Ectopic Liver Tissue on the Gallbladder Wall Encountered During Laparoscopic Cholecystectomy.

Ectopic liver tissue is a rare developmental anomaly that is not directly connected to the liver. We encountered ectopic liver tissue on the surface of the gallbladder wall during laparoscopic cholecystectomy. It has vasculature arising from the liver parenchyma and is classified according to its branching pattern. Ectopic liver tissue has been reported to occur in a variety of locations, and when encountered in surgery, it is clinically important to identify ectopic liver tissue with vascular supply to prevent unexpected bleeding. Ectopic liver tissue should be resected and examined histologically for the potential for malignancy when detected during surgical intervention.

Additional superdrainage reduces anastomotic fistula and stenosis after gastric tube reconstruction with cervical anastomosis for esophageal cancer.

Objective: Gastric pull-up is a common procedure to reconstruct the continuity of the upper digestive tract after esophagectomy. However, this technique sometimes causes postoperative anastomotic leakage or stricture, resulting from congestion of the gastric tube. We performed additional microvascular venous anastomoses to solve this problem. The purpose of this study was to compare postoperative anastomotic leaks and strictures in cases with or without additional venous superdrainage after gastric tube reconstruction. Methods: A total of 117 consecutive patients with cervical and thoracic esophageal cancer who underwent thoracoscopic esophagectomy with gastric tube reconstruction in the National Nagasaki Medical Center between 2011 and 2021 were analyzed retrospectively. Of these patients, 46 did not undergo additional venous anastomoses (standard group), and 71 who underwent gastric pull-up surgery after November 2014 have added this surgical procedure to their routine (superdrainage group). We compared the frequency of postsurgical leakage and stricture in the 2 groups retrospectively. Results: Fifteen patients (32.6%) developed postoperative leakage in the standard group and 6 (8.5%) did so in the superdrainage group. Twelve patients (26.1%) showed postoperative anastomotic stricture in the standard group and 7 (9.9%) did so in the superdrainage group. Patients who did not undergo additional venous superdrainage were significantly more likely to develop postsurgical leakage (χ2 test P < .01) and anastomotic stricture (χ2 test P < .05). The mean time taken to perform additional venous anastomoses was 54.2 minutes. Conclusions: Our study revealed that performing additional venous anastomosis for as little as 1 hour can significantly reduce the incidence of postoperative leakage and stenosis. This procedure is of merit to perform after total esophagectomy with gastric tube reconstruction.

Predictors and preventers of postoperative bedridden status in the elderly ages over 75 after emergency general surgery: a retrospective cohort study.

Aim: We investigated the proportion of bedridden patients after emergency surgery among the elderly ages over 75; defined as the latter-stage elderly in Japan, the associated factors, and interventions used to prevent it. Methods: Eighty-two latter-stage elderly patients who underwent emergency surgery for non-traumatic illness between January 2020 and June 2021 in our hospital were included in the study. Backgrounds and various perioperative factors were compared retrospectively between the groups including patients who became bedridden from Performance Status Scale 0 to 3 before admission (Bedridden group) and those who did not (Keep group). Results: Three cases of death and seven patients who were bedridden before admission were excluded. The 72 remaining patients were divided into the Bedridden group (n = 10, 13.9%) and the Keep group (n = 62, 86.1%). There were significant differences in the prevalence of dementia, pre- and postoperative circulatory dynamics, renal dysfunction, coagulation abnormality, length of stay in the high care unit/intensive care unit, and number of hospital days, with a relative risk of 13 (1.74-96.71), a sensitivity of 1.00, and a specificity of 0.67 for a preoperative shock index of 0.7 or higher being associated with the Bedridden group. Among patients with a preoperative shock index of 0.7 or higher, there was a significant difference in SI at 24 h postoperatively between the two groups. Conclusion: Preoperative shock index may be the most sensitive predictor. Early circulatory stabilization seems to be protective against patients becoming bedridden.

Double vision approach applied by two teams for retrosternal gastric conduit for gastric tube cancer.

