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ObjectivesAn extra-anatomic reconstruction would be beneficial in preventing recurrent malignant dysphagia. A long gastric tube that allowed a sufficient blood flow was necessary to perform the successful cervical anastomosis through the retrosternal route.MethodsThe gastric tube was created by means of separate division and closure of the seromuscular and submucosal-mucosal layers (stepwise group) in 15 consecutive patients and by means of full-thickness cutting of the stomach and closure of the seromuscular layer (standard group) in 22 patients. We compared these 2 types of gastroplasties in terms of total length of the tube, blood flow, and the incidence of anastomotic leakage. Blood flow was measured with a laser Doppler flowmeter during surgical intervention.ResultsThe gastric tube in the stepwise group was significantly longer than that in the standard group (P < .01, unpaired t test). Tissue blood flow at the site of anastomosis in the stepwise group was significantly greater than that in the standard group (P < .01, unpaired t test), and the rate of anastomotic leakage in the stepwise group was significantly lower than that in the standard group (P < .05, χ2 test).ConclusionWe consider this technique to be a useful procedure for retrosternal reconstruction after subtotal esophagectomy.

Background: Since corticosteroids are indispensable hormones, partial or cortical-sparing adrenalectomies may be adopted for the surgical treatment of adrenal diseases. In this article, we describe the techniques and results of these procedures.

Background: We have performed endoscopic thyroidectomy by an anterior chest approach and by an axillary approach. In this study, we evaluate the efficacy of these two types of endoscopic procedures and conventional open surgery. Methods: Each procedure was performed in 15 patients. The degree of surgical invasiveness and the nature of patients' complaints after surgery were compared using results of the operation and a questionnaire. Results: Although the mean operating time for the endoscopic procedure was significantly longer than for open surgery, there was no postoperative pain difference in the three groups. Three months after surgery, the incidence of swallowing discomfort was higher in the open surgery group than in endoscopic surgery group. All of the patients treated using the axillary approach were satisfied with the cosmetic results. However, three patients (20%) treated using the anterior chest approach and 11 patients (73%; p < 0.01) who underwent open surgery complained about the cosmetic results. Conclusions: The incidence of postoperative complaints after endoscopic surgery is significantly lower than after open surgery. Patients treated using the axillary approach can obtain cosmetic results superior to those achieved with other procedures.

Purpose. The technique of dynamic graciloplasty is not yet-completely satisfactory. Its function could be improved by ensuring total wrapping of the neoanus with the muscular part of the gracilis, but this can only be achieved by dividing the main blood vessels, which are considered essential for blood supply to the flap. We devised a vascular delay technique to preserve the flap without these vessels, which we performed first experimentally, then clinically, with promising results. Methods. Seventeen Japanese white rabbits were given graciloplasty after electrical stimulation, vascular ligation, or no preparation. The neoanus was assessed manometrically and histologically 5 days later. The good results seen in the animals encouraged us to start performing enhanced dynamic graciloplasty clinically. Five patients were given electrical stimulation and the vascular delay technique was carried out before dynamic graciloplasty. Results. Vascular delay in the rabbits preserved the muscle flap, but electrical stimulation had a limited effect. In all five patients, the neoanus was successfully wrapped with the muscular part of the flap. There were no ischemic symptoms or perioperative complications. Furthermore, the neoanal pressure increased significantly with electrical stimulation from 23.8 cm H 2 O to 89.2 cm H 2 O. Satisfactory continence was achieved in three of the four patients whom we were able to evaluate. Conclusion. Dissection of the main vessels of the gracilis muscle with vascular delay and long-term electrical stimulation may optimize the gracilis flap in patients requiring dynamic graciloplasty.

