須田 康一

食道の多発ヨード不染には高度飲酒・喫煙が関与すると報告されており、食道粘膜に多発のヨード不染を呈する症例は食道癌のハイリスク群である。多発不染を呈する食道粘膜面においては、ヨード不染として認識される病変の癌・非癌の診断が非常に難しく、また領域診断も困難であることが多い。多発ヨード不染を呈する食道粘膜(まだら不染食道)におけるヨード不染帯において、癌・非癌の診断に有用であるのがPC signを用いたヨード不染帯の鑑別である。これはヨード散布2〜3分後に癌部においてピンク色の色調を呈する現象であり、多発ヨード不染帯内に存在する表在型食道癌の領域診断を可能にする。また、表在型食道癌内視鏡治療後においては、背景食道粘膜に多発不染帯を呈する症例では呈さない症例に比べ異時性多発重複癌が多くみられる傾向にある。治療後の経過観察においても定期的なヨード散布により、早期病変を見逃さないよう注意する必要性がある。(著者抄録)

<p>自己免疫性水疱症は自己抗体により細胞間接着が障害され，皮膚や重層扁平上皮に水疱が形成される疾患の総称である．多くは皮膚に水疱やびらんを形成するが，目，鼻，口腔粘膜，口唇，咽喉頭，食道などの重層扁平上皮にも水疱やびらんを形成することがある．しかし，咽喉頭および食道粘膜における病変の発生頻度や特徴についてはよく知られていない．この研究においては，自己免疫性水疱症における上部消化管内視鏡検査の重要性を評価することを目的とし，内視鏡的な咽喉頭食道病変の発生頻度をprimary endpoint，内視鏡的・臨床的特徴を見出すことをsecondary endpointとして評価を行った．口腔または咽喉頭病変を50.4％，咽喉頭病変を30.8％に認めた．通常観察で食道粘膜面に異常を認めなかった症例の40.6％において機械的刺激による表皮剥離または血疱形成（Nikolsky現象）を呈した．全体の16.8％に通常観察で食道病変を認め，56.0％がNikolsky現象陽性を呈した．皮膚病変を認めない29.2％の症例において，77.7％に口腔または咽喉頭病変，36.1％に食道病変，58.3％にNikolsky現象を認めた．上部消化管内視鏡所見より自己免疫性水疱症を疑うことは可能であり，その内視鏡的特徴および所見を理解しておくことは重要である．</p>

73歳男。62歳時に頸部食道癌と診断され、喉頭全摘を回避するため化学放射線療法を施行され、2コース施行後の効果判定はCRであった。初回治療から9年半後、嚥下時違和感および咽頭痛が出現し、上部消化管内視鏡検査で切歯17cm〜22cm迄に白苔を伴う隆起性病変を認めた。食道造影検査では下咽頭〜頸部食道右側壁に陰影欠損像を認め、その肛門側に25mm大の腫瘤像を認めた。生検病理診断では肉腫様変化を示す低分化な扁平上皮癌が疑われ、食道癌(Ce CRT-Type 5b cT2N0M0 cStage II)と術前診断し、咽頭喉頭頸部食道全摘・遊離空腸再建・永久気管孔造設を行なった。手術検体病理組織学的診断では部分的に角化を伴い、地図状・中小胞巣状に浸潤する癌であり、扁平上皮癌(pT3、INFb、pIM0、ly0、v0、pPM0、pDM0、pRM0、pN0、pStage II)と診断した。現在術後半年経過しているが、無再発生存中である。

BACKGROUND: Higher morbidity in total gastrectomy than in distal gastrectomy has been reported, but laparoscopic subtotal gastrectomy (LsTG) has been reported to be safe and feasible in early gastric cancer (GC). We determined the surgical, nutritional and oncological outcomes of LsTG for advanced gastric cancer (AGC). METHODS: Of the 816 consecutive patients with GC who underwent radical gastrectomy at our institution between 2008 and 2012, 253 who underwent curative laparoscopic gastrectomy (LG) for AGC were enrolled. LsTG was indicated for patients with upper stomach third tumors, who hoped to avoid total gastrectomy, <4 cm to the esophagogastric junction and a 2-cm proximal margin with cut end negative in frozen section, whereas laparoscopic conventional distal gastrectomy (LcDG) and laparoscopic total gastrectomy (LTG) were performed otherwise. Surgical outcomes and postoperative nutritional status were primarily assessed. RESULTS: Of 253 patients, the morbidity (Clavien-Dindo classification grade ≥ III) was 17.0% (43 patients). The 3-year overall survival and 3-year recurrence-free survival rates were 80.2 and 73.5%, respectively. LcDG, LsTG and LTG were performed in 121, 27 and 105 patients, individually. Morbidity was strongly associated with LTG (P = 0.001). Postoperative loss of body weight was significantly greater after LTG in comparison with LcDG or LsTG (P < 0.001). No difference in morbidity and postoperative loss of body weight were observed between LcDG and LsTG group. CONCLUSIONS: LG for AGC was feasible and safe surgically and oncologically. LsTG for AGC may be safer than LTG from surgical and postoperative nutritional point of view.