Gastric tube cancer is classically treated with resection through a midline sternal incision. However, because of its invasiveness and limited reconstructive potential, transdiaphragmatic laparoscopic or thoracoscopic dissection of the gastric tube has been investigated. As resection from only the abdominal or thoracic cavity is difficult, we performed surgery with a thoracic surgeon approaching from the thoracic cavity and an abdominal surgeon simultaneously approaching from the cervical and abdominal regions. The gastric tube may be tightly adhered to the back of the sternum, cervicothoracic transition or thoracoabdominal transition. Dissection can be safely performed by operating from two directions simultaneously, the neck and chest or chest and abdomen, to successfully withdraw the gastric tube from the abdominal cavity. We performed this surgery in four cases. This collaborative operation provided a good surgical view and allowed for safe dissection of the gastric tube without requiring sternotomy.

Prognostic significance of NY-ESO-1 antigen and PIGR expression in esophageal tumors of CHP-NY-ESO-1-vaccinated patients as adjuvant therapy.

The aim of this study was to determine the efficacy and the biomarkers of the CHP-NY-ESO-1 vaccine complexed with full-length NY-ESO-1 protein and a cholesteryl pullulan (CHP) in patients with esophageal squamous cell carcinoma (ESCC) after surgery. We conducted a randomized phase II trial. Fifty-four patients with NY-ESO-1-expressing ESCC who underwent radical surgery following cisplatin/5-fluorouracil-based neoadjuvant chemotherapy were assigned to receive either CHP-NY-ESO-1 vaccination or observation as control. Six doses of CHP-NY-ESO-1 were administered subcutaneously once every two weeks, followed by nine more doses once every four weeks. The endpoints were disease-free survival (DFS) and safety. Exploratory analysis of tumor tissues using gene-expression profiles was also performed to seek the biomarker. As there were no serious adverse events in 27 vaccinated patients, we verified the safety of the vaccine. DFS in 2 years were 56.0% and 58.3% in the vaccine arm and in the control, respectively. Twenty-four of 25 patients showed NY-ESO-1-specific IgG responses after vaccination. Analysis of intra-cohort correlations among vaccinated patients revealed that 5% or greater expression of NY-ESO-1 was a favorable factor. Comprehensive analysis of gene expression profiles revealed that the expression of the gene encoding polymeric immunoglobulin receptor (PIGR) in tumors had a significantly favorable impact on outcomes in the vaccinated cohort. The high PIGR-expressing tumors that had higher NY-ESO-1-specific IgA response tended to have favorable prognosis. These results suggest that PIGR would play a major role in tumor immunity in an antigen-specific manner during NY-ESO-1 vaccinations. The IgA response may be relevant.

Prevention of well-leg compartment syndrome following lengthy medical operations in the lithotomy position.

PURPOSE: Compartment syndrome that occurs after lengthy surgery in the lithotomy position is known as well-leg compartment syndrome. It has serious consequences for patients, including amyotrophic renal failure, limb loss, and sometimes even death. This study aimed to identify effective preventive measures against well-leg compartment syndrome using a retrospective cohort study of 1,951 patients (985 and 966 in the prevention and control groups, respectively). MATERIAL AND METHODS: The following preventive interventions were analyzed: (1) changing from the lithotomy position to the open-leg position, (2) removing lower leg pressure caused by the lithotomy position, (3) limiting leg elevation based on the height of the right atrium, (4) horizontally repositioning the operating table every 3 hours, and (5) decompressing the contact area of the lower leg in the lithotomy position during operation. RESULTS: Eight cases of well-leg compartment syndrome occurred in the control group, whereas no well-leg compartment syndrome occurred in the prevention group. CONCLUSION: These findings suggest that the five interventions assessed can prevent the development of well-leg compartment syndrome.

Cricopharyngeal myotomy for cricopharyngeus muscle dysfunction after esophagectomy.

