Prognostic significance of intrahepatic lymphatic invasion in colorectal liver metastases.

BACKGROUND: Intrahepatic lymphatic invasion is an adverse prognostic factor after hepatectomy for colorectal liver metastases (CLMs). However, most patients in previous reports had liver resection before the era of FOLFOX/FIRI-based chemotherapy. METHODS: Forty-six patients who underwent hepatectomy for CLMs from 2004 to 2020 were evaluated. We histologically evaluated portal invasion, intrahepatic lymphatic invasion, and biliary invasion on hematoxylin-eosin slides. We also collected the following clinicopathologic factors: gender, age, timing, the number and maximum size of CLMs, preoperative tumor markers, neutrophil/lymphocyte ratio, location, and lymph node metastases of primary cancer, and chemotherapy after hepatectomy. A multivariate Cox proportional hazard model was used to define the relationship between overall (OS) or disease-free survival (DFS) and clinicopathologic factors. RESULTS: Histological invasions were portal invasion in 8 (17.4 %), intrahepatic lymphatic invasion in 6 (13.0 %), and biliary invasion in 5 (10.9 %). Chemotherapy for recurrence after hepatectomy (n = 29) was performed in 22 and 14 of those who received FOLFOX/FIRI-based chemotherapy. By multivariate analysis, the number of CLMs (p < 0. 01) and presence of intrahepatic lymphatic invasion (p = 0.02) were independent predictors of recurrence. The number of CLMs (p = 0.02) and prehepatectomy carcinoembryonic antigen level (p = 0.02), but not intrahepatic lymphatic invasion (p = 0.18), were independent predictors of survival using multivariate analysis. CONCLUSIONS: The presence of intrahepatic lymphatic invasion adversely affected patient's DFS, but not OS in patients with CLMs in the era of FOLFOX/FIRI chemotherapy. FOLFOX/FIRI-based chemotherapy might improve OS, even in patients with positive intrahepatic lymphatic invasion.

Ectopic pancreatic adenocarcinoma in Meckel's diverticulum: a case report.

BACKGROUND: Malignant neoplasms arising from Meckel's diverticulum are rare and an adenocarcinoma in Meckel's diverticulum originating from ectopic pancreatic tissue is even rarer. Herein, we report a patient with an ectopic pancreatic adenocarcinoma in Meckel's diverticulum who was successfully treated with surgery and chemotherapy. CASE PRESENTATION: A woman in her sixties presented to another hospital with abdominal pain. Plain computed tomography suggested an abdominal tumor and she was referred to our hospital. Enhanced computed tomography revealed a 23-mm low-density tumor in the abdominal cavity. Surgery was performed with a tentative diagnosis of a mesenteric tumor, such as a gastrointestinal stromal tumor, schwannoma, or lymphoma. First, we inspected the peritoneal cavity with a laparoscope. This revealed numerous nodules in the small bowel mesentery, suggesting peritoneal dissemination. A 20-mm-diameter white tumor was found in the small intestine and diagnosed as a small intestinal cancer. The small intestine was partially resected laparoscopically through a small skin incision. The patient's postoperative course was uneventful, and she was discharged on postoperative day 9. Pathological examination revealed well-differentiated adenocarcinoma in the small intestine. The tumor had developed from a sac-like portion protruding toward the serosal side and had a glandular structure lined with flattened atypical cells. Neither pancreatic acinar cells nor islets of Langerhans were evident, suggesting a Heinrich type 3 ectopic pancreas. The final diagnosis was an adenocarcinoma originating from an ectopic pancreas in Meckel's diverticulum. After a smooth recovery, the patient commenced chemotherapy for pancreatic cancer. CONCLUSIONS: We present a very rare case of ectopic pancreatic carcinoma in Meckel's diverticulum.

DUPAN-2 as a Risk Factor of Early Recurrence After Curative Pancreatectomy for Patients With Pancreatic Ductal Adenocarcinoma.

