[Eight mm Port-Site Hernia Following Robot-Assisted Abdominoperineal Resection for Rectal Cancer-A Case Report].

A 70s woman with a history of asthma and dyslipidemia underwent a robot-assisted abdominoperineal resection for rectal cancer. The ports were placed as per the method of Shizuoka Cancer Center and no intraoperative complications were observed. The colostomy was constructed in the left lower abdomen by the retroperitoneal route. The 12-mm port part was closed in 2 layers, the fascia and dermis, and the 8-mm port part was closed only in the dermis. The postoperative course was good; however, the patient vomited 10 days after surgery. Abdominal computed tomography revealed an incarcerated small intestine in the 8-mm port of the left abdomen, and it was diagnosed as port-site hernia incarceration. Emergency laparotomy hernia repair was performed on the day. A part of the 8-mm port was incised to 30-mm and the fascia dilatation to 30-mm was observed. The color tone of the incarcerated small intestine was good. Only adhesion peeling was performed, the small intestine was returned, and the fascia was closed. The postoperative course was uneventful and the patient was discharged 17 days after the second surgery. At the 1 year postoperative follow-up, recurrence of hernia or rectal cancer was not observed.

[Long-Term Survival of a Patient with Hepatocellular Carcinoma after Surgical Resection of Metachronous Hilar Lymph Node Metastases].

The recurrence of hepatocellular carcinoma(HCC)is primarily due to intrahepatic metastases. Additionally, extrahepatic HCC metastases most commonly occurs in the lungs, lymph nodes, adrenal glands, and bones. Systemic chemotherapy is the standard treatment for extrahepatic metastases. Although several reports on surgical resection of lymph node metastases (LNM) in patients with HCC have been published, its clinical benefits remain controversial. We report a case in which surgical resection of LNM was performed in a patient with HCC. The patient was a 74-year-old woman diagnosed with HCC and non-B non-C chronic hepatitis, for which she underwent a laparoscopic partial hepatectomy. The pathological diagnosis was St-A, 1.6×1.4 cm, confluent multinodular type, pT1N0M0, fStage Ⅰ. Nine months later, 2 LNM on the liver hilum were detected and managed with sorafenib. Sorafenib was discontinued after 2 months due to the development of Grade 3 hand-foot syndrome. Since no new lesions were detected on follow-up, lymph node resection was performed. The patient remains disease-free 4.5 years postoperatively.

Laparoscopic anatomical liver resection using indocyanine green fluorescence imaging.

BACKGROUND: Anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target area have been established as essential methods for curative treatment of hepatocellular carcinoma (HCC) and have subsequently been applied to other malignancies. However, laparoscopic anatomical liver resection (LALR) procedures are very difficult to reproduce, and the confirmation of demarcation of the hepatic segment on a monitor is also challenging. Recently, indocyanine green (ICG) fluorescence imaging has been used to identify hepatic tumors and segmental boundaries during hepatectomy. Herein, we describe LALR using ICG fluorescence imaging. METHODS: Three patients underwent pure LALR using ICG fluorescence imaging at our institute. One patient underwent anatomical partial liver resection for HCC, another underwent segmentectomy 3 for metastatic liver cancer, and the third underwent right anterior sectionectomy for HCC. To visualize hepatic perfusion and the demarcation line by negative staining using an optical imaging system, 2.5 mg ICG was injected intravenously during surgery following clamping or closure of the proximal Glissonean pedicles. RESULTS: For all three cases, ICG fluorescent imaging clearly delineated the demarcation lines and allowed identification of intersegmental planes to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. This allowed surgeons to recognize the direction and guide the transection of the liver parenchyma when performing LALR. CONCLUSION: LALR using ICG fluorescence imaging is a feasible procedure for resection of the tumor-bearing hepatic region and facilitates visualization of the demarcation line and identification of the boundaries of the hepatic sections.

Laparoscopic transabdominal preperitoneal approach for giant inguinal hernias.

