須田 康一

膵頭十二指腸切除術(PD)を開腹で行う場合には、膵頭部に流入する動脈遮断を先行させる目的で腸間膜アプローチがよく用いられる。一方、腹腔鏡補助下PDでは開腹術と異なり腹腔内のスペースが限られるため、膵頭部全体を腹側に挙上する操作が困難である。そのうえで門脈系を先行遮断すると、鬱血による出血の増加をきたすため、動脈先行遮断が適している。また、腹腔鏡下手術では一般に「手前から奥」「内側から外側」の操作が適している。今回著者等は、開腹PDで報告されている腸間膜回転解除によって上腸間膜動脈を直線化し、「手間から奥」「内側から外側」にその分枝を処理しうる腸間膜回転解除術を用いた動脈先行遮断を腹腔鏡補助下に行い、良好な結果が得られたので報告した。

53歳男。約4年前に前医で胃上部食道浸潤癌に対し開腹胃全摘、脾摘術、結腸後経路Roux-en-Y再建、約3年前に癒着性イレウスに対し腹腔鏡下癒着剥離術を受けていた。経過観察中に食道空腸吻合部口側に病変が出現した。上部消化管内視鏡で食道空腸吻合部口側の食道前壁側に3cm大の0-I型病変を認め、一部に結節を伴っていた。造影CTで遠隔転移やリンパ節転移を認めなかった。局所再発と診断し、腹腔鏡・胸腔鏡下に中下部食道切除・Roux-en-Y再建を施行した。術中迅速腹腔内洗浄細胞診は陰性で、腹膜播種を認めなかった。食道空腸吻合部を含めて中下部食道を切除し、Roux-en-Y再建を行った。病理診断はpor2、pT3、ly1、v1、pN0、pPM0、pDM0であった。術後、癒着に伴う近位側空腸閉塞と回腸閉塞を発症し、十二指腸空腸吻合と回腸部分切除を行ったが、経過良好で術後69日に退院となった。

75歳男。26年前に他院で早期胃癌に対して開腹幽門側胃切除術を施行された。今回、貧血の精査目的に施行した上部消化管内視鏡検査で残胃空腸吻合部に癌を認めたため、腹腔鏡下残胃亜全摘術を行い、良好な結果が得られた。手術手技の実際を以下の手順に従って報告した。1)横行結腸間膜と小腸の癒着剥離。2)横行結腸と腹壁の癒着を利用した術野展開。3)残胃後壁と膵体部前面の癒着剥離。4)残胃小彎と肝左葉の癒着剥離。5)リニアステイプラーによる残胃離断。6)Overlap法による残胃空腸吻合。

BACKGROUND: The aim of this study was to analyze the oncological aspects of gastric cancer following laparoscopic gastrectomy with D2 lymphadenectomy (LG-D2). METHODS: We retrospectively evaluated the long-term outcomes of 354 patients who underwent LG-D2 for primary gastric cancer. Recurrence patterns and predictors of peritoneal metastasis were analyzed. RESULTS: Median follow-up time was 43.8 months. Five-year overall survival rates for yp/pStages I, II, and III gastric cancer were 93.7, 78.5, and 42.2 %, respectively. Recurrence was observed in 86 patients. Peritoneal metastasis was the most frequent recurrence pattern (n = 51), followed by hepatic metastasis (n = 17). Lymphatic recurrence at distant sites was observed in 10 patients. No locoregional lymph node metastasis or local recurrence was seen. Nine of 51 cases of peritoneal recurrence were detected by probe laparoscopy. Peritoneal recurrence rates were significantly higher in yp/pT4 and yp/pN3 diseases compared with yp/pT ≤ 3 and yp/pN ≤ 2 diseases. Multivariate analyses demonstrated that yp/pT4, yp/pN3, tumor size ≥70 mm, vascular invasion, and undifferentiated tumors were predictors of peritoneal recurrence following LG-D2. CONCLUSION: Long-term outcomes of gastric cancer following LG-D2, including recurrence patterns and predictors of peritoneal metastasis, were comparable to those following open D2 gastrectomy. LG-D2 showed good local control. Probe laparoscopy after LG may be effective in detecting peritoneal recurrence, which is not determined with less invasive examinations, including a CT scan. Future large-scale prospective studies are desirable to evaluate not only surgical but also oncological benefits and safety of LG-D2 for advanced gastric cancer.

