Surgery and Transplant Surgery

About the esophagus

The esophagus is a tubular gastrointestinal tract about 25 cm long that carries food from the throat to the stomach. Swallowed food flows into the stomach by gravity and the peristalsis of the esophagus. The throat is connected to the trachea, and the chest is surrounded by important organs such as the lungs, trachea, heart, aorta, and spine. , is also associated with the difficulty of treatment.

About esophageal cancer

I) Characteristics of esophageal cancer

The number of deaths from esophageal cancer in Japan ranks 6th among men and 13th among women, which is not so high. However, considering that it is a rare disease (lifetime risk of contracting 1 in 52 people, gastric cancer 1 in 9 people), it can be said that it is a highly malignant cancer.

Although many studies have been conducted on the development of esophageal cancer, the exact cause has not been elucidated. At present, environmental factors, especially alcohol consumption and smoking, are considered risk factors for esophageal cancer, although genetic factors are also important.

Early-stage esophageal cancer is asymptomatic and is often discovered during routine checkups. In advanced cancer, symptoms such as a feeling of being stuck in food and difficulty in swallowing appear. As the disease progresses, chest pain, loss of appetite, and weight loss also occur. It may be found with neck lymphadenopathy, cough, and hoarseness (hoarse voice). This is due to paralysis of the recurrent laryngeal nerve, which is responsible for vocalization, due to metastasis to the surrounding lymph nodes.

II) Progression and stage of esophageal cancer

Once cancer is found, tests will be needed to determine how far it has progressed. This is because treatment will vary depending on the severity of the disease.

Esophageal cancer develops from the mucous membrane of the esophagus and initially stays within the mucosa, but as it progresses, it gradually reaches the submucosa, muscle layer, and adventitia (a. wall invasion). Also, in the process of progressing, some cancer cells enter blood vessels and lymph vessels and fly to lymph nodes (b. lymph node metastasis) or to distant organs such as the liver and lungs (c. blood circulation). sex transfer).

a. Wall invasion depth

Esophageal cancer is classified into T1a (up to the muscularis mucosae), T1b (up to the submucosa), T2 (up to the muscle layer), T3 (up to the adventitia), and T4 (invasion into surrounding organs) according to its depth, as shown in the figure below. increase. For gastric cancer and colorectal cancer, shallow cancer (T1) to the submucosa is called "early cancer", and cancer that has spread to the muscle layer or deeper (T2-T4) is called "advanced cancer". However, even if esophageal cancer is as shallow as T1b, it is not uncommon (approximately 50%) to develop lymph node metastasis at an early stage. distinguishes it from good “early cancer”.

b. Lymph node metastasis

Esophageal cancer tends to spread to lymph nodes from an​ ​early stage. Therefore, it is necessary to carefully check the presence and extent of lymph node metastasis before treatment. Surgery requires extensive removal of lymph nodes.

c. Hematogenous metastasis

Hematogenous metastasis occurs when cancer cells enter the veins and spread to other organs. In this state, unlike lymph node metastasis, esophageal cancer must be considered a systemic disease.
Based on these three factors, the progression of esophageal cancer is determined (Stage 0-IVb).

III) Treatment of esophageal cancer

Esophageal cancer is a disease with a very poor prognosis, and if left untreated, it progresses, leading to bleeding, obstruction, and ultimately systemic disease, which is life-threatening.
Treatment should be determined comprehensively based on the degree of progression and general condition. The Japan Esophageal Society has published the "Guidelines for Diagnosis and Treatment of Esophageal Cancer", and treatment policies are basically determined according to these guidelines, but this requires specialized knowledge, experience, and judgment. At our hospital, all patients who have been diagnosed with esophageal cancer are invited to participate in the "esophageal disease joint conference", which is held by doctor from all departments involved in the treatment of esophageal cancer, including Gastroenterology medicine, Radiation Oncology, radiotherapy, Oncology. I am considering treatment options. Stage 0 esophageal cancer can be cured by endoscopic treatment. The treatment of esophageal cancer of stage I to III is basically surgery. As with surgical treatment, chemoradiotherapy is highly effective and is expected to become more mainstream than surgery in the future. However, at present, the treatment results are considerably inferior to those of surgery, and surgery for residual or recurrent disease (called salvage surgery) places a great burden on the body. The basic policy is to perform surgery whenever possible.

Surgery for esophageal cancer

In thoracic esophageal cancer, the esophagus is surrounded by the lungs, trachea, heart, aorta, and spine. , is the common way to reach the esophagus in the middle of the body. Then, the esophageal lesion and the periesophageal and perigastric lymph nodes that may have metastasized are removed. All of the esophagus except the neck and 1/3 of the stomach will be removed. The operation is called a subtotal esophagectomy.

After removing the esophagus, the remaining stomach is stretched into a long, thin tube (called a gastric tube) that is lifted up and connected to the esophagus in the neck. Therefore, not only the thoracotomy, but also the abdomen (called laparotomy) and a small opening in the neck are required for the operation.

It is a very big operation that takes about 8 to 10 hours. Our hospital has introduced thoracoscopic surgery since 1998, and has accumulated experience in more than 200 cases. It is of course less stressful on the body than open-chest surgery, with smaller wounds and less impact on the lungs. I think that surgery is possible. Since 2018, robot-assisted surgery has been introduced, making it possible to perform more detailed surgery with less risk of complications. In addition, surgery to remove the esophagus from wounds in the neck and abdomen (mediastinoscopic esophageal surgery) without thoracotomy or manipulation of the thoracic cavity is also suitable for cases (low lung function, elderly people) as a surgery with less burden on the body. etc.).

Although it varies slightly depending on the surgical procedure, drinking water and oral intake are started about one week after the surgery. If all goes well, you can leave the hospital 2-3 weeks after the surgery.

complications of surgery

Esophageal surgery is said to be a major surgery, and it must be said that the risk of various problems (called complications) occurring during and after surgery is greater than in other surgeries. Due to the accumulation of medical technology, knowledge and experience, the number of patient deaths due to esophageal surgery has decreased significantly compared to the past. A 2011 national registry showed a complication rate of 41.9% and a postoperative mortality rate of 3.4% (National Clinical Database; NCD). Although this data is considerably better than the results of surgery in Europe and the United States, it is said that the risk is still very high compared to other surgeries ^[1]. The three major complications after surgery for esophageal cancer are pneumonia, recurrent laryngeal nerve paralysis, and suture failure.

1) Respiratory complications (pneumonia, 15%; NCD)

Since metastasis of esophageal cancer is likely to occur in the lymph nodes around the trachea in the mediastinum, it is necessary to clean the area (called lymph node dissection). This makes it difficult to take a big enough breath or cough up phlegm after surgery. Swallowing is also easily impaired, making it more likely to cause aspiration (difficulty in swallowing, causing food to flow into the respiratory tract). As a result, respiratory complications such as pneumonia (10%) and atelectasis may occur. If it is short-term, it can be treated by sucking sputum with a bronchial fiber, but if airway and respiratory management (sputum suction, artificial respiration, etc.) is prolonged, tracheotomy is required for long-term treatment. there is. Although it has decreased since the introduction of thoracoscopic surgery, it is still a life-threatening complication.

2) Recurrent laryngeal nerve palsy (about 20%; NCD)

The nerves that drive the vocal cords recurve the great vessels in the thoracic cavity (right-subclavian artery, left-aortic arch) and enter the vocal cords through the sides of the trachea. This lymph node around the recurrent laryngeal nerve is the most common site of lymph node metastasis of esophageal cancer and should be removed. Therefore, paralysis symptoms appear at a relatively high rate. If it is mild, it is called hoarseness and the voice is hoarse, but it may make it difficult to breathe or cause aspiration. Nerve function usually returns and improves within 6 months, but vocal cord surgery may be required if function is not restored.

3) Suture failure (13.3%; NCD)

Since the stomach is lifted up to the neck and anastomosed and reconstructed, blood flow tends to be poor near the tip, so saliva and gastric juice will leak if the joint is not firmly attached. This is called suture failure. If the leak is mild, wound care alone will heal. Prolonged fasting may be required. Gastric tube necrosis (2-3%) may occur when a large area of the gastric tube suffers from blood flow obstruction, and the gastric tube may rot, requiring emergency surgery. Mediastinitis is life threatening.

この他にも、乳び胸、術中・術後出血、創感染、敗血症、深部静脈血栓症などの合併症のリスクがあります。
当院では、手術を安心して受けていただくために、合併症の予防対策に特に力を入れており、全国的に見ても良好な治療成績を達成しています^[2,3]。その結果、術後に退院するまでに要する日数が短縮しています。

Perioperative management

Even if you go to great lengths to undergo surgery, you will not be able to achieve your goal of "curing cancer" unless you can overcome complications. Of course, surgery centered on the surgeon and postoperative management are important, but preoperative oral care (dentist), respiratory rehabilitation (physiotherapist), intensive care from the early postoperative period (Anesthesiology), breathing and swallowing It is a disease that requires team medical care through multidisciplinary cooperation, such as rehabilitation (physical therapist), medication guidance (pharmacist), nutrition guidance (nutritionist), etc., and the function of the entire hospital is questioned.

About outpatient visits

In order to monitor your physical condition for a while after the operation, you will be asked to go to the outpatient clinic to detect cancer recurrence or metastasis at an early stage.

As the term "5-year survival rate" is often used, it is necessary to undergo long-term examinations until it can be determined that the cancer has been cured. Once every 3 to 6 months, we will check for recurrence due to lymph node metastasis or hematogenous metastasis, mainly through blood sampling and CT scans. Recurrences may be treated with surgery or radiotherapy. In addition, esophageal cancer is characterized by many “multiple cancers in the pharynx and larynx region”, and in order to detect this early, we have patients undergo an upper gastrointestinal endoscopy at least once a year.

Surgery results

According to the "National Esophageal Cancer Registry Survey Report" by the The Japan Esophageal Society, the 5-year survival rate for those who can be resected by surgery is 55.6%. Although treatment results have improved, it is undoubtedly a disease with a particularly poor prognosis among malignant tumors of the digestive system, and treatment is sometimes difficult.

Efforts to improve treatment outcomes are ongoing. For example, in a clinical trial called JCOG9907, results showed that "preoperative chemotherapy (FP therapy) + surgery" was effective for stage II and III esophageal cancer (5-year survival rate of 60.1%). ). Since then, “neoadjuvant chemotherapy + surgery” has become the standard treatment in Japan. At our hospital, we aim to further improve treatment results by performing DCF therapy, which has a higher response rate, as preoperative chemotherapy.

