Hand-assisted laparoscopic surgery on a gigantic primary retroperitoneal mature cystic teratoma: A case report.

INTRODUCTION: Primary teratomas in the retroperitoneum are rare, incidentally identified in children, and resected using a laparoscopic approach. However, when it increases in size, the laparoscopic approach is technically demanding, leaving a large skin incision for tumor removal. PRESENTATION OF CASE: The patient was a 20-year-old woman who presented with chronic left flank pain. Abdominal and pelvic computed tomography (CT) revealed a 25-cm wide giant polycystic and solid retroperitoneal tumor containing calcification located in the upper portion of the left kidney, strongly compressing the pancreas and spleen. No other metastatic lesions were observed. Additionally, abdominal magnetic resonance imaging (MRI) revealed that the polycystic tumor consisted of serous fluid and fatty components, and bone and tooth components were found in the tumor center. Therefore, the patient was diagnosed with retroperitoneal mature teratoma and a hand-assisted laparoscopic surgery using bikini line skin incision was performed. The specimen was 27 × 25 cm in size, weighing 2512 g. Histology revealed that the tumor was a benign, mature teratoma without a malignant component. The postoperative course was uneventful and the patient was discharged on postoperative day 7. The patient remained healthy without any recurrence and the postoperative scar is barely visible under direct vision. DISCUSSION: Primary retroperitoneal mature teratomas can enlarge without initially causing symptoms and can be incidentally identified using imaging studies. CONCLUSION: A hand-assisted laparoscopic approach using a bikini line skin incision is safe, minimally invasive, and provides better cosmesis.

[A Case of Goblet Cell Adenocarcinoma Incidentally Diagnosed after Appendectomy That Required Additional Bowel Resection with Lymph Nodes Dissection].

A 54-year-old male presented to the clinic, complaining of dull lower abdominal pain that started a day ago. There was a tenderness on right lower quadrant on palpation and abdominal computed tomography(CT)showed that dilated appendix with a diameter of 12 mm. The patient was diagnosed with acute appendicitis and laparoscopic appendectomy was performed on the same day. The tip of the appendix was swollen and looked purple, gangrenous appendicitis findings were identified. However, histopathology detected GCA on resected appendix with positive surgical margin and additional tumor resection was indicated. Laparoscopic ileocecal resection with D3 lymph nodes dissection was performed 24 days after the first surgery. Resected specimen showed that the stump of the appendix was palpable as a mass in the orifice of the appendix and histopathology revealed the remnant of the appendiceal GCA. No lymph nodes tumor metastasis was identified. Chromogranin A and synaptophysin were positive and Ki-67 was approximately 50%. According to the guideline of neoadjuvant chemotherapy for colon cancer, oral 5-fluorouracil therapy was performed for half a year after the second surgery and the patient remains still healthy without recurrence 1 year after the surgery. Here, we experienced a rare case of GCA of the appendix that was detected incidentally after appendectomy for acute appendicitis.

[A Case of Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma Causing Perforation of the Small Intestine].

Monomorphic epitheliotropic intestinal T-cell lymphoma(MEITL)is very rare and aggressive subtype of lymphoma with poor prognosis. A 60-year-old man complaining of abdominal pain was underwent partial resection of the jejunum for panperitonitis with a small intestinal perforation. The histopathological and immunohistochemical findings led to the diagnosis of MEITL. Postoperative course was uneventful. One month after the operation, the patient was scheduled for 6 courses of CHOP regimens. He presented with bowel obstruction twice during the 3 courses of CHOP. As the recurrence of MEITL could not be ruled out, diagnostic laparoscopy was performed. Laparoscopic findings revealed no recurrence and adhesive small bowel obstruction. The patient was followed closely without treatment after 6 courses of CHOP. The patient has been alive without recurrence 18 months after the resection. We reported a case of monomorphic epithelial intestinal T- cell lymphoma causing jejunal perforation.