BACKGROUND: Pharyngoesophageal dysphagia sometimes develops after esophagectomy. However, severe dysphagia after esophagectomy due to cricopharyngeus muscle dysfunction is a rare complication. There are no recommended clinical treatments for cricopharyngeus muscle dysfunction after esophagectomy. We report a case of myotomy for cricopharyngeus muscle dysfunction after esophagectomy. CASE PRESENTATION: A 75-year-old man with mild dysphagia diagnosed with advanced esophageal cancer by esophagogastroduodenoscopy at a clinic was admitted to our hospital. He had occasional mild dysphagia when he swallowed solid foods. After chemotherapy, the patient underwent minimally invasive esophagectomy with regional lymph node dissection and was reconstructed with a gastric conduit and cervical anastomosis by the retrosternal route. Aspiration pneumonia developed after esophagectomy without paralysis of the vocal cords. In esophagoscopy, there was no stricture around the anastomosis. However, severe pharyngoesophageal dysphagia with cricopharyngeus muscle dysfunction was revealed by videofluoroscopic examination. Bilateral cricopharyngeal myotomy was performed because balloon dilations had failed. The histological findings revealed atrophy and fibrosis of the cricopharyngeus muscle fibers. Pharyngoesophageal dysphagia improved immediately after myotomy. The patient swallowed solid food easily without dysphagia 12 months after myotomy. CONCLUSION: Dysphagia after esophagectomy was worsened by cricopharyngeus muscle dysfunction. Cricopharyngeus myotomy may lead to long improvement of pharyngo-oesophageal dysphagia after esophagetomy.

S-1 and CPT-11 Plus Ramucirumab (IRIS+Rmab) as Second-Line Chemotherapy for Patients with Oxaliplatin-Refractory Metastatic Colorectal Cancer (mCRC): A Multicenter Phase II Study in Japan (N-DOCC-F-C-1701).

This multicenter phase II N-DOCC-F-C-1701 trial is being planned in order to investigate the efficacy and safety of CPT-11+S-1 +Ramucirumab (IRIS+Rmab), which is anticipated to have a stronger anti-tumor effect than IRIS+Bmab in patients with metastatic colorectal cancer (mCRC) previously treated with oxaliplatin (L-OHP) containing regimen, in consideration of the result of RAISE, FIRIS and some phase II trials of IRIS+Bevacicizumab (Bmab). The number of patients is set at 38 for the statistical analysis, assuming an expected median PFS of 5.0 months (threshold: 3.0 months). The primary endpoint of the study is the progression free survival (PFS), and the secondary endpoints are the overall response rate (ORR), overall survival (OS), adverse events (AE), quality of life (QOL) and review of nausea and vomiting. This trial is registered in the UMIN Clinical Trials Registry as UMIN000028170. We intend to start conducting the trial in September 1, 2017. If this trial meets the endpoint, IRIS+Rmab might be supported as a new optional standard regimen for mCRC.

Comprehensive immune complexome analysis detects disease-specific immune complex antigens in seminal plasma and follicular fluids derived from infertile men and women.

BACKGROUND: Autoimmune reactions and subsequent inflammation may underlie spermatogenic dysfunction and endometriosis-related infertility. The aim of this study is to identify disease-specific antigens in immune complexes (ICs) in seminal plasma (SP) and in follicular fluid (FF). METHODS: Immune complexome analysis, in which nano-liquid chromatography-tandem mass spectrometry is employed to comprehensively identify antigens incorporated into ICs in biological fluids, was performed for specimens collected from infertile couples undergoing assisted reproduction. Forty-two male patients consisting of subjects with oligozoospermia (n = 6), asthenozoospermia (n = 8), and normal semen analysis (n = 28). Fifty-eight female patients consisting of subjects with ovarian endometriosis (n = 10) and control women without disease (n = 48). RESULTS: Four disease-specific antigens were identified in subjects with oligozoospermia, while five disease-specific antigens were detected in subjects with asthenozoospermia, some of which are involved in sprematogenesis. Eight antigens were detected only in subjects with endometriosis. CONCLUSION: Functional characteristics of disease-specific antigens were found to correspond to the pathogenesis of male and female infertility. The formation of ICs may contribute to spermatogenic dysfunction and endometriosis-related infertility via loss of function of the related proteins. Immune complexome analysis is expected to be a valuable tool for the investigation of novel diagnostic methods and treatment strategies for infertility.

Swollen joints and peripheral arthritis are signs of malignancy in polymyalgia rheumatica.

