IRIS U kit usefulness in transanal total mesorectal excision for lower rectal cancer to avoid urethral injury.

Transanal total mesorectal excision (taTME) has improved the laparoscopic dissection for rectal cancer in the narrow pelvis. Although taTME has more clinical benefits than laparoscopic surgery, such as a better view of the distal rectum and direct determination of distal resection margin, an intraoperative urethral injury could occur in excision ta-TME. This study aimed to determine the feasibility and efficacy of the ta-TME with IRIS U kit surgery. This retrospective study enrolled 10 rectal cancer patients who underwent a taTME with an IRIS U kit. The study endpoints were the safety of access (intra- or postoperative morbidity). The detectability of the IRIS U kit catheter was investigated by using a laparoscope-ICG fluorescence camera system. Their mean age was 71.4±6.4 (58-78) years; 80 were men, and 2 were women. The mean operative time was 534.6 ± 94.5 min. The coloanal anastomosis was performed in 80%, and 20% underwent abdominal peritoneal resection. Two patients encountered postoperative complications graded as Clavien-Dindo grade 2. The transanal approach with IRIS U kit assistance is feasible, safe for patients with lower rectal cancer, and may prevent intraoperative urethral injury.

Blood Perfusion Assessment by Indocyanine Green Fluorescence Imaging for Minimally Invasive Rectal Cancer Surgery (EssentiAL trial): A Randomized Clinical Trial.

OBJECTIVE: The aim of the present randomized controlled trial was to evaluate the superiority of indocyanine green fluorescence imaging (ICG-FI) in reducing the rate of anastomotic leakage in minimally invasive rectal cancer surgery. BACKGROUND: The role of ICG-FI in anastomotic leakage in minimally invasive rectal cancer surgery is controversial according to the published literature. METHODS: This randomized, open-label, phase 3, trial was performed at 41 hospitals in Japan. Patients with clinically stage 0-III rectal carcinoma less than 12 cm from the anal verge, scheduled for minimally invasive sphincter-preserving surgery were preoperatively randomly assigned to receive a blood flow evaluation by ICG-FI (ICG+ group) or no blood flow evaluation by ICG-FI (ICG- group). The primary endpoint was the anastomotic leakage rate (grade A+B+C, expected reduction rate of 6%) analyzed in the modified intention-to-treat population. RESULTS: Between December 2018 and February 2021, a total of 850 patients were enrolled and randomized. After the exclusion of 11 patients, 839 were subject to the modified intention-to-treat population (422 in the ICG+ group and 417 in the ICG- group). The rate of anastomotic leakage (grade A+B+C) was significantly lower in the ICG+ group (7.6%) than in the ICG- group (11.8%) (relative risk, 0.645; 95% confidence interval 0.422-0.987; P =0.041). The rate of anastomotic leakage (grade B+C) was 4.7% in the ICG+ group and 8.2% in the ICG- group ( P =0.044), and the respective reoperation rates were 0.5% and 2.4% ( P =0.021). CONCLUSIONS: Although the actual reduction rate of anastomotic leakage in the ICG+ group was lower than the expected reduction rate and ICG-FI was not superior to white light, ICG-FI significantly reduced the anastomotic leakage rate by 4.2%.

Laparoscopic Total Devascularization of the Upper Stomach and Splenectomy (Hassab's Procedure) Under Indocyanine Green Fluorescence Imaging: Initial Experience.

The use of surgical treatment for refractory isolated gastric varices has decreased owing to the development of endoscopic and radiologic procedures, although surgeries are sometimes required as the final method. A 75-year-old Japanese woman was diagnosed with solitary gastric varices. Initially, intraoperative splenic artery embolization was performed using the balloon transcatheter technique under general anesthesia. Laparoscopic splenectomy was performed safely owing to preoperative splenic artery embolization. Intraoperative indocyanine green (ICG) fluorescence angiography was performed following the injection of 5 mL of ICG; the remnant stomach was observed using laparoscopic equipment with an ICG imaging system, and blood flow from the remnant gastric artery was confirmed. The blood did not pool or wash out immediately, which confirmed successful devascularization of the stomach. The total operative time was 269 minutes, and the intraoperative blood loss was 500 mL. The patient's postoperative course was good, and at 21 days after the last operation, she was discharged from our hospital in remission. Real-time fluorescence angiography with ICG is a reliable and objective technique of assessing blood flow of the stomach. Accurate, extensive devascularization in the lower esophagus and upper stomach was performed using Hassab's procedure in combination with ICG imaging.

