Short- and long-term outcomes of laparoscopic radical gallbladder resection for gallbladder carcinoma: A multi-institutional retrospective study in Japan.

BACKGROUND/PURPOSE: Laparoscopic resection of gallbladder carcinomas remains controversial. This study aimed to evaluate the surgical and oncological outcomes of laparoscopic procedures for suspected gallbladder carcinoma (GBC). METHODS: In this retrospective study, data regarding suspected GBC treated with laparoscopic radical cholecystectomy before 2020 in Japan, was included. Patient characteristics, surgical procedure details, surgical outcomes, and long-term outcomes were analyzed. RESULTS: Data of 129 patients with suspected GBC who underwent laparoscopic radical cholecystectomy were retrospectively collected from 11 institutions in Japan. Among them, 82 patients with pathological GBC were included in the study. Laparoscopic gallbladder bed resection was performed in 114 patients and laparoscopic resection of segments IVb and V was performed in 15 patients. The median operation time was 269 min (range: 83-725 min), and the median intraoperative blood loss was 30 mL (range: 0-950 mL). The conversion and postoperative complication rates were 8% and 2%, respectively. During the follow-up period, the 5-year overall survival rate was 79% and the 5-year disease-free survival rate was 87%. Recurrence was detected in the liver, lymph nodes, and other local tissues. CONCLUSION: Laparoscopic radical cholecystectomy is a treatment option with potential favorable outcomes in selected patients with suspected GBC.

Is frequent measurement of tumor markers beneficial for postoperative surveillance of colorectal cancer?

PURPOSE: To determine whether frequent measurement of tumor markers triggers early detection of colorectal cancer recurrence. METHODS: Of 1,651 consecutive patients undergoing colorectal cancer surgery between 2010 and 2016, 1,050 were included. CEA and CA 19-9 were considered to be postoperative tumor markers and were measured every 3 months for 3 years, and then every 6 months for 2 years. Sensitivity analysis of elevated CEA and CA19-9 levels and multivariate analysis of factors associated with elevated CEA and CA19-9 levels were performed. The proportion of triggers for detecting recurrence was determined. RESULTS: The median follow-up period was 5.3 years. After applying the exclusion criteria, 1,050 patients were analyzed, 176 (16.8%) of whom were found to have recurrence. After excluding patients with persistently elevated CEA and CA19-9 levels before and after surgery from the 176 patients, 71 (43.6%) of 163 patients had elevated CEA levels and 35 (20.2%) of 173 patients had elevated CA19-9 levels. Sensitivity/positive predictive values for elevated CEA and CA19-9 levels at recurrence were 43.6%/32.3% and 20.2%/32.4%, respectively. Lymph node metastasis was a factor associated with both elevated CEA and CA19-9 levels at recurrence. Of the 176 patients, computed tomography triggered the detection of recurrence in 137 (78%) and elevated tumor marker levels in 13 (7%); the diagnostic lead interval in the latter 13 patients was 1.7 months. CONCLUSION: Tumor marker measurements in surveillance after radical colorectal cancer resection contribute little to early detection, and frequent measurements are unnecessary for stage I patients with low risk of recurrence.

An International Retrospective Observational Study of Liver Functional Deterioration after Repeat Liver Resection for Patients with Hepatocellular Carcinoma.

Whether albumin and bilirubin levels, platelet counts, ALBI, and ALPlat scores could be useful for the assessment of permanent liver functional deterioration after repeat liver resection was examined, and the deterioration after laparoscopic procedure was evaluated. For 657 patients with liver resection of segment or less in whom results of plasma albumin and bilirubin levels and platelet counts before and 3 months after surgery could be retrieved, liver functional indicators were compared before and after surgery. There were 268 patients who underwent open repeat after previous open liver resection, and 224 patients who underwent laparoscopic repeat after laparoscopic liver resection. The background factors, liver functional indicators before and after surgery and their changes were compared between both groups. Plasma levels of albumin (p = 0.006) and total bilirubin (p = 0.01) were decreased, and ALBI score (p = 0.001) indicated worse liver function after surgery. Laparoscopic group had poorer preoperative performance status and liver function. Changes of liver functional values before and after surgery and overall survivals were similar between laparoscopic and open groups. Plasma levels of albumin and bilirubin and ALBI score could be the indicators for permanent liver functional deterioration after liver resection. Laparoscopic group with poorer conditions showed the similar deterioration of liver function and overall survivals to open group.