OBJECTIVES: Several patients with pancreatic ductal adenocarcinoma (PDAC) experience postoperative early recurrence (ER). We evaluated PDAC patients to identify the risk factors for postoperative ER (≤6 months), including preoperative serum DUPAN-2 level. METHODS: We retrospectively evaluated 74 PDAC patients who underwent pancreatectomy with curative intent. Clinicopathological factors including age, sex, body mass index, postoperative complications, pathological factors, preoperative C-reactive protein/albumin ratio, neutrophil/lymphocyte ratio, modified Glasgow prognostic score, preoperative tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9, SPAN-1, and DUPAN-2), and history of adjuvant chemotherapy were investigated. Early recurrence risk factors were determined using multivariate logistic regression analysis. RESULTS: Recurrence and ER occurred in 52 (70.3%) and 23 (31.1%) patients, respectively. Univariate analysis revealed that postoperative complications, C-reactive protein/albumin ratio ≥0.02, neutrophil/lymphocyte ratio ≥3.01, carbohydrate antigen 19-9 ≥ 92.3 U/mL, SPAN-1 ≥ 69 U/mL, DUPAN-2 ≥ 200 U/mL, and absence of adjuvant chemotherapy were significant risk factors for ER. In multivariate analysis, DUPAN-2 ≥ 200 U/mL (P = 0.04) and absence of adjuvant chemotherapy (P = 0.02) were identified as independent risk factors for ER. CONCLUSIONS: A higher level of preoperative DUPAN-2 was an independent risk factor for ER. For patients with high DUPAN-2 level, neoadjuvant therapies might be required to avoid ER.

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute.

BACKGROUND AND OBJECTIVES: In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis. METHODS: Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks. RESULTS: No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01). CONCLUSIONS: Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.

Elevated Preoperative DUPAN-2 Level Predicts Locoregional Recurrence After Pancreatectomy in Patients With Pancreatic Ductal Adenocarcinoma.

BACKGROUND/AIM: The diagnostic value of serum DUPAN-2 level has been reported; however, the relationship between preoperative DUPAN-2 level and recurrence pattern has not been fully investigated in pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS: We retrospectively analyzed 50 patients with PDAC who underwent pancreatectomy. The relationships between clinicopathologic factors and site-specific disease-free survival (DFS) were analyzed using Cox proportional hazard and receiver operating characteristic (ROC) curve analyses. RESULTS: The tumor location was the pancreatic head in 31 patients and the body/tail in 19 patients. Of the 50 patients, 34 had recurrence (median DFS, 11 months). Fifteen patients had hematogenous recurrence, and 16 had locoregional recurrence. In multivariate analysis, adjuvant chemotherapy [p=0.01; odds ratio (OR)=8.10; 95% confidence interval (CI)=1.58-41.6] and venous invasion (p=0.01; OR=8.33; 95%CI=1.53-45.4) were significant factors for hematogenous recurrence-free survival, whereas the neutrophil-to-lymphocyte ratio (p=0.03; OR=2.57; 95%CI=1.10-5.98) and DUPAN-2 level (p<0.01; OR=1.00; 95%CI=1.000-1.002) were significant factors for locoregional recurrence-free survival. In ROC curve analysis, the area under the curve of DUPAN-2 level was 0.613 for hematogenous recurrence and 0.682 for locoregional recurrence. In the log-rank test, the hematogenous and locoregional recurrence-free survival rates of patients with higher DUPAN-2 levels were significantly worse than those with lower DUPAN-2 level. CONCLUSION: Elevation of preoperative DUPAN-2 level independently predicts locoregional recurrence after surgery. Patients with elevated preoperative DUPAN-2 level may benefit from neoadjuvant chemoradiation therapy to avoid postoperative locoregional recurrence.

Maximum Diameter of the Gallbladder Determined Presurgically Using Computed Tomography as a Risk Factor for Difficult Emergency Laparoscopic Cholecystectomy in Patients With Mild to Moderate Acute Cholecystitis.

