Next-Generation Sequencing for Non-Ampullary Duodenal Carcinoma Suggesting the Existence of an Adenoma-Carcinoma Sequence.

Duodenal tumors with a sporadic adenoma-carcinoma sequence are extremely rare. For such clinically suspected cases without a specific family history, performing a comprehensive gene search is important to understand the germline mutation background. We present a 68-year-old woman without a genetic or familial history of familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome, or Lynch syndrome who presented to Kosei Hospital, Japan, with exertional dyspnea induced by abdominal pain lasting 3 weeks. A duodenal tumor was suspected by contrast-enhanced computed tomography. Esophagogastroduodenoscopy showed a lesion accompanied by a white microprotuberance on the descending part of the duodenum opposite the papilla, with a giant ulcerative lesion at the center of the white lesion. Biopsy revealed a low-grade adenoma, high-grade adenoma, and adenocarcinoma. Immunohistochemical analysis of the adenoma and adenocarcinoma showed Ki-67, p53, cytokeratin 20, caudal-type homeobox 2, and carcinoembryonic antigen positivity and cytokeratin 7 negativity. The findings suggested the presence of an adenoma-adenocarcinoma sequence in duodenal carcinoma. However, in the mutational analysis using next-generation sequencing, c.4348C>T (p.Arg1450Ter) mutation in APC was detected in all normal mucosal, adenoma, and carcinoma tissues. This mutation is common in FAP patients. Even if the presence of an adenoma-adenocarcinoma sequence in duodenal carcinoma is suggested in cases without a familial FAP history, as in this case, genetic analysis may reveal FAP. Thus, performing a comprehensive genetic analysis of duodenal carcinoma patients with a possible adenoma-carcinoma sequence is necessary to explore their genetic background.

Ascending Colon Schwannoma Surgically Treated after Accurate Preoperative Diagnosis.

Colorectal schwannomas are rare and usually benign gastrointestinal mesenchymal tumors. However, these tumors are often overtreated, possibly owing to misleading malignant potential. To our knowledge, there have been no previous reports of ascending colon schwannoma preoperatively diagnosed as benign schwannoma. Herein, we report a case of ascending colon schwannoma accurately diagnosed by endoscopic biopsy and successfully treated by wedge resection. The patient was a 76-year-old woman with complaints of bloody stool. She had no relevant past medical history. Radiological findings revealed a protruded mass in the ascending colon, and colonoscopy revealed a submucosal tumor measuring approximately 3 cm in diameter with a reddish and uneven surface. Histological and immunohistochemical analysis for vimentin and S100 protein of the specimen obtained by endoscopic biopsy confirmed the diagnosis of schwannoma. Thus, we performed laparoscopy-assisted endoscopic full-thickness resection of the ascending colon wall, as appropriate for a benign soft tissue tumor. The postoperative course has been uneventful for 2 years. This case demonstrates that colonic schwannoma can be successfully treated with adequate resection if an accurate preoperative diagnosis is made, thereby avoiding overtreatment, such as surgery for colorectal tumor including lymph node dissection. Preoperatively diagnosed schwannomas should be treated by wedge resection, with postoperative pathological findings confirming the presence or absence of malignancy. Additional resection should be considered for very rare cases of coexisting malignant tissue.

Xenopericardial roll graft replacement for infectious pseudoaneurysms and graft infections of the aorta.

BACKGROUND: Which graft material is the optimal graft material for the treatment of infected aortic aneurysms and aortic graft infections is still a matter of controversy. Orthotopic aortic reconstruction with intraoperatively prepared xenopericardial roll grafts without omentopexy was performed as the "initial" operation to treat aortic infection or as a "rescue" operation to treat graft infection. Mid-term outcomes were evaluated. METHODS: Between 2009 and 2013, orthotopic xenopericardial roll graft replacement was performed to treat eight patients (male/female: 6/2; mean age: 69.5 [55-80] yr). Graft material: equine/bovine pericardium: 2/6; type of operation: initial 4/rescue 4; omentopexy 0. Additional operation: esophagectomy 2. Mean follow-up period: 2.6 ± 1.6 (1.1-5.1) years. RESULTS: Replacement: ascending 3, arch 1 (reconstruction of neck vessels with small xenopericardial roll grafts), descending 3, and thoracoabdominal 1. Pathogens: MRSA 2, MSSA 1, Candida 1, E. coli 1, oral bacillus 1, and culture negative 2. Postoperative local recurrence of infection: 0. Graft-related complications: stenosis 0, calcification 0, non-infectious pseudoaneurysm of anastomosis 2 (surgical repair: 1/TEVAR 1). In-hospital mortality: 2 (MOF: initial 1/rescue 1); Survival rate exclusive of in-hospital deaths (~3 y): 100 %, but one patient died of lung cancer (3.6 yr). CONCLUSIONS: Because xenopericardial roll grafts are not composed of synthetic material, the replacement procedure is simpler and less invasive than the standard procedure. Based on the favorable results obtained, this procedure may have the possibility to serve as an option for the treatment of aortic infections and aortic graft infections not only as a "rescue" treatment but as an "initial" treatment as well.