Background: The use of endoscopic procedures leads to a reduction in the size of the surgical scar, making it more inconspicuous. In this paper, we evaluated the merits and limits of endoscopic neck surgery. Methods: Between August 1999 and July 2000, 102 patients underwent neck surgery in our department for thyroid or parathyroid disease. Twenty-eight of them were treated by the axillary. A 12-mm and two 5-mm trocars were inserted through the skin of the axilla. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed. Results: Endoscopic procedures were performed successfully in 26 cases (19 thyroidectomies and seven parathyroidectomies). There were two conversions to open procedures. The mean operating times for the thyroidectomies and parathyroidectomies were 212 and 171 min, respectively. No evidence of injury to the recurrent laryngeal nerve was observed in any of the cases. The postoperative cosmetic status of the patients was excellent. Conclusion: We believe that endoscopic thyroidectomy and parathyroidectomy by the axillary approach will find a role in the treatment of endocrine diseases in the neck.

Background: We perform laparoscopic partial adrenalectomy without sectioning the adrenal central vein has been described because it is important to preserve this vein in the remnant adrenal gland in order to maintain its function. In this article, we describe our technique for laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein. Methods: The procedures were performed in four patients with aldosterone-producing adenomas (APA) and two patients with pheochromocytomas. Results: There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed that remnant adrenal function had been preserved in all cases. Conclusion: Since the vascular bed adjacent to the remnant adrenal gland is integral to the preservation of its function, it is important to perform procedures that do not separate the remnant adrenal gland from the retroperitonium space. Because the operative field is clearly visualized on the high-magnification video monitor, this delicate procedure can be performed with a high degree of accuracy via the laparoscopic approach. We consider this operative technique to be useful for selected cases.

食道胃静脈瘤に対するHassab手術, 経腹的食道離断術および内視鏡的硬化療法 (EIS) 後の経過観察中に早期胃癌を認め, 幽門側胃切除術を施行しえた症例を経験した.症例は63歳の男性で, 1987年胃静脈瘤の診断でHassab手術および経腹的食道離断術, 1995年食道静脈瘤を認めEISを施行した. 1997年4月胃内視鏡検査で前庭部に早期胃癌を認め, 腹部血管造影X線検査ではHassab術後のため胃の栄養動脈は右胃・胃大網動脈であった. 同年5月19日胃癌に対して手術を施行した. 右胃・胃大網動脈および十二指腸を結紮・切離した後も胃の血行は良好であったため, 幽門側胃切除術を施行した. 病理組織診断は低分化型腺癌, 深達度sm, 術後経過は良好で第26病日に退院した. Hassab手術, 食道離断術およびEIS施行後ある程度の期間が経過した後には幽門側胃切除術は安全に行える可能性があると思われたので報告した.

Virchowならびに大動脈周囲リンパ節転移を有した進行S状結腸癌に対して根治度Bの切除術を施行し, 術後6年現在, 無再発生存が得られた症例を経験したので報告する.症例は48歳の女性で, 1991年9月左鎖骨上窩の腫瘍にて来院した. リンパ節生検および注腸検査よりVirchowリンパ節転移を伴った進行S状結腸癌と診断された. 11月8日S状結腸切除ならびにD4郭清を施行した. 病理組織診断は中分化型腺癌, ss, n4 (+), P0, H0, M (+), ow (-), aw (-), ly (3), v (3), stage IVであった. リンパ節転移 (合計16/48) を認め, 特に腹部大動脈周囲には多数の転移 (9/30) が認められた. 術後補助療法として, 5年間UFT600mgの内服を行ったが, 現在術後6年, 無再発生存中である.n4症例の予後は一般的に不良とされているが, 自験例のように積極的な手術および補助療法により予後が改善される症例も認められると思われたので報告した.

