[A case of primary lung metastatic pancreatic tumor resected following chemoradiotherapy].

We observed a case of pancreatic metastasis of lung cancer being resected following chemoradiotherapy and reported with a review of the literature. The patient was a 60-year-old man and previously underwent an upper lobectomy of the right lung for the primary lesion and chemoradiotherapy for the metastatic lesion in the lower lobe of the right lung. During the follow-up period, positron emission tomography-computed tomography scan revealed a tumor in the pancreatic body, which was a hyperechoic mass on endoscopic ultrasonography (EUS) and hypervascularity on Sonazoid angiography. Fine needle aspiration cytology under EUS revealed dense growth of tumor cells with increased nuclear chromatin, markedly atypical nuclei, and eosinophilic sporangia. Immunostaining showed CK7 (+), CK20 (-), TTF-1 (+), and napsin A (+). He was diagnosed with pancreatic metastasis of lung cancer, underwent preoperative chemoradiotherapy followed by distal pancreatectomy and splenectomy, and discharged without perioperative complications. The right lower lobe metastasis of lung cancer was detected during an outpatient visit following chemoradiotherapy. However, he was found rectal cancer and considered a scheduled surgery. Forty-two months postoperatively, he was found dead at home;the cause of death was shock due to extreme dehydration.

Three millimeter needlescopic splenectomy using three-port technique: report of three cases.

We report our experience with needlescopic splenectomy (NS) for the surgical treatment of idiopathic thrombocytopenic purpura using a 3-mm needlescope with three ports. One patient was male and two were females, and their mean age was 58 years. The patient was placed in the right lateral decubitus position. The first 12-mm port was introduced through the lateral margin of the left rectus abdominis muscle, and the other two 3-mm ports were inserted in the left upper quadrant. NS was performed by a standard technique under the observation of 3.3-mm needlescope. The surgical procedure was successfully completed in all the patients. The mean duration of surgery, intra-operative bleeding volume and post-operative hospital stay were 176 min, 70 ml and 4.7 days, respectively. There were no particular peri-operative complications in spite of dense adhesions or simultaneous laparoscopic procedures. Our method is safe and feasible with low morbidity and without impairing cosmetic benefits.

A New Technique to Repair Vesicorectal Fistula: Overlapping Rectal Muscle Plasty by Transanal Endoscopic Surgery.

OBJECTIVE: To evaluate clinical results of a novel surgical technique, we developed to repair vesicorectal fistula (VRF) occurring after prostatectomy, hospital records of the patients, who underwent the new surgical treatment, were assessed. METHODS: The novel surgical technique is called "overlapping rectal muscle plasty," which is performed under transanal endoscopic microsurgery (TEM). During the new procedure, a complete fistulectomy was first performed, and then the proper muscle layer of the rectum was folded, overlapped, and sutured to create a thick wall between the rectum and urinary bladder. This operation was carried out in 15 patients with VRF following radical prostatectomy. RESULTS: The operation was safely performed in all patients with an average time of 127.2 min. Fistula was corrected in 13 patients (86.7%), who were then freed from both urinary and intestinal diversions. CONCLUSIONS: Overlapping rectal muscle plasty by TEM is a safe procedure. The success rate seems to be acceptable in selected patients. This new repair method may be considered as a minimally invasive option in the surgical treatment of VRF after prostatectomy.

CLEAN-NET: a modified laparoendoscopic wedge resection of the stomach to minimize the sacrifice of innocent gastric wall.

BACKGROUND: To avoid excessive sacrifice of the tissue surrounding the submucosal tumor in gastric wedge resection with a stapling device, we perform a "combined laparoscopic and endoscopic approach for neoplasia with a nonexposure technique" (CLEAN-NET). Herein the operative technique of CLEAN-NET is described and its short-term outcomes in 50 patients are evaluated. PATIENTS AND METHODS: Between December 2015 and July 2017 CLEAN-NET was performed in 50 patients with gastric submucosal tumors. During the operation, the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. When seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. The mucosa is then transected with a stapling device to execute full-thickness resection of the specimen. Finally, the seromuscular defect is repaired by hand-sewn suture. The hospital records of the 50 patients were reviewed to assess the outcomes. The margin width was compared with those measured in another group with 19 patients, who underwent conventional wedge resection with a stapling device. RESULTS: The operation was completed as CLEAN-NET and the tumor was resected en-bloc without rupture in all patients. The average operation time ranged from 50 to 220 min with an average of 105.4 min. The post-operative course was uneventful. Microscopically the surgical margin was tumor-negative (R0 resection) in all cases. The margin width in the CLEAN-NET group was smaller than that in the wedge resection group (5.4 mm ± 2.5 vs. 33.1 mm ± 14.7). CONCLUSIONS: CLEAN-NET can be performed safely with an acceptable operation time. CLEAN-NET can be a useful option in the laparoscopic surgical treatment of gastric submucosal tumors, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided.