Reduced port laparoscopic subtotal cholecystectomy for Mirizzi syndrome with a bilio-biliary fistula: A case report.

A 65-year-old male diagnosed with Mirizzi syndrome with a bilio-biliary fistula was referred to our department and underwent single-incision laparoscopic surgery with an assistant trocar. As typical laparoscopic cholecystectomy could not be performed due to the coexistence of a bilio-biliary fistula, we performed laparoscopic subtotal cholecystectomy as a bail-out procedure according to the recommendation of the recent Tokyo Guidelines (TG18). The neck of the remnant gallbladder could be easily sutured with the effective use of an assistant trocar, and the surgery was completed without any complications. The patient was discharged 5 days after surgery without any complications. While little has been reported on the efficacy of reduced port surgery for Mirizzi syndrome, our surgical approach, i.e. reduced port surgery with an assistant trocar, enabled secure and easy suturing as a bail-out procedure and seemed to be an efficient method that is both less-invasive and safe.

[Two Cases of Lower Rectal Cancer in Which Temporary Ileostomy Could Be Avoided by Using the Pull Through Procedure].

We report 2 cases of lower rectal cancer in which temporary ileostomy was avoided by using the Pull through procedure. Case 1 was a 59-year-old man with a BMI of 29.67 who was diagnosed as having lower rectal cancer after a positive stool occult blood test. He had a strong refusal to use a ileostomy and was obese, so he underwent laparoscopic intersphincteric resection using the Pull through procedure. Reconstruction was performed on the 7th postoperative day. He was discharged from the hospital on the 14th day after the initial surgery. Case 2 was a 65-year-old woman with a BMI of 27.65 who was referred to our department for additional resection after ESD for a lesion in the lower rectum. As in the previous case, she was obese and refused to use a ileostomy, so we chose to perform a laparoscopic intersphincteric resection using the Pull through procedure. Reconstruction was performed on the 7th postoperative day, and she was discharged on the 25th day after the initial surgery. Patient satisfaction was high, and the Pull through procedure may be an option for patients with lower rectal cancer who have difficulty in undergoing temporary ileostomy.

[A Case of Surgical Resection for Ascending Colon Cancer with Protein-Losing Gastroenteropathy].

An 84-year-old man visited our department for further examination of anemia and elevation of tumor marker levels. Colonoscopy revealed a huge circumferential type 3 tumor in the ascending colon. Significant hypoalbuminemia was observed at 1.1 g/dL, and prolonged hypoalbuminemia was considered to be caused by protein-losing gastroenteropathy due to the large tumor. In this case, we performed right hemicolectomy, and performed single-stage anastomosis. The resected specimen showed a huge type 3 lesion with a diameter of 140×120 mm in the ascending colon, which directory invaded to the cecum and ileum. After the operation, there were no particular complications, and albumin levels gradually improved. Although hypoalbuminemia is one of the risks of anastomotic leakage, there are many reports with one-stage anastomosis and with a good course, including our case. Therefore, it was considered necessary to examine each case regarding the surgical procedure.

[A Case of Low-Grade Appendiceal Mucinous Neoplasm with Extra-Appendiceal Mucin Extrusion Successfully Treated with Laparoscopic Surgery].

A 49-year-old male patient, who presented with abdominal pain, was suspected of having acute appendicitis. Abdominal computed tomography revealed a swollen appendix, accompanied by a 40 mm low-density mass located behind the appendix. He was diagnosed with an appendiceal mucinous neoplasm, and laparoscopic ileocecal resection was performed. A soft tumor was found proximal to the swollen appendix and was adhered tightly to the iliopsoas muscle. The tumor cells were exfoliated carefully, and the tumor was excised en bloc without any injury. Histopathological examination revealed a low- grade appendiceal mucinous neoplasm(LAMN)accompanied by extra-appendiceal mucin extrusion due to the lack of epithelial lining. Because LAMN is potentially malignant, surgical excision was performed as first-line therapy. In the surgical management of LAMN, preventing intraoperative rupture is essential to avoid pseudomyxoma peritonei. To achieve this, a magnified laparoscopic surgery may be useful. Although no definitive guidelines describing the indications of lymph node dissection or the appropriate extent of resection exist, laparoscopic ileocecal resection may be used to manage cases of LAMN.