References:

1. Takeuchi H, Miyata H, Ozawa S, Udagawa H, Osugi H, Matsubara H, Konno H, Seto Y, Kitagawa Y. Comparison of Short-Term Outcomes Between Open and Minimally Invasive Esophagectomy for Esophageal Cancer Using a Nationwide Database in Japan.Ann Surg Oncol 2017;24:1821-7
2. Kobayashi H, Kondo M, Mizumoto M, Hashida H, Kaihara S, Hosotani R. Technique and surgical outcomes of mesenterization and intra-operative neural monitoring to reduce recurrent laryngeal nerve paralysis after thoracoscopic esophagectomy: A cohort study. Int J Surg 2018;56 :301-6.
3. Kobayashi H, Kondo M, Kita R, Hashida H, Shiokawa K, Iwaki K, Kambe H, Mizuno R, Kawarabayashi T, Sumi T, Kaihara S, Hosotani R. Cause of recurrent laryngeal nerve paralysis following esophageal cancer surgery and preventive surgical technique along the left recurrent laryngeal nerve. Mini-invasive Surg 2020;30.
4. Tachimori Y, Ozawa S, Numasaki H, Ishihara R, Matsubara H, Muro K, Oyama T, Toh Y, Udagawa H, Uno T, Registration Committee for Esophageal Cancer of the Japan Esophageal S. Comprehensive registry of esophageal cancer in Japan, 2012 Esophagus 2019;16:221-45.

shape and function of the stomach

The stomach is one of the organs that digests and absorbs food. is in The entrance of the stomach that borders the esophagus is called the cardia, and the exit of the stomach that leads to the duodenum is called the pylorus.
The main role is to temporarily store food, eat it in small portions until it becomes porridge, and send it out from the pylorus to the duodenum (small intestine) little by little. Surgery on the stomach reduces or eliminates these functions. A diet is necessary to compensate for this. (described later)

About stomach tumors

stomach cancer

I) Formation and progression of gastric cancer

Gastric cancer is the most common and well-known gastric tumor. Gastric cancer develops from the mucous membrane of the stomach and gradually penetrates deep into the submucosa, muscular layer, and subserous layer (wall invasion). Along the way, some cancer cells enter the lymphatic vessels and blood vessels in the wall of the stomach, fly along the lymphatic flow to lymph nodes, and fly along the bloodstream to distant organs such as the liver and lungs. To do. This is called metastasis, which is why gastric cancer is called a “malignant” tumor.

a. Wall invasion depth

The depth to which gastric cancer has reached is classified into T1 to T4 as shown in the figure below. The deeper the gastric cancer is, the more likely it is to metastasize. Generally, gastric cancer that is shallow to the submucosa (T1) is considered to be early gastric cancer with low metastasis potential, and gastric cancer deep in the muscle layer or deeper with a high possibility of metastasis. is treated as advanced gastric cancer. When gastric cancer breaks through the serosa and emerges outside the stomach (T3), cancer cells may spill out into the stomach and metastasize to the peritoneum (called peritoneal metastasis or dissemination). In addition, infiltration of the surrounding internal organs is called infiltration (T4), and other organs may need to be removed together with gastric cancer resection. You can't know these things unless you actually look inside your stomach, but you can make a certain amount of predictions with gastroscopes and CT scans before formulating a treatment policy.

b.Relocation

Cancer metastasis can be roughly divided into three types: (1) lymph node metastasis, (2) hematogenous metastasis (liver, lung, etc.), and (3) peritoneal metastasis (dissemination). Gastric cancer is known to often develop lymph node metastasis from a relatively early stage. In addition, it is known that it often stays in metastases in the lymph nodes near the stomach for a while. For this reason, in the treatment of gastric cancer, the method of removing the lymph nodes around the stomach that may have metastasized together with the gastric lesion has been established as a standard surgery.
Lymph node metastasis is also important in determining the progress of gastric cancer. In other words, the progress of gastric cancer is determined by the depth of gastric cancer and the degree of lymph node metastasis (advancement, stage).

Ⅱ) Progression of gastric cancer (advancement, stage)

The progression of gastric cancer (called the degree of progress or stage) is currently classified into 6 stages, I, IIA, IIB, III, IVA, and IVB, in accordance with the regulations of the Japanese Gastric Cancer Association. will be The treatment method will be selected based on the results of gastroscopy, CT scan, etc., and the expected progress of your stomach cancer. In addition, the easiness of recovery of gastric cancer after treatment varies depending on the progress.

III) Treatment of gastric cancer

The table below is based on the gastric cancer treatment guidelines (revised in January 2018) by the Japan Gastric Cancer Society. Currently, treatment methods that are widely used and considered appropriate are listed as routine medical care, depending on the progress of gastric cancer.

Treatment methods for gastric cancer include (1) endoscopic treatment (mucosal resection with a gastrocamera), (2) surgery, (3) chemotherapy (anticancer drugs), and (4) radiotherapy. Early-stage cancer that remains in the mucosa is often targeted for endoscopic treatment, but even if it is an early-stage cancer, there is a possibility that it has metastasized to the lymph nodes, or other advanced cancer. Surgery is considered the most effective treatment. Surgery is a method of removing the stomach and the lymph nodes around the stomach together, but as explained in the later section, if the stomach can be partially left (pyloric gastrectomy or cardia gastrectomy). There is also a case where the entire stomach is removed (total gastrectomy). In addition, if the cancer grows and connects to another organ, it may be necessary to remove that organ as well (combined resection).

However, if there is metastasis to more distant organs or lymph nodes (stage IVB), it cannot be removed by surgery, so chemotherapy is the main treatment. Even in this case, palliative surgery may be performed to improve symptoms, such as when the stomach is blocked by a tumor or bleeding from the tumor continues.

• *The range of lymph nodes to be resected differs depending on the stage of cancer progression.
• ⁑For advanced cancers that have a high recurrence rate even with surgery and adjuvant chemotherapy, we also provide multidisciplinary treatment that combines preoperative chemotherapy and surgery.
• ⁂Even in stage IV, there are cases where a normal gastrectomy, not a palliative surgery, is performed after chemotherapy.

In addition, a pathological examination is performed in which the resected gastric cancer is examined in detail under a microscope to confirm the correct stage. In this case, unlike the stage classification before surgery, it is further classified into 8 stages such as IA, IB, IIA, IIB, IIIA, IIIB, IIIC, and IV. Results are usually available 2-3 weeks after surgery, so we will explain the results at the first outpatient visit after you leave the hospital. Depending on the stage of the pathological examination results, adjuvant chemotherapy (anticancer drug treatment given for a limited period to prevent recurrence) may be recommended after surgery.

In addition to this, there are examinations (examination laparoscopy) that look into the stomach with a laparoscope to check whether the cancer has spread outside the stomach and whether there is peritoneal dissemination, and before surgery By using anti-cancer drugs (preoperative chemotherapy), we also actively perform multidisciplinary treatments that aim to improve curability (completely cure cancer) as much as possible.

In addition to the treatments recommended in the gastric cancer treatment guidelines, there are a wide variety of treatment methods for gastric cancer. When performing surgery, there are different approaches such as robot-assisted surgery, laparoscopic surgery, and open surgery. Based on the individual patient's physical condition, cancer progression, etc., we will propose the best treatment options for the patient, including clinical trials that are not listed in the guidelines. I am trying to get it. At our hospital, we regularly hold joint conferences with the Department of Gastroenterology of Oncology, Department of Radiological Imaging, Diagnostic Clinical Pathology, and Surgery for gastrointestinal diseases. We provide daily medical care, so please do not hesitate to consult us regarding treatment methods other than diagnosis and surgery.

About Stomach Cancer Surgery

I) Patient-friendly, minimally invasive surgery Laparoscopic surgery, robot-assisted surgery

Laparoscopic surgery involves inflating the stomach (intra-abdominal cavity) with carbon dioxide gas, inserting a camera (laparoscopic) through the navel, and inserting cylinders with a diameter of about 1 cm into 4-5 points of the abdomen. It is a surgery performed by inserting and removing surgical instruments from. Robot-assisted surgery is an extension of this.

Recently, most gastric cancer surgeries are laparoscopic or robotic. Depending on the patient's medical condition, a normal laparotomy may be performed, so please feel free to contact the doctor.

Laparoscopic surgery not only causes less trauma to the patient, but also enables delicate surgery with less bleeding due to the magnifying effect.

II) Scope of gastrectomy Pyloral side gastrectomy, total gastrectomy, cardial side gastrectomy

Surgery for stomach cancer consists of removing the stomach and removing the surrounding lymph nodes. The area to be resected depends on the location and progress of the cancer. In order to focus on the QOL (quality of life) of postoperative patients, we take various measures such as avoiding total gastrectomy as much as possible.

a. Pyloral gastrectomy

If the cancer exists on the exit (pylorus) side of the central part of the stomach, about 2/3 to 3/4 of the exit side of the stomach including the pylorus is resected, and the stomach on the entrance (cardia) side is removed. You can leave This is called a pyloric gastrectomy. By directly connecting the remaining stomach to the duodenum, or by lifting the small intestine and connecting it to the stomach, food and digestive juices pass through.

b.Total gastrectomy

If the cancer has spread near the cardia, surgery to remove the entire stomach may be necessary. Since the stomach is completely gone, a passageway is created by connecting the esophagus and the lifted small intestine.

c. Cardiac gastrectomy

In the case of early-stage cancer near the cardia of the stomach, we perform a surgery called cardia gastrectomy to avoid total gastrectomy. Since more than half of the stomach remains, postoperative weight loss and nutritional status are said to be less than after total gastrectomy.

The scope of gastrectomy is determined not only by the location and spread of the cancer, but also by comprehensively judging the degree of progression of the cancer, the age of the patient, and physical strength. We may propose other surgical methods, or change the resection range and surgical method depending on the situation during the operation.

Efforts related to surgery

When you are told that you have stomach cancer or are told that you need surgery, you may have various concerns and questions. We would like to introduce the efforts we are making for patients who actually undergo surgery.

I) Oral care

If it is decided to undergo surgery, we hand out a referral letter to all patients and ask them to see a dentist. Keeping the oral cavity clean is very important from the viewpoint of preventing complications such as postoperative pneumonia. Not only that, chewing is also important after gastrectomy, so we work with many practitioners to treat caries (cavities), extract teeth, and make dentures (dentures) before surgery. going.

II) Nutrition guidance, ONS

Gastrectomy can lead to various post-gastrectomy complications. The function of the stomach is to store the food you eat, break it down into small pieces by peristalsis, disinfect it with gastric acid, digest it, and send it to the intestinal tract. Symptoms appear when these functions are lost as the stomach becomes smaller or disappears. Specifically, first, the amount of food that can be eaten at one time is reduced. Then, it becomes easy to have diarrhea because the digestive absorption capacity decreases. In addition, since food directly enters the small intestine, symptoms such as dumping syndrome, such as bloating and pain in the stomach early after eating, cold sweats due to hypoglycemia about 2 hours after eating, and blackness in front of the eyes. And so on. These symptoms often improve gradually over a period of months, but they cannot be completely removed. Body weight may temporarily decrease from a few percent to 10% or more after surgery. It will gradually increase again, but even if the stomach cancer is cured, it will not return to the original weight. Diet therapy is important for improving these symptoms, minimizing weight loss, and maintaining physical fitness.

At our hospital, a registered Registered Dietitian provides nutritional guidance for diet therapy twice during hospitalization (at the time of admission and before discharge), and also after discharge as an outpatient. Specifically, based on split meals, which is a method of reducing the amount of meals at one time and increasing the number of meals, it explains in detail how to eat efficiently and precautions. At the outpatient clinic, we also evaluate whether the diet is going smoothly at home and whether the necessary nutrients are being taken. Some people ask about eating out and alcohol consumption. In addition, ONS (Oral Nutrition Supplementation) is used to actively compensate for nutritional deficiencies by having patients drink enteral nutritional supplements and concentrated liquid diets in addition to their normal diet. We are making various efforts from inpatient to outpatient so that the nutritional status of children can be improved as much as possible.

I will explain according to the above document.

In addition, our hospital is a facility member of the "Stomach Surgery and Postoperative Disorder Research Group". In order to help patients lead a comfortable daily life after gastrectomy, we use the booklets and printouts created by the study group, as well as the PGSAS app provided by the study group. We strive to give you a deeper understanding of the current state of your life.

Post-surgery evaluation table for gastric cancer using the PGSAS app. By entering information such as the contents of the questionnaire filled out by the patient and the surgical procedure, it is possible to visually understand the actual condition of post-gastrectomy disorders at that time.

