Single-incision Laparoscopic Appendectomy for acute Appendicitis using a 10-mm Laparoscope and the Glove Port Technique.

OBJECTIVE: To evaluate the single incision laparoscopic appendectomy (SILA) using existing instruments, the 10-mm laparoscope, and glove port technique. METHODS: SILA was performed on 16 patients (8 male cases, 8 female cases) between June 2012 and September 2015. A 20-mm incision was made in the umbilicus and a wound retractor was placed. A 10-mm trocar for the laparoscope and two 5-mm trocars were fixed to the three fingers of the latex gloves and it was attached to the wound retractor. Another thin forceps were inserted from right low abdomen. RESULTS: Average age of patients was 32.6 ± 17.7 years. Preoperative average white blood cell was 13,325 ± 4,584 /mm3, and average CRP was 1.81 ± 3.70 mg/dL. Preoperative body temperature was 36.8 ± 0.5°C. The mean appendix size was 9.6 ± 2.3 mm and none of the patients had an abscess on preoperative CT. The CT also revealed a fecal pellet in 5/16 (31%) of patients. Mean operation time was 66.4 ± 25.4 minutes, and minimal intraoperative bleeding was observed in all patients. Average hospital stay was 5.3 ± 1.9 days and none of the patients had complications. CONCLUSION: SILA using the 10-mm laparoscope and glove port technique may be a safe and feasible operation for mild to moderate appendicitis.

Adenoma of the nipple, focusing on the contrast-enhanced magnetic resonance imaging findings: report of a case.

A woman in her 50s was referred to our hospital for an investigation of a right breast tumor. The tumor was palpated below the nipple, but there was no erosion or nipple discharge. Mammography showed a well-defined high-density tumor, measuring 2 cm in diameter, without calcification, and ultrasonography showed a low-echoic mass with a fluid component with posterior echo enhancement and a lateral shadow. Contrast-enhanced magnetic resonance imaging (CE-MRI) demonstrated a 1.3 × 0.8 cm solid component and a gradually increasing time-intensity curve. We performed lumpectomy and the pathological findings were adenoma of the nipple. The pattern of the time-intensity curve might be attributed to moderate fibrosis of the tumor. Contrast-enhanced MRI is therefore considered to be very useful in the diagnosis of breast disease because it can show the nature and extent of the breast lesion; however, we should be aware that various patterns have been observed on CE-MRI for adenoma of the nipple.

Early laparoscopic cholecystectomy for acute gangrenous cholecystitis.

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications and conversion to open cholecystectomy. We investigated whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. Pathologic diagnoses and outcomes were analyzed in patients who underwent laparoscopic or open cholecystectomy at our hospital, January 2002 to September 2005. Of 30 patients with acute gangrenous cholecystitis, 16 underwent early laparoscopic cholecystectomy, 10 underwent open cholecystectomy, and 4 were converted to open cholecystectomy (conversion rate, 20.0%). There was no significant difference in operation time or intraoperative bleeding. The requirement for postoperative analgesics was significantly lower (6.4+/-7.3 vs. 1.5+/-1.2 doses, P<0.05) and hospital stay significantly shorter (8.6+/-2.1 vs. 15.6+/-6.3 d, P<0.01) after laparoscopic cholecystectomy. There were no postoperative complications in either group. Thus, early laparoscopic cholecystectomy seems appropriate for acute gangrenous cholecystitis. Conversion to open cholecystectomy may be required in difficult cases with complications.

A case of incarcerated umbilical hernia in an adult treated by laparoscopic surgery.

A 42-year-old, obese woman was admitted to our hospital 3 h after the sudden development of abdominal pain. Her umbilical region was swollen and she was diagnosed with incarceration of an umbilical hernia by computed tomography. Although we tried, we were unable to reduce the hernia with a manipulative procedure. We decided to perform an emergency laparoscopy. Once general anesthesia was induced, we achieved hernia reduction. From a laparoscopic view, the portion of strangulated small intestine was neither necrotic nor perforated. The size of the hernial orifice was ∼2 × 2 cm, and thus, we selected a 12 × 12 cm composite mesh to cover the hernia defect by at least 5 cm in all directions. The surgical procedure was uneventful and the total operation time was 112 min. The patient recovered uneventfully and was discharged on postoperative day 9. She remains free of recurrence 20 months after surgery.

Unavoidable human errors of tumor size measurement during specimen attachment after endoscopic resection: a clinical prospective study.