Foreign body granulomas mimic peritoneal dissemination caused by incarcerated femoral hernia perforation: A case report.

BACKGROUND: Foreign body granuloma (FBG) is a well-known type of granulomatous formation, and intraabdominal FBG (IFBG) is primarily caused by surgical residues. Multifocal IFBGs caused by gastrointestinal perforation is an extremely rare and interesting clinicopathological condition that resembles peritoneal dissemination. Here, we present a case of IFBGs mimicking peritoneal dissemination caused by bowel perforation and describe the value of intraoperative pathological examinations for rapid IFBG diagnosis. CASE SUMMARY: An 86-year-old woman with an incarcerated femoral hernia was admitted to the hospital and underwent operation. During the operation, the incarcerated ileum was perforated during repair due to hemorrhage necrosis, and a small volume of enteric fluid leaked from the perforation. The incarcerated ileum was resected, and the femoral hernia was repaired without mesh. Four months later, a second operation was performed for an umbilical incisional hernia. During the second operation, multiple small, white nodules were observed throughout the abdominal cavity, resembling peritoneal dissemination. The results of peritoneal washing cytology in Douglas' pouch and the examination of frozen nodule sections were compatible with IFBG diagnosis, and incisional hernia repair was performed. CONCLUSION: IFBGs can mimic malignancy. Intraoperative pathological examinations and operation history are valuable for the rapid diagnosis to avoid excessive treatments.

Accumulation of Uroporphyrin I in Necrotic Tissues of Squamous Cell Carcinoma after Administration of 5-Aminolevulinic Acid.

5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence is widely used for the intraoperative detection of malignant tumors. However, the fluorescence emission profiles of the accompanying necrotic regions of these tumors have yet to be determined. To address this, we performed fluorescence and high-performance liquid chromatography (HPLC) analyses of necrotic tissues of squamous cancer after 5-ALA administration. In resected human lymph nodes of metastatic squamous cell carcinoma, we found a fluorescence peak at approximately 620 nm in necrotic lesions, which was distinct from the PpIX fluorescence peak at 635 nm for viable cancer lesions. Necrotic lesions obtained from a subcutaneous xenograft model of human B88 oral squamous cancer also emitted the characteristic fluorescence peak at 620 nm after light irradiation: the fluorescence intensity ratio (620 nm/635 nm) increased with the energy of the irradiation light. HPLC analysis revealed a high content ratio of uroporphyrin I (UPI)/total porphyrins in the necrotic cores of murine tumors, indicating that UPI is responsible for the 620 nm peak. UPI accumulation in necrotic tissues after 5-ALA administration was possibly due to the failure of the heme biosynthetic pathway. Taken together, fluorescence imaging of UPI after 5-ALA administration may be applicable for the evaluation of tumor necrosis.

Brief Report: Cumulative Incidence of Autism Spectrum Disorder Before School Entry in a Thoroughly Screened Population.

The present study aimed to identify the cumulative incidence of autism spectrum disorder (ASD) in a thoroughly screened population and to examine the behavioral and motor characteristics observed in children with ASD at the age of 18 months. Subjects were 1067 children who underwent a screening assessment for ASD at the routine 18-months health checkup. By the age of 6 years, 3.1% (4.3% of boys and 2.0% of girls) were diagnosed as having ASD by their attending pediatricians. Higher rate of difficulties in motor skills and social and communication skills had been reported in children with ASD at 18 months of age. This study showed that careful community-based screening system may be helpful in detecting ASD at early age.

[A Case of Initially Unresectable Advanced Gastric Cancer Radically Resected by Conversion Surgery after Nivolumab Immunotherapy].