胃静脈瘤を合併した特発性門脈圧亢進症の手術前後に肝血行動態を検討し, 術後肝内門脈血流の改善が示唆された症例を経験した.症例は41歳の女性で, 特発性門脈圧亢進症・胃静脈瘤に対してHassab手術を施行した. 術前の血管造影X線検査では脾腫, 脾静脈から門脈本幹の拡張, 肝内末梢門脈の造影不良ならびに側副血行路である臍静脈の開存・拡張がみられたが, 術後は門脈本幹・臍静脈の径は軽減し, 肝内末梢門脈枝の描出が良好となった. 99mTc in-vivo標識赤血球肝動脈門脈血流シンチでの肝右葉/門脈臍部血流比は術前門脈臍部優位であったが, 術後肝右葉優位に逆転した. 術前の123I-IMP経直腸門脈シンチではほとんどの123I-IMPは門脈から大循環へshuntされていたが, 術後はshunt量が低下し, 肝内に集積された.以上よりHassab手術後門脈大循環shunt量の低下および肝内門脈血流の改善が示唆された特発性門脈圧亢進症の1例を経験したので報告する.

Clostridia are the main cause of nontraumatic spontaneous gas gangrene. Poor blood flow due to arterial occlusion exacerbates the anaerobic condition. Fulminant gas gangrene in a 54-year-old man with atherosclerosis obliterans was treated by revascularization of the iliac artery using endarterectomy, and his gangrenous lower leg was amputated. However, he died from renal failure.

Giant cell arteritis (GCA), an inflammatory vasculopathy that preferentially affects medium-sized and large arteries, has diverse symptoms and varied clinical courses that can make the diagnosis difficult. We describe a 75-year-old woman in whom GCA presented as lack of a pulse in the right arm. Although steroid therapy is generally effective for treating GCA, surgical intervention provides a biopsy specimen for a definitive diagnostic study and restores blood flow in the affected limb. GCA should be considered along with atherosclerosis in cases of occlusive disease of the upper extremity, especially if the patient is an elderly woman.

Background: During the past 3 years, minimally invasive procedures have been adopted for the surgical treatment of primary hyperparathyroidism, and we have tried to perform endoscopic total parathyroidectomy for renal hyperparathyroidism. Methods: Five 5-mm trocars were inserted through the skin of the anterior chest under a general anesthesia. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed. Results: Endoscopic procedure was successfully performed in five patients. The mean duration of total parathyroidectomies was 236 min. No evidence of injury to the recurrent laryngeal nerve was observed in any cases. At follow-up, the serum calcium and parathyroid hormone levels had returned to within the normal range in all patients. Postoperative cosmetic status was excellent. Conclusion: We believe that endoscopic total parathyroidectomy by the anterior chest approach will find a role in the treatment of renal hyperparathyroidism.

Neck surgery has recently become one of the newest fields for the application of endoscopic surgery because the resultant scar is small and inconspicuous. Still, some patients feel even a small scar on the neck is not cosmetically acceptable. We therefore have developed a new technique of endoscopic thyroidectomy by the axillary approach that leaves no scar on the neck at all. When this method is used, the small scar in the axilla is completely covered by the patient's arm in a natural manner. The cosmetic result is excellent, and sensory loss in the neck is negligible because the area of surgical dissection is small. We believe that endoscopic thyroid surgery by the axillary approach will find a role in the treatment of thyroid disease.

Recently, aggressive hepatectomies or hepatic arterial infusion chemotherapy for liver metastasis from gastric or colorectal carcinoma have been performed, and the number of successful studies of liver metastasis have increased. However, there have been few successful cases of liver metastasis from esophageal carcinoma by surgery or chemotherapy. Herein, we show the benefits of radiation therapy for the treatment of liver metastasis from esophageal carcinoma. A 60-year-old woman with a 5-cm solitary liver metastasis from esophageal squamous cell carcinoma was treated with radiation therapy. The treated volume was encompassed by the anteroposterior and right lateral opposing fields, shaped by a multileaf collimator. The daily fraction size was 1.8 Gy, 5 days per week, for a total dose of 54 Gy. During the course of treatment, the patient did not experience any complications. After radiotherapy, abdominal computed tomography showed that the enhanced solid tumor had changed to a very low-density mass lesion with a clear margin, and the size was decreasing gradually between the 6 months. Radiotherapy could be a treatment of choice in patients with liver metastasis from esophageal squamous cell carcinoma.