BACKGROUND: Early or emergency laparoscopic cholecystectomy (LC) was recommended in the 2018 Tokyo Guidelines for patients with mild to moderate acute cholecystitis (AC). Although surgical difficulty is frequently encountered during these surgeries, risk factors for predicting surgical difficulties have not been fully investigated, especially based on computed tomography (CT) findings. MATERIALS AND METHODS: We investigated 72 patients who underwent emergency LC with mild (n=45) to moderate (n=27) AC. Patients who previously underwent presurgical percutaneous or endoscopic biliary drainage were excluded from this study. Difficult LC was defined using any of the following surgical factors: surgical duration ≥180 minutes, blood loss ≥300 g, or a conversion to open cholecystectomy. Subsequently, several presurgical clinical factors were analyzed, including sex, age at surgery, experience of the surgeon, interval between symptom onset and surgery, body mass index, diabetes history, presurgical white blood cell count, and C-reactive protein level. Moreover, stones in the cystic duct or perigallblader fluid and the maximum thickness and diameter of the gallbladders were evaluated via presurgical CT. Finally, logistic regression analysis was performed to compare the relationship between surgical difficulty and each clinical factor. RESULTS: The average age at surgery of the included patients was 60.3 (range: 25 to 88 y), surgical duration was 112.2 (range: 29 to 296 min), and surgical blood loss was 55.2 (range: 0 to 530 g). Furthermore, 4 (5.6%) had to undergo open cholecystectomy, whereas postsurgical complications occurred in 5 (6.9%) patients. In addition, the mean postsurgical admission duration was 7 (range: 3 to 63 d). Thus, 12 patients experienced difficult LC, whereas 60 experienced nondifficult LC. Of the evaluated clinical factors, patients who experienced difficult LC showed higher presurgical C-reactive protein levels (10.78 vs. 6.76 mg/dL, P =0.01) and wider gallbladder diameters (48.4 vs. 41.8 mm, P <0.01) than those who experienced nondifficult LC. By univariate logistic regression analysis, results also showed that patients with a maximum gallbladder diameter had a higher risk of experiencing difficulty during emergency LC ( P =0.02). Moreover, the gallbladder diameter's cutoff value was 43 mm after the receiver operating characteristic curve analysis. CONCLUSIONS: In patients with mild to moderate AC, emergency LC can safely be performed. However, performing LC might be technically difficult in patients with AC after the identification of severe gallbladder swelling during presurgical CT.

A totally extraperitoneal approach for endoscopic resection of a congenital prepubic sinus through the pubic symphysis.

BACKGROUND: A congenital prepubic sinus (CPS) is a rare congenital anomaly in which a duct remnant extends from the skin opening near the pubic symphysis to various parts and the lesions are mostly located in the preperitoneal space. The totally extraperitoneal (TEP) approach is an operational method that provides a good field of view for the preperitoneal space. We report the CPS through the pubic symphysis in which complete resection was achieved by a TEP approach. TEP approach was minimally invasive and achieved satisfactory cosmetic outcome. CASE PRESENTATION: We herein report the case of a 13-year-old boy with a fistula opening near the dorsal penis. He was admitted to our hospital due to fever and lower abdominal pain. Abdominal ultrasonography and computed tomography revealed an abscess inside a fistula lumen on the posterior surface of the rectus abdominis muscles in the midline of the lower abdomen. Under a diagnosis of CPS, which was located in the preperitoneal space, endoscopic resection was performed by a totally extraperitoneal approach. After making an umbilical incision, the rectus abdominis muscle was excised outward to expose the preperitoneal space. A single-port system was placed in the preperitoneal space. Three 5-mm-port trocars were inserted. As the preperitoneal cavity was expanded, a sinus connecting to the pubic symphysis was confirmed. The pubic symphysis did not connect with the bladder. Because the fistula was penetrated with the pubic symphysis, the remaining caudal fistula was removed from the body surface with a small spindle-shaped incision around the fistula opening. Finally, the sinus was completely resected, with confirmation from both the cranial side and dorsal side of the pubic symphysis. We were able to perform complete resection of the CPS with good visibility and without any peritoneal damage. There were no intraoperative complications. His postoperative course was uneventful during the 1-year follow-up. CONCLUSIONS: The TEP approach may be feasible for the resection of a CPS and may allow safe and secure resection due to good visibility, even in pediatric patients.