[A Case of Type 4 Gastric Cancer with Peritoneal Dissemination Successfully Treated with Conversion Surgery after Intensive S-1 plus Oxaliplatin Chemotherapy].

S-1 plus oxaliplatin(SOX)chemotherapy is now widely used for the treatment of unresectable gastric cancer but there are few case reports about conversion surgery following SOX. Hereby, we report a case of type 4 gastric cancer with peritoneal dissemination successfully treated with conversion surgery after intensive SOX chemotherapy. A 69-year-old female was diagnosed of type 4 gastric cancer by upper endoscopy(por1, HER2 negative)and peritoneal disseminations were identified on left diaphragm and mesentery under direct vision. After 11 courses of SOX chemotherapy, CT revealed that primary tumor markedly decreased in size. Therefore, staging laparoscopy was performed and peritoneal disseminated lesions disappeared. Peritoneal cytology also turned negative. Subsequently, total gastrectomy and splenectomy were performed. Histology revealed that tumor was categorized as por2, ypT2N3M0, ypStage ⅢA, and Grade 2 in histological evaluation criteria. SOX was continued as an adjuvant chemotherapy for another 6 months and the patients remain healthy without recurrence. Unresectable gastric cancer with peritoneal dissemination can be successfully treated with conversion surgery following SOX chemotherapy and staging laparoscopy was useful to evaluate peritoneal dissemination. When conversion surgery is indicated for gastric cancer with peritoneal dissemination, downstaging should be confirmed by staging laparoscopy.

[A Case of Multiple Metachronous Metastases from Hepatocellular Carcinoma to Thoracic Spine and Right Adrenal Invading Right Kidney with Tumor Thrombus in the Inferior Vena Cava That Was Treated with Chemotherapy, Radiotherapy, Intravascular Therapy, and Surgery].

For extrahepatic recurrence after primary hepatocellular carcinoma resection, molecular targeted therapy is the first- choice and no consensus is reached on the indication of surgical resection of extrahepatic metastasis. However, when the extrahepatic lesion extends to vena cava, tumor thrombus can cause acute pulmonary embolism that can lead to fatal consequences. Here, we experienced a case of multiple metachronous metastases from hepatocellular carcinoma to thoracic spine and right adrenal invading right kidney with tumor thrombus in the inferior vena cava. Local radiation therapy to thoracic vertebra, molecular targeted therapy, and transcatheter arterial chemoembolization were performed but tumor thrombus still occluded vena cava. Therefore, to prevent pulmonary embolism and to bridge to immunotherapy, right adrenalectomy, right nephrectomy, thrombectomy and replacement of inferior vena cava were performed. The patient remains healthy 6 months after the surgery and still receiving immunochemotherapy.

Hybrid laparoscopic pancreas-preserving subtotal duodenectomy for suspected early duodenal cancer: A case report.

INTRODUCTION: Non-ampullary duodenal adenomas rarely show malignant potential. However, such adenomas located in the periampullary area are suspected of being malignant and require surgical treatment. PRESENTATION OF CASE: A 75-year-old man presented with a 30-mm wide, endoscopically-unresectable laterally spreading tumor in the periampullary area. Biopsy showed a tubular adenoma; however, the size and color of the tumor strongly suggested malignancy. Therefore, a hybrid laparoscopic pancreas-preserving subtotal duodenectomy (HLPPSD) was performed. Laparoscopically, a Kocher maneuver was performed. The jejunum was divided 10 cm distal to the ligament of Treitz, and the duodenum was also divided at the supraduodenal-angle. The Shuriken method was applied, and the surgery converted to an open procedure. The common bile and pancreatic ducts were divided, and the subtotal duodenum and 10 cm of the jejunum were removed. Thereafter, the jejunal stump was hand-sutured to the duodenal stump. Cholangiojejunostomy and pancreatojejunostomy were performed under direct vision. Finally, an umbilicoplasty was performed. The histology revealed that the tumor was a carcinoma in situ. DISCUSSION: Endoscopic resection is the first-choice for duodenal adenoma suspected of malignant potential. When the endoscopically-unresectable tumor is located in periampullary area, pancreatoduodenectomy is generally selected because ampulla cannot be preserved. However, HLPPSD is an alternative option. CONCLUSIONS: Non-ampullary duodenal adenomas can be malignant when the tumor is large and red. In these cases, HLPPSD can be useful; less invasive than conventional pancreaticoduodenectomy; leaves only a 3-cm, round scar, in addition to the laparoscopic port scars; and combines the benefits of both open and laparoscopic surgeries.