[Malignant gastrointestinal lymphoma with cicatricial stenosis after complete response to chemotherapy].

A 75-year-old woman presented complaining of anorexia. A malignant gastrointestinal lymphoma was diagnosed, and chemotherapy was initiated. After 2 months, she developed vomiting. Computed tomography (CT) revealed thickening of the jejunal wall and dilatation of the intestine proximal to that area. Positron emission tomography-CT showed no uptake. Small bowel stenosis due to cicatricial stenosis after chemotherapy was suspected. Laparoscopic partial resection of the stenotic small bowel segment was performed. Histopathologically, only granulation tissue was seen with no evidence of tumor. Occasionally, cicatricial stenosis can develop after chemotherapy for malignant gastrointestinal lymphoma. Therefore, this condition must be considered an important complication of treatment for this disease.

[A case of adult gastric volvulus treated using upper gastrointestinal series].

Here, we report a case of adult gastric volvulus that was treated using an upper gastrointestinal series and provide a review of relevant reports. A 55-year-old woman presented with upper abdominal pain. Abdominal computed tomography revealed mesenteroaxial gastric volvulus. We performed an upper gastrointestinal series after the placement of a nasogastric tube. We successfully performed detorsion by repositioning. There was no recurrence of gastric volvulus after the detorsion. However, considering the risk of recurrence, we also performed laparoscopic gastropexy. The postoperative course was uneventful, and she was discharged from the hospital on postoperative day 3. No recurrence of symptoms has been observed to date.

[Maintenance of Long-Term Stable Disease(SD)in Metastatic Breast Cancer with Eribulin - A Case Report of Long-Term SD in Japan].

This case report discusses a 48-year-old woman with metastatic breast cancer: T4c(10.5 cm)N2bM1,(OSS, LYM), stage IV, estrogen receptor(ER)(+), progesterone receptor(PgR)(+), human epidermal growth factor receptor-2(HER2) (-), and Ki-67 17.2%. Administration of eribulin was initiated after treatment with anthracycline and taxane. Thereafter, 28 courses of eribulin maintained a SD state for over a year and improved the quality of life(QOL). Eribulin is effective for both prolonging life and improving QOL, which are the main goals in the treatment of metastatic or recurrent cancer. Therefore, this evidence suggests that eribulin can be effective in various clinical situations.

Evaluation of postgastrectomy symptoms after distal gastrectomy with Billroth-I reconstruction using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45).

BACKGROUND: Distal gastrectomy with Billroth-I reconstruction (DGBI) is the most commonly used treatment approach for gastric cancer patients in Japan. The aim of this study was to assess and elucidate the effect of different surgical DGBI techniques on postgastrectomy syndrome (PGS) using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45). METHODS: The newly created PGSAS-45 composed of 45 questions was used in this study. The scale was distributed to 2,922 patients who underwent gastrectomy >1 year prior. Completed forms were returned by 2,520 patients (86 %), of which 909 underwent DGBI. The effects of performing the Kocher maneuver, differences in the size of the gastric remnant and differences the anastomosis technique had on the main outcome measures of PGSAS-45 were analyzed. RESULTS: Patients for whom the Kocher maneuver was performed experienced significantly worse meal-related distress and poorer quality of ingestion. Additionally, a less satisfactory physical and mental component summary from the SF-8 was reported. Patients with larger gastric remnants showed significantly better scores on the diarrhea subscale, a slightly better trend for the need for additional meals and dissatisfaction with eating. Regarding the anastomosis technique, there was no difference between the hand-sewn, circular stapler (CS) and linear stapler end-to-end anastomosis, and there was also no difference between the end-to-end and side-to-end anastomosis with the CS. CONCLUSIONS: The Kocher maneuver may increase meal-related distress, reduce the quality of ingestion and impart a negative effect on quality of life (QOL). The larger gastric remnants may cause reduction in diarrhea and an improvement in meal-related scores.