Ⅲ) Clinical Path, Gastric Cancer Community Collaboration Path

When undergoing gastric cancer surgery, I think there are various questions about what the specific course will be after being hospitalized. A rough schedule that shows when such medical procedures will be performed is called a clinical path. At our hospital, we use the same clinical path for almost all surgical procedures for gastric cancer patients.

By introducing the clinical path, there is an advantage that everyone can easily understand the flow of examinations and treatments after hospitalization and surgery, like a schedule table. For us doctor professionals, it is possible not only to standardize gastric cancer treatment by objectively judging whether it is progressing according to the path, Registered Dietitian, etc.) can aim to further improve the quality of medical care through information sharing. I will give it to you and explain it when you go through the hospitalization procedure.

We aim to be hospitalized on the day before surgery and to be discharged about a week after surgery.

The usual clinical path only includes the contents from hospitalization to surgery and discharge. In our department, we have introduced a schedule for outpatient visits after discharge, such as examination schedules and hospital visit schedules, and we call it the "Stomach Cancer Regional Collaboration Path". Although we mainly target patients with early-stage stomach cancer, we work closely with many general practitioners to ensure that patients can continue to visit our hospitals with peace of mind even after they are discharged from the hospital.

When you undergo actual gastric cancer surgery, we will talk about it according to the explanatory document. We ask that you fully understand the reasons for choosing surgery as a treatment method, the specific surgical method, and the postoperative risks (complications, etc.), and then consent after you are satisfied.

This is the preoperative explanatory document currently in use. I will explain according to this document.

About complications

Early complications after surgery include bleeding, suture failure (the joint between the stomach and the intestine does not stick well), pancreatic fistula, and anastomotic stenosis (temporary obstruction of the joint due to edema, etc.). It can happen.

また、胃の術後の後遺症としてダンピング症候群（胃の貯留能の低下、消失等が原因で起こる様々な症状）や逆流性食道炎、胃内容排出遅延、腸閉塞、胆石症等が起こってしまうことがあります。

In the surgical treatment process, in most cases, the clinical path is used for treatment.

If all goes well, you will be able to leave the hospital approximately 7 to 10 days after the surgery. In the meantime, we will work with a registered dietitian to provide nutritional guidance twice during hospitalization, and instruct you on how to eat if your stomach becomes small or disappears.

About outpatient visits

For early gastric cancer, the possibility of recurrence is low, so outpatient visits are about once every six months to one year. It is an outpatient visit according to the gastric cancer community cooperation pass.

For advanced cancer, adjuvant therapy is often recommended. Regarding anti-cancer drug treatment, our hospital cooperates with the Oncology, so during the anti-cancer drug treatment, the baton will be passed to the Oncology once, but once the anti-cancer drug treatment is completed, we will go to the hospital for surgery every 3 to 6 months. I will.

For both early gastric cancer and advanced gastric cancer, we will ask you to go to the outpatient clinic for about 5 years after surgery, but if there is no recurrence, we will basically ask you to continue to see a doctor in the area.

Number of surgeries in our department

The number of gastric cancer surgeries in our department ranges from 80 to over 100 per year. Among them, the proportion of minimally invasive surgery such as laparoscopic surgery and robotic surgery is increasing year by year, reaching 95% in 2022. In order to provide more body-friendly and high-quality surgeries, treatment is performed mainly by staff of multiple Technology Certified Physician and robotic surgery support proctors.

Gastric submucosal tumor

Most of them become tumors called gastrointestinal mesenchymal tumors (GIST: abbreviation for Gastrointestinal Stromal Tumor). Unlike stomach cancer, it often arises from the stomach wall (muscle) rather than from the stomach mucosa. There is almost no lymph node metastasis, but when it becomes large, the possibility of metastasis to the liver and peritoneal dissemination increases.

Method of treatment

Unlike gastric cancer, there is no need to remove the lymph nodes, so the surgical method is completely different. Laparoscopic surgery is performed for small tumors (less than 5 cm). In particular, tumors that have grown inside the stomach cannot be located by ordinary laparoscopic surgery, and excision of the normal stomach wall causes deformation and narrowing of the stomach. You may. For such cases, we perform LECS surgery (LECS: Laparoscopy & Endoscopy Cooperative Surgery), which is performed jointly with endoscopic (gastric camera) surgery and laparoscopic surgery. It will be a collaborative operation between Gastroenterology and surgery.

About colorectal cancer

Colorectal cancer is cancer that develops in the large intestine (colon, rectum, and anus), which is about 2 meters long.
Colorectal cancer arises from the cells of the mucous membrane of the large intestine, and there are some that arise from the malignant transformation of a part of a benign tumor called adenoma, and others that arise directly from the normal mucosa. The progress is slow, but if left untreated, the enlarged cancer blocks the lumen of the large intestine, causing intestinal obstruction, bleeding from the tumor, and metastasis to other organs such as the liver and lungs. It is expected to be life threatening. Treatment is needed to get rid of the cancer and avoid such dangers.

Treatment for colorectal cancer includes surgery, anticancer drugs, and radiation, but surgery is the main treatment.

The principle of treatment is to remove the cancer cleanly without leaving any residue. If the cancer is confined to the mucosa only, or if there is only a small amount of infiltration in the submucosa, the possibility of lymph node metastasis is extremely low and endoscopic treatment is possible. If there is infiltration deep into the submucosal layer or deeper, there is a certain probability of lymph node metastasis (around 10% in early-stage SM cancer), so the surrounding lymph nodes should also be removed as a preventive measure. need arises. Surgery is required for that.

Types of surgery include (1) ileocecal resection, (2) right hemicolectomy, (3) transverse colectomy, (4) left hemicolectomy, (5) sigmoid resection, (6) rectal resection, rectal amputation (colostomy), etc. It varies depending on the localization of The main surgical methods are open surgery, which has been conventionally performed, and laparoscopic surgery, in which the large intestine is resected by making five small incisions of 5 mm to 1 cm in size on the abdomen.

In 2019, 218 colorectal cancer patients underwent surgery for colorectal cancer in our department. Of these, 179 (82%) were performed by laparoscopic surgery, and the annual number of colorectal cancer surgeries is top class among neighboring prefectures.

At our hospital, we are actively working on laparoscopic surgery in colorectal cancer surgery. In particular, we are working to provide high-quality surgical treatment that is more gentle on the body, led by multiple staff members who are Technology Certified Physician laparoscopic surgery. I'm in.
In addition, the elderly and obese are not excluded from laparoscopic surgery, and laparoscopic surgery is performed with caution for adhesions as much as possible for those who have a history of laparotomy. Even patients with poor general condition (heart, lung, liver, kidney function) are indicated if they can tolerate general anesthesia.

About robot-assisted rectal surgery

The large intestine is roughly divided into the colon and the rectum based on the difference in structure and position of the organ. Robotic-assisted colectomy and rectal resection is a robotic-assisted laparoscopic colectomy and rectal resection. Currently, we are mainly using a surgery support robot called "Da Vinci" developed in the United States, but we plan to introduce cutting-edge equipment, including recently developed domestic robot equipment.

Compared to conventional open surgery, robot-assisted surgery has the same advantages as conventional laparoscopic surgery, such as smaller incisions, less pain, faster postoperative recovery, and less bleeding during surgery. I'm here. It should be noted that the greatest feature of robotic equipment is the support of robotic forceps that can bend intricately. It also has the advantage of enabling precise manipulation and enabling surgical techniques that are difficult to achieve with laparoscopic surgery. Therefore, in addition to the same advantages as conventional laparotomy and laparoscopic surgery, "more delicate and precise surgery" becomes possible.

Delicate and precise surgery can be expected to reduce damage to surrounding organs and improve curability. Especially in the case of the rectum, by carefully preserving the close pelvic plexus (nerves responsible for urination and sexual function) through delicate manipulation, postoperative urinary and sexual functions can be maintained and early recovery can be expected. , It is possible to perform surgery with “less aftereffects and gentle on the body”. Also, rectal cancer is generally associated with an artificial anus, and the closer the cancer is to the anus, the more likely it will become an artificial anus. In robotic surgery, by making full use of the characteristics of the robot, which is good at precise movements even in a narrow pelvis, it is possible to operate deep into the pelvis, making it possible for more patients to preserve the anus. Achieving functional preservation of the anus, etc., is thought to be beneficial in improving postoperative quality of life for patients.

For these reasons, we have proactively adopted robotic surgery for colorectal cancer ahead of others. And recently, we are actively introducing robotic surgery for colon cancer.

Progress after surgery

The hospitalization period after surgery is about one week, but the situation varies depending on the location of the cancer, the degree of progression, and the state of the abdomen (adhesions and obesity). We try to explain to each patient and family so that they can receive it with sufficient understanding. In addition, we have introduced the latest postoperative recovery strengthening program and strive for early recovery. Surgery naturally causes great damage to the body. The goal is to minimize the damage caused by the surgery as much as possible so that the patient can recover to the pre-operative state of health as soon as possible. To that end, not only doctor and nurses, but also pharmacists, physical therapists, nutritionists, social workers, medical office workers, and other staff involved with patients are involved as a team.

Risks and complications associated with surgery include bleeding, infection, and suture failure, which may require drainage surgery and colostomy. It is said to be a complication in about 1.5% of colon cancer surgeries. After-effects associated with rectal surgery include neuropathy (dysuria, defecation disorder, and sexual dysfunction). We take preventative measures to avoid complications as much as possible, and if they do occur, we will discover them as soon as possible and respond and treat them.

In colon surgery (especially rectal surgery), a colostomy may be created. Sometimes it's temporary, sometimes it's permanent. If a colostomy is created, the nurse will provide careful guidance on how to care for the colostomy. We have several certified nurses who specialize in colostomy care, and we also provide long-term follow-up after discharge (stoma outpatient).

About anticancer drug treatment

Treatment other than surgery includes anticancer drug treatment. It depends on the progress (stage) of the cancer. There have been remarkable advances in anticancer drug treatment for colorectal cancer, and certain effects can be expected.

Even if the disease has progressed a little and metastasis to the liver or lungs is recognized, if the condition is operable, it may be completely cured by surgery. If cancer is discovered after metastasis, which is difficult to completely remove, is treated with anticancer drugs in addition to surgery. In addition, for rectal cancer, anticancer drug treatment may be given before surgery to make the disease smaller before surgery. Anticancer drugs may be used to prevent recurrence after surgery.

Even if the cancer recurs after surgery, if it is found early, it may be completely cured by resection, but in most cases, anticancer drug therapy is the main treatment. Anticancer drug treatment is performed in cooperation with Oncology at our hospital. Prior to anticancer drug treatment, genetic testing is performed to determine if it is effective, and a central venous reservoir is placed to facilitate anticancer drug treatment. In this way, surgical techniques and anticancer drug treatments for colorectal cancer (colon cancer and rectal cancer) are progressing day by day. It is necessary to develop a comprehensive treatment strategy that includes cancer drug treatment. At our hospital, we have introduced a clinical system that goes beyond the boundaries of clinical departments to determine better treatment strategies for both Oncology and related clinical departments.

There are various treatments for liver cancer, each with its own characteristics. Therefore, in order to select a treatment method, it is necessary to first understand the liver to some extent. Let's work together to find the best treatment.

Liver anatomy and function

The liver is an organ located in the upper right abdomen, surrounded by the ribs on the cranial half.

The liver is a highly vascularized organ made up of three types of blood vessels, the portal vein, hepatic artery, and hepatic vein, and the bile duct, which carries bile.