The necessity of intensive surveillance colonoscopy for patients with a remaining right colon after resection of colorectal cancer: a retrospective cohort study.

PURPOSE: To clarify how often postoperative surveillance colonoscopy should be undertaken based on the risk factors for the development of metachronous cancer (MC) and advanced adenoma (AA) after surgery for colorectal cancer. METHODS: We collected data of consecutive patients who underwent curative resection for primary colorectal cancer between 2005 and 2012, with preoperative colonoscopy and surveillance colonoscopy at 1 year after surgery (406 patients, mean age: 69 years, 59% male). The detection rates of AA (with villous features, > 10 mm or high-grade dysplasia) and MC by surveillance colonoscopy were the primary outcomes. RESULTS: At 5 years, colonoscopy was performed as postoperative surveillance an average of 3.2 times. AA and MC were detected in 57 (14.0%) and 18 patients (4.4%), respectively. Both lesions were more common in the right colon (n = 43) than in the left colon (n = 28). The detection rate did not differ to a statistically significant extent according to the number of colonoscopies performed for surveillance (p = 0.21). However, after left-sided colectomy, both types of lesions were more commonly detected in those who received ≥ 3 colonoscopies than in those with one or two colonoscopies (p = 0.04). CONCLUSION: A remaining right colon after left-sided colectomy was associated with a higher risk of developing AA and MC. Physicians should consider performing surveillance colonoscopy more frequently if the right colon remains after surgery.

Multicenter Propensity Score-Based Study of Laparoscopic Repeat Liver Resection for Hepatocellular Carcinoma: A Subgroup Analysis of Cases with Tumors Far from Major Vessels.

Less morbidity is considered among the advantages of laparoscopic liver resection (LLR) for HCC patients. However, our previous international, multi-institutional, propensity score-based study of emerging laparoscopic repeat liver resection (LRLR) failed to prove this advantage. We hypothesize that these results may be since the study included complex LRLR cases performed during the procedure's developing stage. To examine it, subgroup analysis based on propensity score were performed, defining the proximity of the tumors to major vessels as the indicator of complex cases. Among 1582 LRLR cases from 42 international high-volume liver surgery centers, 620 cases without the proximity to major vessels (more than 1 cm far from both first-second branches of Glissonian pedicles and major hepatic veins) were selected for this subgroup analysis. A propensity score matching (PSM) analysis was performed based on their patient characteristics, preoperative liver function, tumor characteristics and surgical procedures. One hundred and fifteen of each patient groups of LRLR and open repeat liver resection (ORLR) were earned, and the outcomes were compared. Backgrounds were well-balanced between LRLR and ORLR groups after matching. With comparable operation time and long-term outcome, less blood loss (283.3±823.0 vs. 603.5±664.9 mL, p = 0.001) and less morbidity (8.7 vs. 18.3 %, p = 0.034) were shown in LRLR group than ORLR. Even in its worldwide developing stage, LRLR for HCC patients could be beneficial in blood loss and morbidity for the patients with less complexity in surgery.

Should Lymph Nodes Be Retrieved in Patients with Intrahepatic Cholangiocarcinoma? A Collaborative Korea-Japan Study.

BACKGROUND: This study was performed to investigate the oncologic role of lymph node (LN) management and to propose a surgical strategy for treating intrahepatic cholangiocarcinoma (IHCC). METHODS: The medical records of patients with resected IHCC were retrospectively reviewed from multiple institutions in Korea and Japan. Short-term and long-term oncologic outcomes were analyzed according to lymph node metastasis (LNM). A nomogram to predict LNM in treating IHCC was established to propose a surgical strategy for managing IHCC. RESULTS: A total of 1138 patients were enrolled. Of these, 413 patients underwent LN management and 725 did not. A total of 293 patients were found to have LNM. The No. 12 lymph node (36%) was the most frequent metastatic node, and the No. 8 lymph node (21%) was the second most common. LNM showed adverse long-term oncologic impact in patients with resected IHCC (14 months, 95% CI (11.4-16.6) vs. 74 months, 95% CI (57.2-90.8), p < 0.001), and the number of LNM (0, 1-3, 4≤) was also significantly related to negative oncologic impacts in patients with resected IHCC (74 months, 95% CI (57.2-90.8) vs. 19 months, 95% CI (14.4-23.6) vs. 11 months, 95% CI (8.1-13.8)), p < 0.001). Surgical retrieval of more than four (≥4) LNs could improve the survival outcome in resected IHCC with LNM (13 months, 95% CI (10.4-15.6)) vs. 30 months, 95% CI (13.1-46.9), p = 0.045). Based on preoperatively detectable parameters, a nomogram was established to predict LNM according to the tumor location. The AUC was 0.748 (95% CI: 0.706-0.788), and the Hosmer and Lemeshow goodness of fit test showed p = 0.4904. CONCLUSION: Case-specific surgical retrieval of more than four LNs is required in patients highly suspected to have LNM, based on a preoperative detectable parameter-based nomogram. Further prospective research is needed to validate the present surgical strategy in resected IHCC.