BACKGROUND: Many surgical techniques have been developed to treat inguinal hernia. In recent years, the laparoscopic transabdominal preperitoneal (TAPP) approach has been widely performed to repair inguinal hernia. Giant inguinal hernia (GIH) is an extremely rare disease that is a challenge for general surgeons. GIH appears when patients neglect the treatment for many years and it is defined as an inguinal hernia that extends below the midpoint of inner thigh in standing position. According to previous publications, the Lichtenstein tension-free hernioplasty is recommended to repair GIH. In this article, we describe consecutive four cases of GIH repaired via the TAPP approach. METHODS: From April 2015 to March 2017, 200 patients underwent hernioplasty against inguinal hernia at our hospital. Inguinal hernias were treated via the TAPP approach in principle. We performed hernioplasty via the TAPP approach in all 4 patients (2%) who met the definition of Type 1 GIH. Demographic information, maximum diameter of hernia sac, hernia orifice size, and surgical data were obtained. RESULTS: The mean operative time was 135 min. No intraoperative complications were encountered. All patients could walk from postoperative day 1 and were discharged home early, but they all had scrotal seromas. Three patients did not need puncture or drainage, but one of them required puncture. All seromas disappeared within 6 months. There was no recurrence in the 8- to 24-month follow-up. CONCLUSION: The TAPP approach is a feasible, safe therapeutic option that may reduce wound size and pain following surgical treatment of Type 1 GIH.

A resected case of gallbladder metastasis with symptoms of acute cholecystitis in multiple metastatic ductal carcinoma of the breast.

Gallbladder metastasis from breast cancer, especially from ductal carcinoma, is rare. Herein, we report a rare case of gallbladder metastasis from ductal carcinoma of the breast that was diagnosed after laparoscopic cholecystectomy (LC) for acute cholecystitis. A 78-year-old woman presented with right upper abdominal tenderness and positive Murphy's sign during chemotherapy for advanced multiple metastases of the breast cancer. Abdominal ultrasonography and computed tomography showed a slightly thickened gallbladder wall and two calculi. After a diagnosis of acute calculous cholecystitis was established, LC was performed. Pathological examination revealed poorly differentiated adenocarcinoma infiltrating the submucosal and subserosal layer over the entire gallbladder, and a lymph node metastasis in the gallbladder neck. Immunohistochemical examination revealed that the tumor cells tested positive for estrogen receptor and negative for progesterone receptor, which was consistent with primary breast cancer. The patient was uneventfully discharged without abdominal pain 7 days later. Although she subsequently underwent several chemotherapies, she died 16 months later. In conclusion, gallbladder metastasis should be considered in patients with multiple metastatic breast cancer who present with signs or symptoms of cholecystitis. Moreover, LC should be considered to relieve the symptoms of cholecystitis for improved prognosis, even in a patient with multiple metastases.

Omental abscess due to a spilled gallstone after laparoscopic cholecystectomy.

Omental abscess due to a spilled gallstone is extremely rare after laparoscopic cholecystectomy. Herein, we report a 68-year-old man who presented with left upper abdominal pain after laparoscopic cholecystectomy for gangrenous cholecystitis. Seven months prior to admission, gallbladder perforation with spillage of pigment gallstones and bile occurred during laparoscopic cholecystectomy. The spilled gallstones were retrieved through vigorous peritoneal lavage. Abdominal computed tomography showed a 3 × 2.5 cm intra-abdominal heterogeneous mass, suspected to be an omental abscess, and ascites around the spleen. Exploratory laparoscopy revealed an inflammatory mass within the greater omentum. Laparoscopic partial omentectomy and abscess drainage were performed, and a small black pigment gallstone was unexpectedly found in the whitish abscess fluid. Abscess fluid culture results were positive for extended-spectrum ß-lactamase-producing Escherichia coli and Streptococcus salivarius, which were previously detected in the gangrenous gallbladder abscess. The histopathological diagnosis was abscess in the greater omentum. Postoperative course was uneventful, and the patient was discharged 13 days later. In conclusion, we report a successful case of laparoscopic management of an omental abscess due to a spilled gallstone after LC. It is important to attempt to retrieve spilled gallstones during LC because they may occasionally result in serious complications.

[A case of intracholecystic papillary neoplasm of the gallbladder (ICPN) examined using contrast-enhanced endoscopic ultrasonography].

