[A Case of Transverse Colon Cancer with Gastrointestinal Amyloidosis Prevented from Anastomotic Leakage by Multidimensional Approach].

The patient was a 68-year-old woman who was on hemodialysis due to systemic amyloidosis and nephrotic syndrome. Biopsy revealed amyloid deposition in the stomach, duodenum, and colon. A transverse colon tumor was found on a follow- up CT after the aortic dissection surgery. We performed lower gastrointestinal endoscopy and contrast-enhanced CT and diagnosed transverse colon cancer with gastric wall infiltration(cStage Ⅲc). We considered that transverse colon resection was oncologically sufficient. However, due to concurrent gastrointestinal amyloidosis, which increased the risk of anastomotic leakage we performed laparoscopic extended right hemicolectomy to avoid colon-colon anastomosis with partial gastrectomy. Additionally intraoperative indocyanine green(ICG)fluorescence imaging showed that the fluorescence signal in the small intestinal wall was satisfactory, while it was weak in the colon wall. As a result, we suspected of impaired blood flow of colon wall due to an amyloidosis, so we additionally created a loop ileostomy. It is said that gastrointestinal amyloidosis raises the risk of anastomotic leakage. A case of transverse colon cancer complicated by gastrointestinal amyloidosis in which we successfully prevented anastomotic leakage through a multidimensional evaluation and approach is reported, along with a literature review.

A case of laparoscopic sigmoidectomy using thermography for colonic blood flow assessment.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is widely used in gastrointestinal surgery and is considered useful for reducing anastomotic leakage; however, because ICG remains in the tissue for a certain amount of time, we occasionally must re-evaluate colonic blood flow over a short time period during surgery. Herein, we verify the usefulness of thermography (TG) for evaluating colonic blood flow in a patient who underwent a laparoscopic sigmoidectomy for sigmoid colon cancer. CASE PRESENTATION: The patient is 43-year-old man who underwent laparoscopic resection of the sigmoid colon for colon cancer. After vascular treatment of the colonic mesentery, ICG/TG identified the boundary between ischemic and non-ischemic colon tissues. An additional 2 cm of colonic mesentery was resected because of the presence of a diverticulum noted at the intended site of oral anastomosis when attaching the anvil head. After additional vascular treatment of the colonic mesentery and administration of ICG, fluorescence was observed in the colon; however, TG identified the zone of the temperature transition on the surface of the colonic mesentery, even after additional colonic mesentery resection in the same region as previously observed. This zone was used as the cut-off line. There were no complications, such as anastomotic leakage, after the surgery. CONCLUSION: Although accumulation of similar cases is necessary, TG has the potential for use as an auxiliary diagnostic tool in clinical practice. TG can depict the presence or absence of blood flow based on surface temperature without the use of imaging agents, and is inexpensive and easy to perform.

Indications for lateral lymph node dissection in patients with rectal neuroendocrine tumors: A case report and review of the literature.

The optimal surgical indications for small rectal neuroendocrine tumors (NETs) are controversial. Generally, treatment guidelines for rectal NETs >2 cm or with potential lymph node (LN) metastasis recommend formal oncologic low anterior resection (LAR) with total mesorectal excision (TME). However, rectal NETs have the potential to metastasize to the lateral lymph nodes (LLNs). To the best of our knowledge, there are no detailed reports in English on LLN metastasis from rectal NETs. A 47-year-old man diagnosed with a rectal NET underwent endoscopic submucosal dissection (ESD). The pathological diagnosis was NET G1. The tumor was 10 mm in diameter, and the tumor depth reached the submucosal layer. A period of 3 years after ESD, the patient was diagnosed with LN metastasis in the mesorectum and LLN metastasis on the left side from the NET. Robotic TME and bilateral LN dissection were performed. The pathological findings indicated that two of the 18 LNs in the mesorectum were metastatic, and all the LLNs on the left side were negative. In contrast, 1 of the 6 LLNs on the right side was metastatic. Early-stage rectal NETs can metastasize to the LLNs, and it is very difficult to detect LLN metastasis based on size alone. TME alone may be insufficient to treat rectal NETs, and additional LLN dissection may be an important treatment strategy. However, it is increasingly difficult to determine the surgical indications for optimally timed LLN dissection.

