Total RAMIE with three-field lymph node dissection by a simultaneous two-team approach using a new docking method for esophageal cancer.

BACKGROUND: Thoracic esophageal cancer surgery using robotic approaches for the thoracic and abdominal parts has recently been reported as total robot-assisted minimally invasive esophagectomy (RAMIE). We herein present the first report of a new technique for esophageal cancer: total RAMIE with three-field lymph node dissection (3FLND) by a simultaneous two-team approach using a new docking method. METHODS: We reviewed 20 patients who underwent total RAMIE with 3FLND by a simultaneous two-team approach at the National Cancer Center East Hospital from March 2023 to September 2023. Short-term surgical outcomes and the safety and efficacy of this technique were analyzed. RESULTS: The mean operative time for abdominal surgery with this new docking technique was 135 ± 19.6 min. The total operative time was 488 ± 42.9 min, and the time from the end of abdominal manipulation to the end of surgery was 80.1 ± 15.6 min. The intraoperative blood loss was 116.7 ± 64.4 mL. The incidence of anastomotic leakage, postoperative vocal cord paralysis, and postoperative pneumonia was 10%, 5%, and 10%, respectively. The median postoperative hospital stay was 14 days (range 11-63 days). No in-hospital deaths occurred, and R0 resection was possible in all cases. The average number of lymph nodes dissected was 87.7. CONCLUSION: These results demonstrate that total RAMIE with a simultaneous two-team approach using the new docking method can be safely introduced. The simultaneous cervical and abdominal manipulation with the new docking method allowed total RAMIE without prolonging the operating time, suggesting that it may be a valuable approach for esophageal cancer surgery.

Robot-assisted transcervical esophagectomy with a bilateral cervical approach for thoracic esophagectomy.

BACKGROUND: Thoracic esophageal cancer resection through the neck approach has recently been reported as mediastinoscopic surgery. We present the first report of a new minimally invasive technique for thoracic esophageal cancer: robot-assisted transcervical esophagectomy with a bilateral cervical approach. METHODS: Ten cases of robot-assisted bilateral transcervical esophagectomy performed at the National Cancer Center Hospital East, Japan, from February 2023 to August 2023 were reviewed. The short-term surgical outcomes were presented, and the feasibility and efficacy of this procedure were discussed. RESULTS: The mean operation time for the cervical procedure was 184.2 ± 23.6 min. The total time for the whole procedure was 472.7 ± 28.4 min, and total intraoperative blood loss was 162.2 ± 40.0 ml. Among the 10 cases, one patient developed recurrent nerve paralysis, one patient developed pulmonary complications, and no patients developed postoperative pneumonia. The median postoperative hospital stay was 22 (range: 12-43) days. No patients developed severe postoperative surgical complications, which were graded as Clavien-Dindo ≥ III. The total number of surgically harvested mediastinal lymph nodes was 37.2 ± 11.2. CONCLUSIONS: Robot-assisted bilateral transcervical esophagectomy, a novel procedure for thoracic esophageal cancer, was safe and feasible. Using this procedure, the incidence of recurrent nerve palsy, which is a problem with transcervical esophagectomy and mediastinoscopic esophagectomy, is expected to decrease.

Bilateral and asymmetrical localization of language function identified by the superselective infusion of propofol in an epilepsy patient with a mild malformation of cortical development: illustrative case.

BACKGROUND: Atypical localization of language function can result in unexpected postsurgical deficits after cortical resection, but it is difficult to predict the risk in the presurgical evaluation. The authors experienced a rare case of the bilateral and independent existence of different components of language function identified by segmented evaluation of anatomical anterior and posterior language areas using the superselective infusion of propofol. OBSERVATIONS: A 32-year-old right-handed female presented with drug-resistant epilepsy. Comprehensive epilepsy evaluation suggested that the epileptic foci involved the whole left frontal lobe but provided less evidence of structural abnormality. To estimate the extent of functional deterioration likely to be caused by an extended left frontal lobectomy, the authors evaluated segmented cortical function in the ipsi- and contralateral hemispheres by the superselective infusion of propofol into the branches of the intracranial artery. The results revealed bilateral and asymmetrical localization of language function because the patient presented with different components of aphasia in each hemisphere. Based on the authors' assessment of her functional tolerance, an extended left frontal lobectomy was performed and resulted in neurological deficits within the anticipated range. LESSONS: An accurate understanding of the correlations between vascular and functional anatomy and the highly specific evaluation of language function provides more advanced presurgical assessment, allowing more tailored planning of cortical resection.