[A case of ruptured giant splenic artery aneurysm].

A 68-year-old woman presented with general malaise. Her vital signs were unstable, and abdominal computed tomography revealed giant (10 cm) splenic artery aneurysm with evidence of rupture. We first occluded the root of the splenic artery using a balloon catheter. Next, we resected the distal pancreas and spleen because of the aneurysm size and destruction of the related vasculature. After surgery, the patient's condition improved, and she was discharged from the hospital on postoperative day 18. Because ruptured giant splenic artery aneurysms are very rare, we report this case with a review of the literature.

Laparoscopic splenectomy for sclerosing angiomatoid nodular transformation of the spleen: Report a case.

INTRODUCTION AND IMPORTANCE: Sclerosing angiomatoid nodular transformation (SANT) of the spleen is an extremely rare benign lesion. CASE PRESENTATION: Here, we describe the case of a 52-year-woman who was diagnosed with sclerosing angiomatoid nodular transformation of the spleen. Abdominal contrast-enhanced CT revealed a solid lesion in the splenic hilum that was slowly enhanced between the portal venous and equilibrium phases incidentally. Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed FDG accumulation within the mass, with a maximum standardized uptake value (SUVmax) of 2.57. Based on these findings, the patient was scheduled for laparoscopic splenectomy. The total operating time was 193 min, and the intraoperative blood loss was 20 ml. The resected specimen was 9.0 × 8.4 × 5.6 cm and dark brown in colour with a large central stellate fibrotic scar. CLINICAL DISCUSSION: Pathological examination revealed nodular angioma lesions and the proliferation of fibrotic interstices and inflammatory cells. We could diagnose the SANT by the only HE staining without Immunohistochemical staining. CONCLUSION: Although SANT is a rare benign lesion, which is difficult to definitively diagnose based on preoperative imaging findings alone, it should be considered in cases of solitary splenic lesions, and we recommend performing LS and subsequent histological examination for the diagnosis of this disease.

Robotic transabdominal preperitoneal repair for recurrent inguinal hernia after Kugel hernioplasty: A case report.

INTRODUCTION AND IMPORTANCE: The laparoscopic posterior approach adapts the advantages of Kugel hernioplasty, making it possible to perform it at the new layer even if the inguinal hernia is recurrent following the anterior approach, producing a high level of completion. However, in laparoscopic surgery for recurrent inguinal hernia using posterior approaches, dissecting the extraperitoneal space is difficult. Robotic surgery may enable precise dissection, even if the space is severely adhered. Here, we report a robotic approach after extraperitoneal approach for recurrent inguinal hernia, which developed after Kugel hernioplasty. CASE PRESENTATION: A 78-year-old Japanese man, who underwent left inguinal hernia repair (Kugel hernioplasty) 2 years ago, presented with recurrent reducible left inguinal swelling. A peritoneal incision was created above the deep inguinal ring to treat the primary right inguinal hernia. The pressure in the left inguinal region revealed a spermatic cord lipoma protruding from the internal inguinal ring as a recurrent inguinal hernia of the abdominal cavity. CLINICAL DISCUSSION: Robotic transabdominal preperitoneal repair for recurrent inguinal hernia is effective, especially after posterior approach Kugel hernioplasty, in which dissection of the extraperitoneal space is difficult. In the present case, the peritoneal flap was conserved without removing the direct Kugel patch. CONCLUSION: Kugel hernioplasty, which is a posterior approach, would result in severe extraperitoneal space adhesion. Essentially, a new and previously unused approach is preferable to the previous approach in patients with recurrent inguinal hernias. Robotic approach is effective for recurrent inguinal hernias even if the space was severe adhesion.