内視鏡手術は低侵襲であり、拡大視効果による緻密な手技が可能であるため、近年急速に増加している。しかしながらその操作性は乏しく、複雑な手術ほど難易度は高まる。内視鏡手術の欠点を補うために開発されてきた機器のひとつが、内視鏡手術支援ロボットである。現在、臨床に最も利用している高性能な手術支援ロボットはda Vinci Surgical System(Intuitive Surgical Inc.,Sunnyvale,CA,USA)(以下、da Vinci)である。このロボットの使用によって手術をより精密に、より安全に施行しうる可能性がある。今回、上部消化管外科領域における内視鏡手術、およびロボット支援手術について概説する。(著者抄録)

症例は49歳,女性.10年前より近医で貧血・低蛋白血症,胃内に多発するポリープを指摘されていた.2014年3月に嘔吐にて当院救急外来を受診.貧血・低蛋白血症を認め,緊急入院となった.上部消化内視鏡検査では,胃全体にポリープが多発し,前庭部では幽門を覆い通過障害をきたしていた.腹部造影CT検査で,胃体上部から幽門にかけて,造影効果を伴う腫瘤が胃の内腔を占拠し,胃内口側に液貯留を認めた.絶食と輸血による内科的治療にて全身状態が改善した後に,腹腔鏡下胃全摘術を実施した.切除標本においては,胃全体にびまん性浮腫状のポリポーシスを認めた.組織学的に胃限局性若年性ポリポーシスを診断された.術後合併症なく経過し,貧血・低蛋白血症はともに改善した.胃限局性若年性ポリポーシスは稀な疾患であるが,今回腹腔鏡下胃全摘術を行い,良好な経過をたどった症例を経験したので若干の文献的考察を加えて報告する.(著者抄録)

A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA (TM) Reloads with Tri-Staple (TM) Technology combined with Endo GIA (TM) Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes. We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(A (R)) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics. There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites. Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.

In recent years, the number of facilities performing endoscopic surgeries, i.e., thoracoscopic and laparoscopic surgery, of the upper gastrointestinal tract has increased. Endoscopic surgery has many advantages, such as magnification effects, good lighting, and a wide field of view in deep, narrow spaces. On the other hand, there are some technical difficulties in performing endoscopic procedures as in conventional open surgeries. Compared with endoscopic surgery, robotic surgery may facilitate more accurate, safer operations. The da Vinci Surgical System is a high-quality robotic system used for endoscopic surgeries, which offers a three-dimensional view, more degrees of freedom of the instruments, a tremor-filtering system, etc. However, in the absence of adequate operator skill and knowledge, the system cannot provide substantial improvements in the surgical technique. Endoscopic and robotic surgery must be used to offer treatment to patients which is at least equivalent to conventional surgery.

内視鏡下手術は低侵襲であり,拡大視効果による緻密な手技が可能であるため,近年急速に増加している.しかしながらその操作性は乏しく,複雑な手術ほど難易度は高まる.内視鏡下手術の欠点を補完しようと開発されてきた機器の一つに,内視鏡下手術支援ロボットがある.現在,最も流通している高性能な手術支援ロボットはda Vinci Surgical System(Intuitive Surgical Inc.,Sunnyvale,CA,USA)(以下,da Vinci)であり,このロボットを使用することで手術をより精密に,より安全に施行しうる可能性がある.しかし,それは決して手術技能を飛躍的に高める機器なのではなく,執刀医の手術に対するしっかりとしたコンセプトがなければ,その機能は十分に発揮されない.内視鏡下手術においても,またロボット支援手術においても,患者のため安全対策に最大限配慮し,最良の治療を進めていくことが重要である.(著者抄録)

