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We applied a new concept of “image overlay surgery” consisting of the integration of virtual reality (VR) and augmented reality (AR) technology, in which dynamic 3D images were superimposed on the patient’s actual body surface and evaluated as a reference for surgical navigation in gastrointestinal, hepatobiliary and pancreatic surgery. We carried out seven surgeries, including three cholecystectomies, two gastrectomies and two colectomies. A Macintosh and a DICOM workstation OsiriX were used in the operating room for image analysis. Raw data of the preoperative patient information obtained via MDCT were reconstructed to volume rendering and projected onto the patient's body surface during the surgeries. For accurate registration, OsiriX was first set to reproduce the patient body surface, and the positional coordinates of the umbilicus, left and right nipples, and the inguinal region were fixed as physiological markers on the body surface to reduce the positional error. The registration process was non-invasive and markerlesss, and was completed within 5 min. Image overlay navigation was helpful for 3D anatomical understanding of the surgical target in the gastrointestinal, hepatobiliary and pancreatic anatomies. The surgeon was able to minimize movement of the gaze and could utilize the image assistance without interfering with the forceps operation, reducing the gap from the VR. Unexpected organ injury could be avoided in all procedures. In biliary surgery, the projected virtual cholangiogram on the abdominal wall could advance safely with identification of the bile duct. For early gastric and colorectal cancer, the small tumors and blood vessels, which usually could not be found on the gastric serosa by laparoscopic view, were simultaneously detected on the body surface by carbon dioxide-enhanced MDCT. This provided accurate reconstructions of the tumor and involved lymph node, directly linked with optimization of the surgical procedures. Our non-invasive markerless registration using physiological markers on the body surface reduced logistical efforts. The image overlay technique is a useful tool when highlighting hidden structures, giving more information.

Transgastric access is a major route in natural orifice translumenal endoscopic surgery (NOTES); gastrotomy should be performed unless it would damage surrounding organs in the peritoneal cavity. This article describes a novel rendezvous gastrotomy technique over a direct percutaneous endoscopic gastrostomy (PEG). In six live porcines, the gastrotomy involved applying a direct PEG through the abdominal wall into the stomach and exchanging to a needle trocar. An endoscopic balloon catheter was passed through the trocar by rendezvous technique. Then the inflated balloon and endoscope were advanced to the peritoneal cavity through the gastrotomy. Transgastric cholecystectomy was performed with a hybrid needle grasper through the same percutaneous site and the gastrotomy was closed with endoscopic clips. The rendezvous gastrotomy technique could reduce guidewire exchange. The success rate was 100% (6/6). Mean times for transgastric peritoneoscopy and cholecystectomy were 25.5 and 83.5 min. Mortality and morbidity was 0%. The addition of the extra trocar was unnecessary in all procedures. The advantage of this introduction system includes the creation of controlled gastric perforation, which is easier to close. It provides reliable transgastric access and increases safety. It simplifies transgastric NOTES and provides less invasive hybrid NOTES procedure.

胆管閉塞を来した好酸球性胆管炎の2症例を経験した. 症例1は53歳の女性で, 検診にて肝異常陰影を指摘された. CT, ERCPで肝左葉の肝内胆管閉塞を認めた. 胆汁細胞診は良性であったが胆管癌も否定できず肝左葉切除術を施行した. 病理組織学的には胆管閉塞部位に多数の好酸球浸潤を認めた. 術後18か月再発の兆候はない. 症例2は87歳の女性で, 主訴は右上腹部痛. ERCPで下部胆管閉塞と総胆管結石を認め, 閉塞部位の組織診で好酸球主体の炎症細胞浸潤を認めた. 内視鏡的胆道拡張術, 切石術により症状は軽快した. 術後17か月再発の兆候はない. 文献上, 好酸球性胆管炎として報告されている症例は18例と少ない. 悪性疾患を念頭に高侵襲な治療が施行された報告もあるが, 近年臨床報告の増加から徐々に病態が解明されつつあり, 内視鏡的治療が主体となっていくと考えられる. 本疾患の知見と的確な診断により治療の低侵襲を維持できると考えられた.

It is common to use systemic chemotherapy, instead of hepatic arterial infusion (HAI) of 5-fluorouracil (5-FU) or other cytotoxic agents, for unresectable hepatic metastases in colorectal cancer patients. Nevertheless, systemic administration of anticancer agents such as FOLFOX or FOLFIRI is sometimes difficult to continue for infirm patients. A 71-year-old female who had undergone sigmoidectomy for sigmoid colon cancer received HAI for 12 months because of big bilobar hepatic metastases and poor performance status. Thereafter, a two-stage hepatectomy(first, left lobe: second, S7+8 and S5) was performed successfully. She has been alive for 2.5 years after the first operation but with two small lung metastases in the left lobe. Because of bad performance status and her weak social and familial conditions, treatment with standard systemic chemotherapy could not be continued. In such cases, HAI should be performed if the metastases are limited to the liver.

