[A Case of Surgical Resection of a Combined Hepatocellular and Cholangiocarcinoma with Hemobilia from Intraductal Tumor Thrombus].

We report a case of combined hepatocellular and cholangiocarcinoma with hemobilia. A 65-year-old man was admitted to our hospital because of pain in the right hypochondralrigion. Abdominal ultrasonography revealed bile duct dilatation in the lateral segment of liver and blood test findings showed elevation of the hepatobiliary enzyme, so ERC was performed and hemorrhage from the duodenal papilla was observed. In cholangiography, dilation of the left hepatic bile duct and filling defect were observed, and in the peroral cholangioscopy, a hemorrhagic papillary elevated lesion was identified in the left hepatic bile duct and diagnosed as adenocarcinoma as a result of biopsy. Left hepatectomy with caudate lobe, extrahepatic bile duct resection, lymph node dissection was performed by diagnosis of intrahepatic cholangiocarcinoma. In the resected specimen, tumor size was 16 mm, which was found in the left hepatic duct and invasived into the liver parenchyma. Histopathological examination revealed a combined hepatocellular and cholangiocarcinoma. Gemcitabin was administered as adjuvant chemotherapy for 8 months, but 1 year and 8 months after the operation, it recurred in the liver. Gemcitabin was administered, but it became PD, now it has changed to S-1 and it is SD for 2 years.

[Four Cases of Gastrointestinal Perforation Associated with Bevacizumab].

Four cases of gastrointestinal perforation associated with bevacizumab(BEV)were examined. Case 1: A 82-year-old male received FOLFIRI plus BEV for recurrent liver metastasis after rectal cancer resection. A lower esophageal perforation occurred 22 days after BEV administration and drainage was performed. Case 2: A 69-year-old female received FOLFOX4 plus BEV for unresectable rectal cancer and liver and lung metastasis. A rectal perforation occurred 6 days after BEV administration and suturing closure of the hole and colostomy was performed. Case 3: A 69-year-old female, received carboplatin(CBDCA) plus pemetrexed(PEM)plus BEV for unresectable left lung cancer and adrenal gland and lymph node metastasis. A small intestinal perforation occurred 15 days after BEV administration and ileocecal resection and primary anastomosis was performed. Case 4: A 73-year-old female received CBDCA plus PEM plus BEV for unresectable left lung carcinoma and pleural metastasis. A diverticulum of sigmoid colon perforation occurred 30 days after BEV administration and suturing closure of the hole and colostomy was performed. When we observe fever, abdominal pain, elevation of the inflammatory reaction after BEV administration, we should immediately examine gastrointestinal perforation.

The incidence of cardiovascular thrombotic complications after laparoscopic resection in colorectal cancer in Japanese hospitals: A large-scale clinical study.

Aim: The aim of this retrospective study was to investigate the incidence of cardiovascular thrombotic complications after laparoscopic resection in colorectal cancer. Methods: This study involved 2017 patients with stages 0-III colorectal cancer who underwent laparoscopic surgery at 17 Japanese hospitals between January 2010 and December 2013. We assessed the incidence of postoperative cardiovascular thrombotic and haemorrhagic complications. Results: Laparoscopic surgeries were performed in 1152 men and 865 women with 1405 colon and 612 rectal cancers, respectively. Overall, 3%, 38%, 17%, 8%, and 9% of patients had comorbidities of heart failure, high blood pressure, diabetes, history of stroke, and vascular disease, respectively. Antithrombotic agents were being consumed by 17% of patients. The types (and perioperative rest periods) of the antithrombotic agents were aspirin in 58% (18.6 days), clopidogrel in 19% (21.1 days), cilostazol in 13% (13.3 days), and warfarin potassium in 21% (14.6 days) of cases with antithrombotic agents. Surgical time and blood loss in the total cohort were 234 minutes and 56 mL. Four cases (0.2%) had cardiovascular thrombotic complications, including one severe cardiac infarction and one stroke with major sequelae (CHADS2 scores were 2 points in both cases). Hemorrhagic complications occurred in 19 cases (0.9%). In particular, the incidence of the major gastroduodenal haemorrhagic ulcer was higher in cases with antithrombotic agents than without them (0.05% vs 0%, P = .02). Conclusion: The incidence of cardiovascular thrombotic complications was rare, although severe cardiac infarction and stroke could occur even after minimally invasive surgery in colorectal cancer.

Local skin flap reconstruction for abdominal wound dehiscence after abdominal surgery with a stoma: report of two cases.