Single-incision multiport laparoendoscopic surgery using a short-type flexible endoscope and its usefulness in cholecystectomy.

INTRODUCTION: We previously demonstrated the advantages of a short-type flexible endoscope as a working scope in laparoscopic surgery through single-incision procedures in animal experiments. In this report, we examined the outcomes of laparoscopic surgery through a single incision using a flexible endoscope in a clinical setting. Specifically, we performed cholecystectomy using single-incision multiport laparoendoscopic (SIMPLE) surgery. METHODS: Thirteen patients with cholecystolithiasis or gallbladder polyp underwent SIMPLE cholecystectomy using a newly developed short-type flexible endoscope with a working length of 60 cm. Twenty-seven patients underwent standard single-incision laparoscopic cholecystectomy using a 5-mm rigid laparoscope. We retrospectively compared the surgical outcomes between the two groups. RESULTS: SIMPLE cholecystectomy using the short-type flexible endoscope was successfully carried out. No gallbladder perforation occurred, but perforation occurred in four cases in the standard laparoscopic cholecystectomy group; however, the difference was not statistically significant. Although no other surgical outcomes differed between the two groups, the flexible endoscope had several advantages over the standard laparoscope. The scope provided a flexible view of the operating field. The gallbladder dissection using the cutting device via the scope was easier and safer than that in standard single-incision laparoscopic cholecystectomy. The water-jet, suctioning, and self-cleaning lens functions of the scope served the surgery well. CONCLUSIONS: SIMPLE cholecystectomy using a short-type flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but this endoscope with multiple functions may make the surgical procedures less stressful and safer.

Inflammatory mass formation caused by gastric ectopic pancreas: report of a case.

Ectopic pancreas is a relatively rare condition that only occasionally causes the development of symptoms. This report presents a case of ectopic pancreas presenting as an inflammatory mass that formed in the gastric wall, which was successfully treated by surgical resection. A 32-year-old female was admitted due to a 3-year history of recurrent episodes of upper abdominal pain. Contrast-enhanced computed tomography showed an irregularly enhanced mass of heterogeneous density in the gastric antrum. Gastroscopy revealed a submucosally elevated mass with a central umbilication in the gastric antrum. These studies indicated the presence of a 3-cm ectopic pancreas associated with inflammatory changes. The patient underwent laparoscopic local resection of the stomach. Microscopic examination of the lesion revealed heterogenic pancreatic tissue containing islets, dilated pancreatic ducts, and massive fibrosis in the gastric wall, with acinar atrophy and inflammatory cell infiltration. These findings indicated the formation of an inflammatory mass in the ectopic pancreas.

Long-term outcomes of combination of endoscopic submucosal dissection and laparoscopic lymph node dissection without gastrectomy for early gastric cancer patients who have a potential risk of lymph node metastasis.

BACKGROUND: Our recently developed procedure, a combination of endoscopic submucosal dissection (ESD) and laparoscopic lymph node dissection (LLND), may lead to the elimination of unnecessary gastrectomy in early gastric cancer (EGC) patients having a potential risk of lymph node metastasis (LNM). OBJECTIVE: To examine the long-term outcomes of the combination of ESD and LLND. DESIGN: A retrospective study using consecutive data. SETTING: Single academic center. PATIENTS AND INTERVENTIONS: Twenty-one EGC patients having a potential risk of LNM were treated by ESD followed by LLND. MAIN OUTCOME MEASUREMENTS: Long-term outcomes of the combination of ESD and LLND. RESULTS: The histopathological examination of the dissected lymph nodes confirmed the absence of LNM in 19 of the 21 patients. Two patients who had LNM were followed without any additional surgery in accordance with the patients' wishes. During the median follow-up of 61 months, all of the patients were alive without any recurrent disease. Two patients (10%) had symptoms such as abdominal distention and belching, which were associated with disturbed gastric emptying between meals. Endoscopic examination 2 years postoperatively revealed food residue problems in 3 patients (15%). However, the preoperative quality of life was restored with no dietary restrictions, and body weight was well maintained in all of the patients. LIMITATIONS: A retrospective study with a small number of patients. CONCLUSIONS: The combination of ESD and LLND can be an effective, minimally invasive treatment that maintains long-term quality of life for selected EGC patients having a potential risk of LNM.

Surgical indications and procedures for bleeding peptic ulcer.

Recent important insights into the surgical treatment of bleeding peptic ulcer are reviewed in this article. Although the widespread use of endoscopic treatment and interventional radiology has reduced the number of surgical cases, surgery still plays a pivotal role in managing bleeding peptic ulcer. Failure to stop the bleeding by endoscopy and/or interventional radiology is the most important indication for emergency surgery. An early elective/planned surgery after the initial endoscopic control to prevent life-threatening rebleeding seems justified in patients who have risk factors for rebleeding, although its true efficacy still remains controversial. The surgical procedures in emergency situations should be limited to safe hemostasis. The addition of acid-reduction surgery may be unnecessary as a result of the increasing utilization of proton pump inhibitors. Angiographic embolization may be a less invasive alternative to surgery, and may further enhance endoscopic hemostasis.

