須田 康一

食道癌術後の乳び胸はまれな合併症であり、治療法は確立されていない。今回われわれは、ロボット支援下食道亜全摘術後に乳び胸を発症した症例を経験したため報告する。症例は50歳、女性。進行食道癌のため術前化学療法を施行後、ロボット支援下食道亜全摘術を行った。術後経過は良好であったが、術後15日目に突然の呼吸苦が出現、CT検査で右胸水を認めた。右胸腔穿刺を施行し、乳び胸と診断した。完全中心静脈栄養管理・ソマトスタチンの投与を行ったが改善なく、術後20日目に右鼠径部よりリピオドールによるリンパ管造影検査を施行した。明らかな造影剤の漏出は認めなかったが、胸水は徐々に減少し術後28日目に胸腔ドレーンを抜去した。リピオドールによるリンパ管造影は、術後乳び胸に対する診断のみならず治療的観点からも有用な手技の一つと考えられた。(著者抄録)

鼠径リンパ節郭清を施行した肛門管腺癌のうち、鼠径リンパ節転移(鼠径転移)陽性11例と陰性62例の治療成績を比較した。鼠径転移陽性例は陰性例に比して高齢で、術前血清CEAおよびCA19-9が高値で、非分化型腺癌、T4b、高度リンパ管侵襲例が多く、間膜内の転移リンパ節数および側方の転移リンパ節数が有意に多かった。鼠径転移陽性例の根治度A手術の施行率は63.6%(7例)と陰性例(93.5%)に比べて有意に低率であるが、Stage III症例では鼠径転移陽性例と陰性例で再発率、予後に差を認めなかった。鼠径転移陽性例では初再発部位として鼠径リンパ節(2例)、全再発部位では骨盤内再発(4例)が陰性例に比べて有意に高率であった。Stage III肛門管腺癌では鼠径転移陽性の治療成績は鼠径転移陰性と同等だが、鼠径リンパ節および骨盤内再発に注意した術後フォローアップが必要と考えられた。(著者抄録)

A 50-year-old woman diagnosed with clinical Stage Ⅲ esophageal squamous cell carcinoma, received 2 cycles of docetaxel, cisplatin, 5-fluorouracil(DCF)therapy followed by robotic esophagectomy. In the 15th postoperative day, she suddenly had difficulty in breathing and a chest CT finding showed a large amount of right pleural effusion. Thoracocentesis yield a 1 L of chylous fluid confirmed diagnosis with postoperative chylothorax and conservative treatment was initiated. However, chylothorax was not improved. Therefore, a lipiodol lymphangiography from the inguinal lymph node was performed at the 20th postoperative day. Although the site of leakage could not identify, amount of drained pleural effusion was gradually decreased after lymphangiography, and drain was decannulated in the 28th postoperative day. Lipiodol lymphangiography may be a useful modality for both diagnosis and treatment for chylothorax after esophagectomy.

We reviewed clinical records of 73 cases with anal canal adenocarcinoma who underwent bilateral inguinal lymph node (ILN)dissection. Eleven patients with positive ILN metastasis(ILNM)were compared with 62 patients with negative ILNM in clinicopathological items and treatment outcomes to evaluate the effectiveness of ILN dissection. Positive ILNM were older, higher preoperative serum levels of CEA and CA19-9, more frequencies of undifferentiated carcinoma, T4b and severe lymphatic invasion than negative ILNM. And the number of mesorectal and lateral node metastasis were significantly more in positive ILNM than negative ILNM. Although the frequency of curability A surgery was significantly less in positive ILNM (63.6%)than negative ILNM(93.5%), there were no significant differences in recurrence rate and prognosis between positive ILNM and negative ILNM in Stage Ⅲ cancer. Recurrence in ILN occurred significantly more in positive ILNM (2 cases) than in negative ILNM(0 case)as initial recurrent site. And recurrence in pelvic local site occurred significantly more in positive ILNM(4 cases)than in negative ILNM(6 cases). Although there was no significant difference in oncological outcome in Stage Ⅲ anal canal adenocarcinoma, ILN recurrence and pelvic local recurrence should be cared for positive ILNM in postoperative follow-up.