[A Case of Solitary Right Adrenal Metastasis from Rectal Cancer].

An 86-year-old woman underwent laparoscopic high anterior resection for RS rectal cancer. Histological examination showed tub2-por, pT3, pN2a, Stage ⅢB disease. Given the age of the patient, adjuvant chemotherapy was not administered. Five months after the surgery, her carcinoembryonic antigen(CEA)level was elevated and a 42×25mm mass was detected in the right adrenalby computed tomography(CT). Metastasis from rectalcancer was suspected but no other lesions were detected by positron-emission tomography(PET)-CT. Nine months after the surgery, laparoscopic right adrenalectomy was performed. Histological examination revealed that the right adrenal tumor had moderately-differentiated adenocarcinoma very similar to the primary rectalcancer; therefore, the right adrenall esion was diagnosed as metastasis from the previous rectalcancer. The tumor marker levelreturned to normall evelafter the second surgery. The patient was discharged on the 8th post-operative day but declined adjuvant chemotherapy due to her age. Six months later, liver, lung, and peritoneal metastasis were identified by CT. We report this case of solitary adrenalmetastasis from rectalcancer resected by laparoscopic right adrenalectomy.

[Surgical Treatment Outcome of Patients with Colorectal Cancer Having Ulcerative Colitis].

This study aimed to evaluate the surgical treatment outcome of patients with colorectal cancer having ulcerative colitis (UC). METHODS: We examined 112 patients who underwent the surgery from 1998 to 2016. Among the 112 patients, 14 were complicated with malignant tumor(9 with colorectal cancer and 5 with dysplasia-assciated lesion or mass)We performed group comparison between patients with(group A)and without(group B)colorectal cancer. RESULTS: The median age in group A was 58.1 years, which was significantly older than that in group B. The duration of disease in group A was 13.2 years, which was significantly longer than that in group B. Surgical procedures in group B were as follows; 5 cases had ileoanalanastomosis (IAA), 4 cases had ileo-analcanalanastomosis (IACA), 2 cases had ileorectal anastomosis(IRA), and 1 case had interspincteric resection(ISR) and abdominoperinealresection (APR)Laparoscopic sigmoid colectomy was performed in a patient aged 52 years because he was diagnosed with sporadic sigmoid colon cancer. Periodic endoscopic screening was not performed in 5 patients with pT2 colorectalcancer in group B. endoscopic submucosaldissection (ESD)was performed in 2 patients aged>70 years with rectal pTis cancer. CONCLUSION: Elderly patients with UC were often complicated with colorectalcancer, and these patients are indicated for surgicalprocedures other than IAA to preserve defecation function. Patients with UC should undergo periodic endoscopic screening for early detection of malignant tumor and definitive surgicalresection.

[A Case of Metachronous Ascending Colon Metastasis from Gastric Cancer That Was Difficult to Diagnose].