Aim: To analyze the clinical course and prognosis in patients diagnosed with polymyalgia rheumatica (PMR) complicated by the presence of malignancies.Methods: We retrospectively screened the case files of 216 patients hospitalized in our department between 2011 and December 2016 for the results of a thorough physical examination and data on treatment for rheumatic diseases. We identified 53 patients with PMR according to Bird's criteria and 43 patients with 2012 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) classification criteria for PMR, then analyzed the clinical and serologic manifestations of PMR in patients with (n = 6) and without (n = 47 in Bird' criteria, n = 37 in 2012 EULAR/ACR criteria) malignancy.Result: No significant differences in age, gender, smoking, and serum markers were observed between PMR patients with and without malignancy, but there were statistically significant differences in tender joint counts and the presence of swollen joints and peripheral arthritis in both Bird's criteria and 2012 EULAR/ACR criteria.Conclusion: The presence of swollen joints and peripheral arthritis may be useful signs that indicate the coexistence of malignancies in patients with PMR.

Effect of early mobilization on postoperative pulmonary complications in patients undergoing video-assisted thoracoscopic surgery on the esophagus.

BACKGROUND: Esophagectomy performed via thoracotomy is associated with a high rate of postoperative pulmonary complications. Video-assisted thoracoscopic surgery at the esophagus (VATS-E) can reduce the rate of postoperative pulmonary complications. VATS-E is being increasingly implemented owing to its benefits. This procedure makes early patient mobilization possible, because there is minimal thoracic wall invasion, and thus, less postoperative pain. This study aimed to identify the efficacy of early mobilization in patients undergoing VATS-E. METHODS: We retrospectively reviewed the patients who underwent VATS-E between November 2008 and October 2016. All the patients underwent preoperative physiotherapy and postoperative early mobilization for standard perioperative management. We examined the relation between early mobilization and the factors affecting postoperative pulmonary complications and the duration of physiotherapy with regard to the surgical outcome of VATS-E. RESULTS: A total of 118 patients who underwent VATS-E were assessed. The incidence of postoperative pulmonary atelectasis decreased with early mobilization, and earlier mobilization was associated with a better decrease (P < 0.001). Multiple logistic regression analysis identified the percentage of volume capacity [odds ratio (OR) 0.96; 95% confidence interval (CI) 0.93-0.99] and initial walking (OR 1.82; 95% CI 1.40-2.48) as independent risk factors for postoperative pulmonary atelectasis. In addition, the presence or absence of atelectasis was found to reduce the necessary period of physiotherapy (P < 0.001). CONCLUSION: Our results indicated that early mobilization reduces the incidence of postoperative pulmonary atelectasis, which may also contribute to early recovery in patients who undergo VATS-E.

The Feasibility and Efficacy of Laparoscopic Extended Total Mesorectal Excision for Locally Advanced Lower Rectal Cancer.

BACKGROUND/AIM: Extended total mesorectal excision (ETME) is defined as en bloc resection of the adjacent organs outside the mesorectal fascia, that is indicated in cases with locally advanced lower rectal cancer (T4 tumor). The aim of this study was to evaluate the clinical and oncological outcomes of laparoscopic ETME (L-ETME) for locally advanced lower rectal cancer. PATIENTS AND METHODS: The present study analyzed clinical outcomes and oncological outcomes of 11 consecutive patients who underwent L-ETME for cT4 lower rectal cancer in Nagasaki Medical Center between 2012 and 2015. RESULTS: Of the 11 patients, 7 underwent neoadjuvant therapy, and 7 underwent pelvic node dissection. One case (7.1%) underwent resection of anterior organs (prostate), 6 cases (54.5%) had resection of the lateral organs (neurovascular bundle, hypogastric nerve, pelvic plexus, ovary, and internal iliac blood vessels) and 4 cases (36.4%) had resection of both anterior and lateral organs. In all cases enrolled in this study, R0 resection was achieved. The median operation time and intraoperative blood loss were 416 min and 350 ml, respectively. The postoperative complication rate was 18.2% (2/11). The 3-year overall survival rate was 79.5%, and the 3-year local recurrence-free survival rate was 87.5%. There was no mortality and no re-operation in this series. CONCLUSION: The results of the present study suggest that L-ETME is feasible and has efficacy for locally advanced lower rectal cancer.

Predictors of portal and splenic vein thrombosis after laparoscopic splenectomy: a retrospective analysis of a single-center experience.