Pathological factors related to lymph node metastasis of submucosally invasive gastric cancer: criteria for additional gastrectomy after endoscopic resection.

BACKGROUND: There are currently no universally accepted indications and criteria for additional gastrectomy after endoscopic resection of submucosally invasive cancer. The purpose of the present study was to establish accurate indications and criteria for such additional gastrectomy on the basis of lymph node metastasis risk. METHODS: We investigated 130 submucosally invasive gastric cancers and analyzed the pathological risk factors for lymph node metastasis. The tumors were evaluated for pathological factors in the area of invasion, and factors were compared between the cases with lymph node metastasis and those without. RESULTS: Univariate logistic regression analysis showed that tumor minor axis length, depth of invasion, histological classification of the area of submucosal invasion, absence of lymphoid infiltration, ulceration or scar in the lesion, and lymphatic and venous invasion are statistically significant risk factors for lymph node metastasis. Multivariate logistic regression analysis showed that the absence of lymphoid infiltration and the presence of lymphatic invasion are statistically significant as risk factors for lymph node metastasis. CONCLUSIONS: We present a scoring system on the basis of the pathological criteria tested in this study. Our findings enable more accurate identification of patients who should undergo additional gastrectomy after endoscopic resection.

Functional outcomes according to the size of the gastric remnant and the type of reconstruction following distal gastrectomy for gastric cancer: an investigation including total gastrectomy.

OBJECTIVE: In gastric cancer, various methods of gastric resection have been devised according to the location of the primary tumor and the depth of invasion. Functional outcomes were compared among different types of reconstruction following open 2/3- or 4/5 distal gastrectomy for gastric cancer. METHODS: Resection and reconstruction were performed by one of the following three methods, depending on the depth of cancer invasion and the date of the procedure relative to the introduction of Roux-en-Y reconstruction: distal 2/3 gastrectomy with Roux-en-Y reconstruction (1/3 Roux-en-Y, n = 30); distal 4/5 gastrectomy with Roux-en-Y reconstruction (1/5 Roux-en-Y, n = 15) and distal 2/3 gastrectomy with Billroth I reconstruction (1/3B1, n = 30). Open total gastrectomy with Roux-en-Y reconstruction (total gastrectomy with RY reconstruction, n = 30) was taken as the control procedure. RESULTS: Comparison of postoperative/preoperative body weight ratios and food intake ratios revealed better preservation among patients with a larger remnant stomach (the 1/3 Roux-en-Y and 1/3B1 groups), regardless of the reconstruction. The gastric emptying pattern in larger remnant stomach groups was milder than in the 1/5 Roux-en-Y and total gastrectomy with RY reconstruction groups. Reflux esophagitis was often observed on endoscopy in the 1/3B1 group. CONCLUSIONS: Better functional outcomes were observed in patients with a large remnant stomach regardless of the reconstruction.

Bilateral laparosocopic lateral lymph node dissection by the totally extraperitoneal approach after intersphincteric resection of the lower rectum: report of a case.

Introduction and Importance: Lateral lymph node dissection (LLND) for recurrent lateral pelvic lymph node metastasis could be the only surgical treatment to improve its prognosis, but is difficult and challenging technically. Case Presentation: A 75-year-old Japanese man who underwent a radical laparoscopic intersphincteric resection to treat double lower rectal cancer. Computed tomography and MRI showed lower rectal wall thickening and bilateral lateral lymph node swelling. The authors scheduled and performed the LLND for recurrent lateral pelvic lymph nodes after ISR by the totally extraperitoneal (TEP) approach. The bottom of the obturators lymph node (#263D) were positive for metastasis histologically. Clinical Discussion: The TEP approach is an especially effective option for the treatment of bilateral LLND. Conclusion: Herein, the authors introduce our surgical technique: successful challenging treatment of the LLND by the TEP approach after intersphincteric resection of the lower rectum.

A study of the effectiveness of the bilateral and contralateral occult inguinal hernia repair by total extraperitoneal repair with intraperitoneal examination.