BACKGROUND: Gastric cancer is the third leading cause of cancer-related death worldwide and surgical resection remains the sole curative treatment for gastric cancer. Minimally invasive gastrectomy including laparoscopic and robotic approaches has been increasingly used in a few decades. Thus far, only a few reports have investigated the oncological outcomes following minimally invasive gastrectomy. AIM: To determine the 5-year survival following minimally invasive gastrectomy for gastric cancer and identify prognostic predictors. METHODS: This retrospective cohort study identified 939 patients who underwent gastrectomy for gastric cancer during the study period. After excluding 125 patients with non-curative surgery (n = 77), other synchronous cancer (n = 2), remnant gastric cancer (n = 25), insufficient physical function (n = 13), and open gastrectomy (n = 8), a total of 814 consecutive patients with primary gastric cancer who underwent minimally invasive R0 gastrectomy at our institution between 2009 and 2014 were retrospectively examined. Accordingly, 5-year overall and recurrence-free survival were analyzed using the Kaplan-Meier method with the log-rank test and Cox regression analyses, while factors associated with survival were determined using multivariate analysis. RESULTS: Our analysis showed that age > 65 years, American Society of Anesthesiologists (ASA) physical status 3, total or proximal gastrectomy, and pathological T4 and N positive status were independent predictors of both 5-year overall and recurrence-free survival. Accordingly, the included patients had a 5-year overall and recurrence-free survival of 80.3% and 78.2%, respectively. Among the 814 patients, 157 (19.3%) underwent robotic gastrectomy, while 308 (37.2%) were diagnosed with pathological stage II or III disease. Notably, our findings showed that robotic gastrectomy was an independent positive predictor for recurrence-free survival in patients with pathological stage II/III [hazard ratio: 0.56 (0.33-0.96), P = 0.035]. Comparison of recurrence-free survival between the robotic and laparoscopic approach using propensity score matching analysis verified that the robotic group had less morbidity (P = 0.005). CONCLUSION: Age, ASA status, gastrectomy type, and pathological T and N status were prognostic factors of minimally invasive gastrectomy, with the robot approach possibly improving long-term outcomes of advanced gastric cancer.

BACKGROUND: Robotic gastrectomy (RG) has increased since being covered by universal health insurance in 2018. However, to ensure patient safety the operating surgeon and facility must meet specific requirements. We aimed to determine whether RG has been safely implemented under the requirements for universal health insurance in Japan. METHODS: Data of consecutive patients with primary gastric cancer who underwent minimally invasive total or distal gastrectomy-performed by a surgeon certified by the Japan Society for Endoscopic Surgery (JSES) endoscopic surgical skill qualification system (ESSQS) between October 2018 and December 2019-were extracted from the gastrointestinal surgery section of the National Clinical Database (NCD). The primary outcome was morbidity over Clavien-Dindo classification grade IIIa. Patient demographics and hospital volume were matched between RG and laparoscopic gastrectomy (LG) using propensity score-matched analysis (PSM), and the short-term outcomes of RG and LG were compared. RESULTS: After PSM, 2671 patients who underwent RG and 2671 who underwent LG were retrieved (from a total of 9881), and the standardized difference of all the confounding factors reduced to 0.07 or less. Morbidity rates did not differ between the RG and LG patients (RG, 4.9% vs. LG, 3.9%; p = 0.084). No difference was observed in 30-day mortality (RG, 0.2% vs. LG, 0.1%; p = 0.754). The reoperation rate was greater following RG (RG, 2.2% vs. LG, 1.2%; p = 0.004); however, the duration of postoperative hospitalization was shorter (RG, 10 [8-13] days vs. LG, 11 [9-14] days; p < 0.001). CONCLUSIONS: Insurance-covered RG has been safely implemented nationwide.

