Fluorescence cholangiography for detection of a cystic duct drained into an accessory hepatic duct: A case report.

INTRODUCTION: Laparoscopic cholecystectomy is a safe and standard procedure, but serious bile duct injury may occur due to anatomical anomalies of the biliary tract, especially the accessory hepatic duct. The use of intraoperative fluorescence cholangiography with indocyanine green during laparoscopic cholecystectomy can reportedly prevent bile duct injury. PRESENTATION OF CASE: A 55-year-old woman with upper abdominal pain was referred to our hospital. Laboratory investigations revealed elevated leukocytes and biliary enzymes, while computed tomography demonstrated increased fatty tissue density around the gallbladder. Magnetic resonance cholangiopancreatography and drip infusion cholangiographic-computed tomography showed that the cystic duct drained into an accessory hepatic duct. Due to the diagnosis of cholelithiasis with a biliary anomaly, we performed laparoscopic cholecystectomy using fluorescence cholangiography with indocyanine green. We were able to recognize the accessory hepatic duct and cystic duct, then safely dissect the cystic duct without bile duct injury. DISCUSSION: Laparoscopic cholecystectomy is generally regarded as a safe procedure, but complications and even mortalities can arise in patients with anatomical anomalies of the biliary tract. The aid of intraoperative fluorescence cholangiography with indocyanine green allowed to recognize and identify the accessory hepatic duct and cystic duct, allowing us to operate without injury to the bile duct. CONCLUSIONS: Our experience supports the ease of use, safety, and effectivity of fluorescence cholangiography with indocyanine green. This may become the optimal standard technique to prevent bile duct injury.

Impact of pathological complete response following neoadjuvant chemotherapy (gemcitabine, nab-paclitaxel, S-1) and radiation for borderline resectable pancreatic cancer: a case report and review of literature.

BACKGROUND: Pancreatic cancer (PC) is a highly lethal malignancy, even if surgical resection is possible (median survival: < 30 months). The prognosis of borderline resectable pancreatic cancer (BR-PC) is even worse. There is no clear consensus on the optimal treatment strategy, including pre/postoperative therapy, for BR-PC. We report a patient with BR-PC who achieved clinical partial response with neoadjuvant chemoradiation therapy (NACRT) and underwent curative resection, resulting in pathological complete response (pCR). CASE PRESENTATION: A 71-year-old man with jaundice and liver dysfunction was referred to our department because of a 48-mm hypo-vascular mass in the pancreatic head with obstruction of the pancreatic and bile ducts and infiltration of superior mesenteric vein and portal vein. The lesion was identified as atypical cells which suggested adenocarcinoma by biopsy, and he was administered NACRT: gemcitabine and nab-paclitaxel, following S-1 and intensity modulated radiation therapy. After reduction in the tumor size (clinical partial response), pancreaticoduodenectomy was performed, and pCR achieved. Postoperative adjuvant chemotherapy with S-1 was initially administered and the patient is currently alive with no recurrence as of 2 years after surgery. CONCLUSIONS: NACRT is a potentially useful treatment for BR-PC that may lead to pCR and help improve prognosis.

A successful operation for giant intra-abdominal desmoid tumors associated with familial adenomatous polyposis: A case report.

Desmoid tumors are benign proliferations of spindle cells originating in fibro-aponeurotic tissue. Many patients with familial adenomatous polyposis (FAP) die from desmoid tumors, which can arise spontaneously but often appear to be surgically induced by prophylactic colectomy. Desmoid tumors are the second most common cause of death in patients with FAP, second to colorectal cancer. Many patients can live a long life with desmoid tumors without symptoms, but when symptoms (ranging from bowel or ureteric obstruction to bowel perforation with abscess and fistula) appear or there is a risk of functional impairment, a wide spectrum of therapies (local and systemic) are valuable in improving the symptoms and controlling the disease. A half-Japanese, half-Caucasian male, who had been diagnosed with intra-abdominal desmoid tumors associated with FAP at age 13, was treated using abdominal wall incision for decompression and chemotherapy from the age of 38. The therapeutic outcome was progressive disease, based on the modified response evaluation criteria in solid tumors (mRECIST), and when he visited our hospital at age 41 the desmoid tumor had invaded the small bowel with a fistula to the abdominal wall. We performed a palliative operation to improve his symptoms, which were fever, abdominal pain, vomiting, and difficulty eating. As the tumor was extremely large and had invaded the small intestine, massive resection including the small intestine was required. To prepare for anticipated massive bleeding, a balloon catheter was placed in the superior mesenteric artery just prior to surgery. Although the operation was extremely difficult, following surgery the patient regained his ability to eat and when discharged was ambulatory and without short-bowel syndrome. We report our experience treating one of the largest reported intraperitoneal desmoid tumors. Resection resulted in a good postoperative course, with improved quality of life and prognosis.