Impact of vascular abnormality on contrast-enhanced CT and high C-reactive protein levels on postoperative pancreatic hemorrhage after pancreaticoduodenectomy: A multi-institutional, retrospective analysis of 590 consecutive cases.

BACKGROUND: /Objectives: This study aimed to elucidate the efficacy of CT findings and perioperative characteristics to predict post-pancreatectomy hemorrhage (PPH): a critical complication after pancreaticoduodenectomy. METHODS: The records of 590 consecutive patients who underwent pancreaticoduodenectomy at three institutes between 2012 and 2018 were included. The presence of a vascular wall abnormality or ascites with high density (vascular abnormality) on postoperative day (POD) 5-10 contrast-enhanced CT (early CT), perioperative characteristics, and any PPH or pseudoaneurysm formation (PPH events) were analyzed through a multivariate analysis. RESULTS: PPH events occurred in 48 out of 590 patients (8%). The vascular abnormality on early CT and the C-reactive protein (CRP) value on POD 3 were independent risk factors for PPH events after POD5 (vascular abnormality: odds ratio 6.42, p = 0.001; CRP on POD 3: odds ratio 1.17, p = 0.016). The sensitivity of vascular abnormality for PPH events was 24% (7/29), and the positive predictive value was 30% (7/23). The combination of vascular abnormality and a high CRP value (≥15.5 mg/dL) on postoperative day 3 had a higher positive predictive value of 64% (7/11) than the vascular abnormality alone. None of the seven PPH events that occurred more than one month after surgery were foreseen via early CT. CONCLUSION: The combination of vascular abnormality and high CRP value was associated with increasing risk of PPH events after pancreaticoduodenectomy, but the low sensitivity of early CT must be noted as an important shortcoming. The normal findings on early CT could not eliminate the risk of late PPH.

[Appendiceal Goblet Cell Carcinoid Successfully Treated with Bevacizumab plus mFOLFOX6 Regimen-A Case Report].

A 67-year-old man presented with abdominal distention and vomiting.Computed tomography revealed bowel obstruction due to a cecal tumor.We performed laparoscopic ileocecal resection after decompression with an ileus tube. Intraoperative findings included multiple disseminated nodules on the mesenterium surrounding the cecal tumor.The histopathologic diagnosis was poorly differentiated adenocarcinoma, which consisted of glandular proliferation of atypical epithelial cells and dispersed infiltration of goblet cells. Immunohistochemistry showed positively stained neuroendocrine markers, such as CD56, chromogranin, and synaptophysin.The patient was diagnosed with goblet cell carcinoid of the appendix and treated with combination chemotherapy of bevacizumab, fluorouracil, folinic acid, and oxaliplatin.He remained free from progression for over 1 and half years with this treatment.Subsequent chemotherapy was ineffective, and he passed away.There is no established chemotherapy regimen for goblet cell carcinoid, which has the aspects of both adenocarcinoma and neuroendocrine tumors.However, the present case suggested the efficacy of the mFOLFOX6 regimen in combination with bevacizumab for appendiceal goblet cell carcinoid.

A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients.

BACKGROUND: Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system. METHODS: Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836. RESULTS: Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD. CONCLUSION: LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.

[Sigmoid Colon Cancer with Lateral Lymph Node Metastasis That Presented with Gastric Perforation].