Surgical outcomes of totally extraperitoneal repair for inguinal hernia: A retrospective multicenter propensity score-matched study.

BACKGROUND: Laparoscopic surgical approaches, including total extraperitoneal repair (TEP), have been widely accepted for inguinal hernia repair in Japan. However, there are limited data regarding recurrence after TEP in Japan, given the limited versatility of this procedure. This study retrospectively evaluated the rates of hernia recurrence after TEP and open mesh repair at multiple Japanese centers. METHODS: This retrospective study evaluated 1917 patients who underwent inguinal hernia repair at 32 institutions in the Oita prefecture between January 2014 and December 2015. Eligible patients were grouped according to whether they underwent TEP (1011 patients) or open mesh repair (636 patients). Propensity score matching was performed 1:1 (total: 1076 patients, 538 patients from each group). The outcomes of interest were recurrence, morbidity, and postoperative recovery. RESULTS: The TEP and open mesh repair groups had similar baseline characteristics. After propensity score matching, there was no significant difference between the two groups in terms of recurrence rate (TEP: 0.5% vs open mesh repair: 1.0%, P = .375). However, the TEP group had significantly longer operating times (median: 70.2 min vs 65.0 min, P < .001), significantly less blood loss (0-5.1 mL vs 0-20.4 mL, P < .001), and significantly shorter postoperative hospital stays (median: 5.0 days vs 6.4 days, P < .001). The overall incidences of morbidity were 6.2% in the TEP group and 7.2% in the open mesh repair group (P = .535). CONCLUSION: This multicenter retrospective study with propensity score matching revealed that the recurrence rates were similarly low for TEP and open mesh repair of inguinal hernia. Thus, a well-trained surgical team could use TEP as a standard procedure.

Current status of endoscopic surgery in Japan: The 14th National Survey of Endoscopic Surgery by the Japan Society for Endoscopic Surgery.

In Japan, the first endoscopic surgery, a laparoscopic cholecystectomy, was performed in 1990. Since then, operative procedures have been standardized, and the safety and efficacy of endoscopic surgery have been evaluated. In accordance with the social acceptance of endoscopic surgery as a less invasive type of surgery, the number of endoscopic procedures performed has increased in all surgical domains. The Japan Society for Endoscopic Surgery (JSES) has played an important role in the development of endoscopic surgery in Japan. Notably, a technical skills certification system for surgeons was established by the JSES to train instructors on how to teach safe endoscopic surgery. Furthermore, the JSES has conducted a national survey every two years to evaluate the status of endoscopic surgery over time. In 2017, 248 743 patients underwent endoscopic surgery in all surgical domains, such as abdominal, thoracic, mammary and thyroid gland, cardiovascular, obstetrics and gynecology, urologic, orthopedic, and plastic surgery. The 14th National Survey of Endoscopic Surgery conducted by the JSES demonstrated the status of laparoscopic surgery in Japan in 2016-2017.

Endoscopic surgery in Japan: The 13th national survey (2014-2015) by the Japan Society for Endoscopic Surgery.

In Japan, the first endoscopic surgery, a laparoscopic cholecystectomy, was performed in 1990. Since then, the operative procedure has been standardized, and the safety and usefulness of endoscopic surgery have been evaluated. In accordance with the social acceptance of endoscopic surgery as a less-invasive surgery, the number of endoscopic procedures has been increasing in all surgical domains. The Japan Society for Endoscopic Surgery (JSES) has played an important role in the development of endoscopic surgery in Japan. For example, JSES established a technical skills certification system for surgeons to train instructors how to teach safe endoscopic surgery, and the organization performs a national survey every 2 years. In 2015, a total of 211 953 patients underwent endoscopic surgery in all surgical domains, including abdominal, thoracic, mammary and thyroid gland, cardiovascular, obstetrics and gynecology, urologic, orthopedic, and plastic surgery. The course of laparoscopic surgery's development and its current status are reported here based on the results of the most recent questionnaire survey conducted by JSES.