Based on these vessels, they are divided into two lobes, the left lobe and the right lobe. The left and right lobes are further divided into four segments, the lateral segment, the medial segment, the anterior segment, the posterior segment, and eight subsegments (S1 to S1). 8).

The liver has many functions, such as storing nutrients, making proteins, breaking down drugs and poisons, and making bile, which is a digestive juice. Therefore, in order to evaluate the function of the liver, it is necessary to combine these various functions comprehensively, and when treating the liver, a safe treatment method is selected based on the Child-Pugh classification below.

Child-Pugh Classification
This is a method to evaluate the function of the liver using five items. The total score is then used to divide cirrhosis from early stage to late stage.

liver tumor

Various tumors, including benign and malignant, occur in the liver, and many tumors are targets for surgery. Liver cancer includes primary liver cancer, which originates from the liver itself, and metastatic liver cancer, in which cancer from other organs metastasizes to the liver.

1. Most primary liver cancers are hepatocellular carcinomas, and others include intrahepatic cholangiocarcinoma.
2. Metastatic liver cancer causes liver metastasis not only from gastric cancer such as gastric cancer and colon cancer, but also from lung cancer and breast cancer. The treatment policy varies depending on the type of cancer, but in the case of metastatic liver cancer from colorectal cancer, there is a possibility that it can be completely cured by resecting the liver metastasis, so surgery is aggressively performed in conjunction with chemotherapy.

Treatment of primary liver cancer

Treatment methods for hepatocellular carcinoma include surgery (hepatectomy), radiofrequency ablation therapy, embolization therapy, arterial injection therapy, drug therapy, and Gastroenterology section) and liver transplantation (see section on liver transplantation for details).

Which of these treatments is most appropriate depends on the individual patient's circumstances. Therefore, guidelines as a treatment policy for liver cancer have been proposed as "liver treatment guidelines", and treatment is performed according to these guidelines.

In the case of intrahepatic cholangiocarcinoma, surgical indications and surgical methods are selected in consideration of the site and size of the tumor, presence or absence of lymph node metastasis, presence or absence of bile duct invasion, and presence or absence of intrahepatic metastasis.

liver resection

resection range

The scope of liver resection is determined based on the concept of "preserving liver function and leaving no cancer". Specifically, it is classified into several types based on tumor localization and liver function.

Depending on the surgical procedure, the surgical procedure can be performed in about 3 hours, or it may take more than 10 hours.

resection method

In addition to open surgery, liver resection methods include laparoscopic and robot-assisted minimally invasive surgery.

Compared to conventional open surgery, minimally invasive surgery results in smaller wounds, so there are advantages such as faster postoperative recovery and less bleeding. limits minimally invasive surgery. Currently, approximately 70% of liver resections are performed using minimally invasive surgery.

Simulation/Navigation

By constructing a 3D image based on images taken before surgery, it is possible to set the resection range and surgical method, estimate the degree of difficulty of surgery and the expected remaining liver capacity, and select the optimal surgical method that is neither excessive nor deficient. Decide In addition, intraoperative ICG fluorescence imaging is used to visualize the tumor and the liver region to be resected in real time for navigation during liver resection.

Postoperative course

After the operation, you can start eating from the second day.
Although there are individual differences, you can return to society in about a month after the operation.

Complications after hepatectomy include bleeding, bile leakage, ascites, pleural effusion, and liver failure.

After surgery for liver cancer, there is a possibility that the remaining liver will recur.

In our department, we provide outpatient follow-up for those who have received liver transplants and those who have become donors for living-donor liver transplants. We also offer consultations on liver transplantation. Below is a brief description of the general aspects of liver transplantation.

1. What is living donor liver transplantation?

Liver transplantation is a treatment that transplants a liver donated by another person to a person with serious liver disease who cannot be cured by medical treatment. Live liver transplantation is a surgical procedure in which a part of the liver is removed from a healthy person and transplanted, while brain-dead liver transplantation is transplantation from a brain-dead donor. Living donor liver transplantation was performed for the first time in the world in 1988, and more than 10,000 living donor liver transplantations have been performed in Japan since 1989. On the other hand, brain-dead liver transplantation was performed for the first time in Japan in 1999, and more than 700 cases have been performed so far. Recently, there are 300 to 400 living-donor liver transplants and 60 to 90 brain-dead liver transplants each year.

Liver transplantation is targeted for patients with poor prognosis due to severe liver disease or severely impaired QOL. Various liver diseases are indicated, but transplant surgery is generally performed for the following diseases.

<Target disease>

• Decompensated liver cirrhosis (hepatitis viral, secondary biliary, liver cancer complications, etc.)
• Congenital liver/biliary diseases such as congenital biliary atresia and congenital metabolic disorders
• Primary biliary cholangitis, Budd-Chiari syndrome, primary sclerosing cholangitis, etc.

However, not everyone with the above diseases can receive a liver transplant. Since liver transplantation is a physically demanding treatment, the age of the transplant recipient (recipient) is generally considered to be up to 70 years old, and the age of the living donor to be up to 65 years old (depending on the facility). .

2. Content of surgery

In transplant surgery, the organ donor's (donor's) liver (whole or part) is first removed. Whole liver in brain-dead donors, part of liver in living donors (outer segment (approximately 1/4 of total liver), left lobe of liver (approximately 1/3), right lobe of liver (approximately 1/2 to 2/3)) extract the The size of the liver to be transplanted depends on the size of the recipient's liver and the size of the donor's liver.

The recipient's liver is completely removed and the donor's liver is transplanted. When the blood vessels of the transplanted liver and the recipient's blood vessels are all connected and blood flow resumes, the transplanted liver begins to function. Next, the bile duct of the transplanted liver and the recipient's bile duct (or intestine) are sewn together to recreate the bile flow path, and the abdominal wound is closed to complete the transplant surgery. Generally, it takes 6-8 hours for living donor surgery and 10-12 hours for recipient surgery.

3. Risks and Complications of Transplant Surgery

Liver transplantation is a major surgery with many risks, and the surgery is not without risk of death. Surgery is performed by doctor with extensive experience in liver surgery, but if the patient's preoperative condition is poor, the risk of surgery increases accordingly.
Complications of surgery include bleeding, blockage of connected blood vessels, bile leakage, bile duct stenosis, and intestinal obstruction. In addition, there are various risks such as rejection, infection, and renal failure that requires dialysis.
Several immunosuppressants are administered immediately after surgery. Immunosuppressants are necessary to prevent rejection, but care must be taken because they also lower the natural immunity, making infections more likely to occur. In addition, treatment may be necessary for hypertension and diabetes as a side effect of the drug itself.
Rejection includes acute rejection and chronic rejection, but in both cases treatment with immunosuppressants is required. If treatment is unsuccessful, the transplanted liver will eventually fail, leading to liver failure. Therefore, it is very important to continue taking immunosuppressants to prevent rejection.

Four. General postoperative course

The recipient will be placed in the intensive care unit for a while after the operation, then continue treatment in a general ward, and if there are no particular problems, they will be discharged in 1 to 2 months. During hospitalization, blood tests and ultrasonography are performed many times, and if there are any problems, tests such as CT, liver biopsy, cholangiography, and gastroscopy are considered.
Living donors are generally hospitalized for about 1 to 2 weeks, and then return to normal life after receiving treatment at home.
After being discharged from the hospital, you will visit the hospital regularly. Recipients need to continue to visit the hospital to take immunosuppressants for the rest of their lives. Living donors also go to the hospital for a while after surgery to check their physical condition.

Five. Liver transplant results

The 5-year survival rate (percentage of those who survive 5 years after transplantation) of those who have undergone liver transplantation is said to be about 70-80% for adults and about 80-90% for children. There is no difference in living-donor liver transplantation. However, the success rate varies depending on the type of disease and conditions before surgery.
Living donor safety is the most important requirement for living-donor liver transplantation. Most of the donors have recovered enough to return to their daily lives, but there have been more than 10 cases of donor death in living-donor liver transplantation worldwide, including one case in Japan.

6. Liver Transplant Benefits

Perhaps the greatest benefit of liver transplantation is that patients who would soon die without a transplant may be able to return to a normal life with this treatment. However, the history of liver transplantation is still short, and it is not yet clear how long this condition can be maintained after transplantation.

About the biliary tract

The bile duct is the path through which the bile produced in the liver flows to the duodenum, and consists of the bile duct and the gallbladder. The bile duct begins as a thin branch in the liver, and many branches join together to finally form a single bile duct that passes through the pancreas and opens into the papilla of the duodenum. The bile ducts are divided into intrahepatic bile ducts, hilar bile ducts, distal bile ducts, gallbladder, and duodenal papilla (Fig. 1). The gallbladder is a pear-shaped organ that temporarily stores bile. Bile is a yellow-brown digestive juice produced by the liver that aids in the digestion of fats.

Diseases of the biliary tract ①Biliary tract cancer

Biliary tract cancer is divided into ``cholangiocarcinoma'' and ``gallbladder cancer'' depending on the site of origin, and cholangiocarcinoma is divided into intrahepatic cholangiocarcinoma, perihilar region cholangiocarcinoma, distal cholangiocarcinoma, and duodenal papilla cancer (hepatic cancer). For intra-cholangiocarcinoma, see Liver disease). Biliary tract cancer is difficult to detect at an early stage because subjective symptoms are difficult to detect, but as the disease progresses, jaundice (yellowing of the skin and the whites of the eyes) appears due to the narrowing of the bile ducts and obstruction of bile flow. Cancer also spreads by invading and metastasizing to the liver, lymph nodes, and other organs.

Besides surgery, there are chemotherapy (anti-cancer drug treatment) and radiotherapy as treatment methods, but surgery is the only treatment that can hope for a cure.

surgery

Surgical methods for biliary tract cancer vary depending on where the cancer occurs and the extent of resection varies depending on the degree of progression. The duration of the operation varies depending on the type of operation, but the short one can take several hours, and the long one can take more than 10 hours.

Hilar cholangiocarcinoma requires liver resection along with the bile duct [Fig.2].

Distal bile duct cancer and duodenal papilla cancer require pancreatoduodenectomy to remove the pancreatic head and duodenum together with the bile duct [Fig.3]

In the case of extensive cholangiocarcinoma extending from the hepatic hilum region to the distal bile duct, combined hepatectomy and pancreaticoduodenectomy should be performed along with the bile duct.

In the case of gallbladder cancer, cholecystectomy is sufficient in the early stages, but if the cancer has progressed and spread to adjacent liver, bile ducts, lymph nodes, etc., the scope of resection will be wider, and not only the gallbladder will be removed. Resection including the liver, bile ducts, and lymph nodes is required [Figure 4].

Pre-surgery preparation

At our hospital, after a thorough evaluation of the condition of the disease in Gastroenterology, we perform surgery aimed at radical resection while maintaining safety (Fig. 5).

If there is jaundice, a procedure called biliary drainage is performed before surgery to remove jaundice because it affects the safety of surgery. The main method is to insert a duct into the bile duct using an endoscope (endoscopic drainage).
When extensive liver resection is necessary, the blood vessel (portal vein) of the resected side of the liver is stuffed with a catheter (portal vein embolization) before surgery to prevent postoperative liver failure, and the left side of the liver becomes enlarged. Surgery may be performed after encouraging regeneration.

Progress after surgery

If the postoperative course goes smoothly, the patient can be discharged from the hospital in about 2 to 3 weeks.
After you leave the hospital, you will have regular visits to the hospital to check for recurrence through blood tests and CT scans. In addition, depending on the condition of the disease, chemotherapy (anticancer drug treatment) may be performed in cooperation with the internal medicine department.