A 74-year-old man visited his local clinic complaining of abdominal pain that persisted for three days. He was diagnosed with diffuse peritonitis and was transported to our hospital. Contrast computed tomography(CT)showed gastric perforation and a tumor in the sigmoid colon with left obturator lymph node metastasis. He was diagnosed with diffuse peritonitis resulting from gastric perforation and performed emergent surgery. As the size of the gastric perforation was large, we performed distal gastrectomy and transverse colostomy. He was discharged without any complications, and a total of 6 courses of SOX with a bevacizumab regimen were administered postoperatively. CT following chemotherapy showed shrinkage of the lesion. He was admitted again for sigmoidectomy with left lateral lymph node resection and discharged from the hospital on postoperative day 8. We administered 2 courses of SOX regimen after the surgery. He remains alive with no recurrence 27months after the first surgery.

The safety and efficacy of laparoscopic hepatectomy in obese patients.

BACKGROUND: Obesity is generally reported to increase the risk of surgical complications. There have been few reports of laparoscopic hepatectomy (LH) in obese patients. The purpose of this study was to compare the safety and efficacy of (1) LH versus open hepatectomy (OH) in obese patients and (2) LH in obese patients versus LH in non-obese patients. METHODS: We introduced LH at our institution in April 2014. LH was performed in 63 obese patients and 108 non-obese patients from April 2014 to May 2017. OH was performed in 79 obese patients from January 2010 to May 2017. This study retrospectively compared the short-term outcomes of the LH obese group with those of the OH obese group and the LH non-obese group. RESULTS: In patient characteristics, the LH obese group included a significantly higher percentage of patients with liver cirrhosis than the OH obese group. The LH obese group had fewer patients with a history of abdominal surgery but more with liver cirrhosis than the LH non-obese group. For short-term outcomes, the LH obese group had significantly less blood loss, fewer intraoperative transfusions, fewer positive surgical margins, and shorter postoperative hospital stays than the OH obese group. In contrast, only operation time was significantly different (longer) in the LH obese group than in the LH non-obese group. There were no significant differences in morbidity or mortality between the LH obese group and either the OH obese or the LH non-obese groups. CONCLUSION: LH in obese patients is safe and effective.

Strangulated Hernia Can Be a Risk Factor of Seroma following Laparoscopic Transabdominal Preperitoneal Repair.

PURPOSES: Seroma is a postoperative complication following laparoscopic transabdominal preperitoneal repair (TAPP) for inguinal hernioplasty. Seroma naturally resolves in most cases, but it can lead to an increased amount of visits to the outpatient clinic and can result in anxiety of the patient. Local inflammation of the inguinal area is etiology of seroma formation. Strangulated hernia involves severe inguinal pain and can lead to severe inflammation and subsequent seroma. There have been no reports demonstrating the links of seroma and strangulated hernia. This study aimed to retrospectively evaluate the risk of seroma after TAPP and to identify the association between strangulated hernia and seroma. METHODS: We treated 300 inguinal hernias by TAPP between 2013 and 2016 at Kurashiki Central Hospital. We used the Chi-square test. Factors significant in each association were further examined using multiple subsequent logistic regressions. RESULTS: A total of 222 hernias were eligible for analysis. The incidence of seroma was 11% (n=25). There were nine cases of strangulated hernias, and three (33%) resulted in seroma. The ratio of strangulated hernia of seroma group is significantly high (p<0.03). Multiple subsequent logistic regressions showed that strangulated hernia was associated with a significantly increased risk for seroma formation (p = 0.023; OR 6.564; 95% CI 1.29-33.3). CONCLUSION: This study shows that strangulated hernia can be a risk factor in seroma formation. This risk should be incorporated into a management plan of TAPP for strangulated hernia, with careful consideration of patients' concerns.

Feasibility of a novel tacking method of securing mesh in transabdominal preperitoneal inguinal hernia repair: Secure tacking against recurrence.