Age, blood urea nitrogen, and lactate: Preoperative risk factors of laparotomy for strangulated small bowel obstruction.

INTRODUCTION: Despite increasing reports of laparoscopy for strangulated small bowel obstruction (SSBO), there is no consensus on outcomes in patients with SSBO. We evaluated the safety and utility of laparoscopy for SSBO and investigated the preoperative risk factors for laparotomy. METHODS: This retrospective study included 107 patients who underwent emergency surgery for SSBO over a period of 6 years. Patients' characteristics and surgical parameters were compared between 27 patients undergoing laparoscopy alone (group L) and 80 patients undergoing laparotomy (group O, including conversion). Univariate and multivariate analyses were performed to determine risk factors for laparotomy. RESULTS: Compared with group L, group O had significantly shorter operation time (59 vs 115 minutes, P < .001), shorter postoperative hospital stay (6 vs 10 days, P < .001), and fewer complications (3 vs 40 cases, P < .001). Age ≥ 68 years (odds ratio [OR] 3.970, P = .021), blood urea nitrogen (BUN) ≥ 14.6 mg/dL (OR 4.360, P = .012), and lactate ≥2.80 mmol/L (OR 12.90, P = .023) were independent risk factors for laparotomy. CONCLUSION: Prognosis was better in patients with SSBO undergoing complete laparoscopy than in patients undergoing laparotomy; however, age, BUN, and lactate were independent preoperative risk factors for laparotomy.

Ascending colon cancer accompanied by tumor thrombosis in the superior mesenteric vein: A case report.

INTRODUCTION: Venous tumor thrombosis occasionally accompanies renal cancer, liver cancer, and pancreatic cancer. Colorectal cancer is seldom accompanied by venous tumor thrombosis in the portal vein or the superior or inferior mesenteric veins (SMV, IMV), and little is known about its features. We report a case of ascending colon cancer with tumor thrombosis in the SMV treated with right hemicolectomy and combined resection of the SMV. PRESENTATION OF CASE: An 82-year-old man with chief complaints of loss of appetite was admitted to our hospital. He was diagnosed with ascending colon cancer accompanied with tumor thrombosis extending to the SMV. He underwent right hemicolectomy and combined resection of the tumor thrombosis and the SMV. Intestinal blood flow was evaluated by intraoperative indocyanine green (ICG) fluorography. He continued to recover well from surgery. No adjuvant chemotherapy was employed because of the patient's advanced age and his own will. He was transferred to another hospital on postoperative day 39. Six months after surgery, abdominal CT showed multiple liver metastases. He died 8 months after surgery. DISCUSSION AND CONCLUSIONS: Radical resection of the primary tumor and surgical thrombectomy should be considered for the treatment of colorectal cancer without distant metastasis accompanied by tumor thrombosis. However, venous tumor thrombosis is representative of an aggressive cancer and that may be a strong risk factor for the development of liver metastasis. Adjuvant systematic chemotherapy in addition to complete surgical resection may be one of the treatment strategies.

Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study.

