Initial Experience in Rectal Cancer Surgery for the Next Generation of Robotic Surgeons Trained in a Dual Console System

[Background]?Robotic surgery for rectal cancer is used worldwide, with an increasing incidence of robotic surgeons. Therefore, the most appropriate educational system for next-generation robotic surgeons should be urgently established. [Methods]?We analyzed 39 patients who underwent robotic rectal surgery performed by a next-generation surgeon with limited experienced in laparoscopic rectal cancer surgery. The dual console system was used in the initial 15 cases, and we assessed short-term outcomes and the learning curve on operative time using the cumulative sum method. [Results]?The patients were divided into two groups: 15 cases in the early phase, and 24 cases in the late phase. The operative time and surgeon console time were significantly shorter in the late phase than the early phase (P?< 0.001). Postoperative complications were more frequently observed in the early phase (P?= 0.049); however, the estimated blood loss and length of hospital stay were not significantly different. In the initial 15 cases that using the dual console, the average operative time changing to the expert surgeon was 82 minutes in the first 5 cases, 19 minutes on average in the next 5 cases, and no change occurred in the last 5 cases. The learning curve peaked after 14 cases, plateaued from case number 15 to 23, and decreased in a linear fashion until the final case. [Conclusion]?Education of a next generation surgeon using a dual console system for robotic rectal cancer surgery was performed safely.journal articl

The First Pilot Comprehensive Evaluation of the Outcomes of Different Types of Robotic Surgeries in the Different Surgical Departments: The Penta, Tetra and Trifecta Achievements in Robotic Surgeries

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Therapeutic Value of Lymph Node Dissection Along the Superior Mesenteric Vein and the Posterior Surface of the Pancreatic Head in Gastric Cancer Located in theLower Third of the Stomach

【Background】 Therapeutic value of lymph node dissection along the superior mesenteric vein (14v) and the posterior surface of the pancreatic head (13) remains unclear in gastric cancer patients. 【Methods】 We reviewed 355 patients with advanced gastric cancer in the lower third of the stomach who had undergone gastrectomy at our hospital. 【Results】 The frequency of lymph node (LN) metastasis was 10.2% and 7.4% in stations 13 and 14v, respectively. The frequency of station 13 metastasis was 26.8% for T3/T4 tumors with group 2 LNs metastasis and 1.4% for all other tumors. The frequency of station 14v metastasis was 22.2% for T3/T4 tumors with group 2 LNs metastasis and 1.8% for all other tumors. The therapeutic values for dissecting LN stations 13 and 14v were 1.9 and 0.9, respectively, similar to the therapeutic value for group 2 LN dissection. 【Conclusion】 Because metastasis to stations 13 and 14v occurs frequently in patients with T3/T4 gastric cancer located in the lower third of the stomach who also have metastasis to group 2 LNs, stations 13 and 14v should be dissected in these patients.journal articl

Portal Vein Stenting for Portal Vein Stenosis After Pancreatoduodenectomy : A Case Report

Portal vein stenosis, which results in serious clinical conditions such as gastrointestinal variceal bleeding and liver failure, is caused by hepatobiliary pancreatic cancer or major postoperative complications after hepatobiliary pancreatic surgery. In recent years, portal vein stenting under interventional radiology has been applied as a more useful treatment method for portal vein stenosis than invasive surgery. We herein report the successful use of a vascular stent for portal vein stenosis after pancreatoduodenectomy. A 66-year-old man with distal cholangiocarcinoma underwent subtotal stomach-preserving pancreatoduodenectomy with resection of the portal vein because of direct invasion to the main portal vein at our hospital. The portal vein was reconstructed without a venous graft. He developed jejunal bleeding near the pancreatojejunostomy on postoperative day (POD) 2. Although embolization of the responsible vessel achieved hemostasis, an intraoperatively inserted drainage tube was needed for a long period of time postoperatively because the embolized afferent jejunum was perforated. He was discharged on POD 39 after removal of the drainage tube. On POD 282, he was readmitted with melena and severe fatigue. Computed tomography revealed an obstruction of the reconstructed portal vein and varices at the hepaticojejunostomy site. We diagnosed variceal bleeding and performed percutaneous transhepatic stenting in the obstructed portal vein. The patient was discharged in good clinical condition on day 15 after stenting. In conclusion, portal vein stenting is a useful and less invasive therapy for portal vein stenosis.journal articl