A 77-year-old man was admitted to our hospital with symptoms of epigastralgia and vomiting. Detailed investigation revealed unresectable advanced gastric cancer accompanied by multiple lymph node metastases and invasion of the pancreas(UM, type 3, cT4b, N3, M0, Stage ⅢC). The patient received nivolumab immunotherapy after first-line S-1 plus oxaliplatin(SOX)chemotherapy and second-line nab-paclitaxel(PTX)plus ramucirumab(RAM)chemotherapy. Remarkable tumor reduction was observed after 3 courses of nivolumab immunotherapy, and the patient subsequently underwent radical total gastrectomy with splenectomy and D2 lymphadenectomy. Histopathological examination of the resected stomach showed a near complete response, and only small metastatic foci remained in No. 2 lymph nodes, resulting in R0 resection. The patient was followed up without adjuvant therapy, and he is alive 6 months after the treatment without any symptoms of recurrence. The mechanism of action of immune checkpoint inhibitors is fundamentally different from that of conventional cytotoxic chemotherapeutic agents. Recently, several reports have described good responses to immune checkpoint inhibitors in cases where conventional chemotherapy has been unsuccessful. When predictive biomarkers of response to immune checkpoint inhibitors are identified, a combination therapy of preceding immunotherapy and subsequent surgery might provide an efficient radical therapeutic effect even in cases of unresectable advanced gastric cancer.

An integrated community mental healthcare program to reduce suicidal ideation and improve maternal mental health during the postnatal period: the findings from the Nagano trial.

BACKGROUND: During the perinatal period, suicides are more likely to occur in those with depression and who are not receiving active treatment at the time of death. Suicide is a common outcome in people with suicide ideation. We developed an intervention program taking care of comprehensive perinatal maternal mental healthcare to prevent suicide ideation. We hypothesized that our intervention program could reduce postnatal suicide ideation and improve maternal mental health. METHODS: We performed a controlled trial to examine the usual postnatal care plus a maternal suicide prevention program (the intervention group) compared with usual postnatal care alone, which comprised home visits by public health nurses without mental health screening (the control group) in Nagano city, Japan. In total, 464 women were included; 230 were allocated to the control group and 234 to the intervention group. The intervention had three components: 1) all the women received postnatal mental health screening by public health nurses who completed home visits during the neonatal period, 2) the intervention was administered by a multidisciplinary clinical network, and 3) systematic follow-up sheets were used to better understand bio-psycho-social characteristics of both the mothers and their infants and develop responsive care plans. We measured the participants' mental health at 3-4 months postpartum (T1) and 7-8 months postpartum (T2) using the Japanese version of the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: Suicidal ideation was significantly lower in the intervention group compared with the control group at T1 (p = 0.014); however, this significant between-group difference did not continue to T2 (p = 0.111). We measured the intervention effects on maternal mental health using the total score of the EPDS, which was significantly improved in the intervention group compared with the control group at T1. Here, the significant difference continued to T2 (p = 0.049). CONCLUSIONS: Our results indicate that our program may reduce maternal suicidal ideation at 3-4 months postnatally and improve women's mental health during the postnatal periods of 3-4 to 7-8 months. Postnatal maternal mental healthcare, including services to reduce suicide ideation, should be included as an important component of general postnatal care. TRIAL REGISTRATION: Name of registry: A multidisciplinary intervention program for maternal mental health in perinatal periods. UMIN Clinical Trials Registry number: UMIN000033396 . Registration URL: https://upload.umin.ac.jp/cgibin/ctr/ctr_view_reg.cgi?recptno=R000038076 Registration date: July 15, 2018. Registration timing: retrospective.

[A Case of Local Recurrence of Transverse Colon Cancer Radically Resected by Extended Surgery].

A 71-year-old male with a past history of Stage Ⅱb transverse colon cancer was pointed out a mass lesion penetrating into the stomach on abdominal computed tomography 1 year after surgery. The mass lesion was pathologically diagnosed as local recurrence of the previous colon cancer by upper gastrointestinal endoscopy. As he presented progressive anemia due to persistent tumor bleeding and no other recurrent lesion was recognized, surgical treatment was performed. Since intraoperative inspection suspected direct invasion to the pancreas, the patient underwent tumor resection in combination with distal pancreatectomy and partial resection of the stomach. Histopathological examination revealed negative surgical margins, resulting in R0 resection. Loco-regional therapies such as surgery and radiotherapy are considered appropriate for the treatment of local recurrence since pathogenesis of local recurrence is different from that of distant metastasis. As local recurrence may show various symptoms, we should aggressively consider surgical resection. Especially, complete resection of recurrent lesion is the only therapeutic strategy which can achieve radical cure. Although worsening of QOL might be a matter of concern depending on the site of recurrence, extended surgery with secure surgical margins is encouraged in cases of solitary recurrence.

