Successful treatment of rectal cancer with pelvic abscess using transrectal drainage followed by laparoscopic radical resection: a case report.

The incidence of rectal cancer with a pelvic abscess is rare; hence, treatment strategies are difficult because both malignant and infectious inflammation need to be addressed. Here, we report the case of a 53-year-old man diagnosed with rectal cancer accompanied by a pelvic abscess. We performed transrectal drainage of the abscess, and a transanal rectal drainage tube was inserted into the abscess cavity. His symptoms rapidly improved, and computed tomography showed that the pelvic abscess had disappeared. Six weeks after drainage, radical laparoscopic Hartmann's procedure with resection of the rectal cancer and incision drainage scar was performed. After adjuvant chemotherapy, laparoscopic stoma closure was performed a year after the operation. The patient showed no evidence of cancer recurrence 1.5 years after radical surgery. Transrectal drainage followed by laparoscopic radical resection can be a less invasive and effective treatment for rectal cancer accompanied by a pelvic abscess.

Successful laparoscopy-assisted repair of a rectovaginal fistula after low anterior resection for rectal cancer: a report of two cases.

BACKGROUND: Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is troublesome and refractory. Although various surgical procedures have been previously described, no definitive procedure has shown a satisfactory outcome. We present two consecutive Japanese patients who underwent successful surgery for an RVF after low anterior resection. CASE PRESENTATION: The patients were two women (61-year-old and a 64-year-old). They were admitted to our hospital with a chief complaint of fecal discharge from the vagina after low anterior resection using the double-stapling technique for rectal cancer. They were diagnosed with RVF. Local surgical procedures, including diverting ileostomy, were unsuccessful in previous hospitals. Therefore, we performed laparoscopy-assisted repair of the RVF. In both patients, laparoscopically robust pelvic adhesions were dissected, and the sigmoid colon was transected at just oral side to the RVF. Thereafter, in combination with a perineal approach, the rectum, along with a previous anastomosis and fistula, were completely removed. Surgeries were completed after vaginal repair, redo coloanal anastomosis, and interposition of the dissected connective tissue. In both patients, the postoperative courses were uneventful. They complained of neither recurrence of any RVF nor fecal incontinence 1 year and 10 months after diverting stoma closure. CONCLUSIONS: A laparoscopy-assisted procedure with reanastomosis and interposition of the perineal connective tissue can be an effective treatment for RVF after low anterior resection for rectal cancer.

Early experience with a new integrated microwave surgical device, Acrosurg Revo®, for laparoscopic surgery: A case series of two patients.

INTRODUCTION: Abdominal surgery uses various energy devices for vessel sealing, tissue dissection, and detachment. Currently, Acrosurg Revo® (Nikkiso Co., Ltd., Tokyo, Japan), a novel energy device using microwaves, has been developed for use in laparoscopic surgery. This report describes the early clinical experience of using this device in two cases of laparoscopic surgery. PRESENTATION OF CASE: Case 1 was of a 64-year-old woman who underwent laparoscopic abdominal incisional hernia repair. Case 2 was of a 56-year-old man with a diagnosis of ascending and sigmoid colon cancer who underwent laparoscopic right hemicolectomy and sigmoid colectomy with D3 dissection. Each surgery was completed using Acrosurg Revo® and an endoscopic electrosurgical unit. The postoperative course was uneventful, and both patients were discharged from the hospital without any complications. DISCUSSION: With this new and novel device, vessel sealing, hemostasis, coagulation, tissue dissection, and detachment were all possible. Notably, there was no spark or mist that hindered the surgical field of view. Furthermore, because microwave coagulation did not result in tissue carbonization, there was a considerable decrease in device tip contamination. CONCLUSION: The Acrosurg Revo® may be a useful energy device for laparoscopic surgery.

Gastric volvulus and giant Bochdalek hernia in an adult patient that were safely repaired by endoscopic reduction and elective laparoscopic surgery.