A 78-year-old woman was found to have gallbladder wall thickening on ultrasonography during a routine health check-up and was referred to our clinic. On contrast-enhanced endoscopic ultrasonography, a papillary lesion measuring 14mm was detected in the fundus, which showed a heterogeneous enhancement at the early phase. She underwent cholecystectomy and gallbladder bed resection. Histological examination revealed that the tumor consisted of mucinous atypical cells, regularly arranged in a high-papillary architecture with delicate fibrovascular cores, which led to the diagnosis of intracholecystic papillary neoplasm of the gallbladder.

[A case of pancreatic mixed acinar-endocrine carcinoma suggested by preoperative ultrasound-guided fine needle aspiration].

A 73-year-old man visited our hospital for consultation regarding a pancreatic tumor. Abdominal computed tomography, magnetic resonance imaging, and endoscopic ultrasound scan (EUS) revealed tumor 2 cm in diameter located in the pancreatic tail. EUS-guided fine needle aspiration (EUS-FNA) suggested pancreatic mixed acinar-endocrine carcinoma, and he underwent distal pancreatectomy. Few reports exist where preoperative EUS-FNA suggested pancreatic mixed acinar-endocrine carcinoma; thus, we report this case.

Curative resection of hilar cholangiocarcinoma in a 25-year-old woman: report of a case.

A 25-year-old woman was referred to our hospital with persistent upper abdominal pain. Preoperative imaging studies revealed a hilar bile duct stricture with portal venous encasement, and the patient underwent curative resection involving extended left hepatectomy and segmental portal vein resection. The pathological findings demonstrated a well-differentiated tubular adenocarcinoma of the bile duct with regional lymph node metastasis (stage IIIB according to the UICC TNM classification), as well as the overexpression of p53 proteins and the K-ras gene mutation in tumor cells. The patient has shown no evidence of recurrence in the 10 months since the operation. Although there are several reports of relatively young adults with cholangiocarcinoma, the majority of such patients demonstrate either an anomalous arrangement of the pancreaticobiliary duct system or primary sclerosing cholangitis. The absence of any morphological abnormalities in this patient's biliary system implicates de novo carcinogenesis as the most likely cause of the cholangiocarcinoma.

[A case of erythema multiforme induced by regorafenib therapy for metastatic colon cancer].

A 47-year-old woman underwent colectomy for advanced colon cancer and thereafter received regorafenib therapy as fourth-line chemotherapy. On treatment day 12, the patient developed erythema multiforme (EM) induced by the regorafenib therapy. Immediately after regorafenib was withdrawn, the patient was treated with oral bepotastine and steroid ointment, which relieved the EM without progressing to Stevens-Johnson syndrome (SJS). Regorafenib is used for third- or fourth-line chemotherapy. Progression of regorafenib-induced EM to SJS may cause critical dysfunction among patients. Before administering regorafenib therapy, the patient should be made aware of this potential adverse effect and be advised to withdraw the treatment and visit the hospital immediately if symptoms of EM are observed.

[Pathological complete response in a large gastric GIST that became resectable after neoadjuvant chemotherapy with imatinib mesylate].

We report a case of a large gastric gastrointestinal stromal tumor (GIST), which became resectable and achieved pathological complete response after neoadjuvant chemotherapy with imatinib mesylate. A 59-year-old man presented with left hypochondrial pain. Abdominal computed tomography (CT) revealed gastric GIST invading the spleen and the diaphragm. Administration of imatinib mesylate was initiated as neoadjuvant chemotherapy. Six months after neoadjuvant chemotherapy with imatinib mesylate, abdominal CT revealed a reduction in tumor size. We judged the tumor resectable and performed partial gastrectomy and splenectomy. Histologically, number of myofibroblasts increased, but no viable tumor cells were observed. Pathological complete response was obtained.

[Three cases of recurrent bile duct cancer diagnosed and treated by double-balloon endoscopy].

