The quality of life after laparoscopic ventral and incisional hernia repair with closure and non-closure of fascial defect.

PURPOSE: In this retrospective, non-randomized study, we compared the quality of life (QOL) of patients who underwent laparoscopic ventral and incisional hernia repair (LVIHR) with fascial defect closure or non-defect closure and examined the factors associated with the QOL after LVIHR. METHODS: Between February 2013 and 2016, we conducted a single-center, follow-up study of 33 consecutive midline hernia patients who underwent LVIHR. Overall, 14 cases underwent intraperitoneal onlay mesh repair (IPOM), and 19 underwent IPOM with fascial defect closure (IPOM-plus). Patients were interviewed using the 36-item Short Form Health Survey (SF-36) to assess their pre- and postoperative QOL (at 1, 3, 6, and 12 months after surgery). The QOL, as assessed by the SF-36, was compared before and at 1 year after surgery, and the risk factors associated with the QOL were examined. RESULTS: Overall, scores for 5 of the 8 domains and 1 of the 3 components of SF-36 had improved by 1 year after surgery compared with before surgery. The scores for the SF-36 domains and components at 1 year post-surgery were comparable in patients undergoing IPOM or IPOM-plus. Obesity, operative time, hernia size, and mesh size were factors correlated with the QOL. CONCLUSIONS: LVIHR improved the QOL, regardless of defect closure.

Strategy of laparoscopic surgery for colon cancer of the splenic flexure: a novel approach.

BACKGROUND: The splenic flexure (SF) anatomy is complex due to multiple vessels, surrounding organs, layers, and irregular adhesions [1-3]. METHODS: Our laparoscopic approach involves a lateral-to-medial approach to the left-sided transverse mesocolon (TM), a medial-to-lateral approach to the left mesocolon (LM), and take-down of the remnant SF. First, the omental bursa is opened and its posterior wall and the anterior layer of the TM are dissected along the pancreas, where a gauze is placed. The TM is spread cephalad. A window in the TM is opened in the gauze seen through the TM. If necessary, the middle colic vessels are divided with lymph node (LN) dissection. Then the left colic artery is divided with LN dissection using a medial approach. The LM is widely dissected from the retroperitoneum to reach the TM window. While observing the pancreas through the window, the LM and TM are divided from the pancreas close to the SF. The descending colon is mobilized from its lateral attachment. Finally, the SF is taken down from the spleen by separating remnant structures, including adhesions. Subsequently, functional end-to-end anastomosis was performed extracorporeally. RESULTS: During March 2012-December 2016, 39 patients with left-sided transverse or descending colon cancer underwent this treatment. The mean operative time, blood loss, number of harvested LNs, and hospital stay duration were 283 min, 45 ml, 15, and 9 days, respectively. No patient needed conversion to open surgery or had organ injury, anastomotic leakage, or Clavien-Dindo III-V complications. There were 7/13/18/1 patients with Stage I/II/III/IV colon cancer, respectively. Nineteen cases had positive LNs. All patients were alive with one local and two distant recurrences at a mean 24-month follow-up. CONCLUSIONS: This is a safe and effective surgical strategy for treating colon cancer of the SF, strategically designed to resect the SF after dissecting the surrounding structures.

[A Resected Case of Cancer in the Ileum of the Blind Loop after an Ileotransverse Colostomy].

We report a resected case of cancer at the ileum of the blind loop. An 81-year-old male underwent an appendectomy for acute appendicitis and an ileotransverse colostomy for postoperative obstruction when he was 14 years old. He underwent radiation therapy for prostate cancer when he was 75 years old. Six years later, enhanced computed tomography revealed a 7 cm mass in the ileum of the blind loop. Colonoscopy showed wall thickening at the ileum of the blind loop, and biopsy revealed an adenocarcinoma. We performed partial resection of the ileum. The patient was discharged 17 days after surgery. Cancer at the ileum of the blind loop after an ileotransverse colostomy has rarely been reported.

Tumescent TAPP: laparoscopic inguinal hernia repair after the preperitoneal tumescent injection of diluted lidocaine and epinephrine saline solution and carbon dioxide gas.

PURPOSE: Laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) is technically difficult and not infrequently followed by postoperative complications and pain, especially when performed by inexperienced surgeons. To simplify TAPP and reduce postoperative pain, we devised a novel procedure whereby TAPP is carried out after the inguinal preperitoneal infiltration of diluted lidocaine and epinephrine saline solution and carbon dioxide gas (tumescent TAPP). This report introduces the concept of tumescent TAPP and summarizes its operative results. METHODS: About 120 ml of diluted lidocaine and epinephrine solution and 60 ml of CO2 gas were infiltrated into the inguinal preperitoneal space through a transabdominal needle before TAPP. Tumescent TAPP was performed for 400 patients (355 men, 45 women; mean age, 63.2 years). RESULTS: Using tumescent TAPP, we found it easier to confirm the inguinal anatomy and dissect the preperitoneal layer and inguinal floor, with less bleeding. The mean operation time was 101.9 min and there were few perioperative complications and minimal pain. CONCLUSIONS: Tumescent TAPP makes conventional TAPP easier and safer; however, this procedure should be verified by a comparative study with conventional TAPP.

Parastomal hernia repair with the Sugarbaker technique using e-PTFE mesh.

PURPOSES: Although surgery is commonly used to treat parastomal hernia, it is very difficult and has shown poor results. Recently, repair with prosthetic materials has been thought to be a more promising method. METHODS: The Sugarbaker technique with e-PTFE mesh (Dualmesh®) performed via open surgery was adopted for seven patients with parastomal hernia. Two of them were recurrent cases. Three of the patients experienced incarceration of the intestine and recovered conservatively before surgery. The median age of the patients at the parastomal hernia repair was 77.6 years old (range 37.7-84.7). RESULTS: The median operative time was 211 min (range 147-256). The median hernia size was 28 cm2 (range 7.5-60 cm2). The median amount of blood loss during the operation was 158 g (range 0-370 g). Surgical site infection was not observed. The postoperative median hospital stay was 17 days (range 13-40) and the median follow-up was 2.4 years (range 1.0-3.7). During the follow-up period, we did not observe recurrence or readmission. CONCLUSIONS: The surgical results were satisfactory with minimal morbidity and no recurrences. The Sugarbaker technique for parastomal repair using e-PTFE mesh may be suitable as a standard method for treating parastomal hernia.

[A case of mucinous cystadenocarcinoma of the appendix with abdominal wall abscess successfully treated by percutaneous drainage and systemic chemotherapy-a case report].

A 76-year-old woman was diagnosed of mucinous cystadenocarcinoma of the appendix. Since there was wide direct invasion into the right psoas muscle, she was judged as inoperable although she had no bowel obstruction. She was received FOLFIRI and bevacizumab treatment. After the first cycle, the tumor progressed rapidly and formed the abdominal wall abscess at the right groin. Since she had a fever and pain at the right groin and the abscess reached the hypodermic, we put a drainage tube into the abscess. The tube was placed, which made her symptoms improved markedly. We have been continuing with FOLFIRI treatment and drainage for 10 months without progressive disease. We report a rare case of the conservative therapy of mucinous cystadenocarcinoma of appendix with abdominal wall abscess.

Surgical resection of extremely rare primary giant splenic angiomyolipoma: a case report.

BACKGROUND: Angiomyolipoma is a benign mesenchymal tumor that develops commonly in the kidney and rarely in other organs. The involvement of the spleen in angiomyolipoma is extremely rare, and only one such case has been reported in the English literature. CASE PRESENTATION: A 27-year-old man presented with adenoid hyperplasia and bilateral palatal tonsillar hyperplasia. During the treatment for adenoid hyperplasia, a 15-cm tumor was detected in the spleen using abdominal ultrasonography and enhanced computed tomography. Partial resection of the spleen was successfully performed. A giant tumor of approximately 13 cm with a smooth surface was observed in the upper left quadrant of the abdomen. The tumor was confirmed to be continuous with the upper spleen, and there was no invasion of the other organs. The postoperative course was good, and the patient was discharged on the 7th postoperative day. The excised specimen was a smooth, extremely soft tumor measuring 123 × 120 × 82 mm. The cleaved surface of the tumor was reddish brown, and a distressing yellow color was observed. Pathological examination revealed a proliferation of mature adipocytes and an increase in the number of blood vessels of various sizes. Furthermore, spindle-shaped cell proliferation foci were visible between the adipocytes and the surrounding blood vessels. Profuse leakage of erythrocytes from the blood vessels, hemosiderin deposition, and small round cell infiltration were also noted. Immunostaining disclosed that the spindle-shaped cells were weakly positive for smooth muscle antibody and were identified as smooth muscle cells. The adipocytes and spindle cells were negative for HMB 45, Melan A, MDM, and CDK4. However, some parts of the cells were positive for estrogen and progesterone receptors. Besides, vascular endothelial cells were positive for CD31 and CD34 and negative for CD8. Based on these findings, the patient was diagnosed to have primary angiomyolipoma of the spleen. CONCLUSIONS: We have reported the surgical treatment for an extremely rare case of giant splenic angiomyolipoma in a young man. Globally, this is the second report on this condition. We believe that partial splenic resection is a feasible option for the management of giant tumors.