Diseases of the biliary tract ② Cholelithiasis and other benign diseases

The formation of stones in the biliary tract is called cholelithiasis, and the most common is cholecystolithiasis, in which stones form in the gallbladder. It may be asymptomatic and incidentally discovered by abdominal ultrasound or CT, but it may also cause symptoms such as gallstone attack, cholecystitis, or gall bladder stones that flow into the bile ducts and become bile duct stones.
As symptoms, right hypochondral pain and right back pain that occur after eating or at night are relatively common, but they may also be perceived as stomach pain or low back pain, and the location and degree of pain vary. Usually, asymptomatic gallbladder stones do not require surgery, but if symptoms of gallbladder stones (cholelithiasis, cholecystitis, bile duct stones) occur even once, surgery is recommended.
In addition to gallbladder stones, surgery may be considered for gallbladder polyps and adenomyomatosis of the gallbladder. Surgery is recommended when there is a possibility of cancer, such as gallbladder polyps larger than 1 cm.

surgery

For benign diseases such as cholecystolithiasis, the gallbladder is removed by laparoscopic surgery (laparoscopic cholecystectomy) [Figure 6].

Three or four holes are made in the abdomen and a laparoscope or forceps are inserted to remove the gallbladder. Recovery after surgery is faster because the incisions are smaller than in open surgery. However, for patients who have had upper abdominal surgery before or who have severe gallbladder inflammation, laparoscopic surgery may be difficult and open surgery may be performed.

Progress after surgery

Normally, in the case of laparoscopic cholecystectomy, the patient is hospitalized on the day of surgery and discharged the next day (2 days and 1 night). Open surgery requires hospitalization for about a week. In most cases, there are no sequelae after removal of the gallbladder. Digestion of fat may be reduced and diarrhea may occur, but this will subside over time.

1) Pancreas

The pancreas is an organ behind the stomach and in front of the spine that has two main functions.
First, it makes a digestive juice called pancreatic juice and secretes it into the duodenum. Pancreatic juice breaks down carbohydrates, proteins, and lipids, and plays a major role in the digestion and absorption of food.
Second, it secretes hormones such as insulin and glucagon into the blood. These are hormones that regulate the concentration of glucose (blood sugar) in the blood, and it is known that abnormalities in the secretory function of these hormones lead to diabetes. Therefore, diabetes can be exacerbated if the pancreas is removed.

2) Pancreatic disease

Pancreatic cancer (invasive pancreatic ductal carcinoma)

A cancer that originates in the pancreatic duct and spreads to the surrounding area. It is divided into “pancreatic head cancer”, “pancreatic body cancer” and “pancreatic tail cancer” depending on the location. Of these, pancreatic head cancer is in contact with the duodenum and bile duct, and since it is close to the liver, it affects these organs as well.

pancreatic cystic tumor

Large and small bag-like tumors called “cysts” are caused by tumors that develop from the cells that produce mucus in the pancreas.

3) Treatment of pancreatic cancer

Treatment options for pancreatic cancer

Treatment of pancreatic cancer includes surgery, nonsurgical treatments, and supportive care.

Classification of pancreatic cancer

Pancreatic cancer is divided into three categories, resectable pancreatic cancer, borderline resectable pancreatic cancer, and unresectable pancreatic cancer, based on whether or not surgery (radical resection) can be performed for pancreatic cancer.

Pancreatic cancer may be completely cured by complete removal of cancer cells (= radical resection) by surgical resection. Therefore, whether or not resection is possible is an important point in treatment selection.

If the cancer has metastasized to organs far from the pancreas, lymph nodes, or the peritoneum, or if it has invaded large blood vessels adjacent to the pancreas, complete resection becomes impossible, and chemotherapy or radiotherapy is selected. I will go.

According to the latest guidelines, preoperative chemotherapy increases the possibility of a radical cure, so it is recommended that anticancer drugs be aggressively administered before surgery even for resectable pancreatic cancer. In the case of borderline pancreatic cancer, anticancer drug therapy or radiation therapy may be performed before surgery to shrink the cancer that has invaded the blood vessels around the pancreas and make it resectable.

Surgery for pancreatic cancer

The extent of resection in pancreatic cancer surgery varies depending on where the cancer occurs and how advanced it is.

① Pancreaticoduodenectomy

This is a surgical procedure performed for cancer that occurs in the pancreatic head. The pancreatic head, duodenum, lower bile duct, gallbladder, and surrounding lymph nodes are all removed.
If the cancer has infiltrated strongly around, the portal vein, which is an important blood vessel, can be partially resected and reconstructed (=portal vein joint resection), or the nerve plexus around the superior mesenteric artery can be resected. Enlargement surgery is performed.
In this surgery, reconstructive surgery is performed on the gastrointestinal tract, which connects the pancreas, biliary tract, and stomach to the jejunum, recreating routes for pancreatic juice, bile, and food to flow.

② Body and tail pancreatic resection

This is a surgical procedure performed for cancer that has occurred in the body or tail of the pancreas. Leaving the head of the pancreas, the body and tail of the pancreas are excised together with the spleen and surrounding lymph nodes. The reason for removing the spleen is that the blood vessels related to the spleen are located on the dorsal side of the body and tail of the pancreas, and there is a high possibility that metastasis has occurred there. This surgery does not require reconstruction of the gastrointestinal tract.

<Laparoscopic pancreatic body and tail resection>

Pancreatic mucinous cystic tumors tend to occur in relatively young women, and at our hospital, we actively perform laparoscopic surgery and robot-assisted surgery for benign or borderline malignant disease as minimally invasive surgery with a small surgical wound. I'm here. Since the scar is small, it has excellent cosmesis, and by reducing the burden on the body, it leads to early recovery after surgery. In addition, for some pancreatic cancers, laparoscopic surgery and robot-assisted surgery are performed by selecting cases while considering the progression of the cancer.

③ Other surgical procedures

When pancreatic cancer or IPMN exist in the wide range of the pancreas, we may resect the whole pancreas (= total pancreatectomy). In this case, insulin cannot be secreted at all, so it is essential to self-inject insulin after surgery.

When cancer cannot be resected because it has spread to other organs or infiltrated the surrounding area, and when the bile duct or duodenum is blocked by cancer, surgery to create a passageway to send bile and food to the small intestine (= bypass surgery). Recently, medical devices such as biliary stents and duodenal stents have been developed, and there are many cases of treatment without surgery.

About preoperative chemotherapy

Preoperative treatment for pancreatic cancer has become standard, and we perform preoperative chemotherapy for resectable pancreatic cancer and resectable borderline pancreatic cancer. The advantage of preoperative chemotherapy is that the rate of radical resection can be improved when the tumor becomes smaller, and the sensitivity to chemotherapy can be determined.

About adjuvant therapy

After surgery, if the cancer is diagnosed as stage I or higher, there is a possibility of recurrence, and adjuvant chemotherapy with anticancer agents is recommended. This can be expected to prevent cancer recurrence and prolong the time until recurrence.

Complications early after surgery

Complications that can occur relatively early after surgery include:

① pancreatic juice leakage

Complications specific to pancreatic surgery. Pancreatic juice containing digestive enzymes secreted from the pancreas leaks into the abdomen from the part where the pancreas and the small intestine are connected in "pancreatoduodenectomy" and the stump of the pancreas in "body and tail pancreatic resection". That's it. Pancreatic juice has the function of dissolving food, but in the stomach and intestines, the mucous membrane protects it, so it does not dissolve your own tissue. However, when the pancreatic juice leaks into the abdomen, it dissolves as if it were digesting the surrounding tissue, and peritonitis may occur at the same time. Bleeding may occur if the blood vessel is ruptured. Pancreatic juice leaks Even if pancreatic juice leaks, if you can guide the pancreatic juice to go out without accumulating in the abdominal cavity (= drainage), in most cases, the pancreatic juice will heal naturally. Depending on the degree of pancreatic juice leakage, long-term treatment may be required from 2 weeks to 1 month for healing.

② Bleeding

There are many arteries and veins around the pancreas, and bleeding may occur from the surgically manipulated site after surgery. Bleeding may also occur as a complication of pancreatic leakage. It can be treated with blood transfusion, but arterial bleeding due to pancreatic juice leakage is stopped by intravascular catheterization.

③ Suture failure

In the case of pancreatoduodenectomy, in addition to the pancreas and small intestine, it is necessary to connect the bile duct to the small intestine, and the stomach to the small intestine. In this case, drainage is performed in the same way as pancreatic juice leakage and treated.

④ Infection

Depending on the site and degree, such as wound infection and intraabdominal abscess, treatment and antibiotic therapy are performed.

⑤ Others

Deep vein thrombosis, pulmonary embolism, chylous ascites, heart/pulmonary/cerebrovascular complications, etc.

After-effects after pancreatic resection

After resection of the pancreas, various long-term sequelae may occur.

(1) Decreased food intake, malnutrition, dumping syndrome, weight loss, etc.

It is expected to improve after a certain period of time after surgery.

② Exacerbation of diabetes

Even if you do not have diabetes to begin with, pancreatic resection may reduce insulin secretion and lead to diabetes, which may require oral treatment such as self-injection of insulin. Patients with pre-existing diabetes may also experience poor postoperative diabetes control. In such cases, treatment will be provided in cooperation with the Department of Diabetes/ Endocrinology at our hospital.

③ Diarrhea

When the pancreas is removed, the secretion of pancreatic juice, which is a digestive juice, is reduced, so digestion of fat may not go well and diarrhea may occur easily, which may result in fatty liver. It is treated by oral administration of digestive enzymes as a substitute for pancreatic juice.

In addition, it is known that excision of the nerve plexus around the superior mesenteric artery for resection of pancreatic cancer causes postprandial diarrhea. It depends on the progress of the cancer, but we prevent it by performing surgery that preserves the nerve plexus as much as possible, but there is a possibility that some symptoms will occur.

4) Course from admission to discharge

You will usually be admitted to the hospital the day before your surgery. You can drink water and tea, including rehabilitation to move your body from the first day after surgery. On the 5th day after the operation, a CT imaging test will be performed. If there are no particular problems, eating will begin. . If there are no complications, patients are often discharged from the hospital 2 to 3 weeks after surgery, but if complications such as pancreatic juice leakage occur, the hospitalization period will be extended.

An important point for life after surgery is to actively move your body. Practicing standing and walking will help you recover better, and sleeping too long not only weakens your muscles but also increases the risk of complications.

The 2-3 days after surgery are the most painful times. Immediately before the operation, you will be given painkillers through a tube inserted through your back to relieve pain. Rehabilitation while relieving pain, such as regular pain relief drips, will lead to a good postoperative course.

5) Outpatient visits

Depending on the degree of progression, postoperative chemotherapy is recommended to prevent recurrence, and treatment is performed on an outpatient basis in cooperation with Gastroenterology and Oncology. Outpatient visits are usually required for 5 years after surgery, and regular blood tests and CT imaging (or abdominal ultrasound, MRI, or PET scan) are done to evaluate for recurrence.

1) What is an inguinal hernia?

An inguinal hernia is a swelling at the base of the foot.

An inguinal hernia is a swelling at the base of the foot. A disease in which the muscle wall at the base of the thigh (groin) weakens and a hole opens, through which the intestines and fat in the abdomen are wrapped in a membrane called the peritoneum and protrude like a bag. That's what I mean. The term “hernia” refers to a protruding condition. Since the intestine often comes out, it is also commonly called "Daccho".

