[A case of laparoscopic partial hepatectomy and splenectomy for hepatocellular carcinoma and pancytopenia].

A 69-year-old woman with chronic hepatitis B and esophageal varices was admitted to our hospital because of a hepatocellular carcinoma( HCC) measuring 3 cm in segment S3. Computed tomography( CT) scan revealed splenomegaly, and the platelet count was 6.0×104/µL. Partial hepatectomy and splenectomy were performed sequentially under laparoscopic guidance in a right half-lateral decubitus position, using 7 working ports. The operation time was 237 min, and the amount of bleeding was 26 mL. Her postoperative course was uneventful, and she was discharged on the 10th day after the operation.

[A case of superficial carcinoma in a diverticulum of the thoracic esophagus].

An upper gastrointestina(l GI) series revealed a diverticulum in the anterior wall of the middle thoracic esophagus of a 72-year-old man. Endoscopy revealed a type 0-IIc lesion in the esophageal diverticulum. The margin of the lesion was unclear. Biopsy proved that it was squamous cell carcinoma. Endoscopic ultrasonography showed that the deepest layer of the tumor was the lamina propria mucosae (cT1a-LPM) and that the underlying muscularis propria was thinning. No distant metastasis or regional lymph node metastasis was detected. Diverticulectomy or endoscopic submucosal dissection (ESD) was out of indication due to the unclear margin and thin muscularis propria. We conducted mediastinoscopy-assisted esophagectomy. The pathological diagnosis of the resected specimen was moderately differentiated squamous cell carcinoma with invasion to the lamina propria mucosae (pT1a-LPM). Pathological examination proved the thinning of the underlying muscularis propria in the diverticulum. The patient is alive without recurrence at 6 months after surgery.

[A case report of surgical treatment for axillary lymph node metastasis from descending colon cancer].

We report a rare case of a 78-year-old woman with metachronous axillary lymph node metastasis originating from descending colon cancer. Her past medical history included right mastectomy for breast cancer at age 53 and distal gastrectomy for gastric cancer at age 70. She underwent a left hemicolectomy for descending colon adenocarcinoma in April 2011. Four months after that operation, 3 enlarging nodules in the left lung and a swollen left axillary lymph node were detected by computed tomography. No tumor was detected in the left breast by ultrasonography and mammography. The lung tumors were resected thoracoscopically, and the left axillary lymph node was excised. These specimens were histologically diagnosed as moderately differentiated adenocarcinoma, which had metastasized from colon cancer, not from the previous breast or gastric cancer. She received adjuvant chemotherapy with uracil and tegafur (UFT) plus Leucovorin for 6 months and is still alive after 12 months without recurrence.

Huge esophageal gastrointestinal stromal tumor successfully resected under mediastino-laparoscopic transhiatal esophagectomy: a case report.

BACKGROUND: Esophageal gastrointestinal stromal tumors (E-GISTs) are often diagnosed early due to complaints such as dysphagia and are rarely found to be huge in size. Here, we report the treatment of a case of huge E-GIST successfully resected by minimally invasive surgery after neoadjuvant imatinib therapy. CASE PRESENTATION: An 86-year-old male patient with a 3-month history of dysphagia was referred to our hospital because of a suspected mediastinal tumor on chest X-ray. The chest computed tomography scan revealed a huge solid tumor, of about 100 mm in diameter, protruding into the left thoracic cavity. Histopathological examination results of fine-needle aspiration biopsy under endoscopic ultrasonography revealed a c-kit and CD34-positive esophageal gastrointestinal stromal tumor. The patient received neoadjuvant therapy with imatinib (400 mg/day) to reduce the size of the tumor and prevent rupture during resection. After 28 days of oral administration of imatinib, the tumor size decreased. However, the patient refused to continue treatment with imatinib and therefore underwent mediastino-laparoscopic transhiatal esophagectomy. We successfully resected the tumor completely with mediastino-laparoscopic surgical techniques. Esophageal reconstruction was performed using a gastric tube in the posterior sternal route. After an uneventful postoperative course, the patient was discharged postoperative day 14. Immunohistochemical findings of the resected specimen showed that the tumor cells were positive for c-kit, DOG-1 and CD34 and negative for smooth muscle actin and S100. CONCLUSIONS: Hybrid surgical procedure utilizing mediastino-laparoscopy might be useful for high-risk patient with esophageal tumors.

Pulmonary metastasectomy for esophageal basaloid squamous cell carcinoma component at 66 months after esophagectomy.

BACKGROUND: Solitary pulmonary metastasis from esophageal basaloid squamous cell carcinoma (BSCC) components is an extremely rare recurrence of esophageal squamous cell carcinoma (SCC). CASE PRESENTATION: A 68-year-old Japanese woman was found to have a suspected malignant mass, approximately 2 cm in diameter, in her left lower pulmonary lobe, at 66 months after undergoing a curative esophagectomy with three-field lymph node dissection for esophageal SCC with a focal basaloid component. After a CT-guided biopsy, pathological examination indicated a metastasis from esophageal BSCC components. She underwent a thoracoscopic partial resection of the left lower pulmonary lobe for the solitary pulmonary metastasis. The pathohistology of the resected specimen led to diagnosis of metastatic esophageal BSCC, which showed immunohistochemical findings similar to those of the primary esophageal carcinoma. The patient received two courses of adjuvant chemotherapy (5-fluorouracil, docetaxel plus nedaplatin) and recovered to resume a normal life with maintenance therapy. However, multiple lung and brain metastases were diagnosed at 2 years after the pulmonary metastasectomy. She survived 5 years and 6 months after the pulmonary metastasectomy, but died at 10 years and 6 months after her initial esophagectomy. CONCLUSION: This was a rare surgical resected case of solitary pulmonary metastasis from esophageal BSCC components.