OBJECTIVE: Objective evaluation of resected specimen and tumor size is critical because the tumor diameter after endoscopic submucosal dissection affects therapeutic strategies. In this study, we investigated whether the true tumor diameter of gastrointestinal cancer specimens measured by flexible endoscopy is subjective by testing whether the specimen is correctly attached to the specimen board after endoscopic submucosal dissection resection and whether the size differs depending on the endoscopist who attached the specimen. METHODS: Seventy-two patients diagnosed with early gastric cancer who satisfied the endoscopic submucosal dissection expanded-indication guideline were enrolled. Three endoscopists were randomly selected before every endoscopic submucosal dissection. Each endoscopist separately attached the same resected specimen, measured the maximum resection diameter and tumor size, and removed the lesion from the attachment board. RESULTS: The resected specimen diameters of the 3 endoscopists were 44.5 ± 13.9 mm (95% Confidence Interval (CI): 23-67), 37.4 ± 12.0 mm (95% CI: 18-60), and 41.1 ± 13.3 mm (95% CI: 20-63) mm. Comparison among 3 groups (Kruskal Wallis H- test), there were significant differences (H = 6.397, P = 0.040), and recorded tumor sizes were 38.3 ± 13.1 mm (95% CI: 16-67), 31.1 ± 11.2 mm (95% CI: 12.5-53.3), and 34.8 ± 12.8 (95% CI: 11.5-62.3) mm. Comparison among 3 groups, there were significant differences (H = 6.917, P = 0.031). CONCLUSIONS: Human errors regarding the size of attached resected specimens are unavoidable, but it cannot be ignored because it affects the patient's additional treatment and/or surgical intervention. We must develop a more precise methodology to obtain accurate tumor size. TRIAL REGISTRATION: University hospital Medical Information Network UMIN No. 000012915.

Seatbelt syndrome with gastric mucosal breaks and intra-gastric wall air leakage.

As numerous reports were published regarding the so-called seatbelt syndrome involved in car crashes, most of them were mentioned about small intestine, duodenum and colon perforations and solid organ bleeding. No reports have been published regarding multiple gastric mucosal tears with intra-gastric wall air leakage with massive bleeding. A 65-year-old woman was admitted after a motor vehicle crash. She vomited massive fresh blood. Gastric mucosal breaks, approximately 5 cm in length, were observed. Computed tomography imaging revealed multiple gastric mucosal breaks. We report a rare case wherein a traffic accident caused a serious condition associated with massive digestive bleeding.

Laparoscopic and endoscopic cooperative surgery for duodenal neuroendocrine tumor (NET) G1: Report of a case.

INTRODUCTION: We report a case of duodenal neuroendocrine tumor (NET) G1 resected by laparoscopic and endoscopic cooperative surgery (LECS) technique. PRESENTATION OF CASE: A 58-year-old woman underwent esophagastroduodenoscopy, revealing an 8-mm, gently rising tumor distal to the pylorus, on the anterior wall of the duodenal bulb. Endoscopic ultrasonography suggested the tumor might invade the submucosal layer. The tumor was pathologically diagnosed as a G1 duodenal NET, by biopsy. Endoscopic submucosal dissection was attempted, but was unsuccessful because of the difficulty of endoscopically performing an inversion operation in the narrow working space. The case was further complicated by the patient's duodenal ulcer scar. We performed a full-thickness local excision using laparoscopic and endoscopic cooperative surgery. The tumor was confirmed and endoscopically marked along the resection line. After full-thickness excision, using endoscopy and laparoscopy, interrupted full-thickness closure was performed laparoscopically. DISCUSSION: Endoscopic treatment is generally recommended for G1 NETs <10mm in diameter and extending only to the submucosal layer. However, some cases are difficult to resect endoscopically because the wall of duodenum is thinner than that of stomach, and endoscope maneuverability is limited within the narrow working space. LECS is appropriate for early duodenal G1 NETs because they are less invasive and resection of the lesion area is possible. CONCLUSION: We demonstrated that LECS is a safe and feasible procedure for duodenal G1 NETs in the anterior wall of the first portion of the duodenum.

Reduction effect of bacterial counts by preoperative saline lavage of the stomach in performing laparoscopic and endoscopic cooperative surgery.

