[Examination of Factors Related to Walking Ability in Patients with Abdominal Cancer].

It has been reported that preoperative rehabilitation reduces the risk of postoperative complications. We examined the factors impacting the efficacy of preoperative rehabilitation. Forty-three cancer patients who underwent abdominal surgery after preoperative rehabilitation at our hospital were assessed". Walkable"was defined as having the ability to walk to the toilet(distance>30 meters)without requiring support. Following the clinical path, if patients became"walkable"by the second day after surgery, they belonged to the smooth group, while the remaining patients belonged to the delayed group. We examined the factors influencing walking ability. The smooth group consisted of 34 patients(79%), and the delayed group consisted of 9 patients(21%). The significant factors related to delays in acquiring walking ability were old age and weakened lower limb function. Improving lower limb function through preoperative rehabilitation may lead to patients acquiring walking ability earlier after surgery, especially in older patients.

[Thyroid Metastasis of Rectal Cancer].

A 65-year-old woman underwent laparoscopic low anterior resection for rectal cancer with distant metastasis to the right lobe of her liver and mediastinal and right subclavian lymph nodes. Since the postoperative chemotherapy resulted in the disappearance of the lymph node metastasis and diminished hepatic metastasis lesion, the enlarged anterior segment of the liver was performed. She was administered chemotherapy for 1 year after the second surgery. Thoracoabdominal computed tomography performed 18 months after the end of the treatment revealed swelling of the left lobe of the thyroid. Ultrasonography showed a 23mm lobulated hypoechoic tumor in the left lobe of the thyroid gland. We suspected thyroid metastasis by aspiration biopsy cytology. Left thyroid lobectomy was performed for definitive diagnosis and local control. Histological examination revealed thyroid metastasis of the rectal cancer. We experienced a rare case of thyroid metastasis from rectal cancer.

Secure, low-cost technique for laparoscopic hepatic resection using the crush-clamp method with a bipolar sealer.

INTRODUCTION: Laparoscopic hepatectomy is difficult because surgeons must perform the transection using many (four and more) energy devices and without direct manual maneuvers. Here we introduce hepatic transection by the classical method with a few (two or three) energy devices. MATERIALS AND SURGICAL TECHNIQUE: We performed laparoscopic hepatectomy for 40 patients with hepatic tumor and liver dysfunction. For parenchymal transection, we used bipolar radiofrequency coagulation forceps connected to a voltage-controlled electrosurgical generator and ultrasonic dissector. The demarcation of the liver surface was made by an ultrasonic dissector. Along the demarcation line, the blades of a BiClamp were opened slightly and inserted into the hepatic parenchyma. We clamped slowly, softly, and gradually, and a small amount of hepatic parenchyma was consequently coagulated and fractured. After the crush, the small vessels and intrahepatic bile duct that were sealed were left as atrophic strings, and the strings were divided by an ultrasonic dissector. Large vessels and Glisson's sheaths were left because of the small clamp. Large Glisson's sheaths and hepatic veins were ligated with a titanium clip or autosutures, and cut without bile leakage or bleeding. The mean operation time of the procedure was 196.9 min, mean blood loss was 69.9 mL, and mean postoperative hospitalization was 9.5 days. No blood transfusions were needed. Two cases had perioperative complications-one involving right shoulder pain and the other involving ascites due to liver dysfunction-but there were no serious postoperative complications. DISCUSSION: The present results appear to demonstrate that this simple and safe method helps decrease intraoperative bleeding and shorten hospital stay.

Solitary Hepatic Eosinophilic Granuloma Accompanied by Eosinophilia Without Parasitosis: Report of a Case.

A 43-year-old Japanese woman visited for a hepatic tumor incidentally found. We suspected eosinophilic granuloma of the liver (EGL) due to visceral larva migrans (VLM). However, neither past history nor medical interview indicated a risk of parasitosis. Blood testing revealed eosinophilia, serum examination showed normal results for immunoglobulin E, and enzyme-linked immunosorbent assay yielded negative for Toxocara and Anisakis. Gastric and colonic endoscopy revealed normal features. Several imagings showed central necrosis of the tumor. After informed consent, laparoscopic resection was performed. Histopathological examination showed EGL without parasites. No recurrence had occurred postoperatively. Most reports documented that EGL are caused by VLM. However, parasites are not always demonstrable on serum, histopathological, or immunochemical examinations. When acting as allergens to induce type I responses, microscopic agents other than parasites in the intestinal tract could induce eosinophilic inflammation in the liver. Accumulation of more cases should help clarify other pathogeneses for EGL.

[A Case Report of Successful Chemotherapy with Tegafur/Gimeracil/Oteracil and Nab-Paclitaxel for Gastric Cancer with Chronic Renal Failure].