Sarcoid-like reaction in lymphadenopathy associated with superficial esophageal squamous cell carcinoma.

Correctly distinguishing metastasis and sarcoid-like reaction in patients with mediastinal lymphadenopathy is clinically important in esophageal cancer. A patient was a 52-year-old Japanese woman with superficial esophageal squamous cell carcinoma and rare case of sarcoid-like reaction. The patient was admitted with pharyngeal discomfort and an upper gastrointestinal endoscopy detected a superficial tumor in the middle thoracic esophagus. Biopsy confirmed a diagnosis of squamous cell carcinoma. Chest computed tomography (CT) showed enlarged lymph nodes around the trachea and in the bilateral hilum of the lung that were found to accumulate label on positron emission tomography CT. One course of chemotherapy in 5-fluorouracil, docetaxel and cisplatin did not affect the lymphadenopathy, which suggested that it was reactive rather than metastatic. The patient had undergone thoracoscopic esophagectomy with lymph node dissection. The pathohistology of the dissected lymph nodes showed noncaseating epithelioid-cell granuloma and no malignant cells. No clinical findings indicative of systemic sarcoidosis were observed, leading to a diagnosis of sarcoid-like reaction with the esophageal cancer. The patient has survived without recurrence for 4 years after beginning the initial treatment. Monitoring the response to chemotherapy may be helpful in distinguishing between metastasis and sarcoidosis-associated lymphadenopathy in esophageal cancer.

Pyogenic spondylodiscitis of the lumbar spine related to anastomotic fistula after surgery for esophageal cancer: a case report.

BACKGROUND: Pyogenic spondylodiscitis is an extremely rare complication of esophagectomy for esophageal cancer. CASE PRESENTATION: A 70-year-old Japanese man, with a previous medical history of type 2 diabetes mellitus, coronary artery disease, and laryngeal cancer, received neoadjuvant chemotherapy and underwent thoracoscopic esophagectomy with gastric tube reconstruction for advanced esophageal cancer. Cervical esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. However, partial necrosis in the gastric tube developed to form refractory anastomotic fistula. Two months after the initial surgery, debridement and free jejunal transfer reconstruction with the pectoralis major muscle flap were performed. Although the postoperative course of the second surgery was uneventful, the patient complained of severe lower back pain and fever. The patient was diagnosed with pyogenic spondylodiscitis according to the results of the magnetic resonance imaging. Enterobacter cloacae were isolated from the arterial blood culture. Sensitive antibiotics were administered continuously, and the patient required to use a lumbar corset for 2 months. Subsequently, his physiological signs and symptoms had completely disappeared. CONCLUSION: To the best of our knowledge, this case study is the first study that reported pyogenic spondylodiscitis of the lumbar spine, a complication of cervical anastomotic fistula after surgery for advanced esophageal cancer.

Performance assessment of the risk index category for surgical site infection after colorectal surgery.

BACKGROUND: The traditional National Healthcare Safety Network (previously National Nosocomial Infections Surveillance) risk index is used to predict the risk of surgical site infection across many operative procedures. However, this index may be too simple to predict risk in the various procedures performed in colorectal surgery. The aim of this study was to evaluate the usefulness of the risk index by analyzing the impact of the risk index factors on surgical site infection after abdominal colorectal surgery. METHODS: Using our surgical site infection surveillance database, we analyzed retrospectively 538 consecutive patients who underwent abdominal colorectal surgery between 2005 and 2010. Correlations between surgical site infection and the following risk index factors were analyzed: length of operation, American Society of Anesthesiologists score, wound classification, and use of laparoscopy. The 75th percentile for length of operation was determined separately for open and laparoscopic surgery in the study model. RESULTS: Univariate analyses showed that surgical site infection was more strongly associated with a >75th percentile length of operation in the study model (odds ratio [OR], 2.07) than in the traditional risk index model (OR, 1.64). Multivariable analysis found that surgical site infection was independently associated with a >75th percentile length of operation in the study model (OR, 2.75; 95% confidence interval [CI], 1.66-4.55), American Society of Anesthesiologists score ≥3 (OR, 2.22; 95% CI, 1.10-4.34), wound classification ≥III (OR, 5.29; 95% CI, 2.62-10.69), and open surgery (OR, 2.21; 95% CI, 1.07-5.17). Performance of the risk index category was improved in the study model compared with the traditional model. CONCLUSIONS: The risk index category is sufficiently useful for predicting the risk of surgical site infection after abdominal colorectal surgery. However, the 75th percentile length of operation should be set separately for open and laparoscopic surgery.

Giant epidermoid cyst of the spleen with elevated CA 19-9 production managed laparoscopically: report of a case.

True splenic cysts are uncommon and are associated with elevated serum and intracystic tumor marker CA 19-9 levels. A 33-year-old woman presented to our hospital with a chief complaint of epigastralgia. Computed tomography of the abdomen showed a 10-cm cystic lesion in the spleen. The serum carbohydrate antigen (CA) 19-9 level was 3,347 U/mL (normal, <37 U/mL). Total laparoscopic splenectomy was performed, and the serum level of CA 19-9 had normalized 2 weeks later. Pathological examination showed a benign true epidermal cyst of the spleen with strong immunohistological staining for CA 19-9. Splenic epidermoid cysts most often occur in young women, and laparoscopic surgery to remove cysts of this type is minimally invasive. Thus, laparoscopic surgery should be the method of first choice for most cases of splenic benign true cyst.