A Bochdalek hernia (BH) is a congenital abnormality with incomplete closure of the diaphragm. It is usually manifested in infants but rarely in adults. Here, we report an adult patient with gastric volvulus and giant BH that were safely repaired by endoscopic reduction and elective laparoscopic surgery, respectively. A 79-year-old woman presented with left upper abdominal pain but no history of trauma. CT revealed a giant BH with gastric volvulus. After emergency endoscopic reduction of the volvulus, elective laparoscopic repair of the BH was performed. The 8 × 8-cm defect was repaired with interrupted nonabsorbable sutures and a mesh. The patient's postoperative course was uneventful, and no complications or recurrence were observed in the 6 months that followed.

Involvement of TRPV1-containing peripheral sensory efferents in hemodynamic responses in a rat hemorrhagic shock model.

BACKGROUND: Mechanisms underlying hemodynamic disturbance in hemorrhagic shock are not completely understood. Transient receptor potential vanilloid 1-expressing afferents are involved in hemorrhagic shock pathology, and transient receptor potential vanilloid 1 antagonist, capsazepine, acts on the central nervous system to improve mortality in a rat hemorrhagic shock model. In contrast, transient receptor potential vanilloid 1-positive efferents promote vasoactive reactions through the release of neuropeptides, including calcitonin gene-related peptides. This study aimed to investigate whether transient receptor potential vanilloid 1-positive peripheral sensory efferents are involved in hemodynamic responses after hemorrhagic shock. METHODS: Male rats underwent hemorrhagic shock (mean arterial pressure 30 mm Hg for 90 min, followed by resuscitation for 30 min) and received capsazepine (5 µM/kg) 30 min after shock induction. A separate cohort of rats subjected to hemorrhagic shock received hCGRP8-37 (300 µg/kg), a calcitonin gene-related peptide receptor antagonist, at 30, 60, or 90 minutes after shock induction. The 24-hour survival rate, mean arterial pressure, heart rate, arterial blood gas, and plasma calcitonin gene-related peptide levels were measured. Tissue blood flow and oxygenation both in the mesentery and skeletal muscle were also assessed. RESULTS: Capsazepine treatment prevented the hemorrhagic shock-induced increase in plasma calcitonin gene-related peptide levels, and hCGRP8-37 treatment improved the 24-h survival rates after hemorrhagic shock at a time-dependent manner. The hCGRP8-37- or capsazepine-treated rats exhibited tissue oxygenation and metabolic conditions comparable to those in control rats at the end of the experiment. CONCLUSION: Transient receptor potential vanilloid 1 plays a crucial role in hemodynamic responses to hemorrhagic shock, partly via calcitonin gene-related peptide release, involved in its peripheral sensory-efferent functions. The hCGRP8-37 appears to improve peripheral circulatory failure, which may be useful as adjunct treatment after hemorrhagic shock.

Electrical stimulation of the vagus nerve improves intestinal blood flow after trauma and hemorrhagic shock.

BACKGROUND: Gut damage after trauma/hemorrhagic shock contributes to multiple organ dysfunction syndrome. Electrical vagal nerve stimulation is known to prevent gut damage in animal models of trauma/hemorrhagic shock by altering the gut inflammatory response; however, the effect of vagal nerve stimulation on intestinal blood flow, which is an essential function of the vagus nerve, is unknown. This study aimed to determine whether vagal nerve stimulation influences the abdominal vagus nerve activity, intestinal blood flow, gut injury, and the levels of autonomic neuropeptides. METHODS: Male Sprague Dawley rats were anesthetized, and the cervical and abdominal vagus nerves were exposed. One pair of bipolar electrodes was attached to the cervical vagus nerve to stimulate it; another pair of bipolar electrodes were attached to the abdominal vagus nerve to measure action potentials. The rats underwent trauma/hemorrhagic shock (with maintenance of mean arterial pressure of 25 mmHg for 30 min) without fluid resuscitation and received cervical vagal nerve stimulation post-injury. A separate cohort of animals were subjected to transection of the abdominal vagus nerve (vagotomy) just before the start of cervical vagal nerve stimulation. Intestinal blood flow was measured by laser Doppler flowmetry. Gut injury and noradrenaline level in the portal venous plasma were also assessed. RESULTS: Vagal nerve stimulation evoked action potentials in the abdominal vagus nerve and caused a 2-fold increase in intestinal blood flow compared to the shock phase (P < .05). Abdominal vagotomy eliminated the effect of vagal nerve stimulation on intestinal blood flow (P < .05). Vagal nerve stimulation protected against trauma/hemorrhagic shock -induced gut injury (P < .05), and circulating noradrenaline levels were decreased after vagal nerve stimulation (P < .05). CONCLUSION: Cervical vagal nerve stimulation evoked abdominal vagal nerve activity and relieved the trauma/hemorrhagic shock-induced impairment in intestinal blood flow by modulating the vasoconstriction effect of noradrenaline, which provides new insight into the protective effect of vagal nerve stimulation.

