancer to LG performed by the ESSQS-qualified surgeons. METHODS: This study enrolled 1,030 patients diagnosed with both clinical and pathological stage ≤ III gastric cancer and undergoing LG from January 2009 to June 2019. ESSQS-qualified surgeons served as the operator or the instructive assistant in all LG procedures involving them. A propensity score-matched analysis was used to retrospectively compare the long-term outcomes between the ESSQS-qualified and non-ESSQS-qualified surgeons. RESULTS: Each group included 315 pairs after propensity score matching. The 3-year recurrence-free survival rates were 84.4% and 81.7% in the non-ESSQS and ESSQS groups, respectively. The difference was 2.7% (95% confidence interval: - 3.20%-8.44%, P < 0.001), and the non-ESSQS group statistically demonstrated noninferiority as the lower 95% confidence limit was greater than the prespecified margin of -10%, indicating the achieved primary endpoint. No significant differences in 5-year recurrence-free survival (non-ESSQS: 78.5% vs. ESSQS: 77.4%, P = 0.627) and 5-year overall survival (non-ESSQS: 80.9% vs. ESSQS: 79.3%, P = 0.475) were found between the two groups. The oncological outcomes stratified according to the presence of pathological stage I, II, and III disease did not significantly differ between the two groups. CONCLUSIONS: LG performed by non-ESSQS-qualified surgeons achieved comparable oncological outcomes to the ESSQS-qualified surgeons, as long as ESSQS-qualified surgeons provided intraoperative instructions, in a high-volume center.

Undergoing another surgery after a previous abdominal procedure can sometimes result in significant abdominal adhesions. We present a case of robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir. A 65-year-old male patient underwent robot-assisted total bladder resection and creation of a urinary reservoir for bladder cancer in 2013. He presented with melena. Thus, the findings revealed advanced low rectal cancer. The robot-assisted low anterior resection was performed in 2022. Extensive adhesions were observed in the pelvic space. The indocyanine green function was appropriately used, and the robotic surgery was completed without injury to the urinary reservoir or major complications. The surgical time was 510 min, and the blood loss volume was 15 mL. The patient had been recurrence free for 12 months following the surgery. Robot-assisted surgery can be beneficial for patients with rectal cancer with significant pelvic adhesions.

The patient is a 60-year-old female with a history of multiple times of recurrences of an esophageal diverticulum. She was referred for a diagnosis of persistent dysphagia and vomiting. Balloon dilation did not improve the symptoms; thus, she was referred for surgery. Esophageal fluoroscopy revealed a 5 cm diverticulum. There was no significant change in the size before and after dilation. Gastrointestinal endoscopy revealed a diverticulum in the lower esophagus, with a residue accumulation. The esophagus directly below the diverticulum was narrowed. The patient was diagnosed with recurrent lower esophageal diverticulum and underwent surgery. The operative findings showed poor coloration of the gastric fundus surrounding operated before by Nissen's method, so the patient underwent lower esophagogastric resection and interstitial jejunal reconstruction. The postoperative course was uneventful and discharged on the 19th day. She is 6 years postoperatively and gained six kg compared to her preoperative weight. She has remained in excellent health.

The patient is a 58-year-old woman. She was referred to our hospital following a computed tomography scan that revealed a 2-cm tumor-like lesion in the pancreatic body. Endoscopic ultrasound fine-needle aspiration examination revealed a suspected undifferentiated carcinoma with pleomorphic type. The patient was diagnosed with anaplastic carcinoma of the pancreas (ACP) and underwent distal pancreatectomy with lymph nodes dissection. The resected body and tail of the pancreas had a nodular tumor measuring 30 mm in diameter. Histologically, the main lesion of the tumor showed well-differentiated adenocarcinoma, and diffuse proliferation of atypical short spindle cells and round cells accompanied by multinucleated giant cells aggregation was observed around the tubular structure; hence, it was diagnosed with ACP. The postoperative course was uneventful, and the patient was discharged 14 days after the operation. It has already been about 5 years since the surgery, and although the tumor has recurred, the patient is still alive and undergoing chemotherapy.

Cases of delayed colo-anal anastomosis (DCAA) are currently reported instead of the colo-anal anastomosis with a protective loop ileostomy for rectal cancer. Post-operative colonic ischemia is considered as one of the serious complications of colorectal resection. Although indication of DCAA should be carefully selected, we experienced a case of post-operative stenosis caused by colonic ischemia after low anterior resection for rectal cancer, followed by this procedure.

術前化学療法施行後にロボット支援下手術を施行し良好な転帰が得られた単発性肝転移を伴うStage IV胃癌の1例を経験したので報告する。症例は70代、男性。肝S3に転移を伴う進行胃癌(cT4aN+M1、cStage IV)と診断し、S-1/CDDP(SP)療法を開始した。4コース施行後の評価CTで転移性肝腫瘍は不明瞭化し、原発巣、リンパ節転移巣も著明な縮小を認めていた。この時点で手術を勧めたが本人は希望せず、SP療法を継続した。計23コース施行後の評価では肝転移巣は不明瞭化したままであったが、原発巣はやや増大を認めた。再度手術を勧めたところ希望されたため、ロボット支援下幽門側胃切除ならびに肝S3部分切除術を施行した。長期間にわたる抗癌剤治療の影響で組織の瘢痕化や脆弱化がみられたが、手術支援ロボットの特性を活かしoutermost layerの同定と同層を維持した郭清を進めていくことで出血が少なく過不足のない郭清手技を施行できた。手術時間391分、出血量は11mLであった。術後合併症は特になく、術後11日目に退院となった。術後病理診断では切除肝には悪性所見は認められず、ypT2N1M0、ypStage IIAであった。術後12ヵ月現在、無再発経過中である。(著者抄録)

十二指腸原発消化管間葉系腫瘍(GIST)は比較的まれである。今回、十二指腸水平脚のGISTに対しKocher授動手技を用いたアプローチで腹腔鏡下に切除し得た1例を経験したので報告する。症例は49歳、女性。身長150cm、体重98.7kg、BMI43.4kg/m2であった。胆石症の精査で十二指腸水平脚に約20mm大の腫瘤性病変を認めた。GISTの可能性が高く、腹腔鏡下十二指腸局所切除を施行した。Kocher授動にて十二指腸球部から水平脚までを授動し、腫瘍部を頭側に引きだし、linear staplerにて局所切除を施行した。手術時間152分、出血量は少量であった。術後経過は良好で、合併症なく術後7日目に退院となった。病理組織学的診断は超低リスクのGISTであった。Kocher授動を用いたアプローチによる腹腔鏡下十二指腸局所切除は、高度肥満症例でも有用な術式の一つになり得ると考えられた。(著者抄録)