2) Causes and symptoms of inguinal hernia

Inguinal hernia, also known as a childhood disease, has slightly different causes in children and adults. In children, it is congenital, but in adults, it is thought that it often occurs due to the weakening of body tissues with age. In addition to age, the burden on the wall of the stomach, such as carrying heavy objects and standing for long periods of time, accumulates on the wall of the stomach, and the muscle wall that supports it becomes partially weakened and gradually becomes like a hole. Intestines and fat come out from there. Depending on where it comes out, it is called an inguinal hernia (groin) or femoral hernia (lower thigh).

This is a surgical procedure performed for cancer that has occurred in the body or tail of the pancreas. Leaving the head of the pancreas, the body and tail of the pancreas are excised together with the spleen and surrounding lymph nodes. The reason for removing the spleen is that the blood vessels related to the spleen are located on the dorsal side of the body and tail of the pancreas, and there is a high possibility that metastasis has occurred there. This surgery does not require reconstruction of the gastrointestinal tract.

3) Inguinal hernia surgery

Surgery is required to fix a hernia. It cannot be cured with medicine. There is also a belt called a hernia band (hernia band) that holds down the hernia, but it is not a fundamental treatment.

Surgery uses an artificial stiffener (mesh) to close the hernia hole and strengthen the weakened abdominal wall. There are various methods of detailed surgery, but in our hospital, we generally perform surgery in two ways. You can choose either an incision in the groin or a laparoscopic method. Whether to use the groin incision method or laparoscopic surgery depends on the patient's physical condition.

In the groin incision method, surgery is usually performed under spinal anesthesia (half anesthesia). In some cases, it may be performed under general anesthesia or local anesthesia. A 5 cm incision is made in the groin (depending on the thickness of the abdomen), and the fat and muscle are separated to expose the hernia bag and hole. (Mesh plug method, Liechtenstein method, Kugel method, etc.).

Laparoscopic surgery is performed under general anesthesia. A hole of about 1 cm is made in the navel and 3 places on both sides, and a tube called a port is passed through it, and carbon dioxide gas is injected to expand the stomach. A camera is inserted to observe the hernia hole from inside the stomach, the peritoneum around the hernia is peeled off, the mesh is spread to cover the hernia hole, fixed with a dissolvable pin, and finally the peeled peritoneum is placed over the peritoneum. suture.

The operation time is 1 hour to 1.5 hours for the inguinal incision method and 1.5 hours to 2 hours for the laparoscopic surgery. Add time for anesthesia. People with large hernias, those who have had hernias for many years, those who are obese, those who have recurrent hernias, and those with hernias on both sides will take longer.

Hospitalization period and postoperative course

In the case of inguinal hernia surgery, you will come directly to the operating room on the morning of the surgery, and after a pre-operative examination by the doctor in charge, you will enter the operating room. After surgery, you will be admitted to the ward.

If you have pain in the wound after surgery, we have prepared painkillers to take, so please do not hold back. Over time, the pain will gradually get better. The part of the hernia that was originally swollen may swell for a while, but the swelling will gradually subside over time.

If things go smoothly, you can leave the hospital the day after the surgery (hospitalization for 2 days and 1 night). After you leave the hospital, you will be asked to visit the outpatient clinic once (1-2 weeks later) for a check-up. The wound is sewn with dissolvable sutures, so there is no need to remove the sutures.

For about 2 to 3 weeks after discharge, please refrain from activities that put a lot of force on your stomach, such as strenuous sports or carrying heavy objects. Depending on the condition of the hernia at the time of surgery, you can return to your normal life in about 1-2 months.

4) Surgical complications

Complications are problems that can occur as a result of surgery. We are always careful not to cause complications during surgery, but unfortunately we cannot eliminate complications. Please understand that there is a small but certain probability of complications in any surgery. The main complications that can occur with inguinal hernia surgery are listed below.

① Postoperative bleeding

The surgery is completed after confirming that there is no bleeding, but sometimes postoperative bleeding or hematoma may occur in the wound. In rare cases, blood transfusion or reoperation for hemostasis may be required.

② Infection

Surgical wounds can become infected and suppurate. In this case, the wound may open, drain pus, and need cleaning. Also, if the mesh becomes infected, the infection may not subside unless the mesh is removed by reoperation.

③ Water accumulates

After surgery, the original hernia space may fill with water and swell as if it were a hernia. It is called a serous seed, but in most cases it will gradually disappear over time. If it doesn't go away easily, you may need to pierce it with a needle to drain the water.

④ Postoperative pain

There will be pain from the wound for a while after the operation, but it will gradually ease over time. Although rare, chronic pain and numbness may remain.

⑤ Hernia recurrence

The hernia may come from a different place than the one reinforced with the mesh, resulting in a similar inguinal hernia condition as before. It is said that recurrence occurs in about a few percent, although reports vary somewhat. Surgery is usually required for treatment. In some cases, the hernia may appear on the side opposite to the one that was operated on.

⑥ Allergies

Some people are allergic to the antibiotics and anesthetics used during surgery. If you are known to be allergic to certain drugs, please consult your doctor beforehand.

⑦Others

麻酔の合併症、静脈血栓塞栓症、心臓や肺の合併症など他にも起こりうる合併症はありおますが、このような合併症が発生した場合には、最善と思われる処置を迅速に講じます。

(Note) With permission from Medicon Co., Ltd., the figures are excerpts from the company's website and explanatory documents for patients.

Our Emergency and Critical Care Center accepts patients of various ages and people with diseases as much as possible and provides emergency medical care. In order to be able to respond immediately to emergency abdominal diseases that require emergency surgery, we have a system in which a full-time surgeon is always on duty every day, including holidays. In addition, we also perform laparoscopic surgery to reduce the burden on patients as much as possible while considering safety and urgency in emergency surgery for emergency diseases.

1) About the system of emergency medical treatment in our department

Our hospital has the philosophy of "providing highly advanced medical care and emergency medical care", and while treating patients of various ages and diseases on a daily basis, at the same time, we accept as many emergency patients as possible, so that citizens can always feel safe. We aim to provide the best medical care possible. In accordance with this philosophy, our department focuses not only on highly advanced medical care for each organ disease listed above, but also on enhancing emergency medical care.

The emergency department of our hospital accepts about 36,000 patients a year, many of whom have acute abdominal diseases, and depending on the severity of their symptoms and condition, special treatment is required. Medical examination, emergency surgery, and semi-emergency surgery (surgery to be performed early after symptoms have stabilized) are necessary. In preparation for such cases, our department always has at least two full-time surgeons on duty and one on standby, and has a system that allows emergency surgery to be performed as quickly as possible 24 hours a day, 365 days a year.

Our department performs an average of 1,300 to 1,400 operations per year, of which approximately 30% (300 to 400) are emergency operations. In addition, even in an environment where surgeries are restricted due to corona measures, the proportion of emergency surgeries has not changed, and we continue to strive to fulfill our responsibilities. We also aim to minimize the burden on patients during emergency surgery, and actively perform highly advanced medical care with minimally invasive procedures such as laparoscopic surgery.

2) Role of our department for emergency abdominal care in an aging society

Currently, Japan is one of the countries facing an unprecedented aging society. For this reason, the percentage of elderly people among patients who visit emergency departments is increasing year by year. In general, the characteristics of the elderly are as follows: 1) The pathology is not simple (complex) because there are many underlying diseases (pre-existing diseases) and a wide range of diseases, 2) Symptoms are vague and difficult to understand, 3) Consciousness disturbance and heart failure These points also apply to elderly patients presenting to the emergency department, such as the tendency to have comorbid symptoms. Furthermore, due to the nature of our hospital, which has focused on emergency medical care for many years under the philosophy mentioned above, there are many regular patients with various acute diseases such as heart failure and stroke, which correspond to 3). is also one of the characteristics of our school.

Therefore, among the patients who come to us with acute abdominal diseases, there are cases where consciousness disturbance and cardiac (circulatory) failure are lurking, and conversely, there are cases where various pathological conditions are complicatedly entwined. There are more than a few cases of acute abdominal disease triggered by a decrease in blood pressure. In addition, there are cases in which “cancer” is discovered for the first time while treating such patients. In emergency medical care for such complicated medical conditions, highly specialized medical care and judgment are required quickly, such as "What is the essential cause of the medical condition?" and "Which treatment should be prioritized?" Our department strives to provide prompt and appropriate life-saving treatment to such patients in cooperation with emergency departments and specialists in each department. In addition, in order to increase the survival rate of elderly patients whose general condition has deteriorated, we have introduced laparoscopic surgery, which minimizes the physical burden on the patient, even when emergency surgery is performed. We provide advanced and minimally invasive treatments.

3) Major abdominal emergency diseases

Examples of abdominal emergencies that require emergency surgery include:

acute cholecystitis

It is a disease in which the gallbladder is acutely inflamed due to gallstones. If the inflammation is severe, the gallbladder may become necrotic or perforated (rotten or torn), allowing bacteria to spread throughout the body, which can sometimes be life-threatening. Symptoms include fever and pain in the pit of the stomach, and some people complain of fatigue and loss of appetite.
It is treated with antibiotics, or a tube is inserted through the skin into the gallbladder to drain the pus out of the body. When it is determined that emergency surgery is necessary, laparoscopic surgery is performed if possible, and the rate of laparoscopic surgery in 2019/2020 was 89%.

Acute appendicitis

This disease is commonly referred to as "Mocho's inflammation". Medically, it refers to a condition in which the thin tail-like part of the appendix attached to the cecum becomes inflamed. Pus may accumulate in the appendix, and in severe cases, it may rupture and the pus may spread throughout the abdomen, leading to peritonitis of the entire abdomen. In some cases, the initial symptoms are pain in the pit of the stomach and around the navel, which may be diagnosed as gastroenteritis, but as the disease progresses, fever and pain in the lower right abdomen are seen.
If the degree of inflammation is mild, it can be cured with antibiotics, but there are cases where it repeats after that. In some cases, repeated appendicitis makes surgery difficult, and we recommend emergency surgery if it is considered safer and more reliably treatable at the time of the visit. Laparoscopic surgery is basically performed instead of open surgery, and in recent years 2016-2020, almost 100% of surgeries are performed by laparoscopic surgery.

*Recently, with the aim of reducing postoperative complications, even in cases of severe appendicitis, antibiotics and treatment to drain pus are used to calm the inflammation and avoid emergency surgery. We also perform laparoscopic surgery again.

bowel obstruction

It is a disease in which the intestine becomes blocked. Symptoms include bloating, abdominal pain, nausea and vomiting. In many cases, during the wound healing process after abdominal surgery, a phenomenon called "adhesion" occurs, in which the intestine and the surgical wound stick together, or the intestines stick to each other, resulting in accidental twisting or bending of the intestines. is the cause. In the early stages, treatment begins with fasting and intravenous drips. Sometimes it is treated by inserting a tube through the nose to expel food and digestive juices from the intestine.
If there is no improvement with the above treatments, or if the torsion is so strong that the blood circulation is poor and the intestine itself rots, an emergency operation is performed. In recent years, laparoscopic surgery has been adopted for such pathological conditions if it is possible.

*Intestinal obstruction may occur due to colorectal cancer, and treatment may be performed jointly with Gastroenterology.

Gastrointestinal perforation

Peritonitis is a disease in which food and feces spread through the stomach and intestines. It is accompanied by quite severe abdominal pain, and sometimes circulatory failure (shock) may occur. Most of them require emergency surgery, but the treatment method and progress vary greatly depending on the location of the hole.

If there is a hole in the stomach or duodenum caused by an ulcer, it is often a relatively mild condition that can be treated without surgery or can be improved simply by suturing the torn part.

