Effective and safe reduction in visceral fat using a formula diet in a short period before highly invasive endoscopic surgery - Case series.

INTRODUCTION: We retrospectively assessed the efficacy and safety of use of short-term formula diet therapy to achieve preoperative reduction in visceral fat immediately prior to highly invasive endoscopic surgery. PRESENTATION OF CASE: We reviewed 5 cancer patients who underwent thoracoscopic and/or laparoscopic-assisted esophagectomy or gastrectomy. The cases were those with a BMI ≥30 kg/m2 or waist circumference ≥100 cm. Patients replaced one meal out of the three main meals with one or two sachets of formula diet (170-340 kcal). The other two meals were set to 600 kcal. The dietary therapy was implemented approximately 1 month before the operation. Weight loss achieved after dietary therapy ranged from 6.4% to 14.1% (p < 0.01). With the exception of one case, the decrease in visceral fat area ranged from 17.0%-40.7% (p = 0.03). Postoperative complications were anastomotic insufficiency in two cases. DISCUSSION: Although the decreases of the visceral fat were effectively implemented, the adverse effects on postoperative complications must be examined in the farther study. CONCLUSION: It was suggested that use of formula diet to achieve preoperative visceral fat reduction in a short period of time immediately prior to highly invasive endoscopic cancer surgery would be an effective and safe strategy.

Laparoscopic abdominal perineal rectal resection for rectal cancer with a horseshoe kidney using preoperative 3D-CT angiography: a case report.

BACKGROUND: A horseshoe kidney is a congenital malformation involving the fusion of the bilateral kidneys and is often accompanied by anomalies of the ureteropelvic and vascular systems. When performing resection of colorectal cancer in a patient with horseshoe kidney, damage to the ureter or excessive renal arteries should be avoided. To achieve this purpose, comprehensive preoperative anatomical assessments and surgical planning are important. Here, we report a case of a laparoscopic abdominal perineal rectal resection for lower rectal cancer with a horseshoe kidney. CASE PRESENTATION: A 79-year-old woman presented with bloody stool and was diagnosed with advanced lower rectal cancer, immediately above the rectal dentate line, without metastasis. A preoperative computed tomography (CT) scan revealed a horseshoe kidney, while a three-dimensional CT (3D-CT) angiography revealed aberrant excess renal artery from the aorta to the renal isthmus. The left ureter ran in front of the isthmus of the horseshoe kidney and presented calculus formation. Laparoscopic abdominal perineal rectal resection was performed with D3 lymph node dissection. During the operation, we mobilized the sigmoid colon mesentery via a medial approach and preserved the left ureter, the left gonadal vessels, and the hypogastric nerve plexus in the retroperitoneum in front of the horseshoe kidney. CONCLUSIONS: We report a rare case of rectal cancer surgery in a patient with a horseshoe kidney. We discuss the anatomical peculiarities of a horseshoe kidney, such as excess renal arteries, inferior vena cava, ureter, gonadal vessels, and nerves, that should be preserved according to the literature. We suggest that preoperative 3D-CT angiography is both useful for revealing the relationship between the vascular system and a horseshoe kidney and helpful when performing laparoscopic surgery for a left-sided colon and rectal cancer to avoid intraoperative injury.

Thoracoscopic resection of a cystic seminoma of the mediastinum.

Mediastinal seminoma is an uncommon tumor that accounts for 25% of primary mediastinal germ cell tumors, which in turn comprise fewer than 5% of all germ cell tumors. Although CT normally shows a solid, lobulated tumor, mediastinal cystic seminoma has rarely been described. Here, we report a 24-year-old man who presented with a mediastinal cystic tumor that was resected after an 18-month delay via video-assisted thoracoscopic surgery while in the supine position; the procedure involved lifting the chest wall with a subcutaneous Kirschner wire. Pathological examination revealed a mediastinal cystic seminoma. No evidence of recurrence has been noted during 25 months of follow-up. Mediastinal cystic seminoma should be considered in the differential diagnosis of cystic lesions of the mediastinum. Moreover, video-assisted thoracoscopic resection may be an appropriate option for the diagnosis and treatment of such lesions.

