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 in...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 CO<sub>2</sub> 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.展开更多
Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has...Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has emerged as a cost-effective strategy for obese diabetic individuals; it has low complication rates and results in durable weight loss, glycemic control and improvements in the quality of life, obesity-related co-morbidity and overall survival. The finding that glucose homeostasis can be achieved with a weight loss-independent mechanism immediately after bariatric surgery, especially gastric bypass, has led to the paradigm of metabolic surgery. However, the primary focus of metabolic surgery is the alteration of the physio-anatomy of the gastrointestinal tract to achieve glycemic control, metabolic control and cardio-metabolic risk reduction. To date, metabolic surgery is still not well defined, as it is used most frequently for less obese patients with poorly controlled diabetes. The mechanism of glycemic control is still incompletely understood. Published research findings on metabolic surgery are promising, but many aspects still need to be defined. This paper examines the proposed mechanism of diabetes remission, the efficacy of different types of metabolic procedures, the durability of glucose control, and the risks and complications associated with this procedure. We propose a tailored approach for the selection of the ideal metabolic procedure for different groups of patients, considering the indications and prognostic factors for diabetes remission.展开更多
Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resectio...Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resection margin(PRM) and its related issues.Thus,the objective of this article is to review several studies on PRM and to summarize the current evidence on the subject.Although there is some discrepancy in the recommended values for PRM between authors,a PRM of more than 2-3 cm for early gastric cancer and 5-6 cm for advanced gastric cancer is thought to be acceptable.Once the margin is confirmed to be clear,however,the length of PRM measured in postoperative pathologic examination does not affect the patient's survival,even when it is shorter than the recommended values.Hence,the recommendations for PRM length should be applied only to intraoperative decision-making to prevent positive margins on the final pathology.Given that a negative resection margin is the ultimate goal of determining an adequate PRM,development and improvement of reliable methods to confirm a negative resection margin intraoperatively would minimize the extent of surgery and offer a better quality of life to more patients.In the same context,special attention has to be paid to patients who have advanced stage or diffuse-type gastric cancer,because they are more likely to have a positive margin.Therefore,a wider excision with intraoperative frozen section(IFS) examination of the resection margin is necessary.Despite all the attempts to avoid positive margins,there is still a certain rate of positive-margin cases.Since the negative impact of a positive margin on prognosis is mostly obvious in low N stage patients,aggressive further management,such as extensive re-operation,is required for these patients.In conclusion,every possible preoperative and intraoperative evaluation should be thoroughly carried out to identify in advance the patients with a high risk of having positive margins;these patients need careful management with a wider excision or an IFS examination to confirm a negative margin during surgery.展开更多
In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic...In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects.Although the current study was limited by its small number of patients and retrospective nature,robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons.Most studies have reported satisfactory results for postoperative short-term coutcomes,such as:postoperative oral feeding,gas out,hospital stay and complications,compared with laparoscopic surgery;the difference is a longer operation time.However,robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery;after the accumulation of several cases,robotic surgery could be expected to result in a similar operation time.Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy.Moreover," total" robotic gastrectomy can be facilitated using a robotsewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique.In conclusion,robotassisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer,provided that long-term oncologic outcomes can be confirmed.展开更多
Background:Unresectable colorectal liver metastases(CRLM)is a condition with poor prognosis.A recent treatment alternative improving survival in patients with unresectable CRLM,has emerged with the introduction of liv...Background:Unresectable colorectal liver metastases(CRLM)is a condition with poor prognosis.A recent treatment alternative improving survival in patients with unresectable CRLM,has emerged with the introduction of liver transplantation(LT),yet not uncontroversial with the current organ shortage.This study aimed to retrospectively investigate the potential of declined donors with acceptable risk as liver graft donors and patients with unresectable CRLM as potential recipients.Methods:All declined donors in central Sweden and all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital,January 2013-October 2018,were identified.Donors were classified according to the European Committee Guide to the quality and safety of organs for transplantation and potential recipients were evaluated by selection criteria,based on studies on the Norwegian Secondary Cancer study database.Results:Out of 1,462 evaluated potential donors,62(2.7 pmp)donors were identified,corresponding to 6-18%of the utilized donor pool.Out of 1,008 included patients with CRLM,25(2.1 pmp)potential recipients were recognized.Eligibility for LT and left-sided colon cancer were favorable prognostic factors.Conclusions:Today’s donor pool could increase with the use of extended criteria donors,which is sufficient and display an acceptable risk-benefit ratio for patients with unresectable CRLM.With current selection criteria a small subset of patients with unresectable CRLM are eligible recipients.This subset of patients has a better survival compared to patients ineligible for LT.展开更多
文摘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 CO<sub>2</sub> 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.