An 80-year-old Japanese woman with chronic renal failure was diagnosed with gastric cancer and 2 primary colon cancers. The colon cancers were treated with laparoscopic colectomy, but the gastric cancer metastasized to the liver with inoperable dissemination. After operative treatment of the colon cancers, 1 year of combination chemotherapy consisting of tegafur/gimeracil/oteracil (TS-1®) and nab-PTX was administered to treat the advanced gastric cancer. Tegafur is a well-known prodrug of 5-FU. Serum densitometry of 5-FU was performed to determine the correct dose of TS-1®. After completion of chemotherapy, no tumor was detected on gastroscopy or dynamic computed tomography. The patient was well with no recurrence 6 months after completion of chemotherapy. CDDP, CPT-11, 5-FU, PTX, and DTX are known chemotherapy agents for treating gastric cancer. Renal excretion is not involved in the metabolism of CPT-11, 5-FU, PTX, or DTX. These agents are metabolized in the liver. CPT-11 metabolism depends on individual hepatic enzymes. Therefore, we believe that nab-PTX and TS-1® are safe and effective agents for patients with chronic renal failure and advanced gastric cancer. Additionally, we also conclude that using serum densitometry of 5-FU to guide the administration of TS-1® can improve both safety and efficacy.

Cytomegalovirus-associated ulceration of gastric conduit after chemoradiotherapy following esophagectomy for cancer.

A 64-year-old man underwent radical esophagectomy for cancer and simultaneous reconstruction using the gastric conduit through the posterior mediastinum. Two courses of adjuvant chemotherapy were performed. Twenty-eight months postoperatively, recurrence of the cancer was detected in the mediastinal lymph nodes, and he underwent concurrent chemoradiotherapy and boost chemotherapy. Endoscopy was then performed to investigate the cause of epigastralgia, and multiple ulcerations were found in the lesser curvature of the gastric conduit. Although a proton-pump inhibitor was orally administered, the ulceration was intractable. Re-examination of the original biopsy specimens and serological testing revealed positivity for cytomegalovirus. The ulcers began to heal after administration of foscarnet sodium. After the treatment, no signs of exacerbation associated with reinstitution of chemotherapy were observed.

Aneurysm of Pancreatic Artery in Association with Celiac Axis Stenosis: Report of a Case and Review of the Literatures.

A 63-year-old Japanese woman with a history of pemphigus was referred to us for abnormal findings of dynamic abdominal CT where three aneurysms of splenic artery and pancreaticoduodenal artery, celiac axis compression, and gall stone. Superior mesenteric artery supplied hepatic arterial flow via pancreaticoduodenal artery. Avoiding transarterial embolization to prompt arterial ischemia of liver/pancreas head/duodenum, she laparotomically underwent cholecystectomy, splenectomy, transection of median arcurate ligament, and ligation of splenic and inferior pancreaticoduodenal artery all at once. Postoperative course was uneventful except drainage of abdominal abscess, and she remained well without aneurysm recurring 40 months post. Important point of treatment for pancreaticoduodenal artery aneurysm associated with celiac artery occlusion/stenosis is both preventive solutions for rupture of aneurysm and hepatic/duodenal/pancreatic arterial ischemia. Remaining main arterial supply for the liver via pancreaticoduodenal artery from superior mesenteric artery would prompt recurrent aneurysm of pancreaticoduodenal artery. When a clinician encounters a case of pancreatic aneurysm associated with celiac axis occlusion, the case should be treated using with multimodality such as interventional radiology, and vascular surgery.

Efficacy of single-incision laparoscopic appendectomy in adults and adolescents using an endolinear stapler.

BACKGROUND: Some investigators recently introduced transumbilical single-incisional laparoscopic appendectomy (SILA), however, those SILA require expensive surgical instruments, or difficult technique. We uniquely propose performing SILA using with endolinear stapler, and compare the clinical results of the present SILA with those of conventional laparoscopic appendectomy. MATERIALS AND METHODS: In brief, the skin of the umbilical hollow is cut, the anterior layer of the rectus sheath and subcutaneous fat is exfoliated widely, and the linea alba is opened. Two low-profile 5-mm-diameter trocars are stabbed through the right rectus sheath, and a 12-mm-diameter trocar is inserted from the opened linea alba. Using a 5-mm laparoscope, and endolinear stapler, the appendix is dissected. Some clinical and operative data of 16 cases treated the present SILA are compared with those of 35 cases treated conventional laparoscopic appendectomy. RESULTS: We performed the present SILA for 16 patients consisted of young women mostly, compared with cases treated conventional laparoscopic appendectomy (mean, 26-year-old vs 51-year-old, p < 0.0001). The results of the SILA we have proposed in adults and adolescents are good in terms of operation time (mean, 64 minutes vs 89.3 minutes, p = 0.049), duration of hospitalization (mean, 4.2 days vs 8.1 days, p = 0.0038), and low frequency of intra- and postoperative complications (one patient of postoperative umbilical granuloma). CONCLUSIONS: We assume that convenience of surgical procedure of the present SILA would affect the shortness of operation time, and that minimal invasive surgical stress of the present SILA would reduce perioperative stress of appendicitis, and ameliorate adolescents with appendicitis earlier. We believe that the SILA we have proposed offers advantages in diversion of conventional surgical instruments, similarity to conventional manipulation of laparoscopic forceps, usage of an endoscopic stapler able to cut cecum in cases of advanced appendicitis extending to the cecum, and obviation of extra-abdominal appendectomy demanding excessive traction of the appendix.