[A case of triple malignant tumors consisting of esophagus, stomach and malignant lymphoma with a histopathological feature of collision between gastric cancer and malignant lymphoma--a case report].

We report a rare case of a collision between a gastric cancer and a malignant lymphoma with a wide systemic metastasis, combined with esophagus cancer, stomach cancer and malignant lymphoma. A 73-year-old man complained of gross hematuria and swelling of the right testis. Magnetic resonance imaging (MRI) revealed that both testes were swollen with unequal contrast and there were numerous tumors in the retroperitoneal space and pelvis. He was diagnosed with malignant diffuse large B cell lymphoma by immunostaining from the extirpated right testis. He received six cycles of R-CHOP therapy. After the second cycle, partial remission was recognized, but the tumors spread again by the fourth cycle. Thereafter, we performed MTX-HOPE therapy as a salvage therapy for four cycles. During this chemotherapy, he felt epigastralgia; esophagus cancer (squamous cell carcinoma) and stomach cancer (highly-differentiated adenocarcinoma) were found by upper endoscopy. However, the gastrointestinal cancer was inoperable, since the malignant lymphoma was progressive. His general status had been exacerbated, and he died about one year after he was diagnosed with malignant lymphoma. Pathological examination revealed that the adenocarcinoma had partly collided with the malignant lymphoma.

[A case with local recurrence of rectal cancer that responded to S-1 and PSK with long-term complete response].

The patient was a 65-year-old male, who underwent low anterior resection for rectal cancer. The pathological diagnosis showed mucinous adenocarcinoma, pSS, and pN0. He complained of diarrhea and melena 4 months after the surgery. Abdominal computed tomography and colonofiberscopy showed a local recurrence of rectal cancer. Because the tumor was diagnosed as unresectable, combined chemotherapy of S-1 (100 mg/day, per os, 4 weeks of treatment and 2 weeks of rest) and PSK (3 g/day, per os, the same schedule as S-1) was started. After the 2 courses of chemotherapy, computed tomography and colonofiberscopy showed a complete disappearance of the tumor. The chemotherapy was continued until the 9th course and then stopped. Five years and 4 months since the induction of a complete response, the patient is still alive without disease recurrence. Combined chemotherapy of S-1 and PSK may be one of useful choices for recurrent colorectal cancer.

[A case of multiple metachronous metastases of colon cancer to the small intestine preoperatively diagnosed by double balloon enteroscopy and radically resected].

The patient was a 75-year-old woman who had undergone resection of a transverse colon cancer two years before. She had anemia and intestinal obstruction, and a diagnosis of multiple metastases to the small intestine was made by double balloon enteroscopy. Eleven metastatic foci were resected by partial resection of the jejunum and ileum. Adjuvant FOLFOX chemotherapy was given, achieving a 26-month disease-free survival. The double balloon enteroscopy was useful in the definitive diagnosis of this case, and aggressive resection with adjuvant chemotherapy contributed to the good outcome.

Penetration and Perforation of Terminal Ileum Diverticulitis.

BACKGROUND: Terminal ileum diverticulitis is a rare clinical disease. It can frequently mimic other processes, such as acute appendicitis. Diagnosis and therapeutic decision making (surgical or conservative treatment) can be complex. We report four interesting cases of terminal ileum diverticulitis. Case Presentation. Case 1: a 55-year-old male presented to us with a 3-day history of severe right lower quadrant pain. Computed tomography (CT) showed penetration of terminal ileum diverticulitis. Following a 7-day conservative treatment, he underwent ileocecal resection. Pathology results revealed a false diverticulum and two in five points of perforated terminal ileum diverticulum. Case 2: a 77-year-old male presented to us with severe right lower quadrant pain and unconsciousness. CT showed penetration of terminal ileum diverticulitis and air in the mesentery. Ileocecal resection was performed 2 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 3: a 61-year-old male presented to us with a right lower quadrant pain for 10 days and fever for 6 days. CT showed penetration of terminal ileum diverticulitis and abscess of the psoas muscle. Puncture and drainage of abscess were performed. Laparoscopic ileocecal resection was performed 30 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 4: a 39-year-old female presented to us with right lower quadrant pain for 9 days, suspicious of appendicitis. CT showed abscess of pericecal area. Puncture and drainage were performed. A drainage tube was located into the cecum through the terminal ileum. Conservative therapy was effective, and she was discharged 23 days postadmission. CONCLUSIONS: All four cases had right lower quadrant pain. Three cases were diagnosed by CT, whereas one was diagnosed by abscess drainage. Two cases required surgical treatment within 3 days, one within about 1 month, and one case did not require surgery. The decision of whether to manage a patient surgically or conservatively is difficult. It is critical not to delay the decision of performing a surgical treatment until each patient reaches a stable general condition.

Laparoscopic cholecystectomy and common bile duct exploration for cholecystocholedocholithiasis with a left-sided gallbladder: report of a case.

A 75-year old woman was admitted to our hospital with right upper quadrant pain, vomiting, and jaundice. Laboratory findings showed elevated total bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, and C-reactive protein levels. Abdominal ultrasonography (US) and drip infusion cholangiographic computed tomography (DIC-CT) showed not only cholecystocholedocholithiasis, but a gallbladder located left of the round ligament and close to the lateral segments of the liver. We performed laparoscopic cholecystectomy (LC) with choledocholithotomy for suspected cholecystocholedocholithiasis with a left-sided gallbladder. Routine ports were inserted in the American configuration for LC. The gallbladder was normogradely separated from the gallbladder fossa, and the fundus of the gallbladder was lifted ventrally and toward to the patient's right shoulder. These procedures provided the usual view for laparoscopic choledochotomy. The patient recovered uneventfully and was discharged on postoperative day 10. To our knowledge, this is the first report of laparoscopic common bile exploration in a patient with a left-sided gallbladder.

Sclerosing Angiomatoid Nodular Transformation of the Spleen: Lessons from a Rare Case and Review of the Literature.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is an extremely rare benign lesion. We herein report a case of asymptomatic SANT of the spleen in a middle-aged woman with early breast carcinoma and an undiagnosed splenic mass, which was successfully treated by laparoscopic splenectomy and diagnosed postoperatively. We also review the literature on SANT to help make knowledge more accessible when clinicians encounter a splenic tumor. The present case taught us the following lesson: the presence of a splenic lesion during follow-up for malignancy is not always indicative of metastasis. Therefore, SANT should be considered in the differential diagnosis.

Late fracture of Groshong ports: A report of the three cases.

BACKGROUND: Totally implantable venous access devices are valuable tools for total parenteral nutrition, chemotherapy, and long-term intravenous therapy. However, late catheter fracture is a well-known complication of totally implantable venous access device, particularly in Groshong silicone catheter. Recently, a specific type of totally implantable venous access device made with Groshong silicone has been introduced to facilitate power injection of contrast medium for enhanced computed tomography. CASES DESCRIPTION: We reported three cases of catheter fracture in power-injectable Groshong silicone totally implantable venous access device. From May 2012 to August 2014, 66 patients underwent power-injectable Groshong silicone totally implantable venous access device implantation at our institution, with a median follow-up of 20.1 (range 0.2-58.1) months. The catheters in all patients were inserted into the internal jugular vein under ultrasound guidance and were connected to the port implanted in the upper chest through the subcutaneous tunnel. Chemotherapy was administered using these routes. Fractures of all three cases specifically showed a torn catheter section: smooth surface on one side, and a rough edge on the other side of the catheter, suggesting that long-term repeated stretch force may be related with the mechanism of fracture. CONCLUSION: Totally implantable venous access devices with Groshong silicone catheters, if inserted via the internal jugular vein, have a potential risk for late catheter fracture.