Perioperative tight glycemic control using artificial pancreas decreases infectious complications via suppression of inflammatory cytokines in patients who underwent pancreaticoduodenectomy: A prospective, non-randomized clinical trial.

BACKGROUND: We sought to investigate the efficacy of perioperative tight glycemic control (TGC) in reducing of postoperative infectious complications (POICs) and study its impact on early inflammatory mediators in patients who underwent pancreaticoduodenectomy. METHODS: In this non-randomized trial, the artificial pancreas (AP) group received TGC (target glucose range of 80-110 mg/dL; n = 14), while the control group received conventional glycemic control (range of 80-180 mg/dL; n = 15). The primary endpoint was POICs. RESULTS: The AP group had a markedly decreased POIC rate (28.6% vs. 73.3%; P = 0.027), mean glycemic variability (13.5 ± 3.5% vs. 16.4 ± 5.9%; P = 0.038), and plasma interleukin-6 level (26.3 ± 33.8 vs 98.3 ± 89.1 pg/ml; P = 0.036) compared to the control group, but insulin dosage (27.0 ± 13.4 vs. 10.2 ± 16.2 U; P = 0.002) and the adiponectin ratio (i.e., postoperative/preoperative adiponectin; 0.8 ± 0.2 vs. 0.6 ± 0.3; P = 0.021) were markedly higher in the AP group. CONCLUSIONS: Among patients undergoing PD with impaired glucose tolerance, AP facilitated strict glycemic control and resulted in a reduction of anti-inflammatory mediators and POICs. SUMMARY: Perioperative hyperglycemia increases postoperative infectious complications; however, tight glycemic control using artificial pancreas can reduce them via a dual effect. Artificial pancreas facilitates strict and safe glycemic control while reducing anti-inflammatory mediators, including adiponectin, following pancreaticoduodenectomy.

Accuracy, criteria, and clinical significance of visual assessment on diffusion-weighted imaging and apparent diffusion coefficient quantification for diagnosing acute appendicitis.

PURPOSE: To assess the accuracy, criteria, and clinical significance of diffusion-weighted imaging (DWI) signal intensity and apparent diffusion coefficient (ADC) quantification for diagnosing acute appendicitis. METHODS: Fifty-one patients with right lower abdominal pain [uncomplicated appendicitis (n = 25), complicated appendicitis (n = 10), and non-appendicitis (n = 16)] who underwent MR examination were enrolled in this retrospective study. Two radiologists independently measured appendiceal diameter and wall thickness. They assessed whether a wall defect, an abscess, extraluminal air, or an appendicolith was present on axial T2WI; evaluated intensity on DWI using a 5-point scale; and determined the ADC values of the appendix and peri-appendiceal tissue. Statistical analysis was performed to assess imaging findings for the diagnosis of appendicitis and complicated appendicitis. Cut-off values were determined using receiver operating characteristic analysis. RESULTS: For diagnosing acute appendicitis, the accuracy improved from 78.4% using only T2WI to 86.3% using combined T2WI and DWI for reader 1 and from 82.4 to 86.3% for reader 2. For the appendix, the cut-off ADC values that diagnosed appendicitis were 1.41 × 10-3 and 1.26 × 10-3 mm2/s with accuracies of 78.4% and 76.5%, respectively. For the peri-appendiceal tissue, these values of 1.03 × 10-3 and 0.91 × 10-3 mm2/s differentiated between uncomplicated and complicated appendicitis with an accuracy of 97.1%. CONCLUSIONS: Combined DWI and T2WI provided high accuracy for diagnosing appendicitis. The inflamed appendix had lower ADC value than the normal appendix. The peri-appendiceal tissue presenting low ADC value was a notable finding of complicated appendicitis.