On the other hand, if the large intestine is ruptured, it is easy to fall into bacteremia, which spreads bacteria throughout the body from peritonitis caused by stool, or septicemia, which weakens the whole body. For this reason, an artificial anus may be created in an emergency operation, the deterioration of the general condition may be prolonged, requiring treatment in an intensive care unit, and in the worst case, unfortunately, life may not be saved.

*Cancer can also cause a hole in the intestine.

Intra-abdominal organ injury due to trauma

In our hospital, patients with trauma due to accidents are also brought in by ambulance. In particular, severe cases are treated in cooperation with various medical departments centering on the emergency department. In terms of treatment, we do our best to save lives by combining not only surgery but also treatment (by doctor) in which a tube called a catheter is inserted into the blood vessel to clog the blood vessel and stop the bleeding.

Other diseases

In addition to the above, there are various abdominal emergencies such as incarcerated inguinal hernia (see the explanation of inguinal hernia for details) and colonic diverticulitis. Not only the disease but also the patient's age and general condition are different, so for each patient, we explained the disease, the appropriate treatment for it, possible complications, etc. and had them understand. Above all, I try to provide tailor-made treatment.

As a Robotic Surgery Center, all departments work together to actively perform surgery. For more information on robot-assisted surgery, please visit the Robotic Surgery Center website.

Robot-assisted (da Vinci) surgery in surgery

At our hospital, gastric cancer was covered by insurance from June 2018, and esophageal cancer and rectal cancer from October 2018. Recently, it has also been introduced for normal colorectal cancer, pancreatic cancer, and liver cancer, and the indications and cases are increasing year by year.

As of May 2023, our department has 5 robot-assisted surgery proctors certified by the Japan Endoscopic Surgery Society (1 esophagus, 1 stomach, 2 rectum, 1 pancreas). . This is to certify proctors who have acquired standard skills as operators of robot-assisted endoscopic surgery and who can guide others in robot-assisted surgery smoothly and safely. is the required qualification.

We not only aim for a complete cure of cancer, but also provide patients with a better life after surgery. We also actively perform surgery that emphasizes postoperative QOL (quality of life) in order to take advantage of the characteristics of robotic surgery, such as rectal surgery that preserves function.

If you have any questions related to da Vinci surgery for each organ or disease, please feel free to contact the outpatient surgery department. We have specialists such as proctors for each organ, so we will respond appropriately.

As of May 2023, nearly 350 patients have already undergone da Vinci surgery in surgery.

As of May 2023

About the treatment at our hospital for pain after inguinal hernia surgery

What is chronic pain after inguinal hernia surgery?

In recent years, ``inguinal hernia postoperative chronic pain (CPIP)'' has become known as one of the postoperative complications of inguinal hernia surgery. I'm here.

Generally, the pain after inguinal hernia surgery peaks within 1 to 2 weeks after surgery and gradually improves. In some cases, the pain may continue for one to two weeks, but in most cases, the pain can be controlled by taking analgesics, and the pain will reduce over time and eventually disappear. To do. However, the pain may not subside even three months after inguinal hernia surgery, and the pain may interfere with daily life. This condition is diagnosed as `` chronic pain after inguinal hernia surgery'' (CPIP). Pain in the thighs and testicles that was not present before inguinal hernia surgery, as well as pain during sexual intercourse, are considered to be a type of CPIP.

Frequency of chronic pain after inguinal hernia surgery

CPIP is a disease that has been reported mainly in Europe and America since around 2000, and many research reports have been published since then. The frequency varies depending on the degree of pain, but according to a report published in Sweden in 2018, a questionnaire survey of 22,917 patients who underwent inguinal hernia surgery found that 15% after anterior incision, 18% after laparoscopic surgery patients, Pain that interferes with daily life even one year after surgery There was (Br J Surg 2018; 105: 106–112). In addition, a study conducted by 577 facilities in Germany, Austria, and Switzerland, also reported in 2018, found that Laparoscopic hernia radical surgery Of the 20,040 patients who underwent 9.5% 1,900 people Pain during exercise 1 year after surgery had. Also, Patients who require treatment 520 people, total 2.6% (Surg Endosc. 2018;32:1971-1983). Once patients suffer from CPIP, they become exhausted due to the mental stress caused by the pain, and are unable to carry out their daily lives. Against this background, CPIP is widely recognized overseas, not only by medical professionals but also by patients undergoing surgery, as the most unpleasant postoperative complication of inguinal hernia surgery.
On the other hand, it has been reported that the incidence of this disease is lower in Japan than in other countries, but the exact frequency is currently under investigation. In any case, it is a disease that is still relatively unfamiliar to medical professionals in Japan.

Causes and types of chronic pain after inguinal hernia surgery

Currently, the standard surgical method for inguinal hernia surgery is radical surgery using mesh, so most patients who develop CPIP are patients who have undergone surgery using mesh. On the other hand, there are some patients who underwent surgery without mesh insertion and developed CPIP. Additionally, laparoscopic surgery has been reported to have less postoperative pain and a lower incidence of CPIP, but as mentioned above, some patients develop CPIP after laparoscopic surgery. In other words, it is important to be aware that CPIP is a postoperative complication that can occur with any surgical technique.
There are three types of CPIP pain. 1) neuropathic pain, 2) somatic pain, and 3) testicular pain.

① Neuropathic pain

There are three pain-sensing nerves running in the groin and two in the pelvic cavity. The hardening of tissue due to wound healing after surgery is called scarring, and the pain that occurs when these nerves become involved during the scarring process is called neuropathic pain. It is also known that the mesh used in hernia surgery shrinks over time. This neuropathic pain can also occur when nerves are pulled into the compressed mesh, causing compression or pulling of the nerves. Neuropathic pain is the cause of many cases of CPIP that do not respond to treatment with drugs or injections.

​②Somatic pain

​On the other hand, the inserted mesh may contract surrounding tissues, especially muscles, which may interfere with the flexible movement of the groin and pelvis, causing discomfort or pain, or the mesh may twist or twist within the pelvis. This can cause the area to become like a hard lump, which may cause discomfort and pain. This kind of pain is called somatic pain. Although not many patients develop pain that becomes a problem in daily life, once CPIP develops, outpatient treatment becomes difficult.

③Testicle pain

The mesh is placed right next to the vas deferens, where sperm are transported. When the mesh adheres to the vas deferens, the mesh compresses or strains the nerves that run alongside the vas deferens, causing testicular pain. The mesh may sink into the vas deferens itself and erode, causing testicular pain. Outpatient treatment is also extremely difficult in these cases.

Diagnosis and treatment of chronic pain after inguinal hernia surgery, and its results

"Pain" is not something that can be seen by a third party, nor can it be evaluated by blood tests or X-rays. As a result, many patients are troubled by the fact that their condition is often not understood by those around them. Not understanding their pain and not receiving appropriate treatment leads to cumulative mental stress and some people develop depression. In order to provide effective treatment for CPIP, it is most important to know exactly what is causing the pain, and it is important to diagnose the ``type of pain'' mentioned earlier.

There is no established treatment method for CPIP, and there are no specific descriptions of treatment in any domestic or international guidelines. Therefore, treatment of CPIP is extremely difficult.
At our hospital, we actively treat patients suffering from "chronic pain after inguinal hernia surgery." It is necessary to diagnose the type and degree of pain through step-by-step examinations and treatment, so you may need to visit the hospital many times. Please refer to the treatment algorithm for chronic pain after inguinal hernia surgery created by our department.

Diagnosed with chronic pain after inguinal hernia surgery as of October 2023 83 people Patients were treated according to this algorithm. Patients who were able to be treated without surgery 29 people However, 54 patients required surgery. In other words, while it is possible to alleviate pain with treatment using algorithms for refractory CPIP, it is also true that there are many patients who require surgery.
Surgical treatment for CPIP is different from general surgery and has not been established. Therefore, the surgical method is carefully considered, taking into account the patient's symptoms, the details of the previous surgery, and the site where the mesh will be placed.
Generally, surgery involves a certain degree of risk, and sometimes fatal complications such as bleeding, myocardial infarction, cerebral infarction, and pulmonary embolism may occur. In addition, CPIP surgery requires removing the mesh and, in the case of neuropathic pain, identifying and removing the causative nerve, making it an extremely difficult surgery. Furthermore, regarding CPIP surgery, Risks resulting from surgery' should also be considered. in particular," Even with surgery, the pain may not be relieved as expected."" Possibility of experiencing new pain that was not present before surgery"" Possibility of inguinal hernia recurrence” and so on. Therefore, we do not perform simple surgeries. We make decisions only after careful consideration of suitability and after taking time to consult with patients and their families.
As a result of a questionnaire survey conducted on patients who underwent surgery, 90 and above of patients said “very or generally satisfied”, but to put it the other way around, Not 100% of patients are satisfied.Therefore, we perform surgery with the full understanding that ``surgery does not necessarily relieve pain.''

If you continue to experience pain 3-6 months after inguinal hernia surgery, please contact us.
If you have any questions regarding this condition, please contact the "Hernia Outpatient Clinic" every Thursday afternoon.

In inguinal hernia surgery (surgery for prolapse), artificial reinforcing material (called mesh) made of polypropylene or polyester is commonly used, and guidelines recommend the use of mesh. Before 1990-2000, when there was no mesh, hernias were healed by suturing the patient's own tissue, but because the recurrence rate was as high as 10-35%, the use of mesh, an artificial reinforcing material, was recommended. There is a historical background that led to this.

However, is it really a good idea to insert a mesh, which is a foreign object that will never go away, into the body to treat a benign disease called a hernia?

In recent years, groin pain after hernia surgery using mesh (chronic (mansei) pain (Toutu)・Pain during sexual intercourse has been widely discussed in the media and on social networks. A detailed analysis by a specialized department has shown that there is no difference in the rate of chronic pain whether a mesh is inserted or not.Import (hot water) Vas deferens (Seikan)) have been reported to have a negative effect on In a report published in 2018, a questionnaire survey of 22,917 patients who underwent inguinal hernia surgery in Sweden found that 15% of patients underwent anterior incisional surgery using mesh, while 15% of patients underwent laparoscopic surgery. After surgery, 18% of patients report that they still have pain that interferes with their daily life even one year after surgery (Br J Surg 2018; 105: 106–112). Against this background, BBC News, the British national broadcaster, has featured on hernia mesh complications, especially chronic pain, on three separate occasions. https://www.bbc.co.uk/search?q=Hernia+mesh&seqId=df20bf20-56a2-11ee-a0ab-558b52201976&d=SEARCH_PS), overseas Surgery without mesh It is also true that this is being gradually reconsidered.

At our hospital, we have treated many patients who developed chronic pain after hernia surgery using mesh. There are many patients for whom treatment with drugs or injections is ineffective, and the mesh has to be removed surgically.
It has been about 20 years since mesh was actually used, but no one knows how the inserted mesh will affect the human body over the years. The raw materials that make up the mesh are also unknown. There are also reports that the mesh erodes into internal organs (vas deferens, bladder, and intestinal tract) over time (Ann Surg. 2018;267:569-575.). Among the patients who have undergone surgery for chronic pain at our hospital, many have had the mesh removed because of pain more than 10 years after the mesh was inserted.
At our hospital, we also perform inguinal hernia surgery using mesh in accordance with the guidelines. Surgery without mesh We also perform tissue repair methods (called tissue repair methods), which patients can choose from. There are various methods for tissue repair, but the one we use at our hospital is Shouldice method This method has a low incidence of postoperative recurrence and chronic pain, and is the most excellent surgical method among tissue repair methods. The recurrence rate after the Shouldice method is reported to be 1.15% by Shouldice Clinic, the birthplace of the Shouldice method, and if the surgery is performed according to the original method, the results can be equal to or far superior to surgery using mesh. Masu. At our hospital, we have introduced a critical path for all patients who undergo inguinal hernia surgery, and the hospital stay for surgery that does not use mesh is 2 nights and 3 days. Movement restrictions are exactly the same as laparoscopic surgery and mesh surgery.