PURPOSE: The success rate of nonoperative management (NOM) of traumatic liver injury is approximately 90%. Although NOM has become the standard treatment when patients' vital signs are stable, open surgical hemostasis is often selected when these signs are unstable. At our hospital, we extensively use NOM along with transcatheter arterial embolization (TAE) to treat patients with severe abdominal trauma, as per our original protocol. We also apply NOM for severe liver injury with unstable hemodynamics. This retrospective study aimed to investigate the efficacy of NOM for blunt liver injury in hemodynamically stable and unstable patients. METHODS: We retrospectively examined 23 patients with severe liver injuries who underwent NOM after visiting our emergency outpatient department between 2007 and 2017. Patients were assigned to either the stable group with stable hemodynamics or the unstable group with unstable hemodynamics. RESULTS: The stable group comprised 13 patients, and the unstable group comprised 10 patients. All patients underwent TAE. While all patients in the stable group were discharged alive, one patient in the unstable group died during the hospital stay. The response rate to NOM was 90%, and no patient switched from NOM to open surgery. A higher rate of complications with a significantly longer average stay in the intensive care unit was observed in the unstable group. CONCLUSIONS: Even in the unstable group, NOM with TAE performed under careful general management facilitated avoidance of open surgery and provided high survival rates.

Sigmoid gallstone ileus: A case report and literature review in Japan.

INTRODUCTION: Gallstone as a cause of bowel obstruction is rare, and its occurrence in the colon is very infrequent. Here, we report the case of sigmoid gallstone ileus treated with one-stage operation. CASE PRESENTATION: A 65-year-old man visited our hospital because of abdominal pain and nausea. On the basis of the results of computed tomography, the patient was diagnosed with sigmoid gallstone ileus through cholecystocolonic fistula, and an emergency laparotomy was performed. Enterolithotomy, cholecystectomy, and fistula closure were performed in one-stage operation. Postoperatively, the patient developed biliary leakage, which rapidly recovered with conservative therapy. DISCUSSION AND CONCLUSION: The surgical treatment of gallstone ileus remains controversial. For postoperative infection control, one-stage operation can be considered for patients with gallstone ileus associated with cholecystocolonic fistula.

A rare case of secondary small bowel volvulus laparoscopically repositioned: literature review and classification.

BACKGROUND: Secondary small bowel volvulus is a rare condition caused by adhesions after laparotomy or tumors. There are no clear guidelines for indication of laparoscopic surgery. CASE PRESENTATION: A 69-year-old male visited our hospital complaining of epigastric pain. He had a history of hypopharyngeal carcinoma treated via pharyngolaryngoesophagectomy with restoration of esophageal continuity by harvesting a free jejunal autograft 6 years ago. Enhanced computed tomography revealed the whirl sign. An emergency laparoscopic operation was performed following a diagnosis of small bowel volvulus. This revealed rotation of the whole small bowel, involving the superior mesenteric artery as the center, and originating at the adhesion of the proximal and distal small bowel. Laparoscopic manipulation of volvulus and lysis of the adhesion were performed. The patient's postoperative course was uneventful, and he was discharged on hospital day 5. CONCLUSIONS: Laparoscopic surgery may be useful for treating small bowel volvulus; however, the patient's treatment indications should be judged carefully.

Paracecal hernia with intestinal ischemia treated with laparoscopic assisted surgery.

INTRODUCTION: Paracecal hernia is rare, and strangulation with ischemia has been infrequently observed in the limited number of published reports on paracecal hernias. PRESENTATION OF CASE: We describe a case of an incarcerated paracecal hernia with resultant ischemic bowel that was successfully treated with laparoscopic-assisted surgery. A 54-year-old man who had not undergone any surgery previously presented to our hospital with abdominal pain and vomiting. An abdominal computed tomographic scan showed evidence of an intestinal obstruction at a paracecal site. An emergency laparoscopic surgery demonstrated incarceration of a loop of the small bowel in the paracecal fossa. We removed the incarcerated small bowel from the paracecal fossa, noted that the tissue was necrotic, and resected this segment of bowel through a mini-laparotomy incision. The patient was discharged on the 13th postoperative day. DISCUSSION AND CONCLUSION: This case is unique in that the patient presented with small bowel strangulation, causing intestinal ischemia. Laparoscopic surgery is useful in the diagnosis of internal hernias and is also useful for the treatment of small bowel obstruction due to paracecal hernias complicated by ischemic bowel.