[A Case of Gastric Cancer Underwent Two-Stage Gastrectomy after Chemotherapy-Induced Perforation].

A 70's man presenting with a chief complaint of stomachache was found to have advanced gastric cancer with a deep ulcer and some lymph-node metastases. We decided performing a curative operation after 2 courses of S-1 plus cisplatin. On the first course day 13 of chemotherapy, he complained of severe epigastralgia, and we diagnosed as generalized peritonitis due to perforation of gastric cancer. We performed an urgent laparoscopic operation, which made perforation simple closure and omentopexy. Curative distal gastrectomy with D2 lymph node dissection was successfully performed on postoperative day 16.

[A Case of Small Intestinal GIST with Long-Term Survival after Tumor Resection for Repeated Peritoneal Recurrence].

A 70-year-old woman presenting with abdominal pain was admitted to our hospital. Abdominal contrast CT revealed a small intestine tumor of 10 cm with active bleeding and performed partial resection of the small intestine including tumor. Pathological findings were high risk GIST of the small intestine because of spindle cells and c-kit positive. Imatinib 400mg/day as adjuvant chemotherapy was administered. However administration was stopped for 15 days because of the Grade 4 erythema multiforme. Recurrence of peritoneal dissemination was observed in 2 years after surgery and tumor resection was performed, but complete resection was difficult. Within 5 years after surgery, tumor resection was performed on a total of 5 times peritoneal disseminative recurrences, and it was possible to avoid the appearance of symptoms due to tumor augmentation.

Lymphoepithelial cyst with sebaceous glands of the pancreas: a case report.

BACKGROUND: Lymphoepithelial cyst (LEC) of the pancreas is a rare benign tumor. LEC with sebaceous glands of the pancreas is extremely rare, and its histogenesis remains unclear. CASE PRESENTATION: We present a 66-year-old man with an incidental finding of a cystic lesion at the neck of the pancreas. Pancreatic juice cytology results and elevated serum carbohydrate antigen 19-9 and Dupan-2 levels indicated that the cyst was a potential adenocarcinoma. Therefore, a pancreaticoduodenectomy was performed. Macroscopically, the tumor was a unilocular cyst with a thin transparent wall, filled with soft yellow material. Pathological findings showed that the cyst was lined with squamous epithelium, accompanied by dense lymphoid tissue with scattered germinal centers. There were no hair follicles, but sebaceous glands were present in the lymphoid tissue just beneath the squamous epithelium. Therefore, the histopathological diagnosis was an LEC with sebaceous glands of the pancreas. Furthermore, the squamous epithelium surrounding the cyst was pathologically continuous with the tubular structure, indicating that the tubular structure transitioned into the squamous epithelium. CONCLUSIONS: We report an extremely rare case of LEC with sebaceous glands of the pancreas. Moreover, the pathological findings, which showed that the tubular structure transitioned into the squamous epithelium, suggested that this was squamous metaplasia. In order to investigate the histogenesis of LEC of the pancreas, the pathological findings must be evaluated.

[Clinical Evaluation of Hyperthermic Intraperitoneal Chemotherapy(HIPEC)in Colorectal Cancer Patients at High Risk of Peritoneal Recurrence].