Surgical treatments for thyroid diseases require skin incisions that can result in prominent scars, complaints resulting from adhesions, hypesthesia, and paresthesia in the neck. We have developed an endoscopic thyroidectomy using an axillary approach. In this article, we compare our original technique with conventional open surgery from the aspects of surgical invasiveness and patients' complaints after surgery.Each procedure was performed in 20 patients with follicular tumors. The two groups were similar for age, gender, and the mean diameter of the thyroid tumor. No statistically significant difference in the final pathological diagnosis was found between the two groups. Surgical invasiveness and patients' complaints after surgery were compared using results of the operation and a questionnaire.The operating time for open surgery was significantly shorter than that for endoscopic surgery (p0.01). In the endoscopic surgery group, the patient questionnaires revealed that 4 patients had severe anterior chest pain on the first postoperative day. The postoperative pain decreased after, and we could not find any difference between the two groups with regard to postoperative pain. Three months after surgery, one patient who had received an endoscopic procedure complained of slight hypesthesia, and none of the patients complained of discomfort while swallowing. Among the patients who underwent open surgery, 13 patients (65%; p0.01) complained of hypesthesia or paresthesia and 6 patients (30%; p0.05) complained of discomfort while swallowing. All of the patients treated using the endoscopic procedure were satisfied with the cosmetic results, but 15 patients who underwent open surgery complained of unsatisfactory cosmetic results (p0.01).The incidence of postoperative complaints after endoscopic surgery is considerably lower than that after open surgery.

The technique of dynamic graciloplasty is not yet-completely satisfactory. Its function could be improved by ensuring total wrapping of the neoanus with the muscular part of the gracilis, but this can only be achieved by dividing the main blood vessels, which are considered essential for blood supply to the flap. We devised a vascular delay technique to preserve the flap without these vessels, which we performed first experimentally, then clinically, with promising results.Seventeen Japanese white rabbits were given graciloplasty after electrical stimulation, vascular ligation, or no preparation. The neoanus was assessed manometrically and histologically 5 days later. The good results seen in the animals encouraged us to start performing enhanced dynamic graciloplasty clinically. Five patients were given electrical stimulation and the vascular delay technique was carried out before dynamic graciloplasty.Vascular delay in the rabbits preserved the muscle flap, but electrical stimulation had a limited effect. In all five patients, the neoanus was successfully wrapped with the muscular part of the flap. There were no ischemic symptoms or perioperative complications. Furthermore, the neoanal pressure increased significantly with electrical stimulation from 23.8 cmH(2)O to 89.2 cmH(2)O. Satisfactory continence was achieved in three of the four patients whom we were able to evaluate.Dissection of the main vessels of the gracilis muscle with vascular delay and long-term electrical stimulation may optimize the gracilis flap in patients requiring dynamic graciloplasty.

Proximal gastrectomy is currently accepted by surgeons as the most favorable type of operation for the treatment of early gastric cancer in the upper third of the stomach, from both a hormonal and a nutritional perspective. In advanced gastric cancer, total gastrectomy combined with lymph node dissection, a radical procedure, is widely used, because these cases are often complicated by lymph node metastases along the lower part of the stomach. On the other hand, various surgical procedures that preserve organs and their functions to the greatest possible extent have been advocated and put into practice. Besides, several reports have demonstrated that lymph node metastases were found in the splenic hilum but were not found along the lower stomach when the depth of invasion was limited to the muscularis propria. Because of this, proximal gastrectomy with splenectomy is an acceptable treatment for gastric cancer in the upper third of the stomach when the depth of invasion is limited to the muscularis propria. Recently, minimally invasive surgical techniques have attracted interest in all surgical specialties. In this article, we report a hand-assisted laparoscopic procedure that allows lymph node dissection and gastrointestinal reconstruction to be safely and easily performed.