＜文献概要＞ポイント ◆手術のコンセプトを手術チーム間で共有ならびに十分に理解して手術に臨む.◆基本的にはダウンアングルが多用される.◆郭清時にはoutermost layerを意識して近接視野を確保する.◆再建時には遠景を多用し,吻合操作の全体像を把握する.◆術者の鉗子と干渉することが多いが,画面右側より左側に向けて傾けることで干渉が回避されやすい.

2018年に消化器外科領域で保険収載されて以降、ロボット支援手術は急速に普及しており、施設・術者基準やプロクター制度など、安全にロボット支援手術を導入・運用するための環境も整備されつつある。それに伴い食道および胃の悪性腫瘍に対するロボット支援下手術の成績の報告も増加している。特にロボット支援下胃切除ではランダム化比較試験の結果も報告されており、術後合併症減少に寄与する可能性が示唆されている。ロボット支援下手術は高コストやデバイス不足など克服すべき課題も残されているが、これらを解決することにより消化器外科領域で中心的役割を果たすことが期待される。(著者抄録)

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. METHODS: The current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. RESULTS: The patients' preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). CONCLUSION: The novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.

PURPOSE: This study aimed to investigate the clinical efficacy of lower-extremity ultrasonography screening with early intervention for deep venous thrombosis (DVT) on the incidence of venous thromboembolism (VTE) after minimally invasive surgery (MIS) for gastric cancer (GC). METHODS: Between January 2012 and December 2019, 1070 patients were diagnosed with both clinical and pathological stage I-III GC and underwent MIS at our institution. Routine ultrasonographic screening for DVT in lower extremities is performed before MIS. Patients diagnosed with DVT were preoperatively administered anticoagulant therapy. Enoxaparin was routinely administrated after surgery irrespective of the presence of DVT. The incidence of postoperative symptomatic VTE was examined retrospectively. RESULTS: A total of 74 (6.9%) patients were preoperatively diagnosed with DVT. Multivariate analyses revealed that age > 70 years (p = 0.015), female sex (p < 0.001), and positive serum D-dimer test (p < 0.001) were significant and independent risk factors for preoperative DVT. The incidence of symptomatic postoperative VTE was 1 (0.09%); symptomatic VTE developed in one patient among patients without DVT, whereas no patient with DVT developed VTE. CONCLUSIONS: Preoperative DVT screening using lower-extremity ultrasonography followed by preoperative anticoagulant therapy should be considered as a useful strategy to safely perform MIS for GC without increasing the incidence of VTE.

BACKGROUND: Robotic gastrectomy (RG) for gastric cancer (GC) has gradually gained nationwide prominence following 2011 guidelines from the Japan Society for Endoscopic Surgery (JSES), including the surgeons' criteria and the proctor system. In this retrospective study, we examined the short-term outcomes of the initial series of RGs performed by second-generation operating surgeons trained within our institute. METHODS: Between January 2017 and April 2020, five surgeons each performed RG in 20 patients with clinical stage III or lower GC in accordance with the JSES guidelines. We evaluated both the rate of Clavien-Dindo grade II or higher morbidities and the console time required to reach the learning plateau via cumulative summation (CUSUM) analysis. RESULTS: We observed no mortality and 3% of morbidity following RG. Both the operative time (430 vs 387.5 min, P = 0.019) and console time (380 vs . 331.5 min, P = 0.009) were significantly shorter in the second 10 cases than in the initial 10 cases. We observed a remarkable trend in cases of distal gastrectomy (DG), in which the total operative time and console time were significantly shorter in the later cases. Our CUSUM analysis revealed that seven cases were required to achieve a learning plateau in RG when confined to DG. CONCLUSIONS: Non-expert RG surgeons meeting the operating surgeon's criteria from the JSES who had trained under an expert RG surgeon safely performed RG in an initial 20 cases.