Computed tomography of the gastrointestinal manifestation of hereditary angioedema.

We report a case of gastrointestinal manifestation of hereditary angioedema. Computed tomography (CT) revealed wall thickening of the gastric antrum, duodenum, and jejunum. Dilatation of the third part of the duodenum, thickening of the small bowel mesentery and omentum, and retroperitoneal edema were present. The importance of considering this condition in patients presenting such CT findings correlated with the appropriate history is discussed.

Endoscopic surgery in Japan: The 12th national survey(2012-2013) by the Japan Society for Endoscopic Surgery.

In Japan, the first endoscopic surgery, a laparoscopic cholecystectomy, was performed in 1990. Since then, operative procedures have been standardized, and the safety and usefulness of endoscopic surgery have been evaluated. With the acceptance of endoscopic surgery as less invasive than open surgery, the number of the endoscopic procedures continues to increase in all surgical domains. The Japan Society for Endoscopic Surgery (JSES) has had an important role in the development of endoscopic surgery in Japan. For example, JSES established a technical skills certification system for physicians to train instructors to teach safe endoscopic surgery. Additionally, JSES has performed a national survey every 2 years. In 2013, 178 084 patients underwent endoscopic surgery in all surgical domains, including abdominal, thoracic, mammary and thyroid gland, cardiovascular, obstetrics and gynecology, urologic, orthopedic, and plastic surgery. The development and current status of laparoscopic surgery are reported here based on the results of the most recent questionnaire survey conducted by JSES.

Gastric cancer with extragastric lymph node metastasis: multivariate prognostic study.

BACKGROUND: Although many authors have investigated the prognostic factors of gastric cancer, there are few comprehensive studies on the prognosis of patients with extensive lymph node metastasis. The aim of this study was to clarify the prognostic factors of gastric cancer with extragastric lymph node metastasis, using multivariate analysis.METHODS: The study population consisted of 121 patients who had undergone radical gastrectomy and extended lymph node dissection (D2, D3) for gastric cancer with extragastric lymph node metastasis. We examined 18 clinicopathologic factors, including the type of gastrectomy, tumor size, depth of wall invasion, status of lymph node metastasis, and stage of disease. Survival rates were analyzed by the Kaplan-Meier and Mantel-Cox methods, and multivariate analysis was done using the Cox proportional hazards model.RESULTS: The overall 5-year survival rate was 32%, and the 5-year survival rate after curative gastrectomy was 37%. Overall survival rate was associated with the type of gastrectomy, stage of disease, operative curability, tumor size, depth of wall invasion, and anatomical distribution of positive nodes, whereas the survival rate after curative gastrectomy was correlated with the type of gastrectomy, stage of disease, tumor size, gross type, and depth of wall invasion. Independent prognostic factors were operative curability and depth of wall invasion, and survival after curative gastrectomy was influenced only by the depth of wall invasion (mucosa and submucosa [T1], muscularis and subserosa [T2] vs serosa [T3]).CONCLUSION: In patients with gastric cancer with extragastric lymph node metastasis, independent prognostic factors after gastrectomy were operative curability and depth of wall invasion. Long-term survival can be achieved when the patients have no serosal invasion (T1, T2) and are treated by curative gastrectomy.

Laparoscopy in the management of scirrhous gastric cancer.