[A Case of Primary Gastrointestinal Stromal Tumor with First Recurrence 13 Years after Surgery and Second Recurrence in the Omentum 6 Years Later].

A 63-year-old man underwent proximal gastrectomy for gastrointestinal stromal tumor(GIST)of the stomach 19 years ago. Local recurrence of GIST of the stomach occurred 13 years later, and the tumor was resected. Since then, he had adjuvant chemotherapy. Six years later, computed tomography revealed a soft-tissue shadow at the left lateral side of the stomach, and positron emission tomography also revealed fluorodeoxyglucose uptake at the same site. The recurrence of GIST was suspected, and therefore laparoscopic resection was performed. The operative time was 70 minutes. Blood loss was 10 g. Immunohistochemical examination showed positivity for c-kit and CD34, leading to a diagnosis of recurrence of GIST. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. At present, the patient is alive without adjuvant chemotherapy 13 months since surgery. GIST may recur 10 years or more after surgery. Therefore, long-term surveillance seems to be mandatory.

Needlescopic surgery for broad ligament hernia: A case report.

Broad ligament hernia is a rare type of internal hernia. We herein report a case of broad ligament hernia successfully treated by needlescopic surgery. A 41-year-old woman was referred to our hospital with a complaint of nausea and vomiting. Abdominal contrast-enhanced computed tomography showed diffuse dilatation of the small bowel accompanied by a caliber change at the right side of the uterus. She was thus diagnosed with small bowel obstruction due to incarceration through right broad ligament hernia. After bowel decompression, she underwent elective needlescopic surgery using 2- and 3-mm instruments. The defect in the right broad ligament was closed with sutures, and she was discharged 2 days after surgery. In the treatment of broad ligament hernia without bowel ischemia, neither an abdominal incision nor any energy devices are required. In this respect, needlescopic surgery seems to be a promising approach among minimally invasive surgeries.

Integrated mental health care in a multidisciplinary maternal and child health service in the community: the findings from the Suzaka trial.

BACKGROUND: Perinatal mental health problems such as mood disorders are common. We propose a new multidisciplinary health service intervention program providing continuous support to women and their children from the start of pregnancy till after childbirth. The aim of this study was to examine the effects of the program with respect to making women's mental health better in the postpartum period and improving the state of care for women and their children in the perinatal period. METHODS: We performed a controlled study to investigate the effectiveness of the program in Suzaka City, Japan. The women's mental health status was assessed using the Edinburgh Postnatal Depression Scale (EPDS) 3 months postpartum. Of 349 women, 210 were allocated to the intervention group and 139 to the control group. From April 2014 to March 2015, the number of the pregnant women who were followed-up by the multidisciplinary meeting in the intervention and control groups were 60 and 4, respectively. In the same period, the number of the pregnant women who were identified as requiring intensive care were 21 and 2, respectively. RESULTS: The total EPDS score, which was the primary outcome of the present study, differed significantly between the intervention and control groups (Mean [SD] = 2.74 (2.89) and 4.58 [2.62], respectively; p < 0.001). The number of the women receiving counseling from a public health nurse (5.3% in intervention group, 0.7% in control group, p = 0.02), attending maternal seminars (attendant ratio: 46% whereas 16%, p = 0.01), and receiving home visits by public health nurses (home visit ratio: 93.8% whereas 82.6%, p < 0.001) was significantly higher in the intervention group compared to the control group. CONCLUSIONS: The present study indicates that continuum support provided by integrated mental health care through a multidisciplinary maternal and child health service in the community can make women's mental health better in the postpartum period and help women and their children receive more health services from public health nurses. TRIAL REGISTRATION: Name of registry: Research for the effectiveness of a multi-professional health service intervention program of continuum supports for mother and child which starts for pregnancy periods to enhance maternal mental health. UMIN Clinical Trials Registry number: UMIN000032424 . Registration date: April 29th, 2018. Registration timing: retrospective.