Ventriculoperitoneal Shunt Failure 3-year after Shunt Surgery Caused by Migration of Detached Ventricular Catheter into the Cranium: A Case Study of Idiopathic Normal-pressure Hydrocephalus.

Idiopathic normal-pressure hydrocephalus (iNPH) is a neurological disorder that typically presents with gait disturbance, cognitive impairment, and urinary incontinence. Although most patients respond to cerebrospinal-fluid shunting, some do not react well because of shunt failure. A 77-year-old female with iNPH underwent ventriculoperitoneal shunt implantation, and her gait impairment, cognitive dysfunction, and urge urinary incontinence improved. However, 3 years after shunting (at the age of 80), her symptoms gradually recurred for 3 months and she did not respond to shunt valve adjustment. Imaging studies revealed that the ventricular catheter detached from the shunt valve and migrated into the cranium. With immediate revision of the ventriculoperitoneal shunt, her gait disturbance, cognitive dysfunction, and urinary incontinence improved. When a patient whose symptoms have been relieved by cerebrospinal-fluid shunting experiences an exacerbation, it is important to suspect shunt failure, even if many years have passed since the surgery. Identifying the position of the catheter is crucial to determine the cause of shunt failure. Prompt shunt surgery for iNPH can be beneficial, even in elderly patients.

A Case of Haemorrhagic-Onset Glioblastoma With Delayed Diagnosis.

Glioblastoma sometimes develops with acute onset due to intracerebral hemorrhage. Although it is sometimes difficult to diagnose patients with hemorrhagic-onset glioblastoma at the acute phase of intracerebral hemorrhage (ICH), the progressive enlargement of perifocal edema or the development of contrast-enhanced lesion triggers the diagnosis of glioblastoma within six months. Herein, we present a rare case of glioblastoma in which the diagnosis was delayed as long as 17 months after ICH. A 62-year-old man presented with a headache and aphasia. Computed tomography revealed ICH in the left temporal lobe. Magnetic resonance (MR) images revealed that the hematoma had a mix of isointense and surrounding hypointense lesions on T1-weighted MR images and gadolinium-enhanced lesions at the wall and the septum of the hematoma. An endoscopic evacuation of the hematoma was performed. No causative lesions were found during intraoperative and histological examinations. After seven months, abnormal signals were completely resolved on MR images, except for the small and stable enhanced lesion on three-dimensional gadolinium-enhanced T1-weighted MR imaging (3D Gd-T1WI) at the base of the hematoma, which did not change in size for seven months. However, a large gadolinium-enhanced lesion at the left temporal lobe developed 17 months after ICH. He underwent total resection of the lesion and was diagnosed with glioblastoma. He received radiation therapy and temozolomide but died of disseminated recurrence 31 months after ICH. In conclusion, this report presents a didactic case of glioblastoma in which the diagnosis of glioblastoma was delayed 17 months after ICH whereas hemorrhagic-onset glioblastoma was previously considered ruled out in cases in which six months or more have passed after ICH. In order not to overlook these cases, follow-up with 3D Gd-T1WI is essential in the case of suspected tumor-related ICH and close follow-up is recommended when the enhanced lesion does not resolve after a long period even if it does not grow.

[A Case of Colon Cancer with Synchronous Multiple Metastases Successfully Treated with Combined Chemotherapy].