PURPOSE: Of the various methods used, the laparoscopic surgical repair of inguinal hernias is widely performed. We aimed to estimate the incidence of bilateral and contralateral occult inguinal hernias in our surgical population and to compare the results of total extraperitoneal repair (TEP) for bilateral and unilateral inguinal hernias, occult and non-occult hernias. METHODS: We retrospectively reviewed data of patients who underwent TEP for the repair of adult inguinal hernias from January 2012 to November 2018 in our hospital. RESULTS: Of the data of 259 patients included, 134 (51.7%) and 125 (48.3%) had unilateral and bilateral inguinal hernias, respectively, while 70 patients (27%) were found to have a contralateral occult inguinal hernia, intraoperatively. The mean operative time was 129 ± 48 minutes (range, 43-300 minutes) and 167 ± 55 minutes (range, 85-390 minutes) for the unilateral and bilateral groups, respectively, indicating a significantly longer duration of surgery for the bilateral group (P < .05). Recurrence occurred in 1.5% (5/134) and 0.4% (1/250) of the operated hernias in the unilateral and the bilateral groups, respectively, indicating a significantly lower rate of recurrence in the latter group (P < .05). The two groups showed no statistically significant differences with respect to the remaining perioperative data. The incidence of postoperative complications in occult hernias was not significantly different from that in non-occult hernias. CONCLUSIONS: Our TEP method, involving a laparoscopic exploration from the intraperitoneal side, can be safely and effectively utilized for the repair of both bilateral and contralateral occult inguinal hernias.

Successful treatment for sports hernia by total extraperitoneal repair with intraperitoneal examination: Report a case.

Introduction: and importance: TEP might be one of options for treating such a sports hernia. Case presentation: An 18-year-old Japanese male presented with right groin pain for approximately two years. The pain was initially felt on the right side only, especially on kicking. We assessed the patient using laparoscopic examination with an intra-abdominal scope and subsequently diagnosed a sports hernia with a bilateral internal inguinal hernia. We then performed total extraperitoneal repair (TEP) for its treatment. The patient had a good postoperative course and was discharged from our hospital in remission after 3 days. Finally, the patient was able to play soccer without groin pain. Clinical discussion: Chronic groin pain in athletes can be caused by a bulge in the posterior inguinal wall, consistent with an incipient direct inguinal hernia. Conclusion: We show that intraperitoneal examination with TEP might be one of options for treating such a sports hernia. Endoscopic placement of the retropubic mesh must be considered an important option for this type of hernia.

Laparoscopic intraperitoneal mesh repair of an incisional hernia after transverse rectus abdominis myocutaneous flap reconstruction for breast cancer.

Breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap is performed for the treatment of large defects of the breast. However, this may result in an abdominal wall hernia or bulging. A 53-year-old Japanese woman with left breast cancer underwent left skin-sparing mastectomy, sentinel node lymph node dissection, and immediate reconstruction with a contralateral pedicled TRAM flap. Thirty-two months following surgery, right lower abdominal wall hernia (15.5 × 12 cm) and bulging were observed at the suprapubic region. The patient was diagnosed with an incisional hernia and was scheduled for laparoscopic intraperitoneal mesh repair. The mesh was coated with an absorbable hydrogel barrier and was trimmed to 26 × 22 cm, with a 5 cm overlap around the defect. The patient demonstrated a good postoperative course. In conclusion, intraperitoneal onlay mesh with hernia repair closure (IPOM-Plus) is a simple and useful method for hernia repair following TRAM flap reconstruction.

Effects of creating a jejunal pouch on postoperative quality of life after total gastrectomy: A cross-sectional study.