Massive chronic irreducible rectal prolapse successfully treated with Altemeier's procedure.

The guideline for the treatment of rectal prolapse recommends that surgeons select appropriate surgical procedures individually based on each patient's overall status. However, in cases of irreducible or incarcerated rectal prolapse, surgical options are quite limited. Here we present a case of an elderly woman with massive chronic irreducible rectal prolapse. An 87-year-old woman presented to our hospital with a complaint of massive rectal prolapse. The prolapsed rectum was over 20 cm long, and completely irreducible. She underwent perineal rectosigmoidectomy with levatorplasty known as Altemeier's procedure. More than 30 cm of rectosigmoid colon was resected. After the operation, rectal prolapse was resolved completely. Her postoperative course was uneventful, and her quality of life and bowel movements improved. She has since been healthy without recurrence for over 2 years. Altemeier's procedure is applicable even in cases of irreducible rectal prolapse and features acceptable safety and a satisfactory outcome.

[An Elderly Case of Recurrent Neuroendocrine Carcinoma of the Stomach Treated with Ramucirumab].

An 84-years-old man underwent total gastrectomy with D1 plus lymph node dissection in December 2015, and diagnosed as Stage III B neuroendocrine carcinoma of the stomach. An abdominal computed tomography revealed swollen paraaortic lymph nodes and left adrenal grand in May 2016. Since his serum level of CA19-9 was elevated, he was thus diagnosed as having recurrence, and was started chemotherapy with ramucirumab(RAM). After introduction of the chemotherapy, his serum level of CA19-9 was decreased gradually and metastatic foci were also decreased in size. Although the patient required relatively longer administration interval according to the severity of general fatigue, he continued the chemotherapy without severe adverse effects until he rejected further treatment in January 2017, and satisfactory therapeutic result was acquired. While the prognosis of gastric neuroendocrine carcinoma is reported to be very poor, no definitive therapeutic guideline is available at present. Especially in elderly patients, we should pay considerable attention to the selection of chemotherapeutic agents because of their own adverse effects. In the present case, RAM could be administered safely, and it seemed that RAM might become a useful therapeutic option for gastric neuroendocrine carcinoma even in elderly patients.

[A Case of Esophageal Gastrointestinal Stromal Tumor Resected by Mediastinoscope-Assisted Transhiatal Esophagectomy].

A 58-year-old man was followed up for esophageal submucosal tumor at our hospital. Esophagogastroduodenoscopy showed the tumor was located on the left side of the thoracic esophagus and had gradually increased in size. Endoscopic ultrasonography revealed an 18×11.5mm hypoechoic tumor connected to the fourth layer of the esophagus and fine needle biopsy revealed c-kit(+), desmin(-)and a-SMA(-). Double-contrast barium study detected a tumor of diameter 20 mm in the middle-lower thoracic esophagus. We diagnosed an esophageal gastrointestinal stromal tumor(GIST)and performed mediastinoscope-assisted transhiatal esophagectomy with gastric tube reconstruction. The maximum tumor diameter was 25mm and pathological evaluation showed c-kit(+), Ki-67 index of less than 5%, and low-risk GIST by the Fletcher classification. Mediastinoscope-assisted transhiatal esophagectomy might be a useful approach for esophageal GIST, because dissection along the esophagus can be performed without thoracotomy.

Is Single-incision Laparoscopic Cholecystectomy Feasible for Acute Cholecystitis? A Consecutive Study of 60 Cases.