INTRODUCTION: Postoperative chronic pain is an important outcome of hernia surgery. In laparoscopic hernia surgery, either fixation outside the trapezoid of disaster or no fixation is recommended to avoid postoperative pain. To avoid recurrence are transabdominal preperitoneal (TAPP) hernia repair, the myopectineal orifice must be covered with mesh during TAPP, but lifting or shrinking of the mesh can lead to recurrence. The aim of this study was to evaluate the feasibility of a novel technique for mesh fixation to prevent the mesh from lifting off. METHODS: After the preperitoneal space was created during TAPP, the anatomy of the lateral cutaneous nerve of the thigh or the femoral branch of the genitofemoral nerve within the trapezoid of disaster was checked. The mesh was tacked at the trapezoid of disaster without nerve injury, and the mesh was fixed with circumferential tacking. We call this procedure secure tacking against recurrence (STAR). We treated 391 adult patients (478 hernias) with TAPP repair; novel tacking was used in some patients (STAR group, 236 hernias). The results of the STAR group were retrospectively compared with those of patients in whom we did not use this novel tacking (conventional group, 242 hernias). RESULTS: There was no postoperative chronic pain in either group. There were no cases of hernia recurrence in the STAR group, but there were four cases of hernia recurrence in the conventional group (0% vs 1.7%, P = 0.047). These four recurrences consisted of indirect hernia and mesh lifting on the lateral side. CONCLUSION: The STAR procedure is feasible and safety as a standard procedure for securing the mesh during TAPP.

The feasibility and efficacy of pure laparoscopic repeat hepatectomy.

BACKGROUND: Repeat hepatectomy is often required for hepatocellular carcinoma and metastatic tumors. However, this procedure is technically challenging, so laparoscopic repeat hepatectomy (LRH) has not been widely adopted. The aim of this study was to evaluate the feasibility and efficacy of LRH compared with open repeat hepatectomy (ORH) and laparoscopic primary hepatectomy (LPH). METHODS: We introduced laparoscopic hepatectomy at our institution in April 2014. We performed 127 LPH (LPH group) and 33 LRH procedures (LRH group) from April 2014 to April 2017; 37 patients underwent ORH from January 2010 to April 2017 (ORH group). This study retrospectively compared the patient characteristics and short-term outcomes of the LRH and ORH groups as well as the LRH and LPH groups. RESULTS: There were no conversions to open surgery in the LRH group. In comparing the LRH and ORH groups, there were no significant differences in patient characteristics except for the type of approach to the previous hepatectomy (p = 0.004) and indocyanine green retention rate at 15 min (median 12.5 vs. 8.75%, p = 0.026). The LRH group had less blood loss (median 30 mL vs. 652 mL; p < 0.001), less intraoperative transfusion (6.1 vs. 32.4%; p = 0.006), and shorter postoperative hospital stays (median 6.5 days vs. 9.0 days; p < 0.001). There were no differences with regard to operation time, severe postoperative complications, and mortality. In comparing the LRH and LPH groups, there was a significant difference only in past history of abdominal surgery (100 vs. 61.4%; p < 0.001). In the short-term outcomes, the postoperative hospital stay was significantly shorter in the LRH group (median 6.5 days vs. 7 days; p = 0.033), and the other results were comparable between the two groups. CONCLUSIONS: LRH is feasible and useful for repeat hepatectomy, achieving good short-term outcomes.

Feasibility of Endo GIA™ Reinforced Reload with Tri-Staple™ Technology for delta-shaped anastomosis.

BACKGROUND: We report the short-term clinical outcomes of a delta-shaped (DS) anastomosis in laparoscopic distal gastrectomy (LDG), comparing Endo GIA™ Reinforced Reload (Reinforced GIA) with Endo GIA™ (GIA) staplers. METHODS: This was a retrospective analysis of 40 patients who underwent totally LDG with DS anastomosis with Reinforced GIA (group A) and 90 patients who underwent the same procedure with GIA (group B) for clinical T1-T3 gastric cancer from May 2013 to December 2016. Operation time, intraoperative blood loss, hospital length of stay, reconstruction time, and complications were compared. RESULTS: No patients required conversion to open surgery, and no patients died. There was no significant difference between the groups regarding patient background, postoperative hospital stay, and operation time. Bleeding from the V-shaped anastomosis was significantly less frequent in group A compared with group B (0% vs 11.2%, p = 0.021). Anastomosis-related complications were less frequent in group A, but there was no statistically significant difference between the groups. The fasting period in group A was significantly shorter than that of group B (2.81 vs 3.39 days, p = 0.034). CONCLUSION: DS anastomosis using Reinforced GIA can prevent minor postoperative anastomosis leakage. Based on our findings and experience, we recommend DS anastomosis with Reinforced GIA after LDG for gastric cancer as an effective procedure with good short-term outcomes.

Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma.