A 60s man with a history of laparoscopic distal gastrectomy(LDG)of gastric cancer in January 2015was followed up in an outpatient clinic. He remained healthy without recurrence for about 2 years, but in February 2017, colonoscopy identified an elevated lesion that covered one-third of the circumference in the ascending colon. Biopsy revealed that this lesion had poorly differentiated adenocarcinoma. No other metastatic lesions were noted on thoraco-abdominal CT, and tumor markers were not elevated in a blood test. Right hemicolectomy with D3 nodal dissection was performed on March 2017. Although regional lymph node metastasis was noted during surgery, distant metastasis was not identified. Histological examination revealed that the ascending colon tumor had poorly differentiated adenocarcinoma very similar to that of the primary gastric cancer, and the lesion was diagnosed as metastasis from previous gastric carcinoma. Pathological findings showed pPM0, pDM0, pRM0, pCY0, and definitive surgical treatment was confirmed. However, 2 months after the surgery, ascites caused by peritoneal and bilateral supraclavicular lymph node metastases were detected on CT. He passed away 6months after the last surgery. We report a case of metachronous ascending colon metastasis from gastric cancer that was difficult to preoperatively diagnose.

[Assessment of Long-Term Sexual Function after Radical Resection for Lower Rectal Cancer].

The aim of this study was to evaluate the long-term sexual function and risk factors of dysfunction after the autonomic nerve preserving operation for lower rectal cancer. METHODS: We evaluated postoperative sexual function assessed by IIEF5 in 91 patients who responded to the questionnaire by mail. RESULTS: After a median follow-up of 5.5 years, univariate analysis identified 4 risk factors associated with poor sexual function: the elder, over 3 years after surgery, pathological stage III , and lateral lymph node dissection(both side). Poor sexual function assessed by multivariate analysis was significantly associated with the elder(over 60 years). CONCLUSION: From the viewpoint of sexual dysfunction, the autonomic nerve preserving operation( AN4)should be considered for elderly people.

[Assessment of Functional Results after Sphincter-Preserving Surgery in Elderly Patients with Low Rectal Cancer].

The aim of this study was to evaluate postoperative dysfunction and potential problems after a sphincter-preserving operation in elderly patients with low rectal cancer. METHODS: Between 2000 and 2012, 307 consecutive patients with low rectal cancer underwent curative sphincter-preserving surgery. We evaluated postoperative anal and urinary dysfunction in 190 patients who responded to a questionnaire by mail. RESULTS: After a median follow-up of 5.7 years, there was no significant difference between the elderly and a younger group in the Wexner incontinence score. Poor anal function assessed by modified FIQL was significantly associated with the elderly. Poor urinary function assessed by the IPSS score was significantly associated with the elderly, diabetes mellitus, and autonomic nerve preservation(AN2-3). CONCLUSION: From the viewpoint of urinary function, sphincter-preserving surgery with all autonomicnerve preservation(AN4)should be considered for elderly people and patients with diabetes.

[Regrowth of Isolated Local Residual Tumor Effectively Treated with Chemoradiotherapy More Than Five Years after a Resection for Pancreatic Cancer with an Involvement of the Portal Vein].

A 55-year-old man who presented with abdominal pain was diagnosed with pancreatic head cancer involving the portal vein. He underwent pylorus-preserving pancreaticoduodenectomy without a resection of the portalvein, resulting in a macroscopic residualtumor, because radicalresection was impossible owing to the severe localinvasion. Postoperative chemotherapy( GEM plus S-1)was administered. The tumor size decreased and CA19-9 values normalized. Five years after the resection, chemotherapy was stopped. The regrowth of an isolated local residual tumor without a distant metastasis was diagnosed 65 months after the resection. He underwent chemoradiotherapy(CRT)with S-1. The size of the tumor remained stable, but FDG-PET demonstrated a disappearance of high FDG uptake in the tumor and CA19-9 values normalized. We reported a case in which CRT was an effective treatment for the regrowth of localresidualtumor after resection for pancreatic cancer.

Video. Advantages of the laparoscopic approach for intersphincteric resection.