More than 95% of patients with primary hyperparathyroidism have been treated with bilateral neck exploration by experienced surgeons. This procedure has been performed without employing preoperative localization tests or specialized techniques of intraoperative measurement. A renewed interest in unilateral neck exploration for primary hyperparathyroidism emerged (in three developments), in an attempt to maintain the excellent cure rate and to minimize the invasiveness of the procedure. The first development was the introduction of sestamibi scintigrams as a new preoperative localization technique and intraoperative nuclear mapping with a hand-held gamma probe. The localization of adenomas using this technique was much more accurate than that of previous localization studies, allowing unilateral procedures to become feasible. Sestamibi guidance enables parathyroidectomies to be performed much more rapidly through a significantly less invasive dissection. Secondly, the intraoperative quick parathyroid hormone assay allows the confirmation of removal of the parathyroid mass. The third development was endoscopic parathyroidectomy. Various approaches have been shown to be technically feasible, including endoscopic procedures that rely on CO 2 insufflation to create a working space or video-assisted procedures in which the working space is maintained through conventional external retraction. Given the safety and high success rate of the standard exploration, the potential advantages of these new strategies include decreased operating time, local or regional anaesthesia rather then general anaesthesia, and smaller incisions. ( Asian J Surg 2002;25(2):184-7)

The genes implicated in thyroid carcinoma can be categorized as oncogenes or tumor-suppressor genes. The RET oncogene has well-established roles in the development of both medullary and papillary thyroid carcinoma (PTC). Genetic testing for the germline RET mutation is commonly performed, and prophylactic thyroidectomy is carried out at an early stage. The demonstration of a RET rearrangement in a PTC patient may be prognostic factor. TSH-R and Gs alpha are associated with the development of toxic thyroid adenoma (AFTN). The ras oncogene is implicated in the early stages of development of several tumor types. In conclusion, germline screening for RET mutations is now commonly undertaken in patients with medullary thyroid carcinoma.

Although thoracoscopic techniques have been introduced to esophageal surgery, the identification of the left recurrent laryngeal nerve and lymph node dissection along the nerve remain quite difficult. A mediastinoscopic technique via the neck enables an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve. Therefore, a thoracoscopic esophagectomy combined with this technique allows mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily and safely dissected.

Objectives: We sought to investigate the effect of tissue blood flow on the incidence of anastomotic leakage during esophagectomy. Methods: Reconstruction was done with a gastric tube, and all cases involved cervical anastomosis. Tissue blood flow of 43 patients was measured with a laser Doppler flowmeter before emplacement and after anastomosis during surgical intervention. The reconstruction route and tissue blood flow before emplacement and that after anastomosis were analyzed as possible factors influencing anastomotic leakage. Results: Tissue blood flow after anastomosis with leakage was 9.1 ± 2.0 mL/min per 100 g, and that without leakage was 13.7 ± 2.9 mL/min per 100 g. Tissue blood flow with leakage was significantly lower than that without leakage (P

Brachiocephalic fistula is one of the main options to gain blood access for hemodialysis. Although the fistula is easy to establish, puncture becomes increasingly difficult because the cephalic vein runs deep and fibrous tissue is being continually deposited over the cephalic vein. Although superficialization-i.e., the removal of fibrous tissue along the basilic vein-has been performed with conventional surgery, the long incision along the cephalic vein induces the buildup of hard fibrous tissue so that puncture may remain difficult even after the operation. To avoid this problem, we tried superficialization of hemodialysis access using a video-assisted procedure and obtained a good result.

Since a foreign body lodged in the esophagus produces acute symptoms, urgent treatment is essential to prevent fatal complications such as mediastinitis and perforation of the aorta [1]. We encountered an exceptional case who had chronic symptoms due to an esophageal foreign body which resulted in a funnel-type esophageal stricture.

IT HAS BEEN reported that one conventional immunosuppressant FK 506, prolongs allograft survival. However, the effects of the drug on interactions leading to induction of regulatory mechanisms remain unclear. We previously reported that intratracheal delivery of donor splenocytes could induce prolonged survival of a fully allogeneic cardiac graft, resulting in the generation of regulatory cells. Using this model, we examined the influence of FK 506 on the induction of regulatory cells after intratracheal delivery of alloantigen.