A method of gastric conduit elevation via the posterior mediastinal pathway in thoracoscopic subtotal esophagectomy

<p>Abstract</p> <p>Background</p> <p>Despite efforts to improve surgical techniques, serious complications still sometimes occur. Use of a physiological posterior mediastinal pathway has increased given advances such as automated anastomotic devices and a reduction in the incidence of anastomotic sufficiency. Until now the gastric conduit created has been protected by an echo probe cover and, sown to the ventral side of polyester tape placed through the abdomen to the neck, and then blindly elevated to the neck. We report on a new method of gastric conduit elevation.</p> <p>Methods</p> <p>Two 60-cm lengths polyester tape are ligated at both ends to form a loop. An echo probe cover of 10 cm in diameter and 50 cm in length is prepared and the tip cut off, forming a cylinder. The knots in the previously looped polyester tape are inserted into the echo probe cover. The looped polyester tape and echo probe cover is ligated with silk approximately 5 cm in front of the knots on both sides.</p> <p>After dissection is carried out according to practice, the previously crafted polyester tape is inserted into the chest cavity. One end of polyester tape is fixed to the distal esophageal stump with the clips, with the opposite end fixed to the proximal esophageal stump. The echo probe cover that connects the proximal esophagus and distal esophagus is monitored for the presence of creases along the long axis to ensure there are no twists in the echo probe cover.</p> <p>We carry out a laparoscopic-assisted perigastric lymph node dissection, make a small skin incision, and guide part of the thoracic esophagus and stomach outside the body.</p> <p>Either one of the two lengths of polyester tape is connected to the gastric conduit. By pulling up this length of polyester tape from the neck, the gastric conduit can pass through the echo probe cover and be elevated to the neck.</p> <p>Results</p> <p>No perioperative complications such as bleeding or difficulty of the gastric conduit elevation were recognized with this method.</p> <p>Conclusions</p> <p>This method is considered to serve as a useful technique for gastric conduit elevation.</p

Reconstruction of the esophagojejunostomy by double stapling method using EEA™ OrVil™ in laparoscopic total gastrectomy and proximal gastrectomy

Here we report the method of anastomosis based on double stapling technique (hereinafter, DST) using a trans-oral anvil delivery system (EEATM OrVilTM) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection

The Hippo Signaling Pathway Components Lats and Yap Pattern Tead4 Activity to Distinguish Mouse Trophectoderm from Inner Cell Mass

Outside cells of the preimplantation mouse embryo form the trophectoderm (TE), a process requiring the transcription factor Tead4. Here, we show that transcriptionally active Tead4 can induce Cdx2 and other trophoblast genes in parallel in embryonic stem cells. In embryos, the Tead4 coactivator protein Yap localizes to nuclei of outside cells, and modulation of Tead4 or Yap activity leads to changes in Cdx2 expression. In inside cells, Yap is phosphorylated and cytoplasmic, and this involves the Hippo signaling pathway component Lats. We propose that active Tead4 promotes TE development in outside cells, whereas Tead4 activity is suppressed in inside cells by cell contact- and Lats-mediated inhibition of nuclear Yap localization. Thus, differential signaling between inside and outside cell populations leads to changes in cell fate specification during TE formation

A pristine record of outer Solar System materials from asteroid Ryugu’s returned sample

Volatile and organic-rich C-type asteroids may have been one of the main sources of Earth’s water. Our best insight into their chemistry is currently provided by carbonaceous chondritic meteorites, but the meteorite record is biased: only the strongest types survive atmospheric entry and are then modified by interaction with the terrestrial environment. Here we present the results of a detailed bulk and microanalytical study of pristine Ryugu particles, brought to Earth by the Hayabusa2 spacecraft. Ryugu particles display a close compositional match with the chemically unfractionated, but aqueously altered, CI (Ivuna-type) chondrites, which are widely used as a proxy for the bulk Solar System composition. The sample shows an intricate spatial relationship between aliphatic-rich organics and phyllosilicates and indicates maximum temperatures of ~30 °C during aqueous alteration. We find that heavy hydrogen and nitrogen abundances are consistent with an outer Solar System origin. Ryugu particles are the most uncontaminated and unfractionated extraterrestrial materials studied so far, and provide the best available match to the bulk Solar System composition