AIM: To investigate the effects of gastric lavage with 2000 mL of saline in laparoscopic and endoscopic cooperative surgery. METHODS: Twenty two patients who were diagnosed with a gastric gastrointestinal stromal tumor were enrolled. In former term, irrigations of the stomach were conducted whenever it was necessary, not systematically (Non systemic lavage group). In latter term, the stomach was thoroughly cleaned with 2000 mL of saline using an endoscope with a water jet, and Duodenal balloon occlusion was conducted to prevent refluxed bile and pancreatic juice (Systemic lavage+balloon occlusion group). The gastric wall was sprayed with 20 mL of distilled water, and 20 mL of gastric juice was collected in a sterile tube and submitted for culture. 20 mL of ascites was also collected from the laparoscopic ports and submitted for culture. We compared WBC, CRP, BT between two groups, and verify the reduction effect of bacterial counts in Systemic lavage+balloon occlusion group. RESULTS: WBC count before, 1 d after, and 3 d after laparoscopic and endoscopic cooperative surgery (LECS) were 5060 (95%CI: 4250-9640), 12140 (6050-14110), and 6910 (5320-12520) in Non systemic lavage group, 4400 (3660-7620), 8910 (6480-10980), and 5950 (4840-7860) in Systemic lavage+balloon occlusion group. Significant differences between two groups at the day after LECS (P = 0.029) and the 3 d after LECS (P = 0.042). CRP levels in Non systemic lavage group and in Systemic lavage+balloon occlusion group were significantly different at the day after LECS (P = 0.005) and the 3 d after LECS (P = 0.028). BTs (°C) in Non systemic lavage group and in Systemic lavage+balloon occlusion group were also significantly different at the day after LECS (P = 0.004) and the 3 d after LECS (P = 0.006). In a logarithmic comparison, bacterial load before gastric lavage, after lavage, and ascites culture were 6.08 (95%CI: 4.04-6.97), 0.48 (0-0.85), and 0.21 (0-0.56). The bacterial counts before and after gastric lavage were significantly suppressed (P = 0.007), but no significant difference between gastric juice culture after lavage and ascites (P = 0.154). CONCLUSION: Pre-LECS lavage with 2000 mL of saline exhibited a bacteria-reducing effect equivalent to disinfectants and obtained favorable results in terms of clinical symptoms and data.

Two rare gastric hamartomatous inverted polyp cases suggest the pathogenesis of growth.

Gastric hamartomatous inverted polyps (GHIP) are difficult to diagnose accurately because of inversion into the submucosal layer. GHIP are diagnosed using the pathological characteristics of the tumor, including the fibroblast cells, smooth muscle, nerve components, glandular hyperplasia, and cystic gland dilatation. Although Peutz-Jeghers syndrome, juvenile polyposis, and Cowden disease are hereditary, it is rare to encounter 2 cases of monostotic and asymptomatic gastric hamartomas. The pathogeneses of hamartomatous inverted polyps and inverted hyperplastic polyps remain controversial because of the paucity of reported cases. There are 3 hypotheses regarding the pathogenesis of complete gastric inverted polyps. Based on our experience with 2 successive, rare GHIP cases, we affirm the hypothesis that after a hamartomatous change occurs in the submucosal layer, some of these components are exposed to the gastric mucosa and, consequently, form a hypertrophic lesion. In Case 1, our hypothesis explains why a tiny hypertrophic change was first detected on the top of the submucosal tumor using a detailed narrow band imaging-magnified endoscopy. There was no confirmation that the milky white mucous and calcification structures were exuding directly from the biopsy site like Case 1, and in Case 2 the presence of this mucous was indirectly confirmed during an endoscopic submucosal dissection (ESD). Regarding the pathogenesis of GHIP, a submucosal hamartomatous change may occur prior to the growth of hypertrophic portions. An en bloc resection using ESD is recommended for treatment.

Invasive micropapillary carcinoma of the breast in a male patient: Report of a case.

