[A Case of Synchronous Bilateral Breast Cancer with Apocrine Feature].

The patient, a 79-year-old woman, noticed a lump in her left breast, prompting her visit to our hospital. A mass approximately 20 mm in size was palpated in the left A region. Mammography showed a spiculated mass in the left MIO region, while breast ultrasonography revealed an irregularly shaped hypoechoic mass in the left A region, as well as a hypoechoic area in the right C region. Puncture aspiration cytology of both lesions indicated malignancy. Bilateral partial mastectomy and left sentinel lymph node biopsy were performed. The pathological examination revealed apocrine carcinoma in the left and ductal carcinoma in situ with an apocrine feature in the right breast.

Impact of the gastrojejunal anatomic position as the mechanism of delayed gastric emptying after pancreatoduodenectomy.

BACKGROUND: This study investigated the impact of gastrojejunal anatomic position on the incidence of delayed gastric emptying after pancreatoduodenectomy. METHODS: A total of 160 patients were included in the retrospective analysis. The relative anatomic position of the gastrojejunostomy was evaluated using coronal and sagittal plane computed tomography images on postoperative day 7; the coronal cardia anastomotic angle and the sagittal fundus anastomotic angle were measured. In the validation study, 64 consecutive patients were enrolled, and gastric emptying was evaluated using water-soluble contrast medium. The extent of gastric emptying was graded as grade I (no gastric dilatation and no stasis), grade II (gastric dilatation but no stasis), or grade III (gastric dilatation and stasis). RESULTS: Patients with grades B (n = 8) and C (n = 22) delayed gastric emptying were included in the delayed gastric emptying group (n = 30), and the others were included in the nondelayed gastric emptying group (n = 130). The coronal cardia anastomotic angle was not significantly different between the 2 groups, whereas the sagittal fundus anastomotic angle was significantly greater in the delayed gastric emptying group compared to the nondelayed gastric emptying group (median 50.3 vs 64.5 degrees, P < .001). Multivariate analysis, including various risk factors of delayed gastric emptying, indicated that a sagittal fundus anastomotic angle >60 degrees was the only independent risk factor of delayed gastric emptying (odds ratio, 16.59). In the validation study, the median degree of sagittal fundus anastomotic angle increased as the gastric emptying grade increased (grade I, 44.3 degrees; grade II, 55.3 degrees; grade III, 60.7 degrees; P = .014 by analysis of variance). CONCLUSION: The gastrojejunal anatomic position after pancreatoduodenectomy has a significant impact on the incidence of delayed gastric emptying. (Surgery 2017;160:XXX-XXX.).

Application of three-dimensional print in minor hepatectomy following liver partition between anterior and posterior sectors.

BACKGROUND: Minor hepatectomy following liver partition between the right anterior and posterior sectors requires technical ingenuities. In such hepatectomy, we used three-dimensional (3D) print; therefore, our procedure was introduced. METHODS: Digital segmentation of anatomical structures from multidetector-row computed tomography images utilized the original software 'PLUTO', which was developed by Graduate School of Information Science, Nagoya University. After changing the final segmentation data to the stereolithography files, 3D-printed liver at 70% scale was produced. The support material was washed and mould charge was removed from 3D-printed hepatic veins. The surface of 3D-printed model was abraded and coated with urethane resin paint. After natural drying, 3D-printed hepatic veins were coloured by injection of a dye. The 3D-printed portal veins were whitish because mould charge remained. All procedures after 3D printing were performed by hand work. A 3D-printed model of the right posterior sector and a 3D-printed model of other parenchyma were produced, respectively. Measuring the length between the main structures on the liver surface and the planned partition line on the 3D-printed model, land mark between the right anterior and posterior sectors on the real liver surface was produced with scale adjustment. RESULTS: Minor hepatectomy following liver partition between the right anterior and posterior sectors was performed referring to 3D-printed model. The planned liver partition and resection were successful. CONCLUSIONS: Application of 3D-printed liver to minor hepatectomy following liver partition between the right anterior and posterior sectors is easy and a suitable procedure.

Application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament: Preliminary experience.

An 82-year-old woman was diagnosed with cholecystitis with a right-sided round ligament. We planned a single-incision laparoscopic cholecystectomy. Based on the findings of fluorescent cholangiography, the running course of the common bile duct was confirmed before dissection of Calot's triangle, and the confluence between the cystic duct and the common bile duct was exposed after the dissection of Calot's triangle. The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery. Application of fluorescent cholangiography during a laparoscopic cholecystectomy for the patients with a right-sided round ligament should be widely accepted.