＜文献概要＞はじめに 手術支援ロボットda Vinci Surgical System(Intuitive Surgical社;以下da Vinci)は,3Dモニター,多関節,モーションスケール,手振れ防止といった特徴を活かした精緻な手術操作を可能とし,世界のロボット支援下手術市場を席巻してきた.本邦初のロボット支援下胃癌手術として,2002年にHashizumeらが胃癌に対するロボット支援下胃切除術2例の実施を報告した.当科では,ロボットの能力を最大限に活用して腹腔鏡下手術の合併症を軽減し,真の低侵襲手術を実現するため,2009年に全国に先駆けて,個人輸入でda Vinci SHD Surgical Systemを導入し,自費診療下にロボット支援下手術を開始した.症例経験を重ね,ロボットの性能を最大限活用すべく,double bipolar法,ダヴィンチ軸理論,画面4分割理論を考案し,基本手技とセットアップの標準化を行った.2009年11月のda Vinci Sの薬事承認,2012年4月の前立腺全摘術の保険承認によって,泌尿器科領域においてロボット支援下手術は急速に増加した.一方,消化器外科領域においては,Uyamaらによって,多施設共同前向き試験(先進医療B)が実施され,従来型腹腔鏡下胃癌手術のhistorical controlと比較してロボット支援下手術の優越性が示された.この結果を受け,2018年4月に12領域に保険適用が拡大され,現在,ロボット支援下手術は急激に増加している.一方で,診療報酬において保険点数のロボット使用加算は認められず,ロボット支援下手術のコスト低下は急務の課題となっている.

症例は81歳男性。腹痛と嘔吐を主訴に当院を受診した。腹部所見は平坦やや硬で,腹部全体に圧痛と反跳痛を認めた。腹部CT検査では上腹部を中心に腹腔内遊離ガスと膀胱壁在気腫を認めた。上部消化管穿孔による汎発性腹膜炎を疑い,同日緊急手術を施行した。腹腔鏡下で腹腔内を観察すると淡血性の混濁した腹水を中等量認めるも,消化管に明らかな穿孔所見を認めなかった。膀胱右側壁に径1cmの穿孔所見を認め,膀胱破裂に伴う腹膜炎と診断した。穿孔部を縫合閉鎖し腹腔内を洗浄して手術を終了した。術後明らかな合併症を認めなかったが,廃用症候群が進んだためリハビリテーションを行い第35病日に退院した。膀胱破裂の際に腹腔内遊離ガスを伴うことがあり,消化管穿孔との鑑別が困難である。今回,消化管穿孔を疑い緊急手術を施行した気腫性膀胱炎に伴う膀胱破裂の1例を経験したので報告する。(著者抄録)

＜文献概要＞はじめに 手術支援ロボットda Vinci Surgical System(Intuitive Surgical社;以下da Vinci)は,3Dモニター,多関節,モーションスケール,手振れ防止といった特徴を活かした精緻な手術操作を可能とし,世界のロボット支援下手術市場を席巻してきた.本邦初のロボット支援下胃癌手術として,2002年にHashizumeらが胃癌に対するロボット支援下胃切除術2例の実施を報告した.当科では,ロボットの能力を最大限に活用して腹腔鏡下手術の合併症を軽減し,真の低侵襲手術を実現するため,2009年に全国に先駆けて,個人輸入でda Vinci SHD Surgical Systemを導入し,自費診療下にロボット支援下手術を開始した.症例経験を重ね,ロボットの性能を最大限活用すべく,double bipolar法,ダヴィンチ軸理論,画面4分割理論を考案し,基本手技とセットアップの標準化を行った.2009年11月のda Vinci Sの薬事承認,2012年4月の前立腺全摘術の保険承認によって,泌尿器科領域においてロボット支援下手術は急速に増加した.一方,消化器外科領域においては,Uyamaらによって,多施設共同前向き試験(先進医療B)が実施され,従来型腹腔鏡下胃癌手術のhistorical controlと比較してロボット支援下手術の優越性が示された.この結果を受け,2018年4月に12領域に保険適用が拡大され,現在,ロボット支援下手術は急激に増加している.一方で,診療報酬において保険点数のロボット使用加算は認められず,ロボット支援下手術のコスト低下は急務の課題となっている.