INTRODUCTION: We report a rare case of invasive micropapillary carcinoma in the male breast. PRESENTATION OF CASE: A 63-year-old man was referred to our hospital for investigation of a left breast tumor, which could be palpated in the upper lateral quadrant of the left nipple-areola complex. The tumor invaded the areola skin. Ultrasonography showed a 14.8×15.0×12.4mm low echoic mass, with an irregular lobulated border. Core needle biopsy indicated invasive ductal carcinoma, but the subtype could not be accurately determined. Mastectomy with axillary lymph node dissection was performed. Pathological examination indicated invasive micropapillary carcinoma, no lymph node metastasis, and a nuclear grade of 2. Immunohistochemical examination showed positive staining for estrogen and progesterone receptors, but negative staining for HER2. The Ki67 index was 5%. Tamoxifen was administered, and recurrence has not been noted for 1 year. DISCUSSION: Women's IMPC generally shows a high HER2 positivity rate. However, HER2 positivity was noted in only 1 male patient with IMPC (14%) according to our literature review. Furthermore, in all cases of the mixed type that were reviewed, IMPC was associated with papillotubular carcinoma. These findings may be specific to IMPC in male patients. CONCLUSION: IMPC is associated with a high rate of lymph node metastasis or recurrence and advanced vessel invasion, aggressive adjuvant chemotherapy following surgical resection should be selected for patients with IMPC.

Endoscopic management of a rare granulation polyp in a colonic diverticulum.

There are many case reports on colon diverticula that cause irritable bowel syndrome, constipation, bleeding, diverticulitis, stricture due to multiple recurrences of diverticulitis, and perforation. However, few articles have examined neoplasms that arise from a diverticulum, such as adenoma and adenocarcinoma, and there have been no reports of granulation polyps that arise from a colon diverticulum after recurrent diverticulitis. We observed a rare granulation polyp that arose from a diverticulum as a result of repeated episodes of local diverticulitis. Narrow band imaging magnified colonoscopy was very useful to diagnose the polyp as a granulation polyp because of the absence of a pit pattern on the surface of the polyp. We successfully resected the polyp using endoscopic mucosal resection. We inverted the diverticulum, and the resected stalk of the polyp was used to close the diverticulum with an over-the-scope clip. If a granulomatous polyp could arise from a diverticulum, differential diagnosis between a colon neoplasm and a granulomatous polyp would not only be difficult but also necessary for suitable endoscopic treatment.

Retroperitoneal solitary fibrous tumor of the pelvis with pollakiuria: a case report.

BACKGROUND: Solitary fibrous tumor (SFT) is rare soft tissue tumor, and it occurs most commonly in the pleura. Retroperitoneal SFT is generally found by palpable mass or abdominal distention. Here we report a case of SFT presenting pollakiuria. CASE PRESENTATION: A 64-year-old man was referred to our hospital for pollakiuria. Contrasted-enhanced computed tomography revealed a heterogeneously enhanced pelvic tumor of approximately 10 × 8 × 7 cm. Invasion of the surrounding organs, distal metastasis, and lymph node swelling were absent. Therefore, surgical resection was performed. The resected specimen was a 13 × 8 × 5.5-cm encapsulated elastic hard tumor weighing 420 g. Histologically, the tumor consisted of oval or spindle cells growing in a random manner in a collagenous matrix. Immunohistochemically, the specimen was positive for CD34, bcl-2, as well as vimentin and negative for c-kit. On the basis of these findings, a retroperitoneal solitary fibrous tumor (SFT) of the pelvis was diagnosed. CONCLUSION: Surgery is the primary treatment for SFT, and pathologically negative margins are important for good prognosis.

DNA damage signaling is activated during cancer progression in human colorectal carcinoma.

PURPOSE: Recent studies have shown that the DNA damage response (DDR) is activated in precancerous lesions, suggesting that neoplastic cells may avoid apoptosis by impairing the DDR which acts as a barrier against tumor progression. To define the role of the DDR pathway in human colorectal carcinoma, we investigated the level of phosphorylated proteins of the DDR pathway. RESULTS: Immunostaining for pATM, gammaH2AX and pChk2 revealed that all were significantly expressed during tumor progression in advanced carcinoma (vs. normal tissue for pATM [p < 0.05]; vs. normal and adenoma for gammaH2AX [p < 0.05]; and vs. normal tissue for pChk2 [p < 0.05]. Western blot analysis of gammaH2AX and pChk2 revealed that their level increased gradually during tumor progression and was maximal in advanced carcinoma (vs. normal tissue; p < 0.05). No apoptotic cells were found in any tissue sample. EXPERIMENTAL DESIGN: Colorectal tissue samples were obtained at the time of surgery, from 55 patients at two hospitals. The tissues were classified into four groups according to pathology: normal mucosa, adenoma, early carcinoma and advanced carcinoma. We evaluated phosphorylated ataxia telangiectasia mutated (pATM), phosphorylated H2AX (gammaH2AX) and Chk2 (pChk2) protein levels by immunohistochemistry and western blot analysis. We also evaluated apoptosis by the TUNEL assay. CONCLUSIONS: The DDR pathway was activated during cancer progression, but no apoptosis was detected, even among the cells with activated DDR. It is likely that activation of DDR was induced by stress signaling as a consequence of oxidative, replication and mechanical stresses occurring during growth and expansion of the colorectal cancer.