PURPOSE: We herein report the clinical outcomes of hyperthermic intraperitoneal chemotherapy(HIPEC)in patients at high risk of colorectal peritoneal metastasis. PATIENTS AND METHODS: We enrolled 21 patients with advanced colorectal cancer who were received HIPEC between 2009 and 2014. Retrospectively, we evaluated the short-term and long-term outcomes of these cases. RESULTS: We performed HIPEC for 12 patients with primary cancer and 9 with recurrent cancer. Perioperative complications characteristic of HIPEC did not occur. Seventeen patients(81%)had postoperative recurrence, 5 of whom had a peritoneal recurrence, and all of them already had synchronous peritoneal metastasis at the time of HIPEC. Patients with a higher peritoneal cancer index(PCI)had a tendency towards a higher rate of peritoneal recurrence than those with a lower PCI(11[median]vs 4; p=0.08).

[Surgery for Multiple Gastrointestinal Stromal Tumors of the Small Intestine in Patients with Neurofibromatosis Type 1 - A Report of Three Cases].

We report 3 cases of multiple GIST of the small intestine in 3 patients with NF1 who have been followed for over 5 years. All patients presented with melena, and tumors of the small intestine suspected to be GIST were found on endoscopy. We performed partial resections of the small intestine for all 3 patients. After surgery, 1 patient had residual tumors that gradually enlarged during 8 year 2 months and another had residual tumors that have been stable for 8 years. In the third patient, we resected all the tumors, and there has been no sign of recurrence in 6 year 1 month.

[Stage IV Gastric Cancer with Positive Peritoneal Washing Cytology or Peritoneal Dissemination Was Successfully Treated with Gastrectomy and Hyperthermic Intraperitoneal Chemotherapy(HIPEC)Followed by Systemic Chemotherapy - A Report of Two Cases].

Survival of Stage IV gastric cancer is poor. We report 2 cases of Stage IV gastric cancer with positive peritoneal washing cytology or peritoneal dissemination that were successfully treated with gastrectomy and hyperthermic intraperitoneal chemotherapy( HIPEC)followed by systemic chemotherapy. Case 1: A 59-year-old woman. She was diagnosed with advanced gastric cancer and underwent gastrectomy with HIPEC. Her peritoneal washing cytology was positive during the gastrectomy. After the surgery, she underwent chemotherapy consisting of 8 courses of combination S-1 plus CPT-11 and 19 courses of PTX. It has been 5 years and 7 months since she had the surgery and she survives without recurrence of the cancer. Case 2: A 60-year-old woman. She was diagnosed with advanced gastric cancer and peritoneal dissemination(peritoneal cancer index: 3 points). She underwent gastrectomy, hemi-colectomy, and HIPEC. After the surgery, she underwent chemotherapy, 35 courses of combination S-1 plus PSK/DOC, and 13 courses of S-1 plus PSK. It has been 5 years since her surgery and she survives without exacerbation of the cancer. These cases suggest a gastrectomy and HIPEC followed by systemic chemotherapy may represent an effective treatment for advanced gastric cancer with a small amount of peritoneal metastasis.

[Salvage Surgery after CRT for Advanced Esophageal Cancer Resulting in a Pathological Complete Response and More Than Five Years' Survival].

A 62-year-old woman visited our hospital because of dysphagia. She was diagnosed with upper-middle esophageal type 4 cancer, which was 9 cm in length, according to the results of endoscopy. Squamous cell carcinoma was demonstrated using endoscopic biopsy. A CT scan revealed that the tumor had directly invaded into the trachea(cT4). Chemoradiotherapy(CRT) (5-FU and CDDP with 50 Gy of radiation)was administered. Although CT after CRT resulted in shrinkage of the tumor and no further tracheal invasion, esophageal stenosis remained. Therefore, salvage surgery(subtotal esophagectomy with 3-field lymph node dissection)was performed. Pathologically, no carcinoma cells were found in the resected specimen and a com- plete response(grade 3)was diagnosed. The patient received adjuvant chemotherapy(tegafur/uracil at 300mg/day per os) for 1 year. The patient is alive with no relapse of carcinoma more than 5 years after the first treatment.