We report 4 cases of malignant airway obstruction treated by airway stenting. Three cases were caused by esophageal cancer and the fourth case by malignant lymphoma. Two patients with esophageal cancer received chemoradiotherapy after airway stenting and survived for 24 months and 54 months, respectively (without cancer recurrence). One patient with esophageal cancer died of airway bleeding 2 months after stent placement. The malignant lymphoma patient was treated by cyclophosphamide+doxorubicin+vincristine+prednisolone(CHOP) with rituximab. Airway obstruction due to malignancy is an urgent oncological situation that should be treated immediately. Airway stenting shows a marked and immediate improvement in dyspnea. Consequently, the induction of chemoradiotherapy or chemotherapy is possible. Two patients were successfully treated by chemoradiotherapy, of which 1 survived for more than 4 years without any evidence of cancer recurrence. Additional chemoradiotherapy for patients who receive esophageal stenting is controversial because of the high frequency of adverse events. However, chemoradiotherapy after airway stenting may demonstrate acceptable anti-cancer effects with fewer adverse events. Airway stenting was an effective treatment for airway obstruction, and additional treatment is essential for longer survival.

A 69-year-old male was operated on sigmoidectomy for sigmoid colon cancer (SS, N2, H0, P0, M0, stage IIIb) 7 years ago. Two years later, he was diagnosed for rectal cancer and bilateral lung metastases by TBLB. We performed Mile's operation, and the rectal focus was pathologically diagnosed with a recurrence of sigmoid colon cancer. After surgery, chemotherapy with FOLFOX was started for bilateral lung metastases, resulting in CR during the 22 months. But bilateral lung metastases were exacerbated, and then we administered several other chemotherapies. Five years have passed since chemotherapy started, although the focuses tended to progress. Right now, he has been a chemotherapy outpatient for last 5 years.

Although combination of S-1 and cisplatin (CDDP) is a standard therapy for advance or recurrent gastric cancer patients, there are some cases where a CDDP administration is difficult for patients. We here report three such cases of gastric cancer treated by S-1 and docetaxel (DOC) combination therapy. Based on our three cases, we believe that S-1 and DOC combination therapy could be suitable for outpatients showing safety and efficacy.

A 68-year-old male patient with mediastinal node metastasis 40 months after total gastrectomy for advanced gastric cancer, and a 72-year-old male patient with para aortic node metastasis were treated with concurrent chemo-radiotherapy of 1.8 Gy × 5 × 6 week with S-1 (100 mg/body, days 1-14 and 22-35) + docetaxel (30 mg/body, days 1, 8, 22, 29). Although two patients developed a lymph node recurrence during multiple chemotherapies including S-1, they have responded well and demonstrated complete response after chemo-radio therapy. Grade 3 esophagitis was sole adverse side effect. In contrast to the western countries, chemo-radio therapy was not recognized as a standard treatment for gastric cancer in Japan. However, our report suggested that chemo-radio therapy can be an option for the treatment of advanced gastric cancer.

Long-term hemodialysis is considered to be a significant risk factor for cancer, but little is known about the use of oxaliplatin in patients on chronic hemodialysis. A 58-year-old man on chronic hemodialysis was treated for unresectable rectal cancer with synchronous hepatic metastasis by FOLFOX6 therapy with therapeutic drug monitoring. Plasma levels of total platinum, ultrafiltrate (free) platinum and 5-fluorouracil were monitored from the start of oxaliplatin administration to 120 h after the end of oxaliplatin infusion. Pharmacokinetic data of free platinum showed a bimodal pattern, decreased rapidly during the first dialysis and subsequently rose until 48 h after oxaliplatin infusion. The free platinum area under the curve was 15.7-18.9 microg h/ml when 40 mg/m(2) of oxaliplatin was administered, which was comparable to the area under the curve at 85 mg/m(2) in patient with normal renal function. The total platinum level reached a peak immediately before dialysis and gradually decreased. The 5-fluorouracil level decreased rapidly after the start of dialysis and remained constant during the continuous infusion of 5-fluorouracil. Tumor response was judged to be stable disease for >6 months, and no peripheral neuropathy or other toxicity was observed even after 11 courses. FOLFOX6 therapy with reduced dose of oxaliplatin had been safely performed for >6 months without any severe toxicity. The serum levels of free platinum showed bimodal pattern, and this second peak increased the area under the curve of free platinum. This pattern seems to be unique in patients on hemodialysis.