BACKGROUND AND AIM: Autoimmune bullous disease (ABD) is induced by autoantibodies against cell adhesion molecules, and blistering may occur on the mucous membranes of the eyes, nose, mouth, oral cavity, laryngopharynx, and esophagus. Endoscopic prevalence and features of ABD-associated esophageal lesions are not well known. We conducted the present study to assess the endoscopic prevalence of ABD-associated mucosal lesions. METHODS: Endoscopic prevalence of mucosal lesions, particularly laryngopharyngeal and esophageal lesions, was used as the primary endpoint to assess the significance of upper gastrointestinal endoscopy, and clinical and endoscopic features were secondary endpoints. RESULTS: Of 123 ABD patients, 50.4% had apparent oral or laryngopharyngeal lesions and 30.8% had laryngopharyngeal lesions. Esophageal lesions were detected through normal observation in 16.8% of affected patients, whereas 40.6% exhibited epidermolysis or blood blisters by mechanical inducement, regardless of esophageal mucosal lesion detection by normal observation. Additionally, 56.0% exhibited the Nikolsky sign with mechanical inducement. Of the 123 patients, 29.2% did not have exposed skin lesions. Of these patients, 77.7% had oral cavity or laryngopharyngeal lesions, 36.1% had esophageal lesions, and 58.3% exhibited the Nikolsky sign on esophageal mucosa. CONCLUSION: It is important to determine the endoscopic characteristics and findings of ABD. ABD can be suspected from endoscopic findings.

BACKGROUND: For resectable advanced esophageal cancer, a transthoracic esophagectomy following preoperative treatment is recognized as one of the standard treatments. Therefore, predictive markers which can be identified before surgery need to be established to identify patients with a poor prognosis. METHODS: We retrospectively reviewed 102 consecutive patients who underwent curative transthoracic esophagectomy following preoperative treatment in our institution between 2004 and 2013. Based on plasma fibrinogen and serum albumin levels, the pretreatment and preoperative fibrinogen and albumin score (FA score) were investigated and the prognostic significance of the FA score change was compared with RECIST. RESULTS: The patients were classified according to whether the FA score had remained unchanged or decreased (n = 77) or the FA score increased (n = 25). When the correlation between the response rate and change in the FA score was investigated, the response rate was significantly lower in the group with the increased FA score. In the survival analysis, patients in the increased FA score group exhibited a significantly worse recurrence-free survival (RFS) (P = 0.038). A multivariate analysis using the clinical stage and the change in the FA score as covariates revealed that a change in the FA score (HR 1.802; P = 0.047; 95% CI 1.008-3.221) was shown to be a significant independent predictive factor for RFS. CONCLUSIONS: A change in the FA score was shown to be an independent prognostic factor for postoperative recurrence in esophageal cancer patients who have undergone transthoracic esophagectomy following preoperative treatment.

More than 4000 da Vinci Surgical Systems have been installed worldwide. Robotic surgery using the da Vinci Surgical System has been increasingly performed in the last decade, especially in urology and gynecology. The da Vinci Surgical System has not become standard in surgery of the upper gastrointestinal tract because of a lack of clear benefits in comparison with conventional minimally invasive surgery. We initiated robotic gastrectomy and esophagectomy for patients with upper gastrointestinal cancer in 2009, and we have demonstrated the potential advantages of the da Vinci Surgical System in reducing postoperative local complications after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. However, robotic surgery has the disadvantages of a longer operative time and higher costs than the conventional approach. In this review article, we present the current status of robotic surgery for gastric and esophageal cancer, as well as future perspectives on this approach, based on our experience and a review of the literature.