文摘Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has emerged as a cost-effective strategy for obese diabetic individuals; it has low complication rates and results in durable weight loss, glycemic control and improvements in the quality of life, obesity-related co-morbidity and overall survival. The finding that glucose homeostasis can be achieved with a weight loss-independent mechanism immediately after bariatric surgery, especially gastric bypass, has led to the paradigm of metabolic surgery. However, the primary focus of metabolic surgery is the alteration of the physio-anatomy of the gastrointestinal tract to achieve glycemic control, metabolic control and cardio-metabolic risk reduction. To date, metabolic surgery is still not well defined, as it is used most frequently for less obese patients with poorly controlled diabetes. The mechanism of glycemic control is still incompletely understood. Published research findings on metabolic surgery are promising, but many aspects still need to be defined. This paper examines the proposed mechanism of diabetes remission, the efficacy of different types of metabolic procedures, the durability of glucose control, and the risks and complications associated with this procedure. We propose a tailored approach for the selection of the ideal metabolic procedure for different groups of patients, considering the indications and prognostic factors for diabetes remission.
基金Supported by National Research Foundation of Korea Grant funded by the Korean Government,No. 2010-0024825
文摘Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resection margin(PRM) and its related issues.Thus,the objective of this article is to review several studies on PRM and to summarize the current evidence on the subject.Although there is some discrepancy in the recommended values for PRM between authors,a PRM of more than 2-3 cm for early gastric cancer and 5-6 cm for advanced gastric cancer is thought to be acceptable.Once the margin is confirmed to be clear,however,the length of PRM measured in postoperative pathologic examination does not affect the patient's survival,even when it is shorter than the recommended values.Hence,the recommendations for PRM length should be applied only to intraoperative decision-making to prevent positive margins on the final pathology.Given that a negative resection margin is the ultimate goal of determining an adequate PRM,development and improvement of reliable methods to confirm a negative resection margin intraoperatively would minimize the extent of surgery and offer a better quality of life to more patients.In the same context,special attention has to be paid to patients who have advanced stage or diffuse-type gastric cancer,because they are more likely to have a positive margin.Therefore,a wider excision with intraoperative frozen section(IFS) examination of the resection margin is necessary.Despite all the attempts to avoid positive margins,there is still a certain rate of positive-margin cases.Since the negative impact of a positive margin on prognosis is mostly obvious in low N stage patients,aggressive further management,such as extensive re-operation,is required for these patients.In conclusion,every possible preoperative and intraoperative evaluation should be thoroughly carried out to identify in advance the patients with a high risk of having positive margins;these patients need careful management with a wider excision or an IFS examination to confirm a negative margin during surgery.
基金Supported by A grant from the National R & D Program for Cancer Control,Ministry of Health and Welfare,Republic of Korea(1020410)
文摘In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects.Although the current study was limited by its small number of patients and retrospective nature,robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons.Most studies have reported satisfactory results for postoperative short-term coutcomes,such as:postoperative oral feeding,gas out,hospital stay and complications,compared with laparoscopic surgery;the difference is a longer operation time.However,robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery;after the accumulation of several cases,robotic surgery could be expected to result in a similar operation time.Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy.Moreover," total" robotic gastrectomy can be facilitated using a robotsewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique.In conclusion,robotassisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer,provided that long-term oncologic outcomes can be confirmed.
文摘Background:Unresectable colorectal liver metastases(CRLM)is a condition with poor prognosis.A recent treatment alternative improving survival in patients with unresectable CRLM,has emerged with the introduction of liver transplantation(LT),yet not uncontroversial with the current organ shortage.This study aimed to retrospectively investigate the potential of declined donors with acceptable risk as liver graft donors and patients with unresectable CRLM as potential recipients.Methods:All declined donors in central Sweden and all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital,January 2013-October 2018,were identified.Donors were classified according to the European Committee Guide to the quality and safety of organs for transplantation and potential recipients were evaluated by selection criteria,based on studies on the Norwegian Secondary Cancer study database.Results:Out of 1,462 evaluated potential donors,62(2.7 pmp)donors were identified,corresponding to 6-18%of the utilized donor pool.Out of 1,008 included patients with CRLM,25(2.1 pmp)potential recipients were recognized.Eligibility for LT and left-sided colon cancer were favorable prognostic factors.Conclusions:Today’s donor pool could increase with the use of extended criteria donors,which is sufficient and display an acceptable risk-benefit ratio for patients with unresectable CRLM.With current selection criteria a small subset of patients with unresectable CRLM are eligible recipients.This subset of patients has a better survival compared to patients ineligible for LT.