Laparoscopic distal gastrectomy (LDG) is a routinely performed procedure. However, clinical expertise in laparoscopic total gastrectomy (LTG) is insufficient, and it is only performed at specialized institutions. This study aimed to identify critical factors associated with complications after laparoscopic gastrectomy (LG), particularly LTG. A large-scale database was used to identify critical factors influencing the early outcomes of LTG. Of 1248 patients with resectable gastric cancer who underwent LG, 259 underwent LTG. Predictive risk factors were determined by analyzing relationships between clinical characteristics and postoperative complications. Major complications after LTG were analyzed in detail. Multivariate analysis of all LG procedures revealed LTG as a risk factor for complications. Morbidity in the LDG and LTG groups was 6.2 % (52 of 835 patients) and 22.4 % (58 of 259 patients), respectively. Major post-LTG complications included anastomotic leakages and pancreatic fistulae. The rate of anastomotic leakage was significantly higher in the LTG group (5.0 %) than in the LDG group (1.2 %); however, it showed a tendency to decrease in more recent cases. Pancreatic fistulae occurred frequently after LTG with D2 lymphadenectomy (LTG-D2), particularly in cases of concomitant pancreatosplenectomy. Obesity was also associated with pancreatic fistula formation after LTG with pancreatosplenectomy. Compared with LDG, LTG is a developing procedure. Advances in the surgical techniques associated with the LTG procedure will improve the short-term outcomes of esophagojejunostomy. With regard to LTG-D2, establishing optimal and safe #10 node dissection is one of the most urgent issues. Pancreatic fistula after LTG with pancreatosplenectomy must be investigated in the future.

Purpose/Aim: We performed a randomized, prospective animal study to investigate whether inhibiting the renin-angiotensin system with a (pro)renin receptor blocker (PRRB) prevents acute lung injury (ALI) in a rodent model. Materials: We used Thirty-six male Sprague-Dawley rats. We administered lipopolysaccharide (LPS; 2 mg/kg) intratracheally with or without PRRB pretreatment (1 mg/kg/d). Methods: We performed bronchoalveolar lavage (BAL) and lung removal at 4 h after LPS administration and measured levels of inflammatory cytokines, high mobility group box 1 (HMGB-1) protein, and total protein in bronchoalveolar lavage fluid (BALF). Myeloperoxidase (MPO) activity was detected in lung tissue homogenates using a sensitive ELISA. We performed hematoxylin and eosin staining and immunohistochemical staining for nonproteolytically activated prorenin in the left lung. Results: The PRRB decreased leukocyte counts and total protein, tumor necrosis factor (TNF)-alpha, interleukin (IL)-1 beta, IL-2, IL-6, and IL-10 levels in the BALF and MPO activity in lung tissue. The PRRB reduced interstitial edema, hemorrhage, and the neutrophil count in the lung tissues. Consistent with the reduction in lung tissue damage, immunohistochemical staining showed that the PRRB decreased the amount of nonproteolytically activated prorenin. Conclusions: The PRRB blocked LPS-induced inflammatory response in the lung and protected against ALI. Therefore, it is a potential therapeutic agent for preventing ALI.