Laparoscopic cecopexy for mobile cecum syndrome manifesting as cecal volvulus: report of a case.

A 44-year-old woman was admitted to our hospital for investigation and treatment of sudden abdominal pain and distention. Plain abdominal radiography and abdominal computed tomography (CT) findings were suggestive of sigmoid volvulus. She underwent an emergency colonoscopy, and the scope passed easily through the sigmoid colon and reached the ascending colon quickly. However, stenosis with concentricity of the fold was observed in the cecum, which was shifted upward and to the left. Based on these findings, we diagnosed cecal volvulus caused by mobile cecum syndrome. The patient's symptoms resolved quickly after colonoscopic reduction and elective laparoscopic surgery was performed 18 days after admission. Perioperative examination revealed a mobile cecum caused by an elongated ascending colon. We sutured the cecum and ascending colon to the lateral peritoneum laparoscopically with interrupted sutures. The patient recovered well and was discharged on postoperative day 7. An unfixed intestine can be detected easily during laparoscopic surgery, which is minimally invasive and cosmetically, physically, and economically beneficial. Thus, we recommend laparoscopic cecopexy for mobile cecum syndrome.

Laparoscopic resection of an ileal lipoma: Report of a case.

A 63-year-old woman was admitted to our hospital for investigation of upper abdominal pain and vomiting. Ultrasonography (US) showed a hyperechoic mass in the right lower abdomen, and computed tomography (CT) showed a low-density mass and intestinal invagination. Thus, we made a diagnosis of intestinal lipoma with intussusception and performed laparoscopic partial resection of the ileum, including the tumor. The resected specimen contained a round tumor, 25 x 22 x 20 mm, which was identified as an intestinal lipoma histopathologically. Our experience supports earlier reports that US and CT are effective tools in the diagnosis of bowel lipoma. Laparoscopic surgery is the treatment of choice for benign tumors of the small intestine because it is minimally invasive, with cosmetic, physical, and economic benefits.

Ectopic hepatocellular carcinoma arising in the bile duct.

We report a case of ectopic hepatocellular carcinoma arising in the bile duct. A 72-year-old woman was transferred to our hospital with fever, abdominal pain, and jaundice. Contrast-enhanced computed tomography revealed a round mass, measuring 25 mm in diameter, in the bile duct. The mass was causing obstructive jaundice. Endoscopic retrograde cholangiography showed a 27 mm x 21-mm round defect in the superior bile duct. These findings led to a diagnosis of bile duct tumor, and the patient underwent extrahepatic bile duct resection and biliary reconstruction. Gross examination of the tumor showed a fibrous capsule and a stalk arising from the bile duct mucosa. The tumor was diagnosed histopathologically as well-differentiated hepatocellular carcinoma arising in the bile duct.

A case of incarcerated femoral hernia in an infant.

The authors describe the case of an incarcerated femoral hernia in an infant. A 4-month-old female infant was hospitalized with an incarcerated right groin hernia. Attempts to reduce the mass were unsuccessful, so an emergency surgery was performed. During surgery, the hernial sac seemed to protrude under the inguinal ligament. The authors opened the hernial sac and observed a dark red small intestine. The authors did not resect the intestine because its color gradually improved after the constriction was released. The hernial sac passed under the inguinal ligament, and the infant was diagnosed with incarcerated femoral hernia.

Nonocclusive mesenteric ischemia after aorto-iliac reconstruction of a ruptured abdominal aortic aneurysm: report of a case.

We report a case of nonocclusive mesenteric ischemia (NOMI), which developed after Y-grafting for a ruptured abdominal aortic aneurysm (AAA). A 71-year-old man was referred to our hospital with severe abdominal pain and signs of shock. Computed tomography revealed a ruptured AAA, and emergency aneurysmectomy and aortic grafting were performed. However, on postoperative day 7, a large amount of pus was seen oozing from the surgical wound. An emergency laparotomy revealed segmental, highly diffuse necrotic changes of the small intestine, but pulsation of the marginal artery in the necrotic region was palpable and blood flow was well audible by Doppler ultrasound. These findings were consistent with a diagnosis of NOMI.