BACKGROUND: Scirrhous gastric cancer frequently shows extensive tumor spread, and gastrectomy for cure of the disease is not possible in the presence of peritoneal dissemination, which is often overlooked by conventional computed tomography. The aim of this study was to evaluate our experience of 16 patients who underwent laparoscopy in the management of scirrhous gastric cancer, and to examine whether peritoneal dissemination could be diagnosed accurately by laparoscopy.METHODS: All patients had nonobstructed, nonbleeding scirrhous gastric cancer and had no evidence of metastatic disease by ultrasonography and computed tomography. Laparoscopy was performed under general anesthesia with CO(2) pneumoperitoneum. A Hasson trocar and two manipulating forceps were inserted, and the surfaces of the peritoneum, omentum, stomach, spleen, pancreas, liver, and diaphragm were examined.RESULTS: The mean time for laparoscopy was 20 min. Peritoneal dissemination was disclosed in 4 patients (25%), and systemic and intraperitoneal chemotherapy was done without laparotomy. In 12 patients, subsequent gastrectomy with a curative intent was successfully performed. Pathology revealed that the tumor diffusely invaded the whole thickness of the gastric wall; the mean size of resected tumors was 12 cm, and the mean number of positive nodes was 17. Nine patients died of the disease with a mean survival period of 10 months, and 7 patients were alive without recurrence during a mean follow-up period of 11 months.CONCLUSIONS: Laparoscopy is useful for the evaluation of peritoneal spreads of advanced gastric cancer, can avoid unnecessary laparotomy because of peritoneal dissemination, and is important for the choice of treatments in patients with scirrhous gastric cancer.

Pancreatic resection with ultrasonically activated scalpel: preliminary observations.

BACKGROUND/AIMS: Resection of the pancreas was performed with a surgical knife, electrocautery, or an automatic stapler. We histologically and radiologically evaluated the applicability of the ultrasonically activated scalpel (Coagulating Shears, CS, Ethicon Endo-Surgery, Cincinnati, OH, USA) for resecting pancreatic parenchyma and reported our clinical observations on the use of the coagulating shears. METHODOLOGY: Resection of the pancreas was performed with the coagulating shears in 8 patients and with electrocautery in 5. The pancreas was transected with blunt mode of the coagulating shears at output power level of 3. Histologic thermal degeneration of the surface was evaluated with hematoxylin-eosin and Azan-Mallory staining. Radiologic pancreaticography was carried out on 4 resected specimens. We report 8 practical applications of the coagulating shears and compared its use with that of electrocautery in pancreatic surgery. RESULTS: Histologically, a coagulum of degenerated tissue completely closed each end of the vessels in the transected surface of all cases. The mean breadth of thermal degeneration resulting from the use of the coagulating shears was significantly less than that caused by electrocautery (1.33 +/- 0.21 vs. 3.05 +/- 0.34 mm, respectively) Pancreaticograms showed the closed branches of the pancreatic duct, but the closed main pancreatic duct had burst in 1 of 4 cases. Clinically, pancreatic fistula occurred in 1 of 8 patients who underwent pancreatic surgery with the coagulating shears. CONCLUSIONS: Pancreatic resection with the coagulating shears might be effective and feasible as long as the main pancreatic duct is ligated.

Hepatectomy for liver metastasis from ampullary cancer after pancreatoduodenectomy.

A 51-year-old Japanese woman with a solitary liver metastasis originating from a carcinoma of the ampulla of Vater was successfully treated by partial hepatectomy 19 months after curative pancreatoduodenectomy with lymphadenectomy. Histologic examination revealed a stage III well-differentiated tubular adenocarcinoma (pT2, pN1, and pM0). Postoperative serum concentrations of carcinoembryonic antigen increased exponentially to 133 ng/mL. The carcinoembryonic antigen doubling time was 63 days. Computed tomography and ultrasonography of the abdomen showed a solitary metastasis in segment VI of the liver. Since neither local recurrences nor other distant metastases were detected, the patient underwent partial hepatectomy. Histologic study confirmed the presence of a metastatic liver tumor from the ampullary carcinoma. The carcinoembryonic antigen levels returned to normal immediately after the partial hepatectomy. She was well without signs of recurrence 18 months after partial hepatectomy.

Feasibility and functional efficacy of distal gastrectomy with jejunal interposition for gastric cancer: a case series.