PURPOSE: Laparoscopic splenectomy (LS) has become the standard operative approach for splenectomy. Portal or splenic vein thrombosis (PSVT) is a serious and common complication after LS, and lethal complications of PSVT can occur when the portal vein is completely occluded by portal vein thrombosis (PVT). We aimed to clarify the predictors of PSVT after LS and to determine which of them were also predictors of PVT. METHODS: A total of 56 consecutive patients who underwent elective LS were enrolled in this study. The patients were divided into two groups based on the presence or absence of PSVT after LS. In addition, patients with PSVT were divided into two groups: a PVT group and a non-PVT group. The preoperative and intraoperative clinical data were compared among the groups. RESULTS: Thirty (53.6%) patients developed PSVT. The splenic vein diameter was the most useful predictor for the development of PSVT, and 10 mm was an accurate splenic vein diameter cut-off value for use as a predictive factor for PSVT. In addition, the splenic vein diameter was the most useful predictor of the development of PVT from splenic vein thrombosis (SVT), and 14 mm was found to be an accurate cut-off value. CONCLUSION: PSVT is a common postoperative complication that is identified on enhanced computed tomography. The splenic vein diameter is not only a predictor of PSVT but also of the development of PVT from SVT.

Two consecutive successful live birth in woman with 17α hydroxylase deficiency by frozen-thaw embryo transfer under hormone replacement endometrium preparation.

17α-Hydroxylase deficiency is rare autosomal recessive disorder that manifested by hypertension, hypokalemia, delayed sexual development, primary amenorrhea and infertility. The information regarding infertility care and conception in women with this disorder are extremely limited. We report a 24-year-old Japanese woman with primary amenorrhea who was diagnosed as partial 17α-hydroxylase deficiency caused by homozygous 3 bp deletion in exon 1 of 17α-hydroxylase gene. In vitro fertilization with controlled ovarian stimulation was carried out and all viable embryo were frozen. During ovarian stimulation, serum progesterone levels were markedly elevated, and endometrial growth was impaired. Utilizing frozen-thaw embryo transfer under hormonal replacement (glucocorticoid, estradiol and progesterone), she had successfully given two consecutive live birth. Women with 17α-hydroxylase deficiency with residual ovarian reserve can afford reproductive success by appropriate diagnosis and treatment by assisted reproductive technology.

Association between ovarian endometrioma and ovarian reserve.

Endometrioma is one of the main pathologies of endometriosis, though its pathogenesis still remains enigmatic. Ovarian reserve is defined as the number and quality of the follicles left in the ovary at any given time. The cause of infertility in women with endometriosis is multifactorial. Diminished ovarian reserve is major concern in women with endometriosis-associated infertility. Cystectomy for endometriomas could negatively impact on post-operative ovarian reserve. Some women had surgery for endometriomas suffer from poor ovarian response, which directly affects treatment results. In addition, endometriomas themselves may be a cause of diminished ovarian reserve. Destruction of normal histological structure in ovarian cortex may affect dormancy of primordial follicles. Therefore, determination of ovarian reserve may serve as an important role in the management of reproductive health of women with endometriosis. Although the knowledge on the physiology of follicular development and mechanism of maintenance of ovarian reserve are rapidly accumulating, results obtained by ovarian reserve testing after surgery should be carefully evaluated according to the time-points and selected test. Further investigation on this issue is warranted.

The long-term survival in primary retroperitoneal mucinous cystadenocarcinoma: a case report.

BACKGROUND: Primary retroperitoneal mucinous cystadenocarcinoma (PRMC) is extremely rare, and its biological behavior, pathogenesis, optimum treatments, and prognosis remain to be elucidated. We herein report a case of PRMC with an 80-month follow-up. CASE PRESENTATION: A 29-year-old woman was diagnosed with unknown retroperitoneal tumor with benign right ovarian cyst and uterine fibroids, and she underwent laparotomy. The tumor was completely resected with a subsequent histopathological diagnosis of primary retroperitoneal mucinous cystadenocarcinoma (PRMC). Eighty months after surgery, she remains recurrence-free. CONCLUSION: PRMC is an extremely rare tumor. Only around 60 cases have so far been published in the literature. The preoperative diagnosis of PRMC is difficult, and a definitive diagnosis can usually only be made based on the findings of histopathological examinations after surgery. Presently, only radical resection is useful for both diagnostic and therapeutic purposes. The optimal long-term management after surgery is still not well established. Further studies on PRMC are therefore needed to elucidate the etiology and establish effective treatments.