A 68-year-old man having a descending colon cancer with multiple metastases of up to 9.5 cm in the right lobe of the liver(T3, N0, M1a)underwent laparoscopic colon resection for anemia control. Chemotherapy with mFOLFOX6 plus Bmab was administered postoperatively. Because this treatment had little effect, FOLFIRI plus Pmab was initiated 3 months later. A significant reduction in the tumor size was observed. Therefore, we performed laparotomy. However, the liver metastasis had invaded the inferior vena cava, which was not resectable. After the second surgery, we introduced the 5-FU hepatic arterial injection port ia plus Pmab iv, which was effective for 8 months. We then restarted chemotherapy with FOLFIRI plus Pmab. However, the tumor became more enlarged; therefore, we changed the chemotherapy regimen to SOX plus Bmab. Partial reduction in the tumor size was observed again, and the effects lasted for a while. The patient continued visiting the outpatient clinic with almost no symptoms for more than 1 year. He died of the primary cancer 3 years and 8 months after the first visit. We report a case of liver metastasis of colon cancer that could have been controlled successfully by repeatedly using the same pharmacotherapy.

Digital intravascular pressure wave recording during endovascular treatment reveals abnormal shunting flow in vertebral venous fistula of the vertebral artery: illustrative case.

BACKGROUND: An arteriovenous fistula is an abnormal arteriovenous shunt between an artery and a vein, which often leads to venous congestion in the central nervous system. The blood flow near the fistula is different from normal artery flow. A novel method to detect the abnormal shunting flow or pressure near the fistula is needed. OBSERVATIONS: A 76-year-old woman presented to the authors' institute with progressive right upper limb weakness. Right vertebral angiography showed a fistula between the right extracranial vertebral artery (VA) and the right vertebral venous plexus at the C7 level. The patient underwent endovascular treatment for shunt flow reduction. Before the procedure, blood pressures were measured at the proximal VA, distal VA near the fistula, and just at the fistula and drainer using a microcatheter. The blood pressure waveforms were characteristically different in terms of resistance index, half-decay time, and appearance of dicrotic notch. The fistula was embolized with coils and N-butyl cyanoacrylate solution. LESSONS: During endovascular treatment, the authors were able to digitally record the vascular pressure waveform from the tip of the microcatheter and succeeded in calculating several parameters that characterize the shunting flow. Furthermore, these parameters could help recognize the abnormal blood flow, allowing a safer endovascular surgery.

[A Case of Hyaline Vascular-Type Castleman's Disease].

The patient was a 29-year-old female with a chief complaint of transient right-sided abdominal pain. A CT scan revealed homogenously contrasted tumor of 4 cm in diameter with smooth margins and clear borders in the lower part of the pancreatic head. The tumor was contrast-enhanced on MRI and stained on abdominal angiography using the proximal branch of the right colonic artery as a feeding vessel. PET scan showed moderate accumulation. Malignancy could not be ruled out, and tumor resection including the ascending colon was performed. The pathological diagnosis was hyaline vascular-type Castleman's disease in the mesentery of the colon.

[A Case of Ramucirumab-Related Small Intestinal Perforation in Gastric Cancer].

A 54-year-old man underwent laparoscopic distal gastrectomy with D2 lymph node dissection and ante-colic Roux-en-Y reconstruction for gastric cancer. The histopathological diagnosis was pT2N3aM0, pStage ⅢA, HER2 negative. After 8 courses of S-1 plus oxaliplatin as adjuvant chemotherapy, he was diagnosed as peritoneal dissemination and treated with ramucirumab(RAM)plus paclitaxel(PTX). On the 12th day of course 10, he visited to our hospital with abdominal pain. CT showed free air and massive ascites. Emergent surgery was performed under the diagnosis of gastrointestinal perforation. A small intestinal perforation in front of the jejunal limb near gastric-jejunal anastomosis was identified and there was no peritoneal dissemination. We performed partial resection of remnant stomach and jejunal limb by linear stapler and reconstruction by end to side gastric-jejunal anastomosis. Because the gastric and intestinal wall were quite fragile and RAM impaired wound healing as adverse event, we feared about leakage, but he had no major postoperative complications and discharged on the 33th day after surgery. After 24 courses of nivolumab as third-line chemotherapy, the peritoneal dissemination disappeared. He has been alive without recurrence for about 1 year since then.