Background: High-mobility group box 1 (HMGB1) has recently been identified as an important mediator of various kinds of acute and chronic inflammation. The protein encoded by the box-A domain of the HMGB1 gene is known to act as a competitive inhibitor of HMGB1. In this study, we investigated whether box-A gene transfer results in box-A protein production in rats and assessed therapeutic efficacy in vivo using an acute liver failure (ALF) model. Materials and methods: Three types of adenovirus vectors were constructed-a wild type and two mutants-and a mutant vector was then selected based on the secretion from HeLa cells. The secreted protein was subjected to a tumor necrosis factor (TNF) production inhibition test in vitro. The vector was injected via the portal vein in healthy Wistar rats to confirm box-A protein production in the liver. The vector was then injected via the portal vein in rats with ALF. Results: Western blot analysis showed enhanced expression of box-A protein in HeLa cells transfected with one of the mutant vectors. The culture supernatant from HeLa cells transfected with the vector inhibited TNF-alpha production from macrophages. Expression of box-A protein was confirmed in the transfected liver at 72 h after transfection. Transfected rats showed decreased hepatic enzymes, plasma HMGB1, and hepatic TNF-alpha messenger RNA levels, and histologic findings and survival were significantly improved. Conclusions: HMGB1 box-A gene transfer results in box-A protein production in the liver and appears to have a beneficial effect on ALF in rats. (C) 2015 Elsevier Inc. All rights reserved.

The development of an effective rat model of incisional surgical site infection (SSI) has so far proven difficult. In this study, we created a novel incisional SSI model and validated it in terms of both macroscopic and microscopic aspects including its response to treatment using antimicrobial wound-dressing, Aquacel Ag (R). Wounds were created on the dorsum of rats. 3-0 Vicryl (R) threads inoculated with Escherichia coil were inserted in the wound beds in the infection group (n = 6). The wounds were closed for two days to induce infection and then opened and covered with polypropylene sheets during the study. Aquacel Ag was placed under the polypropylene sheet in the infected wounds of the Aquacel Ag group rats (n = 6). The wounds in the control group (n = 6) contained sterile Vicryl thread that had not been inoculated with E. coil. The macroscopic appearance, wound area, bacterial counts, and histology of each group were evaluated. The infection group demonstrated significantly lower wound healing (p < 0.001), greater bacterial counts (median [interquartile range] ratings, 2.15 x 10(7) [0.51 x 10(7) -53.40 x 10(7)] vs 2.07 x 10(4) [0.60 x 10(4)-4.45 x 10(4)] CFU/g, respectively; p < 0.01), and severer histological inflammation (p < 0.001) than the control group. The Aquacel Ag group was only able to show significantly better wound healing than the infection group (p < 0.001). The new incisional SSI model exhibited all clinical manifestations of incisional SSI. It could be utilized to assess the effectiveness of newly developed treatments for incisional SSI. (C) 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

We have previously reported that laparoscopic approach improved short-term postoperative courses even for advanced gastric adenocarcinoma, but not morbidity, in comparison with open approach. The objective of this study was to determine the impact of the use of the surgical robot, da Vinci Surgical System, in minimally invasive radical gastrectomy on short-term outcomes. A single institutional retrospective cohort study was performed (UMIN000011749). Five hundred twenty-six patients who underwent radical gastrectomy were enrolled. Eighty-eight patients who agreed to uninsured use of the surgical robot underwent robotic gastrectomy, whereas the remaining 438 patients who wished for laparoscopic (lap) approach with health insurance coverage underwent conventional laparoscopic gastrectomy. In the robotic group, morbidity (robotic vs lap 2.3 vs 11.4 %, p = 0.009) and hospital stay following surgery (robotic vs lap 14 [2-31] vs 15 [8-136] days, p = 0.021) were significantly improved, even though operative time (p = 0.003) and estimated blood loss (p = 0.026) were slightly greater. In particular, local (robotic vs lap 1.1 vs 9.8 %, p = 0.007) rather than systemic (robotic vs lap 1.1 vs 2.5 %, p = 0.376) complication rates were attenuated using the surgical robot. Multivariate analyses revealed that non-use of the surgical robot (OR 6.174 [1.454-26.224], p = 0.014), total gastrectomy (OR 4.670 [2.503-8.713], p < 0.001), and D2 lymphadenectomy (OR 2.095 [1.124-3.903], p = 0.020) were the significant independent risk factors determining postoperative complications. The use of the surgical robot might reduce surgery-related complications, leading to further improvement in short-term postoperative courses following minimally invasive radical gastrectomy.