AIM: To evaluate a laparoscopic approach to gallbladder lesions including polyps, wall-thickening lesions, and suspected T1 and T2 gallbladder cancer (GBC). METHODS: We performed 50 cases of laparoscopic whole-layer cholecystectomy (LCWL) and 13 cases of laparoscopic gallbladder bed resection (LCGB) for those gallbladder lesions from April 2010 to November 2016. We analyzed the short-term and long-term results of our laparoscopic approach. RESULTS: The median operation time was 108 min for LCWL and 211 min for LCGB. The median blood loss was minimal for LCWL and 28 ml for LCGB. No severe morbidity occurred in either procedure. Nine patients who underwent LCWL and 7 who underwent LCGB were postoperatively diagnosed with GBC. One of these patients had undergone LCGB for pathologically diagnosed T2 GBC after LCWL. All of the final surgical margins were negative. Three of these 15 patients underwent additional open surgery. The mean follow-up period was 26 mo, and only one patient developed recurrence. CONCLUSION: LCWL and LCGB are safe and useful procedures that allow complete resection of highly suspected or early-stage cancer and achieve good short-term and long-term results.

Laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer using the ligament of Treitz approach.

BACKGROUND: Laparoscopic distal pancreatectomy (Lap-DP) for benign lesions or those with low malignant potential has been proven safe and effective, and its performance is now widespread [1-3]. Lap-DP for left-sided pancreatic cancer (PC) is also being increasingly performed. According to some reports, Lap-DP has superior short-term outcomes (blood loss, postoperative hospital stay) and comparable oncological outcomes and overall survival with those of open distal pancreatectomy (Op-DP) [4-6]. PC has highly malignant potential; thus, complete resection and sufficient regional lymphadenectomy with tumor-free margins are very important. Radical antegrade modular pancreatosplenectomy (RAMPS) is an accepted standard Op-DP technique for PC and is reportedly useful for achieving R0 resection and radical lymphadenectomy [7-10]. However, laparoscopic RAMPS (Lap-RAMPS) is not yet popular because of its technical difficulty and lack of adequate evidence. Few reports have described the detailed surgical technique of Lap-RAMPS [11-13]. We employ Lap-RAMPS using the ligament of Treitz approach with the benefit of a laparoscopic view and herein describe the usability of this laparoscopic procedure with a video. METHODS: Our indication for Lap-RAMPS is left-sided PC located ≥1 cm away from the origin of the splenic artery (SPA) without invasion of the superior mesenteric artery (SMA), celiac artery (CA), common hepatic artery (CHA), or portal vein (PV). We apply either anterior or posterior RAMPS to achieve tumor-free margins. Therefore, the left adrenal gland and the nerve plexus around the SMA and CA are resected depending on the extent of the cancer. Three patients underwent Lap-RAMPS for left-sided PC using the ligament of Treitz approach from April to December 2016. This video shows our Lap-RAMPS procedure performed in a 67-year-old man with pancreatic body cancer who was being followed up for autoimmune pancreatitis. The tumor was suspected to have invaded the SPA, splenic vein, and retroperitoneum but was not close to the SMA, CA, CHA, or PV. The patient was put in the supine position with his legs opened, and the operation was performed using five trocars. Early in the operation, we incised the retroperitoneum just beside the ligament of Treitz, and the inferior vena cava and left renal vein (LRV) were exposed with resection of Gerota's fascia under a good laparoscopic view. The left adrenal gland was resected in this case to obtain sufficient tumor-free margins. The origin of the SMA was easily identified above the LRV. The most posterior dissection was carried out early in the operation, making it easy and safe to determine the resected margin and enabling curative resection with sufficient regional lymphadenectomy. After division of the pancreas with a linear stapler, the lymph nodes around the SMA and CA were safely removed. RESULTS: The operative time was 358 min, and the estimated blood loss was 1 ml. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Pathological examination revealed invasive ductal carcinoma (stage III, T3N1M0 according to the 7th edition of the Union for International Cancer Control system) with tumor-free margins. In all three patients, the median operative time and blood loss were 358 (328-451) min and minimal (minimal to 1 ml). One patient underwent anterior RAMPS and the other two patients, including the case mentioned above, underwent posterior RAMPS. One patient developed a grade B pancreatic fistula according to the International Study Group for Pancreatic Fistula (ISGPF) classification, but he recovered promptly with conservative treatment. No life-threatening complications occurred. The median postoperative hospital stay was 14 (10-16) days. CONCLUSIONS: Lap-RAMPS using the ligament of Treitz approach is feasible and extremely helpful in performing minimally invasive, curative resection for well-selected left-sided PC.