[Diagnosis of reactive lymphoid hyperplasia of the liver and difficulty in its differentiation from a malignant tumor: a case report].

A 79-year-old woman presented with a chief complaint of abdominal pain. Imaging findings suggested hepatocellular carcinoma although the serum levels of tumor markers were within the normal range. Thus, we performed hepatectomy of S5 and components separation. Histologically, the tumor was diagnosed as reactive lymphoid hyperplasia of the liver. In reactive lymphoid hyperplasia of the liver, a preoperative diagnosis of a malignant tumor was made followed by a definitive diagnosis after resection. Hence, it is imperative to consider reactive lymphoid hyperplasia as a type of liver tumor that is distinct from hepatocellular carcinoma.

A left thoracic approach in a prone position for thoracoscopic thoracic duct ligation in a patient with post-esophagectomy chylothorax: A case report.

INTRODUCTION: We debate whether or not to approach from right thorax for the left chylothorax after esophagectomy. PRESENTATION OF CASE: A 50s-year-old female underwent right-sided thoracoscopic esophagectomy with three-field lymphadenectomy for esophageal carcinoma (type 0-IIa, 3.4×2.2cm, T1bN0M0, Stage IA), followed by reconstruction with esophagogastric anastomosis through the posterior mediastinum. The thoracic duct was excised and ligated. The left thoracic drainage increased to 2115mL/day on the fifth postoperative day. Thoracic duct injury was diagnosed, and surgery was performed on sixth postoperative day. With the patient in a prone position, the thoracic duct was ligated successfully under thoracoscopy in the left thorax. The leakage point was found in the crushed duct by 8.8-mm titanium clips. Then, we performed mass ligation of the thoracic duct with 11-mm titanium clips below the leakage point after careful dissection. The surgery took 58min, with an estimated total blood loss of 0g. DISCUSSION: Although thoracic duct is anatomically located on the right side of the descending aorta, we employed a left-sided thoracoscopic approach due to the chylous leakage in the left thorax. With the patient in the prone position, surgeons can easily convert from a left thoracic approach to a right thoracic approach immediately without postural change if the thoracic duct cannot be found in the left thoracic cavity. CONCLUSION: This technique is useful and should be considered for patients with left chylothorax.

[A case of rectal gastrointestinal stromal tumor in an elderly patient who was successfully treated with imatinib mesylate with no significant adverse events].

An 89-year-old male patient was found to have a mass with a diameter of 54 mm in the pelvic cavity, connected to the rectum, and was diagnosed with a gastrointestinal stromal tumor (GIST)of the rectum by transrectal biopsy. The patient was treated continuously with 400mg/day of imatinib mesylate with no significant adverse events, and the tumor gradually reduced in size. The tumor reduced in size to a diameter of 24 mm at 57 months post-treatment, and a partial response has been maintained for 60 months. Colorectal GIST is rare, comprising 5% of all GIST cases, and surgical resection is the first choice of treatment. In this case, due to a lack of consent, we chose imatinib mesylate as the treatment. However, imatinib mesylate has been reported to induce adverse events more frequently in older patients, and thus we took care to reduce the treatment dosage. We report this case to highlight that a normal quantity of imatinib mesylate can be administered, with no significant adverse events.

[A case of advanced gastric cancer successfully treated by surgery after chemotherapy with S-1/CDDP].

A-46-year-old male with advanced-stage IV multicentric gastric cancer was treated with S-1/CDDP as neoadjuvant chemotherapy. S-1 (initially 100 mg/day, up to 120 mg/day) was orally administered for 3 weeks (day 1-21) followed by 1 drug-free week as a course, and CDDP (initially 60 mg/day, up to 100 mg/day) was administered by intravenous drip on day 8. After the fourth course, a significant tumor reduction was obtained and curative surgery was performed. Thereafter, S-1 therapy was continued. There has not been any recurrence for 19 months postoperatively.