＜文献概要＞はじめに われわれは膵上縁郭清の際に,総肝動脈(CHA),脾動脈(SPA),左胃動脈(LGA)などの主要な動脈周囲には厚い神経線維の層とその外側にあるいわゆる「outermost layer」と呼ばれる至適な剥離可能層に沿った郭清手技を胃癌根治術の際の手術コンセプトとして重視している.本コラムでは,胃切除術ではなぜ「outermost layer」が重視されるようになったのか,「outermost layer」にまつわる色々をQ&A形式で答えながら考察する.

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)

＜文献概要＞最先端の外科手術治療として行われているロボット支援手術は,10倍に拡大された三次元の視野,自由度の高い多関節機能,手振れ防止機能,モーションスケーリング機能などを有し,従来の腹腔鏡手術の欠点を克服しより精緻な手術操作が可能となることで,合併症の軽減などの手術成績の向上が期待されている.本邦では2012年に最初に前立腺全摘除術に対して保険収載された.2018年4月にようやく消化器疾患に対して保険収載され,これにより手術件数も急速に増加傾向にある.年々さらなる改良がなされ,現在までになしえなかった手術治療のブレイクスルーが期待されている.

A 55-year-old man complained of abdominal distention. Gastroscopy showed a submucosal tumor in the upper-third portion of the stomach, with a biopsy diagnosis of gastrointestinal stromal tumor(GIST). Because abdominal contrast- enhanced CT findings suspected the invasion of the tumor into the pancreatic tail, preoperative imatinib therapy was performed. After 2 weeks of treatment, the tumor had shrunk to 44% of its starting volume. Six months later, CT findings suggestive of the tumor invasion had disappeared. Therefore, the laparoscopic local resection of the stomach was performed. The postoperative course was uneventful. A pathological diagnosis was c-kit-positive GIST, with less than 5/50 HPF of mitotic counts. Imatinib was restarted 2 weeks after the operation. The patient is alive 8 months after the operation, with no obvious recurrence. Preoperative imatinib therapy can be a useful option for large GIST tumors.

Duodenal gastrointestinal stromal tumor(GIST)are relatively rare. Here, we report a case of a duodenal GIST located in the third portion that was successfully treated via laparoscopic local resection using the Kocher maneuver. A 49-year-old woman with a high BMI of 43.4 kg/m2 was diagnosed with a 20 mm duodenal submucosal tumor in the third portion that was suspected to be a GIST; subsequently, she underwent laparoscopic local resection. After mobilization from the first to third portion of the duodenum using the Kocher maneuver, local resection using a linear stapler was completed. The surgery time was 152 minutes, and the estimated blood loss was approximately zero. The postoperative course was uneventful, and she was discharged on the 7th postoperative day. The pathological diagnosis was ultra-low-grade GIST. This procedure can be a useful option for obese patients with good operative field of view.

BACKGROUND: We hypothesized that the Endoscopic Surgical Skill Qualification System (ESSQS) can shorten operative time, resulting in a decrease in postoperative morbidity. Here, we aimed to clarify whether ESSQS-qualified surgeons could decrease the incidence of complications. METHODS: Between January 2009 and June 2019, 1042 patients diagnosed with both clinical and pathological Stage ≤ III gastric cancer and undergoing LG were enrolled. In all LG procedures involving ESSQS-qualified surgeons, these served as the operator or the instructive assistant. The short-term outcomes were retrospectively compared between the ESSQS-qualified and the non-ESSQS-qualified surgeons using a propensity-score matched analysis. RESULTS: After propensity-score matching, 321 patients were included in each group. No significant differences were observed in morbidity rate, and length of hospitalization following surgery, although the non-ESSQS-qualified surgeon group had a significantly longer total operative time (Non-ESSQS-qualified group, 368 [170-779] min vs. ESSQS-qualified group, 316 [147-772] min; p < 0.001), and larger estimated blood loss (Non-ESSQS-qualified group, 28 [0-702] mL vs. ESSQS-qualified group 25, [0-1069] mL; p = 0.042). Multivariate analysis revealed that operative time ≥ 360 min (OR 1.818 [1.069-3.094], p = 0.027) was identified as the only significant independent risk factor determining morbidity. CONCLUSIONS: The incidence of postoperative morbidity did not differ between patients operated by the qualified and nonqualified surgeons, as long as ESSQS-qualified surgeons provide intraoperative instructions.