[A Case of Breast Metastasis of Eccrine Porocarcinoma].

An 80's woman was diagnosed with eccrine porocarcinoma of the head in 2010.T he tumor was removed surgically but relapsed in the cervical and axillary lymph nodes 2 years later.The patient underwent surgery, and received systemic chemotherapy and radiation.Chest CT after treatment revealed an irregular mass and thickened skin in the left breast.Core needle biopsy specimens were used to diagnose metastasis of eccrine porocarcinoma.A wide excision with a 1 cm margin was performed under local anesthesia.After surgery, supraclavicular lymph node recurrence was detected.The patient received palliative care because there was no effective treatment available.Eccrine porocarcinoma is a rare malignant tumor of the intraepidermal sweat duct.Breast metastasis from malignant disease is also rare.To our knowledge, breast metastasis of eccrine porocarcinoma has not been reported.

Initial experiences with MR Image-guided laparoscopic microwave coagulation therapy for hepatic tumors.

PURPOSE: Percutaneous thermal ablation is used for treating hepatic tumors. Recent advances in laparoscopy and imaging modalities have led to the development of a novel image-guided minimally invasive loco-regional treatment. The aim of this trial was to apply laparoscopic assistance to magnetic resonance (MR) image-guided thermoablation instead of ultrasonography, because of its various advantages. METHODS: Patients with hepatic tumors and liver cirrhosis underwent magnetic resonance (MR) image-guided laparoscopic microwave coagulation therapy using a borescope and endoscopic forceps. Six cases of laparoscopic microwave coagulation treatment using MR image guidance were successfully performed between January 2000 and December 2008. Tumors were detected, punctured, and ablated in an open-configured MR scanner. A total of nine hepatocellular carcinoma nodules were preoperatively identified in S3, S5 and S6 (mean diameter = 20.8 ± 5.4 mm). RESULTS: MR-guided microwave coagulation was laparoscopically achieved in all patients without any significant complications that required invasive treatment. The mean length of the operation was 275.3 ± 60.5 min, and the mean postsurgical hospital stay was 10.0 ± 2.3 days. Postoperative confirmation scanning was performed without moving the patients. CONCLUSION: MR-guided laparoscopic microwave coagulation therapy is an effective treatment for hepatic tumors adjacent to other organs, as it allows for more accurate detection of lesions and for tumors to be treated safely while avoiding adjacent organs. It is less invasive than conventional procedures, because the MR real-time guidance enabled continuous monitoring throughout the procedure.

Resectable carcinoma developing in the remnant pancreas 7 years and 10 months after distal pancreatectomy for invasive ductal carcinoma of the pancreas: report of a case.

BACKGROUND: Pancreatic ductal adenocarcinoma, which represents 90% of pancreatic cancers, is one of the most lethal and aggressive malignancies. Operative resection remains the only treatment providing prolonged survival, however, recurrence of pancreatic ductal adenocarcinoma occurs in up to 80% of patients with pancreatic cancer within 2 years of a potential curative resection. There are few reports of pancreatic carcinoma recurrence (primary second cancer) in the remnant pancreas after pancreatectomy. CASE PRESENTATION: A 52-year-old woman underwent a distal pancreatectomy for pancreatic cancer in September 2004. Adjuvant chemotherapy was started after surgery and continued for 4 years. In March 2012, marked elevation of DUPAN-II was observed, followed by an irregular stenotic finding in the main duct. We performed an en bloc resection of the remnant pancreas in July 2012. Histologically, the tumor contained a second primary pancreatic carcinoma with lymph node metastasis. At follow-up 20 months after the second operation, the patient was alive without recurrence. Fourteen cases of resectable cancer developing in the remnant pancreas after a pancreatectomy for cancer have been reported; a minority of these was identified as second primary tumors. Therefore, our patient's primary second cancer is a rare event. CONCLUSION: The patient is considered to have shown a rare, unique pancreatic cancer recurrence. Persistent elevation of a tumor marker and extensive imaging led to proper diagnosis and treatment.