Local recurrences often develop after the resection of bile duct cancer. Imaging modalities do not have sufficient sensitivity or specificity to enable the definite diagnosis of recurrent bile duct cancer, and it may be difficult to decide when to start chemotherapeutic treatment. It is difficult to obtain specimens by conventional endoscopy after Roux-Y biliary reconstruction. The double-balloon endoscope(DBE) has 2 balloons: one at the tip of the endoscope and the other at the over- tube. The 2 balloons are inflated alternately and the endoscope can move through the small intestine in a caterpillar-like manner. DBE simplifies the approach to Roux-Y choledochojejunostomy and to obtaining a pathological specimen. Moreover, endoscopic biliary drainage and cholangiography can be performed with the DBE. Recently, the DBE has enabled systemic chemotherapy to be started after obtaining pathological evidence of malignancy, as well as biliary drainage instead of percutaneous transhepatic biliary drainage in cases with recurrent bile duct cancers. Here, we present 3 cases of recurrent bile duct cancer diagnosed and treated by a DBE.

[A case of postoperative liver metastasis from pancreatic carcinoma treated with percutaneous isolated hepatic perfusion(PIHP)].

We report a case of postoperative liver metastasis arising from pancreatic carcinoma treated with a novel procedure that we developed-percutaneous isolated hepatic perfusion (PIHP). A 69-year-old man diagnosed with pancreatic body cancer(pT3, pN0, pStage III) was treated using distal pancreatectomy and adjuvant therapy with gemcitabine(GEM). Six months later, a metastasis to the medial segment of the liver was found using computer tomography(CT). The patient was treated by chemotherapy with S-1, but the liver metastasis grew, and we therefore employed PIHP as the third-line therapy, using 80 mg doxorubicin (DXR) and 62 mg mitomycin C (MMC). Six weeks after PIHP, the tumor marker carbohydrate antigen 19-9( CA19-9) had decreased from 44,469 to 4,268 U/mL, and the carcinoembryonic antigen(CEA) level decreased from 28.8 to 5.4 U/mL. Although the size of the carcinoma remained the same on CT, some cells had liquefied as a result of necrosis. However, the patient died about 1 year after PIHP due to the growth of liver metastasis, peritoneal metastasis, and local recurrence, reflected by a progressively increasing level of tumor marker. In this case, PIHP seemed to be ineffective due to local recurrence and peritoneal metastasis as well as early enlargement of liver metastasis. However, the reduction in tumor marker levels and the observed tumor necrosis, suggest that PIHP is a potentially effective and promising treatment for liver metastasis arising from pancreatic carcinoma.

[A case of interstitial lung disease associated with gemcitabine treatment in a patient with locally advanced pancreatic cancer following proton beam radiotherapy].

A 69-year-old woman who had locally advanced pancreatic cancer underwent proton beam radiotherapy(67.5 GyE/25 Fr) concurrent with gemcitabine chemotherapy (GEM 800 mg/m2 day 1, 8) at Hyogo Ion Beam Medical Center, followed by GEM chemotherapy (1,000 mg/m2 day 1, 8, 15/28 day)at Kobe University Hospital. She visited our hospital because she was suffering from dyspnea 212 days after first administration of GEM. A chest computed tomography revealed that infiltrations were spreading in the bilateral lung fields. A bronchoscopy showed diffuse alveolar hemorrhage. We diagnosed GEM related interstitial lung disease with diffuse alveolar hemorrhage. We introduced steroid pulse therapy (methylprednisolone 1 g/day) for 3 days followed by oral prednisolone (40 mg/day), which was tapered gradually. She recovered and was discharged on the 24th day after admission.

Feasibility of (18)F-fluorodeoxyglucose positron-emission tomography for preoperative evaluation of biliary tract cancer.

(18)F-Labeled fluorodeoxyglucose positron-emission tomography (FDG-PET), a rapidly evolving functional imaging modality, has recently been shown to be useful in the diagnosis and staging of various malignant tumors due to focal uptake of FDG-labeled glucose in malignant cell populations. However, the role of FDG-PET in the diagnosis and staging of biliary tract cancer is still controversial and has not yet been fully evaluated. The aim of this study was to determine the clinical importance of FDG-PET in the preoperative evaluation of biliary tract cancer and retrospectively clarify the characteristics of false-negative and false-positive cases. We retrospectively analyzed data for 73 consecutive patients diagnosed with cancer of the biliary tract and were admitted to the Department of Hepato-Biliary-Pancreatic Surgery at Kobe University Hospital for treatment, from January 2007 to August 2009. Since the sensitivity, specificity and positive predictive value (PPV) of FDG-PET in the diagnosis of bile duct carcinoma are usually relatively high, FDG-PET is considered to be a useful tool in diagnosing biliary tract cancer. FDG-PET also seems to be useful in clinical decision-making, regarding treatment strategy, including surgery. Our results showed that FDG-PET is highly sensitive in delineating the primary focus of biliary cancer and is a useful tool in preoperative examination. A disadvantage of FDG-PET is its inability to indicate small metastases and false-positive findings of inflamed gallbladder and bile duct lesions.