We investigated the feasibility of new carbon dioxide-enhanced virtual multidetector computed tomography (MDCT) cholangiopancreatography (CMCP) for intraluminal exploration in 73 patients with hepatobiliary and pancreatic disease. CMCP was performed via a percutaneous or transpapillary drainage tube, and, synchronously, intravenous contrast material was employed for virtual angiography; three-dimensional (3D) virtual reality was incorporated using OsiriX and Fovia applications. The capability of carbon dioxide to delineate the biliary and pancreatic system was evaluated. All CMCPs showed complete technical success; complications including pancreatitis or pain never occurred. The incidences of visible third- and fourth-order biliary branches were 100 and 86.0%. The capability of carbon dioxide to pass an obstruction through an occluded hilar bile duct malignancy was 80.0%; it provided feasible information on additional bile duct segments. The full extent of the gallbladder was depicted in 72.7% of the studies. Minimum 2-mm lesions of biliary stones or gallbladder polyps were clearly detected. The main or second-order pancreatic ducts were visible in 100 and 83.3% of the studies, respectively. Carbon dioxide enabled the replacement of mucin and pancreatic juice and facilitated the detection of cystic lesions of intraductal papillary-mucinous neoplasm (IPMN) in 75.0% of the studies. We succeeded in achieving 3D spatial recognition of vascular structures in the cholangiopancreatic region, through the fusion of CMCP and 3DCT arteriography and venography in a single image scanning, and radiation time was decreased. This combined modality proved to be feasible for planning operations and for image-guided navigated surgery in the resection of a malignancy. To our knowledge, this is the first report to demonstrate the diagnostic accuracy of carbon dioxide MDCT cholangiopancreatography and the use of this modality for depicting biliary, pancreatic, and fusion blood vessels simultaneously. Carbon dioxide possesses many advantages over conventional iodinated contrast agents, and it might replace more invasive diagnostic measures in the near future.

Less invasive pancreatic head resection, such as duodenum-preserving pancreatic head resection (DPPHR) has been introduced for the treatment of pancreatoduodenal lesions, especially for benign conditions, for reducing surgical stress and maintaining exocrine and endocrine function of the residual pancreas in consideration of postoperative quality of life (QOL).We investigated the feasibility of a new technique employing three-dimensional (3D) virtual pancreatography using multi-detector CT (MDCT) with carbon dioxide (CO2) gas as a negative contrast agent for detection of intraductal papillary mucinous neoplasm (IPMN) of the pancreas requiring minimally invasive surgery. Branch IPMN is subjected in this study.Contrast-enhanced MDCT scan of the abdomen diagnosed 4- to 20-mm multilocular septated cysts in the head-uncinate process of the pancreas. Endoscopic retrograde pancreatography (ERP) showed multiple cystic lesions in the head-uncinate process with mild dilatation in the remaining pancreatic duct. For localizing diagnosis of these small and multiple pancreatic cysts, we placed an endoscopic pancreatic stent (EPS), and MDCT with injection of CO2 via EPS was examined for the virtual CO2 pancreatography, consisting of OsiriX software system employing 3D virtual anatomic reconstruction with CO2 gas as a negative contrast agent. Virtual CO2 MDCT pancreatography demonstrated that all cystic lesions of the pancreas were contained within the area of the head-uncinate process of the pancreas. We performed DPPHR, and surgical margin of the patient's remnant pancreas was determined as non-malignant by intraoperative histology. There was no residual pancreatic cyst and tumor after surgery. The resected tumor was diagnosed as branch duct type intraductal papillary mucinous adenocarcinoma. According to our minimally invasive DPPHR obtained by virtual CO2 pancreatography, the pancreatic endocrine and exocrine functions of this patient were maintained at almost the same levels as those in his preoperative status. With respect to preservation of the endocrine and exocrine functions of the pancreas, DPPHR is a highly effective surgical procedure due to limited surgical resection.Our new technique of virtual CO2 MDCT pancreatography is a feasible procedure for preservation of the remnant pancreatic function. This is the first report of virtual CO2 pancreatography providing minimally invasive pancreatic surgery.

Liver metastasis is an important prognostic factor in colorectal cancer. The efficacy of resection of metastatic lesions in liver metastasis of colorectal cancer is also widely recognized. However, studies on treatment methods of unresectable cases have not been sufficient and obtaining complete remission (CR) for liver metastasis is rare with chemotherapy. Selection of reliable chemotherapy for unresectable liver metastasis is an urgent necessity. The usefulness of oxaliplatin, 5-flurouracil and leucovorin combination therapy (FOLFOX) has recently been reported, but CR of liver metastasis is rare. The current status and new therapeutic significance of FOLFOX therapy are discussed based on the literature of colorectal cancer chemotherapy to date, and the clinical experience in which we obtained CR for liver metastasis is reported. The patient had stage IV rectal cancer, perforative peritonitis, pelvic abscess and simultaneous multiple liver metastasis. The patient underwent an emergency operation using the Hartmann's procedure. Liver metastasis is considered to be a prognostic factor and FOLFOX was selected as the postoperative chemotherapy, CR of the liver metastasis was obtained. FOLFOX was suggested to have new clinical significance in oncologic emergencies against unresectable liver metastasis in colorectal cancer and should serve as adjuvant chemotherapy that will contribute to improvement of treatment results.