[A Case of Gallbladder Cancer with Long Survival Treated with Resection after Downstaging with GC Therapy].

A 68-year-old woman with a chief complaint of obstructive jaundice was referred to our hospital. She was diagnosed with gallbladder cancer with invasion to the liver, extrahepatic bile duct, right hepatic artery and portal vein. After endoscopic retrograde biliary drainage, she received chemotherapy with gemcitabine and cisplatin. After 9 courses, the size of the tumor and the lymph nodes decreased, and we planned surgery. There were no unresectable factors, and the right hepatic artery and portal vein were detached from the tumor. We performed a subtotal stomach-preserving pancreaticoduodenectomy and gallbladder bed resection. We then performed adjuvant chemotherapy with S-1 for 1 year. The patient remains alive without recurrence, 5 years after the surgery. We report the case of advanced gallbladder cancer with downstaging after GC therapy.

Mesh repair under the anterior lamina of the rectus sheath (MUAR) for abdominal incisional hernia.

PURPOSE: Abdominal incisional hernia is a frequent complication of major abdominal operations. Our method of performing mesh repair under the anterior lamina of the rectus sheath (MUAR) involves placing mesh between the dorsal surface of the anterior rectus sheath and the rectus abdominis muscle. We evaluated the short-term and long-term outcomes of our MUAR method. METHODS: The subjects of this retrospective study were 80 patients with abdominal incisional hernia, who underwent MUAR at our hospital between August, 2009 and September, 2018. We investigated the rate of recurrence and postoperative complications in these patients, who were followed-up postoperatively for at least 18 months. Patients who completed all visits were then followed-up further with questionnaires. RESULTS: The recurrence rate after MUAR was 0%. Postoperative complications consisted of subcutaneous wound infections in two patients (2.5%), successfully treated with wound cleansing and antibiotics; and subcutaneous hematoma in three patients (3.8%), which was spontaneously absorbed in two patients, and removed in one. There were no other complications, such as seroma, intestinal obstruction, mesh infection and bulging, or prolonged postoperative pain. CONCLUSION: Mesh repair under the anterior lamina of the rectus sheath is simple and safe with positive short-term and long-term outcomes, suggesting that it is a good option for incisional hernia repair.

A mesenteric solid tumor with unusual features in a young male: A case report.

The current study presents a mesenteric mesenchymal tumor case, with unusual features in diagnostic imaging and histology. A 16-year-old male was admitted to the hospital with abdominal pain. Computed tomography (CT) revealed an abdominal mass, 2 cm in diameter. The results of contrast-enhanced CT, magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography indicated no specific features suggestive of its histology. Two arteries branching from the superior mesenteric artery were observed feeding the hypervascular tumor. After endoscopic and other laboratory findings revealed no additional lesions, the lesion was diagnosed as a primary mesenteric tumor. As the possibility of malignancy and future bleeding from this tumor could not be ruled out, a resection of the tumor was performed. During the surgery, the tumor, which was well circumscribed and hypervascular, was located in the mesentery of the jejunum. The resected tumor did not exhibit typical histological characteristics, and was labeled as 'myxoid smooth muscle neoplasm of uncertain biologic potential'. At 2 years after surgery, the patient remained well without evidence of recurrence. As primary mesenteric tumors are rare, particularly in young patients, it is considered important that this type of unusual tumor be included in the differential diagnosis for mesenteric tumors.

Case of ileal herniation through the foramen of Winslow diagnosed preoperatively by CT and treated with laparoscopic surgery.

A previously healthy 35-year-old man visited the emergency room complaining of epigastric pain and vomiting. The pain was sudden in onset. His blood tests were within normal limits except for a mild neutrophilia of 14 300/µL. Enhanced abdominal CT scan showed the small intestine dilated into the space between the portal vein and inferior vena cava from the foramen of Winslow. Under the diagnosis of herniation through the foramen of Winslow (HFW), we performed emergency laparoscopic surgery. Laparoscopy revealed an internal herniation of the dilated small intestine through the foramen of Winslow. Because the herniated small intestine was viable, intestinal resection was unnecessary. We released the incarceration under laparoscopy. HFW is very rare and often overlooked, but abdominal CT examination enabled a precise preoperative diagnosis because of characteristic findings. We should consider the possibility of HFW in patients with internal herniation of unknown origin. Laparoscopic surgery for HFW is effective.

[A case with multiple liver metastases from rectal cancer responding completely to FOLFOX for a long duration without exacerbation of peripheral neuropathy].