Role of intraoperative cholangiography in patients whose biliary tree was evaluated preoperatively by magnetic resonance cholangiopancreatography.

BACKGROUND: Routine performance of intraoperative cholangiography (IOC) during cholecystectomy is controversial. The aim of this study was to evaluate the role of IOC during cholecystectomy in addition to preoperative magnetic resonance cholangiopancreatography (MRCP) in our institution over a 12-year period. METHODS: A total of 425 consecutive patients who underwent IOC during cholecystectomy were included in this study. MRCP was performed preoperatively for bile duct evaluation in all patients. When common bile duct (CBD) stones were detected, they were removed endoscopically before the operation. We estimated the results of IOC in terms of the success rate, the detection rate of anatomic abnormality of the biliary system, and the incidence of residual CBD stones. RESULTS: MRCP preoperatively identified 6 (1.4 %) patients with abnormal biliary systems and 56 with CBD stones, which were endoscopically removed. The success rate of IOC was 93.8 % (399/425). Abnormalities of the biliary system were detected in 12 patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %). Of the eight patients with stones, seven had been examined by endoscopy preoperatively and found to have CBD stones. The detection rate of bile duct stones in patients with preoperative endoscopic removal of CBD stones (7/56, 12.5 %) was significantly higher than those with CBD stones first detected during IOC (1/365, 0.3 %) (p < 0.01). Moreover, no residual CBD stones were detected in patients who were operated on within fewer than 12 days from endoscopic treatment to the operation. CONCLUSIONS: IOC is indicated even after preoperative sphincterotomy for CBD stones. In our study, it resulted in a 12.5 % incidence of persistent stones after sphincterotomy. IOC plays an additional role in detecting CBD stones and in revealing abnormalities of the biliary tree in patients whose biliary tree was preoperatively evaluated by MRCP.

Plasma tissue factor pathway inhibitor levels in patients with acute pancreatitis.

BACKGROUND: In acute pancreatitis (AP), disorders of the coagulation-fibrinolysis system are closely related to the severity of the AP and to organ dysfunctions. We previously reported that plasma tissue factor (TF) levels were elevated in patients with AP, particularly in cases of alcoholic AP with pancreatic necrosis. Tissue factor pathway inhibitor (TFPI) is a key regulator of the extrinsic coagulation pathway, but plasma TFPI levels in AP have not yet been determined. METHODS: Plasma TFPI concentrations were measured by enzyme-linked immunosorbent assay in 44 patients with AP on admission. The relationships between AP severity, pancreatic necrosis, organ dysfunction, infection, and prognosis were analyzed. RESULTS: Plasma TFPI levels were increased in AP patients compared with healthy volunteers. Plasma TFPI levels in severe AP were greater than those in mild AP. Plasma TFPI levels significantly correlated with Ranson score, APACHE II score, and Japanese severity score. Plasma TFPI levels in patients with pancreatic necrosis were greater than those in patients without pancreatic necrosis. Plasma TFPI levels in patients with organ dysfunction were greater than those in patients without organ dysfunction. In patients with pancreatic necrosis, the TF/TFPI ratios in non-survivors were lower than those in survivors. Moreover, the mortality rates in patients with TF/TFPI ratios > or = 2.0 were lower than those in patients with TF/TFPI ratios < 2.0. CONCLUSIONS: Plasma TFPI levels were significantly increased in patients with AP, and the elevation was markedly related to the severity, pancreatic necrosis and organ dysfunctions. The imbalance of TF and TFPI may influence the disease state and thereby the prognosis in AP.

Utility of the new Japanese severity score and indications for special therapies in acute pancreatitis.