AIM: Total gastrectomy results in the complete loss of gastric function and the development of severe postgastrectomy syndrome. During the jejunal pouch procedure following total gastrectomies, a substitute stomach is created to alleviate the effects of postgastrectomy syndrome. However, the procedure's effectiveness remains controversial. This study aimed to explore the effect of jejunal pouch creation after total gastrectomy on postoperative quality of life. METHODS: A nationwide multi-institutional cross-sectional study, the Postgastrectomy Syndrome Assessment study NEXT, used the Postgastrectomy Syndrome Assessment Scale-45 questionnaire to explore the optimal gastrectomy procedure for cancer located in the upper third of the stomach or around the esophagogastric junction. The questionnaire consists of 45 items consolidated into 19 main outcome measures relating to postgastrectomy symptoms, amount of food ingested, quality of ingestion, ability for working, level of satisfaction for daily life, and the physical and mental component summary of the 8-Item Short Form Health Survey. Eligible completed questionnaires were retrieved from 1909 patients. Of these, the data were analyzed for 1020 patients who underwent total gastrectomy and 93 patients who underwent jejunal pouch creation after total gastrectomy. RESULTS: Postoperative quality of life was compared between patients with and without pouches. The analysis revealed that patients with pouches, particularly oral pouches, experienced substantially improved postoperative quality of life than those without, even after adjusting for several clinical factors using multiple regression analyses. CONCLUSION: The results suggest that total gastrectomy with jejunal pouch creation, particularly oral pouches, may significantly improve postoperative quality of life.

A case report of the transanal lateral lymph node dissection with a combined abdominal assisted approach for the lower rectal cancer.

INTRODUCTION: Low and mid rectal cancer cells have the tendency to spread in the lateral pelvic lymph node (LPLN). The Japanese guidelines recommend systematic lymph node dissection when a positive LPLN is suspected or in stages II-III rectal cancer. However, laparoscopic lymph node dissection is complex and challenging. We introduce transanal LPLN dissection using an abdominal approach. PRESENTATION OF CASE: A 78-year-old man was diagnosed with advanced rectal cancer. Computed tomography and magnetic resonance imaging showed lower rectal wall thickening and bilateral lateral lymph node swelling. We performed laparoscopic abdominal peritoneal resection with combined bilateral LPLN dissection using abdominal and transanal approaches. He had an uneventful postoperative course with no signs of recurrence at the 5-month follow-up. DISCUSSION: LPLN metastases for low rectal cancer especially occur at the bottom of the deep pelvic spaces. As laparoscopic LPLND for low rectal cancer can be complicated, we adopted abdominal and transanal approaches, which provide the advantage of an anatomical view. This procedure may improve lateral pelvic anatomical structure viewing, and may offer advantages over laparoscopic abdominal approaches for visualizing and dissecting LPLNs. CONCLUSION: Curative resection has become available for rectal cancer with transanal LPLN dissection. LPLN dissection with combined abdominal and transanal approaches is a feasible treatment for advanced rectal cancer.

Successful Laparoscopic Treatment of Pancreatic Metastasis From Sigmoid Colon Cancer: A Case Report.

Progressive colorectal cancer frequently presents with various manifestations, including hepatic, pulmonary, and peritoneal metastases, as well as local and anastomotic site recurrences. However, pancreatic metastasis is extremely rare. Complete surgical resection is currently considered the most effective and only potentially curative treatment for colorectal cancer with distant metastases. We report the successful laparoscopic treatment of a patient with pancreatic metastasis after initial surgery for Stage IV sigmoid colon cancer with pulmonary metastasis. An 84-year-old man was initially diagnosed with sigmoid colon cancer and pulmonary metastasis. Laparoscopic sigmoidectomy and thoracoscopic partial resection of the right lung were performed in 2017. After 8 months, an approximately 20-mm tumor was detected in the pancreatic tail during imaging investigations. We performed laparoscopic distal pancreatectomy without lymph node dissection at 1 year after the initial operation. The histopathological findings suggested metachronous pancreatic metastasis from the sigmoid colon cancer. The patient has had an uneventful postoperative course with no signs of recurrent disease during 29 months of follow-up after the pancreatic surgery. After prior surgery for Stage IV sigmoid colon cancer with pulmonary metastasis, curative resection was performed for pancreatic metastasis. We believe that curative resection may be useful for pancreatic tumors that involve hematogenous metastasis.