BACKGROUND: Valvuloplastic esophagogastrostomy by double flap technique (VEG-DFT) is a promising procedure to prevent reflux after proximal gastrectomy (PG), and is achieved by the burial of the abdominal esophagus into the gastric submucosa; however, laparoscopic VEG-DFT is technically demanding due to complicated suturing and ligation maneuvers. The present study was designed to determine the feasibility and safety of robotic VEG-DFT. METHODS: After robotic PG, seromuscular flaps were extracorporeally created at the anterior wall of the remnant stomach through a small umbilical incision. Then, using a robot, the posterior wall of the esophagus was fixed to the cranial end of the mucosal window, and layer-to-layer sutures were placed between the anterior aspects of esophagus and the remnant stomach. Finally, the anastomosis was covered by seromuscular flaps. Short-term outcomes of 12 consecutive patients who underwent VEG-DFT between January 2014 and December 2015 were assessed. RESULTS: Operations were successfully completed using robotic assistance in all patients. Median operative, surgeon console, and anastomosis times were 406 (324-613 min), 267 (214-483), and 104 (76-186) min, respectively, and median estimated blood loss was 31 (5-130) ml. The first six cases were required to reach a learning plateau. Both mortality and morbidity rates within 30 days after surgery were 0%. Postoperative hospital stay was 10 (9-30) days. No postoperative reflux esophagitis was observed, whereas anastomotic stenosis, which required endoscopic balloon dilation, developed in three patients (25%) in postoperative month 2. There was a significant association between the total number of stitches used for VEG-DFT and anastomotic stenosis (p < 0.001). CONCLUSIONS: Robotic assistance may be useful for VEG-DFT with a short learning curve. Attention is required to prevent postoperative anastomotic stenosis possibly caused by an excessive number of stitches for esophagogastrostomy.

＜ポイント＞胃癌術後腹腔内出血は手術手技による直接的な原因は少なく,術後膵液漏などが原因となる場合が多い.術後出血の診断には,ドレーン排液の急激な変化を見逃さないことが重要であり,早期診断早期治療が求められる.術後出血の診断・治療にIVRは非常に有用であるが,患者のバイタルサインを念頭に再開腹術を躊躇してはいけない.(著者抄録)

食道胃接合部癌に対する手術は,その解剖学的特殊性から縦隔郭清を考慮する必要があるが,主に腫瘍の局在や転移リンパ節の状況によって選択される術式は異なり,再建法を組み合わせると多岐にわたる.主に下縦隔郭清を行う場合は,経胸壁操作と経裂孔操作の二つのアプローチ法が選択されうるが,本稿では経裂孔的下部食道切除術,下縦隔郭清および再建法に関して当科で行っている術式の手順に沿って紹介する.(著者抄録)

食道扁平上皮癌でリンパ節郭清を含む定型的手術を施行し、組織病理学的にT1a-MMと診断した25例(男性21名、女性4名、49〜77歳)を対象とし、初回治療手術19例、内視鏡治療後手術6例であった。内視鏡治療後手術では、リンパ節転移リスクとして想定できる因子は存在しなかった。初回治療手術では、組織型が有意なリスク因子で、組織学的にporの症例では全例にリンパ節転移を認めた。有意ではなかったが、リンパ節転移が存在した4例中3例はlyが陽性であった。初回治療内視鏡治療症例と初回治療手術症例では、組織型が有意なリンパ節転移リスク因子であった。リンパ節転移6例中、3例は組織型がpor、4例が脈管侵襲陽性であった。

BACKGROUND: Distal advanced gastric cancer (AGC) occasionally causes gastric outlet obstruction (GOO). We developed a laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) to restore the ability of food intake. METHODS: This was a retrospective study performed at a single institution. Of consecutive 78 patients with GOO caused by AGC between 2006 and 2012, 43 patients who underwent LSPGJ were enrolled. The procedure was performed in an antiperistaltic Billroth II fashion, and the afferent loop was elevated and fixed along the staple line of the proximal partitioned stomach. Then, patients for whom R0 resection was planned received chemotherapy prior to laparoscopic gastrectomy. The primary end point was food intake at the time of discharge, which was evaluated using the GOO scoring system (GOOSS). Short- and long-term outcomes were assessed as secondary end points. Overall survival was estimated and compared between the groups who received neoadjuvant chemotherapy followed by surgery (NAC group), definitive chemotherapy followed by curative resection (Conversion group), and best supportive care (BSC group). RESULTS: The median operative time was 92 min, blood loss did not exceed 30 g in any patient, and postoperative complications (Clavien-Dindo grade ≥2) were only seen in four patients (9.3 %). The median time to food intake was 3 days, and GOOSS scores were significantly improved in 41 patients (95.3 %). Chemotherapy was administered to 38 patients (88.4 %), of whom 11 later underwent radical resection, and 4 of 11 patients underwent conversion surgery following definitive chemotherapy. Median survival times were significantly superior in the NAC (n = 7; 46.8 months) and Conversion (n = 4; 35.9 months) groups than in the BSC group (n = 26; 12.2 months); however, the difference was not significant between the Conversion and NAC groups. CONCLUSIONS: LSPGJ is a feasible and safe minimally invasive induction surgery for patients with GOO from surgical and oncological perspectives.