A 61-year-old man had undergone five courses of modified FOLFOX6(mFOLFOX6)chemotherapy with calcium-magnesium(Ca/Mg)infusion for a rectal cancer with multiple liver metastases from October 2008. After this treatment, the primary rectal tumor and metastatic tumors were considered as a partial response(PR), and lower anterior resection was carried out in February 2009. After the operation, mFOLFOX6 chemotherapy with bevacizumab was started in March 2009. After 15 courses of chemotherapy, the patient received 7. 5 g of gosha-jinki-gan(TJ-107)daily from August 2009, and the drug compliance was 69%. From the 18th course of chemotherapy in October 2009, glutathione(GSH)was given at a dose of 200 mg before each oxaliplatin administration. From the 35th course of chemotherapy in November 2010, the patient received 1. 5 g of powdered processed aconite root(TJ-3027)daily. TJ-3027 administration was escalated to 4. 5 g daily, and drug compliance was 73%. Grade 4 neutropenia was observed in December 2010, and we reduced oxaliplatin to 65 mg/m(2) from the 37th course. Fifty chemotherapy courses were administered until October 2011. The patient received a total 3, 970 mg/m(2) of oxaliplatin, however, the neurotoxicity level of the patient remained at grade 2. Ca/Mg infusion and TJ-107 administration have been reported not to reduce the activity of FOLFOX individually, and severe side effects are rare. So one must consider the combination treatment of Ca/Mg and TJ-107 for prevention of oxaliplatin-related neurotoxicity.

Effects of TAK-480, a novel tachykinin NK(2)-receptor antagonist, on visceral hypersensitivity in rabbits and ricinoleic acid-induced defecation in guinea pigs.

TAK-480, 4-(difluoromethoxy)-N-((1R,2S)-2-(((3aR,4R,9bR)-4-(methoxymethyl)-2, 3,3a,4,5,9b-hexahydro-1H-pyrrolo[3,2-c]quinolin-1-yl)carbonyl)cyclohexyl)benzamide, is a novel tachykinin NK(2)-receptor antagonist. In this study, we investigated its antagonistic activity and efficacy in animal models of visceral hypersensitivity and stimulated bowel function which have been implicated to underlie the symptoms in irritable bowel syndrome (IBS). TAK-480 showed potent binding affinity for human NK(2) receptors with a marked species difference and a 10,000-fold selectivity versus NK(1) and NK(3) receptors. TAK-480 dose-dependently antagonized colonic contractions induced by administration of the NK(2) receptor-selective agonist beta-Ala(8)-NKA(4-10) (ßA-NKA) in anesthetized rabbits. In a rabbit model of intracolonic zymosan-induced visceral hypersensitivity, TAK-480 markedly inhibited the visceromotor response to colorectal distension, in contrast to the moderate inhibition by the serotonin 5-HT(3)-receptor antagonist alosetron. In addition, TAK-480 suppressed ricinoleic acid-induced defecation without affecting spontaneous defecation in guinea pigs, whereas alosetron suppressed both. Furthermore, TAK-480 inhibited smooth muscle contractions produced by natural tachykinins (substance P, neurokinin A, and neurokinin B) as well as ßA-NKA in an isolated human colon. In conclusion, the novel NK(2)-receptor antagonist TAK-480 improved visceral hypersensitivity and accelerated defecation without causing constipation in experimental animals. Furthermore, the potent functional blockade of NK(2) receptors in human colon might suggest the potential effectiveness of TAK-480 in IBS patients.

Bidirectional regulation of human colonic smooth muscle contractility by tachykinin NK(2) receptors.

In this study, we attempted to clarify the mechanism of tachykinin-induced motor response in isolated smooth muscle preparations of the human colon. Fresh specimens of normal colon were obtained from patients suffering from colonic cancer. Using mucosa-free smooth muscle strips, smooth muscle tension with circular direction was monitored isometrically. Substance P (SP), neurokinin A (NKA), and neurokinin B (NKB) produced marked contraction. All of these contractions were inhibited by saredutant, a selective NK(2)-R antagonist, but not by CP122721, a selective NK(1)-R antagonist or talnetant, a selective NK(3)-R antagonist. ßAla(8)-NKA(4-10) induced concentration-dependent contraction similar to NKA, but Sar(9)-Met(11)-SP and Met-Phe(7)-NKB did not cause marked contraction. Colonic contraction induced by ßAla(8)-NKA(4-10) was completely blocked by saredutant, but not by atropine. Tetrodotoxin or N(G)-nitro-L-arginine methyl ester pretreatment significantly enhanced ßAla(8)-NKA(4-10)-induced contraction. Immunohistochemical analysis showed that the NK(2)-R was expressed on the smooth muscle layers and myenteric plexus where it was also co-expressed with neuronal nitric oxide synthase in the myenteric plexus. These results suggest that the NK(2)-R is a major contributor to tachykinin-induced smooth muscle contraction in human colon and that the NK(2)-R-mediated response consists of an excitatory component via direct action on the smooth muscle and an inhibitory component possibly via nitric oxide neurons.