First Account of Primary Leiomyosarcoma of the Lesser Omentum since Establishment of c-Kit Mutations in Gastrointestinal Stromal Tumors.

BACKGROUND: Primary omental leiomyosarcoma is an extremely rare type of tumor. Leiomyosarcomas originating from the lesser omentum have not been reported since immunohistochemical staining for c-kit has been used for the diagnosis of mesenchymal abdominal tumors. They are yet to be reported since gastrointestinal stromal tumors were categorized. Here we reported a case of successful resection of a lesser omental leiomyosarcoma. CASE PRESENTATION: A 71-year-old man underwent ultrasonography at the outpatient clinic through which an upper abdominal tumor was identified. Following computed tomography and endoscopy, a 4.5 cm submucosal tumor in the lesser curvature of the stomach was highly suspected. A laparoscopic partial resection of the stomach was performed. Histopathological examination revealed the tumor to be a leiomyosarcoma arising from the lesser omentum that did not invade the stomach. Immunohistochemical staining showed that the tumor was negative for CD34, c-kit, and S-100 and positive for desmin and α-smooth muscle actin. No recurrence had been observed 1 year after surgery without adjuvant chemotherapy. CONCLUSIONS: Primary lesser omental leiomyosarcoma, which is difficult to diagnose before surgery given the location of the primary tumor in the lesser omentum, has rarely been reported. Considering the high possibility of malignancy, close observation is essential.

A novel technique of axillary vein puncture involving peripherally inserted central venous catheters for a small basilic vein.

PURPOSE: Peripherally inserted central venous catheters are some of the most useful devices for vascular access used globally. Peripherally inserted central venous catheters have a low rate of fatal mechanical complications when compared to non-tunnel central venous catheters. However, as peripherally inserted central venous catheter access requires a smaller vein, there is a high risk of thrombosis. The axillary vein (confluence of the basilic and brachial veins) can serve as an access for cannulation. Moreover, as this vein is larger than the basilic or brachial vein, it might be a superior option for preventing thrombosis. The risk of catheter-related bloodstream infection should be considered when the puncture site is at the axillary fossa. The aim of this study was to present our new protocol involving peripherally inserted central venous catheters (non-tunneled/tunneled) and a tunneling technique and assess its feasibility and safety for improving cannulation and preventing thrombosis and infection. METHODS: The study included 20 patients. The axillary vein in the upper arm was used for peripherally inserted central venous catheters in patients with a small-diameter basilic vein (<3 mm). When the puncture site was in the axillary fossa, a subcutaneous tunnel of about 3 cm was constructed easily using a peripheral venous catheter. RESULTS: The observed catheter duration was 645 days (median ± standard deviation, 26 ± 22.22 days). Catheterization was successful in all cases, however, two accidental dislodgements were identified. No fatal or serious complications were observed after catheterization. CONCLUSION: Our new protocol for axillary peripherally inserted central venous catheters/tunneled axillary peripherally inserted central venous catheters use for a small-diameter basilic vein is safe and feasible.

Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis.

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

[Laparoscopic biliary surgery].

Laparoscopic cholecystectomy has become the standard treatment for patients with symptomatic gallbladder disease. However, there is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and conversion to open surgery is required because of technical difficulties or complications. The incidence of bile duct injury has increased in laparoscopic cholecystectomy. Meticulous dissection and intraoperative cholangiography could significantly reduce the rate of that injury. Laparoscopic cholecystectomy for acute cholecystitis is still controversial because of surgical difficulty. In our experience, early laparoscopic cholecystectomy is a beneficial option for patients with acute cholecystitis, and it may even be safe in the acute stage. A better alternative for high-risk early operation and septic cases is percutaneous transhepatic gallbladder drainage. The coexistence of gallbladder cancer should be ruled out and preoperative diagnosis should be done carefully. Laparoscopic management of common bile duct (CBD) stones has many advantages. However it has been reported to be demanding and time-consuming to perform, which limits its widespread adoption. In our experience with 258 patients, laparoscopic CBD exploration was feasible for almost all CBD stones. The technical difficulties associated with laparoscopic CBD exploration could be overcome with the development of suitable equipment and increased expertise.