Prognostic Value of Combined Tumor Marker and Controlling Nutritional Status (CONUT) Score in Colorectal Cancer Patients

[Background] Nutritional status is strongly associated with prognosis in cancer patients. Controlling Nutritional Status (CONUT) score is a nutritional marker based on serum albumin, cholesterol, and total lymphocyte count. We investigated the prognostic significance of a combination of the tumor marker carcinoembryonic antigen (CEA) and CONUT score (T-CONUT) in colorectal cancer (CRC) patients. [Methods] A total of 522 patients who underwent surgery for CRC at our hospital were retrospectively enrolled in this study. [Results] Patients were divided into groups based on the results of receiver operating characteristic (ROC) curve analysis as follows: CONUThigh (CONUT score ? 3) and CONUTlow (CONUT score < 3), and CEAlow (< 5 ng/mL) and CEAhigh (? 5 ng/mL). The 5-year overall survival (OS) rates of patients in the CONUTlow and CONUThigh groups were 76.0% and 53.9%, respectively (P < 0.0001), and in the CEAlow and CEAhigh groups were 80.7% and 47.6%, respectively (P < 0.0001). Regarding T-CONUT, the 5-year OS rates of patients with CEAlow/CONUTlow, CEAlow/CONUThigh, CEAhigh/CONUTlow, and CEAhigh/CONUThigh were 84.7%, 69%, 55.3%, and 36.1%, respectively (P < 0.0001). Multivariate analysis identified T-CONUT score as an independent prognostic indicator in CRC patients. [Conclusion] T-CONUT may be a useful tool for predicting prognosis in CRC patients.journal articl

Less Invasive Surgery for Remnant Stomach Cancer After Esophago-proximal Gastrectomy with ICG-guided Blood Flow Evaluation : A Case Report

The standard procedure for remnant gastric cancer after esophago-proximal gastrectomy is total resection of the remnant stomach considering blood supply. However, sometimes surgery may be too invasive due to severe adhesion in the thoracic and mediastinal cavity. The blood supply to the remnant stomach depends on the right gastroepiploic artery and the right gastric artery. Therefore, preservation of the proximal region of the remnant stomach is thought to be anatomically impossible. We report a case of remnant gastric cancer that developed more than 12 years after lower thoracic esophagectomy plus proximal gastrectomy for Siewert Type I squamous cell carcinoma. We used intra-operative indocyanine green (ICG) venous-injection to evaluate blood flow and distal gastrectomy of the remnant stomach was performed by preserving the proximal stomach in the thoracic cavity through an abdominal approach. There were no complications of the remnant stomach or the anastomosis to the jejunum after surgery. In this case, we focused on the blood supply by collateral circulation through the anastomotic line from the remnant esophagus. After confirming blood supply with intra-operative evaluation using ICG fluorescence, less-invasive distal gastrectomy was successfully performed. As the intra-operative ICGbased evaluation for blood supply is a simple and safe method, it might be useful for determining the resection margin of various organs and be effective for the introduction of less invasive surgery. Here, we report a case and a review of the literature.journal articl

Traumatic Gastric Perforation Associated with Cardiopulmonary Resuscitation: A Case Report

Sternal and rib fractures are well-known complications of cardiopulmonary resuscitation (CPR). We experienced a rare case of traumatic gastric perforation associated with CPR that required emergency laparotomy. In this case, we examined whether surgery is essential for gastric perforation associated with CPR. A 67-year-old man experienced cardiopulmonary arrest in the workplace, and bystander CPR was performed by his colleagues. He was then transported by ambulance to our hospital. A large amount of free air was found in the peritoneal cavity on computed tomography at presentation, and perforation of the gastrointestinal tract was suspected. During emergency laparotomy, a 2-cm serosal-muscular layer tear was found in the gastric lesser curvature. The damaged stomach wall was repaired, the abdominal cavity was lavaged, and surgery was completed by placing a drainage tube. The patient’s postoperative course was good and he was discharged on the 26th postoperative day. Emergency laparotomy has been performed frequently for traumatic gastric perforation associated with CPR. However, emergency laparotomy may be avoided by conservative treatment in some cases. Traumatic gastric perforation associated with CPR is a serious complication; however, the life prognosis of cardiopulmonary arrest patients depends on the original disease and the success of CPR. Traumatic gastric perforation associated with CPR is rarely fatal, and bystanders should not hesitate to initiate CPR.journal articl