BACKGROUND: The Japanese severity score (JSS) for acute pancreatitis was revised in 2008. As special therapies for severe acute pancreatitis (SAP), continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) are now utilized in Japan. We investigated the usefulness of the new JSS and the indications for CRAI and EN based on the new JSS. METHODS: We assessed the new JSS in 138 patients with SAP according to the previous Japanese criteria. Usefulness of the new JSS for the prediction of mortality rates was compared with conventional scoring systems by receiver-operator characteristic curve analysis. We analyzed the relationship between the new JSS and prognosis in patients with and without CRAI and EN, respectively. RESULTS: Forty-five patients (33%) were assessed as having mild acute pancreatitis, and 93 patients (67%) were assessed as having SAP. Their mortality rates were 7 and 40%, respectively. The area under the curve for the prediction of mortality rates with the new JSS was 0.822 and was the highest among conventional scoring systems. In patients with new JSS >or= 6, the mortality rate was lower in patients with CRAI than in patients without CRAI (P = 0.129). In patients with new JSS >or= 4, the mortality rate was lower in patients with EN than in patients without EN (P = 0.016). CONCLUSIONS: The new JSS is useful and easier to use for the prediction of prognosis compared to the conventional scoring systems. EN was effective in reducing the mortality rate in patients with a new JSS >or= 4.

Long-term outcome of severe acute pancreatitis.

BACKGROUND/PURPOSE: This study was undertaken to evaluate the post-discharge outcome of severe acute pancreatitis (SAP) and to clarify the prognostic factors for poor outcome. METHODS: In 45 patients, recurrence of acute pancreatitis (AP), transition to chronic pancreatitis (CP), and development of diabetes mellitus (DM) were evaluated. Relationships of the outcome with the findings on admission and the presence/absence of alcohol intake were analyzed. RESULTS: The mean follow-up period was 56+/-6 months. Recurrence of AP was noted in 19% of the patients. The recurrence rate was higher in patients with necrotizing pancreatitis than in those without this feature. C-reactive protein and white blood cell (WBC) count were higher in patients with recurrence of AP. Transition to CP was noted in 22% of patients. The transition rate was higher in those with alcoholic SAP than in those with biliary SAP. In patients with transition to CP, the WBC count, hematocrit, Ranson score, and Japanese severity score were higher, and base excess (BE) was lower, compared with these features in patients without this transition. Development of DM was noted in 39% of patients. Blood glucose and BE were higher in patients who developed DM than in those who did not. CONCLUSIONS: The degree of inflammation and pancreatic necrosis found on admission for SAP may be related to the recurrence of AP. Alcoholic SAP in which the disease is very severe may contribute to the transition to CP. Patients with impaired glucose tolerance readily develop DM after SAP.

Increased levels of soluble triggering receptor expressed on myeloid cells-1 in patients with acute pancreatitis.

OBJECTIVE: To determine the contribution of triggering receptor expressed on myeloid cells (TREM)-1 in acute pancreatitis (AP). DESIGN: Prospective study. SETTING: General intensive care unit at Kobe University Hospital. PATIENTS: Forty-eight patients with AP and seven patients as control. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured serum concentrations of soluble TREM-1 (sTREM-1) at the time of admission by enzyme-linked immunoadsorbent assay. Serum sTREM-1 levels increased significantly in AP (63 +/- 11 pg/mL) and correlated with Ranson score (R = .628, p < .001) and Acute Physiology and Chronic Health Evaluation II score (R = .504, p < .001). Serum TREM-1 levels were higher in patients with early organ dysfunction (which occurred within 7 days after onset) than those without early organ dysfunction (101 +/- 19 vs. 25 +/- 4 pg/mL, p < .001). Incidences of early organ dysfunction in patients whose serum sTREM-1 levels were < or = 40 and > 40 pg/mL were 17% and 83%, respectively (p < .001). The usefulness of serum sTREM-1 in detecting early organ dysfunction was superior to that of C-reactive protein, interleukin-6, interleukin-8, Ranson score, and Acute Physiology and Chronic Health Evaluation II score. Serum sTREM-1 levels decreased with resolution of early organ dysfunction. CONCLUSIONS: Serum sTREM-1 levels were significantly increased and correlated with disease severity and early organ dysfunction in patients with AP. Serum sTREM-1 level may be a useful marker for early organ dysfunction in AP.