上部消化管悪性腫瘍に対するロボット支援下手術は、2018年度から保険収載され、以降施行件数は急激に増加してきている。ロボット支援下食道悪性腫瘍手術は、胃切除と比較し十分な報告例がないものの、従来の胸腔鏡手術よりも局所合併症が減少する可能性に期待がもたれている。ロボット支援下胃切除術は、従来の腹腔鏡手術と比較し、手術時間が長くなり医療コストも増大するが、ラーニングカーブが短くなり、局所合併症を中心とした術後合併症発生率が減少する可能性がある。長期成績に関してはこれからの検討課題である。(著者抄録)

Robotic gastrectomy (RG) using the da Vinci Surgical System for gastric cancer was approved for national medical insurance coverage in Japan in April, 2018, and has been used increasingly since. We reviewed the current evidence on RG, open gastrectomy (OG), and conventional laparoscopic gastrectomy (LG) to identify differences in surgical outcomes between Japan and other countries. Briefly, three independent reviewers systematically reviewed the data collected from a comprehensive literature search by an independent organization and focused on the following nine endpoints: mortality, morbidity, operative time, estimated volume of blood loss, length of postoperative hospital stay, long-term oncologic outcome, quality of life, learning curve, and cost. Overall, the mortality rate of the three approaches did not differ, but RG and LG had less intraoperative blood loss and resulted in a shorter postoperative hospital stay than OG. RG had longer operative times and incurred higher costs than LG and OG. However, in Japan, RG may be more effective than LG and OG for decreasing morbidity. Further studies are needed to establish the specific indications for RG, optimal robotic setup, and dissection methods to best utilize the surgical robot.

＜文献概要＞患者は63歳,男性.食道胃接合部から5mm離れた胃穹隆部前壁に2cm大の壁内発育型消化管間葉系腫瘍(GIST)を指摘された.従来の低侵襲外科手術では噴門機能の温存が困難と判断し,ロボット支援下経皮的内視鏡下胃内手術を行った.胃壁を腹壁に固定後,12mmバルーンポートを3ヶ所に挿入した.Trocar-in-trocar techniqueを用いてda Vinci Xi Surgical System(Intuitive Surgical, Inc. Sunnyvale,CA)をドッキングし,カメラと2本のロボット鉗子を使用した.経胃的に腫瘍を全層で局所切除,摘出し,胃壁欠損部を縫合閉鎖した.手術時間295分,出血量12ml,術後合併症なく術後8日目に退院とした.内視鏡手術支援ロボットを使用することで,噴門近傍前壁の壁内発育型GISTを経皮経胃的に安全に局所切除できる可能性が示唆された.

We report the case of a 70-year-old woman with synchronous advanced esophageal cancer and pancreatic head cancer. To reduce the surgical invasiveness, we performed a two-stage operation that included percutaneous endoscopic gastrostomy and minimally invasive esophagectomy. In the first stage, we performed a percutaneous endoscopic gastrostomy, a thoracoscopic esophagectomy with cervical and mediastinal lymph node dissection, and an esophagostomy without a laparotomy. The second stage, which was performed 28 days after the first operation, consisted of a total gastrectomy, pancreaticoduodenectomy, colonic reconstruction, and jejunostomy. Fifty days after the second operation, the patient was discharged from the hospital. A two-stage operation that includes minimally invasive esophagectomy seems to be useful for avoiding serious postoperative complications, even in patients with rare, synchronous advanced cancers of the esophagus and the pancreatic head.