Clinical and Oncological Outcomes of Laparoscopic Lateral Pelvic Lymph Node Dissection in Advanced Lower Rectal Cancer: Single-institution Experience.

AIM: The aim of this study was to compare the clinical outcomes of laparoscopic versus open surgery for total mesorectal excision (TME) with lateral pelvic lymph node dissection (LPLD) in advanced lower rectal cancer. PATIENTS AND METHODS: Forty-four patients who underwent TME with LPLD for lower rectal cancer (pStage II/III) between January 2008 and December 2014 were divided into two groups according to the type of surgical approach as follows: open LPLD group (OLD, n=17) and laparoscopic LPLD group (LLD, n=27). RESULTS: Operative time was comparable between the groups (p=0.15), whereas intraoperative blood loss and complication rates were significantly less in LLD than in OLD. Postoperative hospital stay was shorter in LLD than in OLD. Overall survival and local recurrence-free survival were similar in the two groups. Disease-free survival was better in LLD than in OLD, although the difference was not significant. CONCLUSION: Laparoscopic TME with LPLD is safe and feasible.

A case of single incision laparoscopic total colectomy for intestinal neuronal dysplasia type B.

INTRODUCTION: Intestinal neuronal dysplasia type B (IND-B) is an infrequent disease of the submucosal plexus of intestine manifesting chronic intestinal obstruction or severe chronic constipation. IND is rarely reported in adult patients. PRESENTATION OF A CASE: The present study reports on the case of a 36 year-old woman suffering from longstanding chronic constipation and who was diagnosed with severe constipation in more than 20 years. Although she began to take a large amount of stimulant laxatives, such as "senna" and "bisacodyl", constipation symptoms did not improve, she was admitted to our hospital. It was diagnosed with refractory constipation of the medication treatment-resistance, total colectomy with ileorectal anastomosis by single incision laparoscopic surgery (SILS) was performed. The final pathological diagnosis was IND-B. DISCUSSION: Refractory constipation after medical treatment is often seen in young generation. SILS has benefits of better cosmesis, reduced morbidity, reduced postoperative pain, and reduced length of hospital stay. CONCLUSION: For the patients with refractory constipation associated with neuropathy such as IND, total colectomy by SILS was very effective.

Clinical and Oncological Outcomes of Laparoscopic Versus Open Surgery for Advanced Rectal Cancer.

AIM: To compare the clinical and oncological outcomes of laparoscopic and open approaches in patients with advanced rectal cancer. PATIENTS AND METHODS: In this study, 78 patients who underwent surgery for advanced middle and lower rectal cancer (pStage II - III) were divided into two groups according to type of surgical approach: laparoscopic surgery (LS group; n=40) and open surgery (OS group: n=38). The clinical outcomes and oncological outcomes were compared between the two groups. RESULTS: The operation time was comparable, whereas operative blood loss and complication rates were significantly less in the LS group compared to the OS group. Cancer-specific survival (CSS) and local recurrence-free survival (LRFS) were similar in the two groups. Disease-free survival (DFS) was better in the LS group than in the OS group. CONCLUSION: LS for advanced rectal cancer was safe and not inferior to OS in clinical and oncological outcomes.

Three-dimensional saline-infusion sonohysterography is useful for the identification of endometrial polyp.

AIM: To determine whether three-dimensional saline infusion sonohysterography (3D-SISH) is useful for the detection of endometrial polyps and whether it can accurately identify the site of attachment within the uterine cavity. METHODS: Sixteen women who underwent preoperative magnetic resonance imaging (MRI), 3D-SISH and subsequent hysteroscopic resection or total hysterectomy and who were surgically diagnosed with endometrial polyps were enrolled. The rate of polyp detection and the accuracy of attachment site within the uterine cavity for each test were examined. RESULTS: Endometrial polyps could only be identified in 37.5% of women using MRI, but could be identified in all women using 3D-SISH. The accuracy rate of the attachment site of endometrial polyps was 87.5% on 3D-SISH and 18.8% (in all patients) or 50.0% (in polyp-detected patients) on MRI, indicating a higher accuracy rate using 3D-SISH. CONCLUSION: We demonstrated that 3D-SISH is useful for the detection and localization of endometrial polyps and is likely to become the examination method of first choice for the identification of endometrial polyps.