Uneven acute non-alcoholic fatty change of the liver after percutaneous transhepatic portal vein embolization in a patient with hilar cholangiocarcinoma - a case report.

BACKGROUND: Portal vein embolization is essential for patients with biliary cancer who undergo extended hepatectomy to induce hypertrophy of the future remnant liver. Over 830 patients have undergone the portal vein embolization at our institution since 1990. Non-alcoholic fatty liver disease is an entity of hepatic disease characterized by fat deposition in hepatocytes. It has a higher prevalence among persons with morbid obesity, type 2 diabetes, and hyperlipidemia. Neither the mechanism of hepatic hypertrophy after portal vein embolization nor the pathophysiology of non-alcoholic fatty liver disease has been fully elucidated. Some researchers integrated the evident insults leading to progression of fatty liver disease into the multiple-hit hypothesis. Among these recognized insults, the change of hemodynamic status of the liver was never mentioned. CASE PRESENTATION: We present the case of a woman with perihilar cholangiocarcinoma who received endoscopic biliary drainage and presented to our institute for surgical consultation. A left trisectionectomy with caudate lobectomy and extrahepatic bile duct resection was indicated for curative treatment. To safely undergo left trisectionectomy, she underwent selective portal vein embolization of the liver, in which uneven acute fatty change subsequently developed. The undrained left medial sector of the liver with dilated biliary tracts was spared the fatty change. The patient underwent planned surgery without any major complications 6 weeks after the event and has since resumed a normal life. The discrepancies in fatty deposition in the different sectors of the liver were confirmed by pathologic interpretations. CONCLUSION: This is the first report of acute fatty change of the liver after portal vein embolization. The sparing of the undrained medial sector is unique and extraordinary. The images and pathologic interpretations presented in this report may inspire further research on how the change of hepatic total inflow after portal vein embolization can be one of the insults leading to non-alcoholic fatty liver disease/ change.

Application of Fluorescent Cholangiography for Determination of the Resection Line During a Single-Incision Laparoscopic Cholecystectomy for a Benign Lesion of the Cystic Duct: Preliminary Experience.

BACKGROUND: To avoid bile leakage from the stump of a cystic duct that is closed at edematous and/or involved areas, the decision regarding the location of the resection line during a laparoscopic cholecystectomy for benign lesions extending into the cystic duct is important and requires technical ingenuity. For these situations, we used fluorescent cholangiography. METHODS: Our procedure for single-incision laparoscopic cholecystectomy utilized the SILS-Port, and an additional pair of 5-mm forceps was inserted via an umbilical incision. As a fluorescence source, 1 mL of indocyanine green was intravenously injected after endotracheal intubation of patients in the operating room. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. RESULTS: Fluorescent cholangiography could be used to identify the border of the lesion in the cystic duct. According to the fluorescent cholangiography results, a location for the resection line of the cystic duct could be identified; therefore, the planned resection was successful and produced a histologically negative margin. CONCLUSIONS: Application of fluorescent cholangiography in the determination of the location of the resection line location during a laparoscopic cholecystectomy for benign lesions of the cystic duct should be widely accepted.

Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy.

PURPOSE: To clarify the clinical value and pitfalls of fluorescent cholangiography (FC) during single-incision laparoscopic cholecystectomy (SILC). METHODS: Our SILC procedure utilized the SILS-Port with additional 5-mm forceps through an umbilical incision. A laparoscopic fluorescent imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. RESULTS: We performed fluorescent cholangiography during SILC in 21 patients. All procedures were completed successfully without biliary injury. The detectability of the running course of the cystic duct, the confluence between the cystic duct and the common hepatic duct, and the common hepatic duct before the dissection in Calot's triangle was 47.6, 71.4, and 81.0 %, respectively. The detectability of biliary structures was worse in 9 obese patients (body mass index ≥ 25.0 kg/m2) than in 12 non-obese patients. The mean operative time for the patients in whom fluorescent cholangiography could identify the running course of the cystic duct before dissection in Calot's triangle (68 ± 16 min) was shorter than that for the other patients (91 ± 35 min; p = 0.037). CONCLUSIONS: Fluorescent cholangiography can prevent biliary injury during SILC and facilitate SILC. Obesity is the most important factor that can prevent identification of biliary structures under fluorescent cholangiography.