BACKGROUND: Intersphincteric resection (IRS) is a surgical technique used to preserve sphincter function, mainly cases of low rectal cancer located less than 5 cm from the anal verge [1, 2]. There have been reports of laparoscopic ISR [3, 4], but discussion of the specific techniques used in this laparoscopic surgical procedure have not been sufficient. For better outcomes of this sophisticated procedure, extreme care must taken to prevent perforation of the rectal wall and to preserve the external sphincter muscle. The most difficult steps for ISR are the circular dissection and separation of the internal sphincter muscle from the external sphincter and puborectalis using the perineal approach. The authors' techniques and the advantages of laparoscopic ISR are shown by a video presentation of three rectal tumor cases. Also, the perioperative outcomes for the patients who underwent laparoscopic ISR with this technique are described. METHODS: From January 2006 to September 2009, laparoscopic ISR with total mesorectal excision was performed for 15 patients (10 men and 5 women). The median age of the patients was 60.5 years. The T categories of the tumor node metastasis (TNM) classification for the rectal cancers were Tis for two patients, T1 for one patient, T2 for four patients, and T3 for eight patients. The median distance from the anal verge to the tumor in this series was 3.7 cm. The Tis cases had large laterally spreading tumors that could not be removed by endoscopic submucosal dissection. The T1 case presented in the video had a small tumor just above the dentate line that had developed in the presence of chronic ulcerative colitis. Because this case required total proctocolectomy and ileal pouch anal anastomosis, local resection was not used (Table 1). Table 1 Patients' clinical characteristics (2006.1-2009.8) No. of patients: 15 Gender (M/F):10/5 Age: years (range): 60.5 (31-75) pT*: Tis (n=2), T1 (n=1), T2 (n=4), T3 (n=8) Distance from anal verge: cm (range): 3.7 (2-5) * Pathological T categories of the tumor node metastagis (TNM) classification CASES: The 68-year-old man in case 1 had a large, laterally spreading rectal tumor. The 61-year-old man in case 2 had rectal cancer, with a tumor located 4 cm from the anal verge. Laparoscopic surgery was performed after neoadjuvant chemoradiotherapy. The 71-year-old woman in case 3 had T1 rectal cancer, with a tumor located just above the dentate line. After dissection of the intersphincteric space, the prolapsing technique was used. METHODS: In the male patients, the rectum with the mesorectum was first dissected to the anal hiatus, initially on the posterior side along the avascular plane. Second, Denonvilliers' fascia was dissected, and the seminal vesicle was exposed. The third step was dissection of the lateral tissues followed by incision of Denonvilliers' fascia with the rectal wall exposure and care taken not to injure the neurovascular bundle (Fig. 1). Along this dissection plane, the puborectalis could be reached and intersphincteric space entered from the lateral side of the rectal wall (Fig. 2). The final step was dissection of the hiatal ligament at the posterior side of the rectum. Nearly circular dissection of the intersphincteric space could be completed. The difficulties associated with the perineal approach were reduced by this abdominal approach, and the tumor could be exteriorized easily. Fig. 1 After incission of the Denonvilliers' fascia at the lateral side of the seminal vesicle puborectalis muscle can be reached at the lateral side of the rectum. Fig. 2 Adhesion line between the puborectalis muscle and rectal wall is enposed. Intersphinecteric space can be entered along this dissection plane at the lateral side of the rectum. RESULTS: The mean duration of surgery was 386 min, and the mean blood loss was 108 ml. The mean postoperative hospital stay was 18 days. The diverting ileostomy was closed at a mean of 7.3 postoperative months. No remarkable perioperative complication was encountered (Table 2). Table 2 Perioperative outcomes (n=15) Duration of surgery: min (range) 386 (319-510) Blood loss: ml (range) 108 (0-180) Postoperative hospital stay: days (range) 18 (11-31) COMPLICATIONS: n (range) Anastomotic leakage 1 Stricture of the anastomosis 1 Pelvic abscess 1 Postoperative period until the stoma closure (months) 7.3 (3-16) CONCLUSION: Laparoscopic ISR enabled reduction of the difficulties associated with the perineal approach. An advantage of laparoscopic ISR is the ability clearly to visualize anatomic structures in the deep pelvic cavity.