On the other hand, the Shouldice method is a complicated surgery that is difficult to reproduce, so there are no facilities in Japan that use it.
Narita, doctor at our hospital, visited Shouldice Hospital in Ontario, Canada, the birthplace of the Shouldice method, and participated in 15 surgeries over three days, giving detailed instructions to staff surgeons on surgical techniques. I had it done. Since then, we have carefully performed tissue repair using the Shouldice method in consultation with the patient. The tissue repair method using the Shouldice method is already approved by insurance medical treatment, so there is no problem in actually performing it. Please note that patients who have undergone radical surgery for prostate cancer or patients with a femoral hernia cannot undergo this surgery. Surgery for recurrence of inguinal hernia may also not be indicated.

If you are undergoing inguinal hernia surgery and wish to have the surgery done without mesh, please contact our outpatient surgery department.
If you have any questions regarding this condition, please contact the "Hernia Outpatient Clinic" every Thursday afternoon.

* This content is intended for doctor people to deepen their understanding of this medical institution, and is not intended for advertising or advertising for the general public. Nice to meet you Kobe City Medical Center General HospitalSurgery and Transplant Surgery My name is Satoshi Kaihara (Satoshi Kaihara) of Director.
As a core hospital in the region, our department handles all kinds of digestive diseases, from benign diseases such as gallstone disease and inguinal hernia to malignant diseases such as gastric cancer, colorectal cancer, and liver cancer. In addition, we respond to emergency illnesses 24 hours a day, 365 days a year. With 8 staff members and 7 Senior Resident staff, we provide medical care with experts in general surgery, upper gastrointestinal surgery, lower gastrointestinal surgery, and hepatobiliary and pancreatic surgery in a wide range of fields such as gastrointestinal surgery, emergency surgery, and transplant surgery, and cooperation with each department is quick and strong. The ability to provide intensive treatment is also a major strength of our hospital.
The annual incidence of colorectal cancer in Japan currently exceeds 150,000, and the opportunities for treatment are increasing. Today, I would like to introduce some of our efforts for surgical treatment and anticancer drug treatment for colorectal cancer. Surgical M.D. Hiroki Hashida (Hiroki Hashida) for minimally invasive surgery of the large intestine, and Yoshifumi Kitamura (Koji Kitamura of the surgical M.D. for liver metastasis. However, for chemical chemotherapy, OncologyDirector Hisaaki Yasui will be in charge.

Satoshi Kaihara
Assistant to Hospitl Director
Surgery and Transplant Surgery Director

Wide range of indications for minimally invasive surgery for colorectal cancer and strengths in postoperative complications

Surgery and Transplant Surgery M.D.
Yuki Hashida (Hiroki Hashida)
Specialized field
Gastroenterological Surgery, Colon Surgery, Endoscopic Surgery
Academic specialist/ Certified Physician
Japan Surgical Society Specialist/Preceptor
The Japanese Society of Gastroenterological Surgery Specialist / Preceptor
Endoscopic Surgery Society Technology Certified Physician, etc.

The most distinctive feature of our Department of Surgery for colorectal cancer is that we aim to combine a minimally invasive approach with an oncologic approach. We have been actively adopting laparoscopic surgery for some time now, and the number of laparoscopic surgeries has been increasing, reaching nearly 90% of all surgeries.

We are working to provide minimally invasive and high quality surgeries. In addition, elderly and obese patients are not excluded from laparoscopic surgeries, and laparoscopic surgeries are performed with care for adhesions even in patients who have previously undergone open abdominal surgery. Even patients in poor general condition (heart, lung, liver, kidney function, etc.) are eligible for laparoscopic surgery if they can receive general anesthesia, and laparoscopic surgery is also indicated for all but a few cases such as large tumors and invasion of other organs. Japan Society for endoscopic Surgery Technology Certified Physician We have performed nearly 2,000 colorectal cancer surgeries in the past 10 years.

The complications of Clavien-Dindo classification Grade IV or higher in the postoperative complication criteria are extremely low at less than 1%, leaving stable results. The average postoperative hospital stay was 7.3 days.

Robotic surgery is performed in almost all cases of rectal cancer. Improving curability and prognosis

Robotic surgery is performed by a doctor who is certified as a robotic surgeon. Robot-assisted surgery for rectal cancer is thought to be able to further improve the advantages of conventional laparoscopic surgery, and currently almost all cases of rectal cancer are treated with robot-assisted surgery.

The robot has multi-joint forceps, and it is possible to operate the pelvic floor, which is difficult with conventional laparoscopic surgery, and to perform complicated and delicate surgical techniques.
The Firefly Imaging System enables real-time tissue evaluation using near-infrared rays and visible light, which can be used as a countermeasure against suture insufficiency. Early recovery is expected, and minimally invasive surgery with few sequelae becomes possible.

In addition, in robotic surgery, even in a narrow pelvis, by fully demonstrating the characteristics of the robot, it is possible to operate deep into the pelvis, making it possible to preserve the anus and avoid permanent colostomy.

Multidisciplinary treatment aiming for complete cure even in stage 4

Surgery and Transplant Surgery M.D.
Yoshifumi Kitamura (Koji Kitamura)
Specialized field
Gastroenterological Surgery, Hepato-Biliary-Pancreatic Surgery, Emergency Surgery
Academic specialist/ Certified Physician
Japanese Gastroenterological Society Specialist / Preceptor
Japanese Society of Hepato-Biliary-Pancreatic Surgery Advanced Technical Specialist
Japanese Association for Acute Medicine Emergency Medicine Specialist Medicine, etc.

In Stage 4, which is metastatic recurrent colorectal cancer, we are aiming for a radical cure through a multidisciplinary approach, including colorectal surgeons, liver surgeons, and medical Oncology.
In our surgery, we perform about 20 operations for metastatic liver tumors every year. Based on past performance, we decide indications for liver resection.

Liver metastases with 4 or more tumors or 5 cm or more in size are defined as resectable borderline liver metastases, and patients with these resectable borderline liver metastases are treated with preoperative chemotherapy before resection. We have a policy of
About half of the patients who have relapsed have recurrence only in the liver, and if resectable, the recurrence site can be aggressively repeatedly resected to improve the prognosis and cure.

Aggressive surgical resection for liver metastases

The number of cases is increasing, and the number of resections by laparoscopic surgery is also increasing rapidly. Liver resection is often very difficult due to its anatomical characteristics. We aim at radical resection led by highly skilled hepato-biliary-pancreatic surgery specialists. Compared to conventional open surgery, laparoscopic surgery has advantages such as faster recovery after surgery and less bleeding as well as aesthetics. surgery is limited. Currently, about 80% of liver resections are performed laparoscopically.

Combined chemotherapy for difficult-to-remove cases

If the liver reserve is less than the limit, we have no choice but to judge that it is unresectable, but sometimes resection becomes possible as the tumor becomes smaller due to chemotherapy. In some cases, liver tumors that are difficult to resect can be resected by selecting a procedure to increase the residual liver by portal vein embolization before surgery or a method of resecting the surgery in two stages (stage hepatectomy). I have.

By constructing a 3D image based on images taken before surgery, it is possible to set the resection range and surgical method, estimate the degree of difficulty of surgery and the expected remaining liver capacity, and select the optimal surgical method that is neither excessive nor deficient. Decide
In addition, intraoperative ICG fluorescence imaging is used to visualize the tumor and the liver region to be resected in real time, which is used as navigation for liver resection to provide higher quality and safer surgery.

Small lesions under the liver capsule can be difficult to visualize with intraoperative ultrasound, so ICG fluorescence imaging is used to identify tumors.

Ever-advancing chemotherapy

Director Oncology
Hisaaki Hisateru Yasui
Specialized field
Drug therapy for solid tumors, supportive care, cancer genomic medicine
Academic specialist/ Certified Physician
The Japanese Society of Internal Medicine Board Certified Member of the Japanese Society of Internal Medicine /Preceptor
Japanese Society of Medical Oncology Oncology Pharmacotherapist, Preceptor, etc.

(1) Adjuvant chemotherapy after resection of liver metastases

In a multicenter joint clinical trial conducted mainly by our hospital, favorable results were obtained by adding adjuvant chemotherapy after liver resection. One cycle of capecitabine and four cycles of capecitabine plus oxaliplatin (CAPOX) were administered as adjuvant chemotherapy after curative resection of liver metastases, and the 5-year recurrence-free and overall survival rates were 65.2% and 87.2%, respectively. , the most common grade ≥3 toxicity was neutropenia (29%)¹⁾. Chemotherapy after hepatectomy is said to have strong side effects, but under the management of the Oncology, sufficient treatment is continued and a good survival rate is obtained.
1) Satake, et al. The Oncologist 2021;25:1–8

Adjuvant chemotherapy with CAPOX for 3 months is well tolerated and is considered one of the promising strategies for curative resection of liver metastases. Based on this, we believe that it is necessary to promote personalized medicine based on genetic characteristics.

(2) Preoperative chemotherapy for unresectable liver metastases

With the introduction of molecular-targeted drugs, even seemingly unresectable multiple liver metastases may become resectable if tumor shrinkage is achieved with chemotherapy. After examining tumor cell biomarkers (RAS/BRAF gene mutation, microsatellite instability, UGT1A1 gene polymorphism), the optimal chemotherapy regimen will be selected and a medical Oncology will perform thorough treatment. Approximately 60% to 70% of responses can be obtained with the first treatment, and 20% to 30% can be expected to undergo radical resection. The therapeutic effect is evaluated every 6 to 8 weeks, and the appropriate timing of surgery is considered in cooperation with the surgical department.
Recently, new treatment options that are expected to be effective, such as new treatments (trials) using immune checkpoint inhibitors, are increasing. Even after second-line treatment, resection may be possible due to tumor shrinkage.
Even stage 4 colorectal Oncology can be cured by radical resection.

Method of referral to surgery and medical Oncology and treatment flow

For introductions to our department, please use the FAX reservation or web reservation described on our website. For online reservations, a special ID and password will be distributed from here, so you can access the dedicated site from there and make a reservation directly to the vacant slot. New patient outpatient appointments are available from 9:00 to 11:00 on all days of the week. After your visit to our hospital, we will contact you as soon as a treatment policy is decided. You will usually be admitted to the hospital one day before the surgery, and you will usually be discharged from the hospital around one week after the surgery. Through regional cooperation, we introduce patients to doctors who have been introduced at the request of patients.

message to teachers

In colorectal cancer, even highly advanced cancer can be expected to have a long-term prognosis through multidisciplinary treatment including surgery and chemotherapy. Some patients hesitate to undergo surgery because of their advanced age, but at our hospital, we have a track record of safely performing minimally invasive surgery on patients over the age of 80, and in some cases over the age of 90. It doesn't matter if the indication for surgery is uncertain, so please introduce me first. We can handle any case.

If you need medical Oncology treatment, we will refer you to our hospital. Our motto is to provide high-quality medical care as a general hospital surgery department. It is important to enhance hospital-clinic collaboration and hospital-patient collaboration, and to have local doctors use our hospital's medical functions.