Robotic gastrectomy (RG) for gastric cancer (GC) has been increasingly performed over the last decade. The technical feasibility and safety of RG for GC, predominantly early GC, have previously been reported; however, few studies have evaluated the oncological outcomes. This study aimed to determine the long-term outcomes of RG for GC compared with those of conventional laparoscopic gastrectomy (LG). Of the 521 consecutive patients with GC who underwent radical gastrectomy at our institution between 2009 and 2012, 84 consecutive patients who underwent RG and 437 patients who received LG were enrolled in this study. Long-term outcomes including the 3-year overall survival (3yOS) and 3-year recurrence-free survival rates (3yRFS) were examined retrospectively. In the RG group, the 3yOS rates stratified by pathological stage according to the Japanese classification of gastric carcinoma (IA, IB, II, and III) were 94.7, 90.9, 89.5, and 62.5 %, respectively. No differences in 3yOS (RG, 86.9 % vs. LG, 88.8 %; p = 0.636) or 3yRFS (RG, 86.9 % vs. LG, 86.3 %; p = 0.905) were observed between the groups. 3yOS was strongly associated with cancer recurrence within 3 years (p &lt; 0.001), while 3yRFS was associated with tumor size aeyen 30 mm (p &lt; 0.001), clinical stage aeyen IB (p &lt; 0.001), estimated blood loss aeyen 50 mL (p = 0.033), and postoperative pancreatic fistula CD grade aeyen III) (p = 0.035). RG for GC was feasible and safe from the oncological point of view in a cohort including a considerable number of patients with advanced GC.

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

INTRODUCTION: Delta-shaped anastomosis has been recognized as a method of intracorporeal Billroth I anastomosis in totally laparoscopic distal gastrectomy. However, the technical aspects and outcomes of the delta-shaped anastomosis in totally robotic distal gastrectomy have never been reported. METHODS: A single-institutional, non-randomized, retrospective study was performed between 2009 and 2013. During the study period, 47 patients underwent robotic distal gastrectomy followed by robotic delta-shaped Billroth I reconstruction, and 165 patients underwent conventional laparoscopic distal gastrectomy followed by laparoscopic delta-shaped Billroth I reconstruction. After 64 were excluded because of insufficient intraoperative video, 43 patients in the robotic group and 105 patients in the laparoscopic group were enrolled in the study. Short-term outcomes were determined from medical records and full-length operative videos. RESULTS: There were no significant differences between the robotic and laparoscopic groups in terms of morbidity (4.7% vs 3.8%), anastomosis-related complications (0% vs 1.0%), non-anastomosis-related complications (2.3% vs 0%), or systemic complications (2.3% vs 0%). Time for reconstruction did not vary between the robotic group (16.6 min [8.8-42.9 min]) and the laparoscopic group (15.8 min [7.2-41.0 min]). There was no mortality in this series. In the conventional group, the morbidity rate was 3.8%. The anastomosis-related complication rate was 1.0% in the conventional group. CONCLUSIONS: Given the excellent short-term outcomes related to anastomosis, delta-shaped anastomosis after robotic distal gastrectomy was at least as feasible and safe as delta-shaped anastomosis after laparoscopic distal gastrectomy.

D2 total gastrectomy combined with splenectomy or pancreaticosplenectomy reportedly increases morbidity and mortality. Totally laparoscopic total gastrectomy (TLTG) for advanced gastric cancer (AGC) remains controversial because of its technical difficulties and lack of long-term results. We determined the feasibility and safety of TLTG for AGC. A single-institution retrospective study was conducted. Ninety-two consecutive AGC patients who underwent radical TLTG were enrolled. The primary end point was morbidity. The patients were observed for 3 years following TLTG. We assessed short-term surgical and long-term outcomes, including 3-year overall survival rates (3yOS) and 3-year recurrence-free survival rates (3yRFS). Early and late morbidities (Clavien-Dindo grade aeyen3) were 26.1 and 6.5 %, respectively. Operative time, estimated blood loss, number of dissected lymph nodes, and postoperative hospital stay were 444 (278-694) min, 100 (0-2267) g, 48 (16-89), and 23 (9-136) days, respectively, and 3yOS and 3yRFS rates were 70.7 and 60.9 %, respectively. Factors associated with postoperative complications and 3yOS were operative time [OR 1.011 (1.006-1.017), p &lt; 0.01] and cancer recurrence within 3 years [HR 312.191 (1.126-86573.245], p = 0.045], respectively. 3yRFS was associated with tumor size (aeyen50 mm) [HR 10.325 (1.328-80.289), p = 0.026], pathological N factor aeyen2 [HR 3.188 (1.196-8.495), p = 0.02], and postoperative pancreatic fistula combined with intra-abdominal abscesses Clavien-Dindo grade aeyen2; [HR 3.670 (1.440-9.351), p = 0.006]. TLTG for AGC is sufficiently feasible and safe from both surgical and oncological point of view.