Secure hemostasis in transhiatal esophagectomy for esophageal cancer with gauze packing

<p>Abstract</p> <p>Background</p> <p>Transhiatal esophagectomy for esophageal cancer implies blind manipulation of the intrathoracic esophagus. We report a secure hemostatic method with gauze packing in transhiatal esophagectomy.</p> <p>Methods</p> <p>The gauze-packing technique is utilized for hemostasis just after removal of the thoracic esophagus during transhiatal esophagectomy. After confirming cancer-free margins, the abdominal esophagus and cervical esophagus are transected. A vein stripper is inserted into the oral-side stump of the esophagus and led to exit from the abdominal-side stump of the esophagus. The vein stripper and the oral stump of the esophagus are affixed by silk thread. A polyester tape is then affixed to the vein stripper, as the polyester tape is left in the posterior mediastinum after removal of the esophagus toward the abdominal side. The polyester tape on the cervical side is ligated with gauze and the polyester tape is removed toward the abdominal side. The oral stump of gauze and new additional gauze are affixed. As the first gauze is pulled out from the abdominal side, the second gauze gets drawn from the cervical wound into the mediastinum. The posterior mediastinum is finally packed with gauze and possible bleeding at this site undergoes a complete astriction. The status of hemostasis with the gauze packing is checked by an observation of color and bloodstain on the gauze.</p> <p>Results</p> <p>Between January 2005 and February 2012, 13 consecutive patients with esophageal cancer underwent a transhiatal esophagectomy with the gauze-packing hemostatic technique. Hemostasis at the posterior mediastinum was performed successfully and quickly in all cases with this method, requiring up to four pieces of gauze for a complete hemostasis. Median required time for hemostasis was 1219 (range 1896 to 1293) seconds and estimated blood loss was 20.4 (range 15 to 25) ml during gauze packing.</p> <p>Conclusions</p> <p>Our technique could minimize bleeding after the removal of the thoracic esophagus. The gauze-packing method is a simple and easy technique for secure hemostasis when performing a transhiatal esophagectomy.</p

Bevacizumab-induced intestinal perforation in a patient with inoperable breast cancer: a case report and review of the literature

Abstract Background Gastrointestinal perforation is known as a serious adverse event, but, for breast cancer, there are very few reports of gastrointestinal perforation. This report highlights gastrointestinal perforation caused by bevacizumab for breast cancer, which is of special interest because gastrointestinal perforations caused by bevacizumab are very rare in breast cancer. Case presentation We describe the case of 54-year-old Japanese woman. She was diagnosed as having inoperable breast cancer T2 N1 M1 (pleura, peritoneum), Stage IV, and received chemotherapy by paclitaxel. There was reduction in the primary tumor and disappearance of the pleural effusion; however, the ascites did not change. We performed diagnostic laparoscopy which revealed that her whole peritoneum was thickened, and her small intestine, colon, and her omentum were grouped and formed an omental cake. We submitted a part of her peritoneum to pathological examination and diagnosed the peritoneum dissemination of breast cancer. On the basis of these results, paclitaxel and bevacizumab combination chemotherapy was started, and a decrease in ascites was seen. However, a gastrointestinal perforation occurred on 26th day of second cycle of bevacizumab + paclitaxel, and we performed an emergency operation. In the operation, the omental cake was resolved, and we could search the full length of the gastrointestinal tract. Two small perforations of her small intestine were seen. We performed simple closures for perforations, and peritoneal lavage and drainage. She was in a state of septic shock, but it improved. It was thought that the small intestinal perforations were caused by the bevacizumab-additional chemotherapy which was very effective. Conclusions We report a very rare and valuable case. This case suggests that the risk of gastrointestinal perforation must be considered in a case of bevacizumab administration, and it is necessary to determine carefully the patient administered bevacizumab, regardless of the type of cancer