INTRODUCTION: Distal gastrectomy with jejunal interposition (DGJI) has been used in our institution for selected patients with gastric cancer as a function-preserving gastrectomy. The aim of this retrospective study was to clarify the feasibility and functional efficacy of DGJI. METHODS: A retrospective analysis was performed in 61 patients who underwent DGJI between 2002 and 2011. RESULTS: Mean operation time was 393.8 min and blood loss was 463.3 ml. Postoperative early major complications developed in 2 (3.3%) patients. The most common complication was gastric stasis, occurring in 7 (11.5%) patients. All patients with complications recovered with conservative treatment, and no operative mortality occurred. Endoscopy 1 year after operation revealed reflux gastritis in 1 patient. Reflux esophagitis was not found in any patient. However, anastomotic ulcer was found in 12 (22.2%) patients over the 1-year period after operation. No patient reported symptoms of early and late dumping syndrome, and 1 (1.9%) patient self-reported diarrhea. CONCLUSIONS: DGJI was a feasible and safe procedure with several advantages in terms of less incidence of reflux gastritis and esophagitis, dumping syndrome and diarrhea. However, this procedure is complicated and time-consuming, and it is necessary to be aware of the potential occurrence of an anastomotic ulcer at the site of the gastrojejunostomy after DGJI.

Five-year survival after surgery for invasive micropapillary carcinoma of the stomach.

Invasive micropapillary carcinoma (IMPC) of the breast, urinary bladder, ovary, and colon has been reported. However, few reports have described IMPC of the stomach. In addition, IMPC has been described as a histological indicator for lymphatic invasion and nodal metastasis, resulting in poor prognosis. We report a case of 5-year survival after surgery for IPMC of the stomach. A 69-year-old woman was admitted to our hospital with symptoms of upper abdominal pain. Upper gastrointestinal endoscopy revealed a tumor at the antrum of the stomach. Histological examination of the biopsy specimen indicated poorly differentiated adenocarcinoma. The patient underwent distal gastrectomy with lymph node dissection. Microscopic examination of the specimen revealed that the tumor consisted of an invasive micropapillary component. Carcinoma cell clusters were floating in the clear spaces. The patient recovered uneventfully and remains alive without recurrence 5 years after surgery.

Multiple Tracheal Diverticula Detected by Multidetector-row Computed Tomography.

Multiple tracheal diverticula are rare. We report a case of a 62-year-old man who had multiple tracheal diverticula that were detected using multidetector-row computed tomography. Axial computed tomography images showed multiple air collections contiguous to the trachea. The multiple air collections were visible as outpouchings of the parts of the trachea between the cartilages, being located almost symmetrically on both lateral sides of the tracheal wall as seen on coronal multiplanar reconstruction images. Virtual bronchoscopy confirmed the presence of multiple openings in the tracheal wall of the diverticular necks. The alteration of the airway was better seen using volume-rendered reconstruction. Thin-slice multidetector-row computed tomography and advanced imaging techniques may increase the frequency of identification of multiple tracheal diverticula.

Laparoscopic examination and resection for giant lipoma of the omentum: a case report and review of related literature.

We report herein the case of a giant lipoma of the greater omentum that was treated by laparoscopic surgery. A 71-year-old male patient was admitted with a diagnosis of sigmoid colon cancer. During preoperative examination, a gallbladder stone and an intra-abdominal giant lipoma were accidentally diagnosed. Laparoscopic examination revealed a smooth-surfaced, giant yellow tumor at the lower border of the greater omentum that was unattached to the surrounding organs. After laparoscopic resection of the tumor and cholecystectomy, a 10-cm midline incision was made in the lower abdomen to remove the tumor and the gallbladder. We then performed a sigmoidectomy for sigmoid colon cancer through the same laparotomy. The resected tumor measured 29 x 19 x 3 cm and weighed 1250 g, and a histopathologic examination revealed a benign lipoma. Laparoscopic examination and resection of a giant lipoma of the omentum are particularly useful.