Feasibility of a new approach for creating a preperitoneal space in transabdominal preperitoneal repair inguinal hernia repair: using a sandwich approach.

PURPOSE: In Japan, transabdominal preperitoneal (TAPP) inguinal hernia repair is performed by firmly pulling the peritoneum inwards to lift it from the underlying deep layer of subperitoneal fascia. It decreases the postoperative pain and discomfort in the inguinal area. The aim of this study was to evaluate the feasibility of the sandwich approach, which is a new technique for creating a preperitoneal space. METHODS: The operation was performed via the sandwich approach. We made sure to protect the preperitoneal fascia areolar layer when making the preperitoneal space. RESULTS: We performed TAPP in 745 patients (876 hernias) treated between October 2006 and April 2015 at Himeji Medical Center and Kurashiki Central Hospital. Before October 2010, we did not use the sandwich approach, and recurrence was observed in three patients. From October 2010, we always used the sandwich approach and never experienced any cases of recurrence. Clavien-Dindo classification Grade 3 or higher postoperative complications occurred in 6 patients (0.8%) between October 2006 and April 2015. Mesh-related ileus was the most frequently observed morbidity. There were no cases of vas differentia or spermatic vessel injury, postoperative chronic pain, or urinary retention. CONCLUSION: The sandwich approach is feasible as another standard dissective procedure for TAPP.

Laparoscopic and Endoscopic Cooperative Surgery for Plexiform Angiomyxoid Myofibroblastic Tumor.

Plexiform angiomyxoid myofibroblastic tumor (PAMT) is a recently described distinctive gastric mesenchymal entity with a peculiar plexiform pattern, bland spindle cells and a myxoid stroma rich in arborizing blood vessels. In this study, we report a new case of this rare gastric tumor resected by laparoscopic and endoscopic cooperative surgery (LECS). A 39-year-old Japanese man was admitted with a gastric mass. Gastroscopy showed an elevated mass in the anterior wall of the gastric antrum. Endoscopic ultrasound examination revealed a focal hypoechoic lesion protruding into the lumen. A partial gastrectomy by LECS was performed, and the patient made an uneventful recovery and remains well 9 months later. The tumor in this case depicted all the typical histopathologic and immunochemical features of gastric PAMT (c-kit negative and smooth muscle actin-positive). Especially, it was characterized by multiple nodules protruding outward within the serosa. Therefore, it is important that the resection line is determined on the serosa to ensure the complete resection of these nodules together.

Undifferentiated carcinoma with osteoclast-like giant cells of the ampullary region: Short term survival after pancreaticoduodenectomy.

INTRODUCTION: Undifferentiated carcinomas with osteoclast-like giant cells (UC-OGCs) of the ampullary region are very rare, with only a few cases reported to date. The clinicopathological features, treatment options, and prognosis of UC-OGCs are unclear. This report describes a patient with UC-OGCs of the ampullary region. PRESENTATION OF CASE: A 78-year-old male patient was admitted for epigastric pain and fever. Contrast-enhanced computed tomography revealed a 2.6-cm mass at the duodenal papilla. Duodenoscopy revealed a smooth red protruding mass compressing the orifice of the papilla of Vater. Biopsy of the mass showed proliferation of osteoclast-like giant cells. A subtotal stomach-preserving pancreaticoduodenectomy was performed, and the tumor was histologically diagnosed as an UC-OGCs of the ampullary region. Carcinoma in situ was also observed, spreading from the tumor at the terminal segment of the common bile duct to the common hepatic duct, with carcinoma cells at the surgical margin of the common hepatic duct. One year after surgery, the patient is alive and without tumor recurrence. DISCUSSION: UC-OGCs of the ampullary region is very rare neoplasm containing osteoclast-like giant cells and mononuclear cells. Osteoclast-like giant cells may originate from reactive mesenchymal cells and carcinoma in situ may spread to the common hepatic duct. Surgery including pancreaticoduodenectomy may be a treatment option for resectable tumors, whereas gemcitabine may be a treatment option for unresectable tumors. CONCLUSION: Carcinoma in situ may spread quite far (5cm) to the common hepatic duct, making it desirable to intraoperatively confirm negative bile duct margins by rapid pathologic diagnosis.