The feasibility of single-incision laparoscopic cholecystectomy (SIL-C) for patients with acute cholecystitis were evaluated based on the timing of operation after onset of symptoms. Sixty patients with acute cholecystitis who underwent SIL-C were divided into 2 groups according to the timing of operation: group E included 23 patients who underwent SIL-C within 72 hours, and group O included 37 patients who underwent SIL-C later. There were no statistical differences between group E and group O in clinicopathologic characteristics. Group E demonstrated significantly shorter operating time and less blood loss than group O. Although the incidences of additional port(s) requirements were not significantly different, 8 patients in group O required open conversion, indicating significantly higher rate. As group E demonstrated favorable surgical outcomes compared with group O, SIL-C for acute cholecystitis seems to be a feasible therapeutic procedure when performed within 72 hours as updated Tokyo Guidelines recommended.

Recent advances in photodynamic diagnosis of gastric cancer using 5-aminolevulinic acid.

Photodynamic diagnosis based on 5-aminolevulinic acid-induced protoporphyrin IX has been clinically applied in many fields based upon its evidenced efficacy and adequate safety. In order to establish a personalized medicine approach for treating gastric cancer patients, rapid intraoperative detection of malignant lesions has become important. Feasibility of photodynamic diagnosis using 5-aminolevulinic acid for gastric cancer patients has been investigated, especially for the detection of peritoneal dissemination and lymph node metastasis. This method enables intraoperative real-time fluorescence detection of peritoneal dissemination, exhibiting higher sensitivity than white light observation without histopathological examination. The method also enables detection of metastatic foci within excised lymph nodes, exhibiting a diagnostic accuracy comparable to that of a current molecular diagnostics technique. Although several complicating issues still need to be resolved, such as the effect of tissue autofluorescence and the insufficient depth penetration of excitation light, this simple and rapid method has the potential to become a useful diagnostic tool for gastric cancer, as well as urinary bladder cancer and glioma.

[A Case of Peritoneal Dissemination of Hilar Cholangiocarcinoma Presenting with Hematuria Six Years after Radical Surgery].

A 76-year-old man underwent radical surgery for Stage IV a hilar cholangiocarcinoma in July 2009, and had been followed at an outpatient clinic. Although no apparent recurrent lesion was detected by PET/CT examination, an elevated CA19-9 level was found in January 2014. He was then started on the oral anticancer drug S-1. However, his CA19-9 level increased gradually. The patient presented to a urological department with a complaint of macrohematuria in May 2015. Detailed examination revealed a mass lesion at the top of the urinary bladder, which was suspected to be peritoneal dissemination of the known hilar cholangiocarcinoma invading the urinary bladder wall. Thus, he underwent partial resection of the urinary bladder in July 2015. A histopathological examination of the resected specimen confirmed the diagnosis of recurrence. The patient is nowreceiving chemotherapy with gemcitabine and cisplatin. Detection of recurrences of cholangiocarcinoma is often difficult since the recurrence pattern of cholangiocarcinoma varies widely. However, early detection might enable longterm survival by adequate treatment including chemotherapy. Therefore, thorough multidisciplinary examinations are required when recurrence of cholangiocarcinoma is suspected. In addition, long-term follow-up after radical surgery is required since cholangiocarcinoma sometimes shows slow progression.

[Usefulness of Transumbilical Laparoscopic-Assisted Appendectomy for a Suspected Case of Hydrops Processus Vermiformis].

A-77-year-old man presented to our hospital with high fever and lower abdominal pain. Enhanced CT of the abdomen revealed swelling of the appendix with wall thickening and fluid collection. We diagnosed appendicitis with abscess formation and performed transumbilical laparoscopic-assisted appendectomy after the inflammation improved in response to antibiotics. Operative findings revealed a cystic lesion ofthe appendix and strong adhesion ofthe appendix to the terminal ileum. Based on these operative findings, we changed the operative procedure to a single-incision laparoscopic assisted ileocecal resection because ofthe possibility ofhydrops processus vermiformis. Histopathological findings revealed hyperplasia ofthe glandular epithelium with nuclear enlargement. Mucinous cystadenocarcinoma ofthe appendix was diagnosed. Additional surgery was not performed due to the patient's request. The patient has been free from recurrent disease for approximately 6 months after the surgery. Transumbilical laparoscopic-assisted appendectomy is useful for preventing pseudomyxoma peritonei and easing changes in extended operations for suspected cases of hydrops processus vermiformis.