ダビンチは高性能な内視鏡手術支援ロボットであり、手術手技をより精密に、より安全に施行し得る可能性がある。しかし、決して手術技能を飛躍的に高める機器なのではなく、執刀医の手術に対するしっかりとしたコンセプトがなければ、その機能は十分に発揮されない。患者のために最大限安全対策に配慮し、最良の治療を進めていくことが重要である。(著者抄録)

Robotic surgery was launched in Japan in 2000. In particular, the development of the da Vinci S Surgical System was a major breakthrough. It was introduced in Japan for the first time through our hospital in January 2009. Since then, the number of surgical robots used has been dramatically increasing, with up to approximately 160 robots all over the country. To date, we have performed more than 500 robotic surgeries, including 180 gastrectomies, at our hospital. Our data suggest that compared with the conventional laparoscopic approach, the use of the da Vinci Surgical System in minimally invasive gastrectomy for gastric cancer might improve short-term outcomes, particularly in terms of preventing postoperative local complications. Thus, we believe that use of surgical robots become increasingly beneficial for more extensive resections and operations that require more advanced skills, even though a couple of issues remain to be solved, such as long operative time, high cost, and limited experience and evidence. In this article, the current status and future perspectives regarding robotic gastrectomy for gastric cancer are presented based on our experience and a review of the literature.

ロボット支援手術の歴史は浅く、当初戦場や無医村における遠隔手術を目的として開発され、1997年3月より臨床応用が始まった。本邦では2009年11月に内視鏡手術支援ロボットda Vinci S HD Surgical System(Intuitive Surgical,Inc.,Sunnyvale,CA,USA)が薬事法承認され、2012年4月から前立腺全摘術に対するロボット加算が保険収載された。2014年2月現在、国内のda Vinci保有台数は161台となり、本邦は世界第2位のロボット保有国となっている。当科では2009年からda Vinci S HD Surgical Systemを臨床導入し、上部消化管外科領域の悪性疾患に対して積極的に使用してきた。本稿では、その臨床経験を基に、胃癌に対するロボット支援手術の現状と展望について概説する。(著者抄録)

内視鏡手術支援ロボット(da Vinci Surgical System:DVSS)による手術は、本邦でも急速に認知されつつある。2012年4月から前立腺癌に対するロボット支援加算が保険収載され、DVSSの本邦導入は急速に進み、2014年7月の時点で約180台保有し、米国に次いで世界第2位の保有国である。しかし、前立腺以外の領域においては保険収載されておらず、ロボット手術の普及は進んでいないのが現状である。我々は自費診療にて食道癌、胃癌などの上部消化管癌に対するロボット支援手術を2009年より積極的に施行してきた。その結果、ロボット支援手術は、従来の内視鏡手術より合併症を減らす可能性を示唆する結果を得た。そこで、上部消化管癌に対するロボット支援手術の概要と有用性について本誌面にて供覧する。(著者抄録)

Esophagectomy with total mediastinal lymphadenectomy with or without cervical lymphadenectomy remains the main option for the curative treatment of esophageal squamous cell carcinoma. However, meticulous mediastinal lymph node dissection frequently induces recurrent laryngeal nerve palsy (RLNP), leading to postoperative laryngopharyngeal dysfunction. Surgical robots have been developed to overcome some of the disadvantages of standard minimally invasive surgery and facilitate precise dissection in a confined surgical field with impressive dexterity. We have been using the surgical robot, da Vinci S HD Surgical System, in the thoracic phase of esophagectomy since 2009. To date, we have performed approximately 30 cases of robotic esophagectomy and have demonstrated the possibility that the use of the robotic system in thoracoscopic esophagectomy in the prone position might reduce postoperative laryngopharyngeal dysfunction related to RLNP. In this chapter, we present updates on the methods and short-term outcomes of robotic esophagectomy based on our experience and review of the literatures.