Abdominal wound dehiscence is a serious complication of laparotomy, and fascial dehiscence in a patient with a stoma is especially difficult to manage. We describe how we performed local skin flap reconstruction for abdominal wound dehiscence in two patients with stomas. One patient underwent sigmoidectomy with a colostomy for peritonitis caused by perforated diverticulitis of the sigmoid colon. Postoperative fascial dehiscence was repaired by rhomboid flap reconstruction. The other patient underwent total gastrectomy, cholecystectomy, and splenectomy. An ileostomy was performed for digestive tract perforation, which was complicated by abdominal dehiscence with necrosis of the fascia. This was repaired by rotation flap reconstruction. The abdominal walls in both patients were repaired successfully without tension.

Correlation between port-to-target distance and procedural difficulty in single-incision laparoscopic cholecystectomy: An observational study.

INTRODUCTION: Single-incision laparoscopic cholecystectomy (SILC) is more challenging than conventional (multiport) laparoscopic cholecystectomy (CLC) because of the increased likelihood of instrument collision and the limited surgical workspace. In SILC, procedural difficulties may increase when the port-to-target distance is long. We aimed to assess the correlation between port-to-target distance and procedural difficulty. METHODS: Thirty-six consecutive patients who underwent SILC at our hospital were included in this study. The umbilicus-to-Calot's triangle distance (UCD) was measured intraoperatively. The correlations between the UCD and operative time were analyzed, and for comparison, CLC cases during the same period (n = 28) were similarly analyzed. Moreover, UCD was estimated from preoperative CT (UCD-CT), and the usefulness of UCD-CT was assessed during SILC and CLC. RESULTS: Thirty-four patients successfully underwent SILC. There were positive correlations between the UCD and pneumoperitoneum time. Multivariate linear regression analysis, including BMI and height, which were previously reported to have a correlation with longer operative time in SILC, showed that UCD is an independent predictive factor for prolonged operative duration. However, BMI and height were not independent predictive factors. UCD and UCD-CT had a very strong positive correlation; therefore, UCD was estimated from CT. UCD-CT had a strong positive correlation with operative time in SILC, but not in CLC. CONCLUSIONS: A longer UCD is an important predictive factor for difficult cases of SILC, but this finding is not applicable in CLC. The usefulness of UCD is specific to SILC.

Surgically Diagnosed Primary Hepatic Angiosarcoma.

Primary hepatic angiosarcoma is a rare tumor originating from endothelial cells in the liver and accounts for approximately 1% of all hepatic malignant tumors. It is difficult to diagnose due to the lack of specific symptoms or tumor markers. No effective treatment exists, but complete surgical resection may achieve a good outcome. Since most primary hepatic angiosarcomas are already at an advanced stage at diagnosis, few reports describe tumors smaller than 2 cm. We report a case of surgery for a 1.7-cm sized primary hepatic angiosarcoma. Further studies are required to improve the preoperative diagnosis of primary hepatic angiosarcoma.

Clinicopathological characteristics of superficial spreading type early gastric cancer.

BACKGROUND AND OBJECTIVES: Superficial spreading type early gastric cancer is characterized by its atypical growth pattern and occasionally indistinct tumor margin. Because it is a rare form of early gastric cancer, the clinicopathological details are not apparent. The aim of this study was to clarify the clinicopathological features of the superficial spreading type of early gastric cancer. METHODS: A retrospective study was conducted in 1,062 surgically resected patients with early gastric cancer. Hospital records were compared between patients with superficial spreading type early gastric cancer and those with more common types of early gastric cancer. RESULTS: Sixty-nine patients (6.9%) had superficial spreading lesions. The male to female ratio was 1.2:1. The most frequent histological type was signet-ring cell carcinoma (32%). The distinguishing histopathological features were submucosal invasion (67%), lymphatic invasion (32%), and lymph node metastasis (30%). There were discrepancies in tumor area between surgical findings and pathological diagnosis in 24 patients (35%) with superficial spreading type. More extensive lymph node dissection was performed and all patients survived in the group with superficial spreading lesions. CONCLUSIONS: The most appropriate treatment for the superficial spreading type of early gastric cancer is wide surgical resection with extensive lymph node dissection.

Distant peritoneal metastasis to a mesh-plug prosthesis in a gastrointestinal cancer patient: report of a case.

A case of distant metastasis to mesh-plug prosthesis in gastrointestinal cancer is presented herein. An 88-year-old man had received mesh-plug repair with high ligation for a recurrence of a right inguinal hernia. Six months later, advanced gastric cancer and advanced transverse colon cancer were detected, and therefore a distal gastrectomy and partial colectomy were performed. Two weeks after the operation, the patient complained of right groin tenderness, and the mesh-plug prosthesis was removed to control any infection. A histopathological investigation demonstrated adenocarcinoma in the plug prosthesis. The patient died of carcinomatosis peritonei 45 days after the last operation.