BACKGROUND: Although the clinical outcome of esophageal cancer has recently improved, the relapse rate remains high for all disease stages. At present, there is no diagnostic method to predict the long-term outcome for esophageal cancer. In this study, we evaluated serum preoperative proinflammatory cytokine levels and investigated the correlation between preoperative interleukin-6 (IL-6) and IL-8 levels and survival of patients with esophageal cancer. METHODS: Between 2008 and 2015, we evaluated preoperative serum cytokine levels in 122 patients who underwent esophagectomy for esophageal cancer. Serum IL-6 and IL-8 levels were measured by enzyme-linked immunosorbent assays. We investigated the relationship between serum cytokine levels and the response to chemotherapy and survival. RESULTS: The preoperative IL-6 levels were significantly associated with shorter recurrence-free survival (RFS, p = 0.001) and overall survival (OS, p = 0.001) after esophagectomy. Higher IL-8 levels were significantly associated with RFS (p = 0.018). In the multivariate analysis, age, preoperative chemotherapy, lymph node metastasis, serum C-reactive protein (CRP) levels and serum IL-6 levels (hazard ratio (HR), 2.888; p = 0.049) were significantly independent prognostic factors of RFS. Additionally, age, pathological stage, and serum IL-6 levels (HR, 3.247; p = 0.027) were shown to be significantly independent prognostic factors of OS. Serum IL-6 levels were significantly higher in the non-responder group (pathological response pGrade0 and pGrade1) after neoadjuvant therapy. CONCLUSIONS: High preoperative serum IL-6 levels are associated with a poor response to chemotherapy or chemoradiotherapy and poor prognosis after esophagectomy. Preoperative serum IL-6 levels may be a useful independent prognostic marker for esophageal cancer patients.

BACKGROUND: In laparoscopic proximal gastrectomy, the hepatic left lateral segment often obstructs the operative field of view, especially around the esophageal hiatus. Therefore, a safe retraction method is needed. The present study aimed to determine the effectiveness of inverting the hepatic left lateral segment in laparoscopic proximal gastrectomy. METHODS: This was a retrospective review of 81 consecutive patients who underwent laparoscopic proximal gastrectomy. Patients were divided into two groups, i.e., the Nathanson liver retractor group (n = 41) and hepatic left lateral segment inverting group (n = 40). The unedited video recordings of the procedures and the patients' medical records were reviewed and compared. RESULTS: The hepatic left lateral segment inverting method provided a more satisfactory view of the operative fields and a wider working space around the esophageal hiatus than the Nathanson liver retractor. No intraoperative hepatic congestion and significantly improved postoperative liver enzyme elevations were observed with hepatic left lateral segment inverting method compared with the Nathanson liver retractor method. CONCLUSIONS: In laparoscopic proximal gastrectomy, the hepatic left lateral segment inverting method appears to provide improvements in both the operative field of view and liver protection compared with the Nathanson liver retractor method.

BACKGROUND: To safely perform minimized gastrectomy based on sentinel node (SN) concept for early gastric cancer patients, intraoperative diagnostic accuracy is indispensable. This study aimed to evaluate the clinical utility of the one-step nucleic acid amplification (OSNA) assay in the intraoperative diagnosis of SN metastasis in early gastric cancer patients compared with that of histopathological examination. METHODS: We conducted a prospective study using the OSNA assay for 43 patients with cT1N0M0 gastric cancer undergoing gastrectomy with SN mapping. All the SNs and selected non-SNs were examined by routine histopathological diagnosis, and the OSNA assay. RESULTS: We performed permanent histopathology (PH) in 1732 lymph nodes (LNs) (286 SNs and 1446 non-SNs) obtained from 43 patients. We also evaluated 439 LNs (286 SNs and 153 non-SNs) with the OSNA assay in addition to PH. Intraoperative histopathology (IH) was performed in 214 LNs (213 SNs and 1 non-SN). PH revealed LN metastasis in 6 patients (14%), all of whom showed positive SNs by PH. The diagnostic accuracy to predict the LN status based on the SN concept by histological examination was 100%. The concordance rate between the OSNA assay and the PH and IH were 0.970 and 0.981 respectively. Discordant results between PH and OSNA assay were observed in 13 LNs. The sensitivity and specificity of the OSNA assay compared with those of PH were 0.636, and 0.988, and compared with those of IH were 0.800, and 0.995. CONCLUSION: Our results suggest that the OSNA assay is a useful and convenient tool for the intraoperative detection of SN metastasis in early gastric cancer patients.