We investigated the association between the Revised Cardiac Risk Index (RCRI) and postoperative outcomes in patients undergoing non-cardiac surgery. The predictive value of the RCRI for the risk of perioperative complications, length of hospital stay and hospital cost were evaluated from a prospective cohort of 119 patients aged a parts per thousand yen65 years undergoing elective major digestive, breast or vascular surgery. Comparing three groups RCRI 0, 1 and a parts per thousand yen2, the morbidity rates were 0, 30 and 68 %; the median length of hospitalization was 5, 14 and 28 days; and the median cost was 665,000, 1,480,000 and 2,160,000 yen, respectively. The mortality rate was 0 % in all groups. The RCRI 0 group included only non-high-risk (breast and peripheral vascular) surgeries. In addition, comparing the two groups by excluding non-high-risk surgeries (RCRI 1 and a parts per thousand yen2), the median morbidity rates were 31 and 67 %, the median length of hospitalization was 15 and 28 days, and the median cost was 1,550,000 and 2,130,000 yen, respectively. The RCRI score was the only independent predictor of the perioperative complications. In the case of non-cardiac surgery, the RCRI can identify patients at higher risk of perioperative complications, a prolonged hospital stay and higher hospital cost.

Background: The renin-angiotensin system (RAS) affects inflammatory responses during sepsis. Nonproteolytic activation of prorenin by the (pro) renin receptor has recently been shown to stimulate the tissue RAS. In the present study, the effect of (pro) renin receptor blocker (PRRB) pretreatment on sepsis in a rat cecal ligation and puncture (CLP) model was investigated. Materials and methods: Male Sprague-Dawley rats underwent CLP and were randomly divided into two groups: PRRB-treated group and control peptide-treated group. Survival was analyzed for 7 d after CLP. The serum concentrations of cytokines and high-mobility group box chromosomal protein 1 (HMGB1) were measured at three time points (0, 3, and 6 h after CLP). Hematoxylin-eosin staining and immunohistochemical staining for nonproteolytically activated prorenin and HMGB1 were performed on the cecum to assess pathologic changes found 6 h after CLP. Results: Treatment with PRRB improved the survival rate of the post-CLP septic rats (P = 0.023). PRRB also significantly reduced serum tumor necrosis factor-alpha, interleukin-1 beta, and HMGB1 levels 6 h after CLP. In CLP rats that were treated with control peptide, the expression of activated prorenin was elevated in peritoneal foam cells. Moreover, expression of HMGB1 was increased in peritoneal inflammatory cells. In contrast, both were markedly suppressed in CLP rats that were treated with PRRB. Conclusions: PRRB significantly improved the survival rate of rats with clinically relevant sepsis, possibly by attenuating a sepsis-induced systemic inflammatory response. We propose that overactivation of the RAS by activation of prorenin in foam cells may be a significant contributor to sepsis. (C) 2014 Elsevier Inc. All rights reserved.

Background: We examined whether tumor growth is enhanced by cecal ligation and puncture (CLP) and suppressed by a neutrophil elastase inhibitor, sivelestat. Materials and Methods: C57BL/6 mice were divided in CLP/sivelestat, CLP alone, and control (simple laparotomy) groups. Murine CT26 colon carcinoma cells were injected subcutaneously into the back of each mouse and tumor growth and serum cytokine levels were assessed. Results: Mice subjected to CLP alone exhibited enhanced tumor growth compared to controls with subcutaneously injected CT26 cells (0.64 +/- 0.24 g vs. 0.021 +/- 0.027 g, p<0.001), while treatment with CLP/sivelestat produced smaller tumors than CLP alone (0.28 +/- 0.23 g vs. 0.64 +/- 0.24 g, p=0.006). Cytokine assays showed suppressed production of interleukin (IL)-6 and IL-10 in the CLP/sivelestat group, and increased IL-6 and IL-10 in the CLP-alone group. Conclusion: Intra-abdominal inflammation induced by CLP enhances the growth of subcutaneously implanted tumors, while perioperative administration of sivelestat suppresses tumor growth by affecting systemic inflammation.