The Da Vinci Surgical System was developed to overcome some of the disadvantages of conventional endoscopic surgery. We have been performing robotic gastrectomy or esophagectomy in patients with resectable gastric or esophageal cancer who agreed to uninsured use of the robot since 2009, resulting in reduced postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. Moreover, the greater the extent of resection and lymph node dissection, the greater this effect, suggesting that the robot may be more beneficial for advanced cancer than for early cancer. In the meantime, there have been a considerable number of reports, mostly focusing on early cancer, that the use of the robot may reduce cost-effectiveness in comparison with the conventional laparoscopic or thoracoscopic approach. Thus, since the beginning of October 2014, we have been conducting a multiinstitutional, single-arm prospective study designed to determine the impact of robotic assistance, which has been approved as advanced medical technology (senshiniryo) by the Japanese Ministry of Health, Labor and Welfare, on the outcomes after minimally invasive radical gastrectomy to treat resectable gastric cancer, with a focus on postoperative complications, long-term outcomes, and cost.

内視鏡手術支援ロボットda Vinci Surgical Systemは,従来の内視鏡外科手術の欠点を補完する複数の特長を有し,局所操作性を向上する.当科では,2009年より進行癌を含む切除可能胃癌・食道癌を対象として自費診療によるロボット支援手術を行い,胃癌術後の膵液瘻や食道癌術後の反回神経麻痺等,局所合併症を軽減する効果を報告してきた.また,ロボット使用の効果は切除郭清範囲が広いほど大きい可能性が示唆され,ロボットは進行癌に対する低侵襲手術を安全に行うための有望なツールと期待される.一方,ロボットの導入・維持には高額なコストが発生し,主に早期癌を対象とした海外の報告では,従来型内視鏡外科手術と比べて費用対効果の悪化が懸念されている.2014年10月より多施設共同前向き単群臨床試験(先進医療B「内視鏡下手術用ロボットを用いた腹腔鏡下胃切除術」)を開始し,ロボット使用による合併症軽減効果やその費用対効果について検証中である.(著者抄録)

Epidemiological studies have implicated lung inflammation as a risk factor for acute cardiovascular events, but the underlying mechanisms linking lung injury with cardiovascular events are largely unknown. Our objective was to develop a novel murine model of acute atheromatous plaque rupture related to lung inflammation and to investigate the role of neutrophils in this process. Lipopolysaccharide (LPS; 3 mg.kg(-1)) or saline (control) was instilled directly into the lungs of male apolipoprotein E-null C57BL/6J mice following 8 weeks of a Western-type diet. 24 h later, atheromas in the right brachiocephalic trunk were assessed for stability ex vivo using high-resolution optical projection tomography and histology. 68% of LPS-exposed mice developed vulnerable plaques, characterised by intraplaque haemorrhage and thrombus, versus 12% of saline-exposed mice (p=0.0004). Plaque instability was detectable as early as 8 h post-intratracheal LPS instillation, but not with intraperitoneal instillation. Depletion of circulating neutrophils attenuated plaque rupture. We have established a novel plaque rupture model related to lung injury induced by intratracheal exposure to LPS. In this model, neutrophils play an important role in both lung inflammation and plaque rupture. This model could be useful for screening therapeutic targets to prevent acute vascular events related to lung inflammation.

＜ポイント＞胃外科領域におけるロボット支援手術はいまだ発展途上であるが,当科では200例超のロボット支援胃切除の経験を重ね,手技の標準化とその普及・啓蒙活動を行ってきた.当科における従来型腹腔鏡下手術との比較では,全合併症発生率,局所合併症発生率,膵液瘻発生率が減少,術後在院日数が短縮し,ロボット手術の潜在的有用性が示唆された.ロボット使用による合併症軽減効果を検証するため,2014年9月よりcStageI/II胃癌を対象とした多施設共同前向き臨床試験が先進医療Bとして承認され,その結果が期待される.(著者抄録)

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.