Secure placement of a peripancreatic drain after a distal pancreatectomy.

BACKGROUND: A peripancreatic drain that is placed after a distal pancreatectomy sometimes migrates and becomes ineffective postoperatively. We devised a new drainage method with fixation of the tip of a peripancreatic drain using a loose loop of an absorbable suture. METHODS: This retrospective study was performed on 84 consecutive patients who underwent a distal pancreatectomy followed by peripancreatic drainage with (n = 31) or without (n = 53) fixation. RESULTS: The fixed drain remained in place postoperatively and was removed easily when the drainage became unnecessary. Pancreatic fistula developed in 4 patients with and 11 patients without drain fixation, the incidence between the patients. None with and 7 patients without fixation required additional drainage (interventional or surgical) for pancreatic fistula, the difference being significant. Time to resolution of pancreatic fistula tended to be shorter after drain fixation than after nonfixation. CONCLUSIONS: Fixation of the tip of a peripancreatic drain is a simple but useful technique for effective drainage after distal pancreatectomy.

Single-port endoscopic cholecystectomy: a bridge between laparoscopic and translumenal endoscopic surgery.

BACKGROUND AND OBJECTIVE: The intentional puncture of the normal viscera is likely the most important issue limiting the widespread use of natural orifice translumenal endoscopic surgery (NOTES). We developed a new procedure for cholecystectomy using a flexible endoscope via a single port placed in the abdominal wall without visceral puncture (single-port endoscopic cholecystectomy; SPEC) as a bridge between laparoscopic surgery and NOTES. This study aimed to evaluate the technical feasibility of SPEC. METHODS: Five pigs were subjected to SPEC. An endoscope was inserted through a 12-mm port placed in the right upper abdomen. After grasping and retracting the gallbladder using a 2-mm retractor that was directly introduced into the peritoneal cavity, gallbladder excision with ligation of the cystic artery and duct using endoclips was carried out. RESULTS: A complete gallbladder excision was carried out easily and safely in all cases. No major adverse events occurred. The mean operating time was 67 min (range 52-84 min). CONCLUSIONS: SPEC is a technically feasible procedure. It is simpler, easier, and safer than NOTES cholecystectomy. SPEC could be a less invasive alternative to the conventional four-port laparoscopic cholecystectomy.

Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor.

BACKGROUND AND OBJECTIVE: Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients. METHODS: Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect. RESULTS: LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients. CONCLUSIONS: LAEFR may be considered one of the so-called hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.

Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels.

BACKGROUND/PURPOSE: Pancreatic fistula, which is one of the main causes of late postpancreatectomy hemorrhage (PPH), is a common complication of pancreatoduodenectomy (PD). It may erode the anastomosis site and vascular wall in its vicinity, resulting in pseudoaneurysm formation and/or the rupture of major vessels. To protect the vessels near the area for pancreaticojejunostomy from potential pancreatic fistula, we have adopted a surgical option by which such vessels are separated from the pancreaticojejunostomy using a pedicled falciform ligament. We reviewed 36 patients who underwent PD that included this option. METHODS: After the PD was completed (before reconstructions), the pedicled falciform ligament was spread widely on the major vessels exposed during resection, and was fixed to the surrounding retroperitoneal connective tissue. These procedures enabled the complete separation of these vessels from the pancreaticojejunostomy. RESULTS: The mobilization and placement of the falciform ligament in the space between the pancreaticojejunostomy and the major vessels were successfully carried out without any complications. Although ten (28%) patients developed pancreatic fistula and three (8%) developed intraabdominal infection, none of the patients developed late PPH. CONCLUSIONS: The present surgical option is technically simple and easy, and may be an effective prophylactic measure against late PPH following PD.

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes.

OBJECTIVE: This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy. METHODS: Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope. RESULTS: A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1). CONCLUSION: This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.

Microscopic cancer cell spread in gastric cancer: whole-section analysis of mesogastrium.

PURPOSE: Cancer cells are often found in adipose connective tissue separate from the primary lesion and outside lymph nodes on routine pathologic examination of resected gastric cancer specimens. To identify the anatomical relationship between such cancer cell spread and lymph nodes, we investigated the microscopic cancer cell spread in the mesogastrium (CSM) by the whole-section analysis of the mesogastrium. METHOD: One thousand five hundred fifty-two sections of the mesogastrium obtained from 37 patients with gastric cancer were subjected. CSM is defined as the existence of cancer cell spread in the mesogastrium separate from the primary lesion. RESULTS: CSM was detected in three (8%) of the 37 patients. CSM was classified into three types. CSM was found in three of the 12 patients with advanced cancer, but not in 25 patients with early cancer. CONCLUSIONS: CSM may occur in the mesogastrium separate from metastatic lymph nodes; therefore, we should pay particular attention to the potential existence of CSM in surgery for gastric cancer.

Wrapping of skeletonized and divided vessels using the falciform ligament in distal pancreatectomy.

BACKGROUND: A pancreatic fistula is a major cause of morbidity in patients undergoing distal pancreatectomy (DP). A pancreatic fistula may expose skeletonized or divided vessels directly to pancreatic juice, creating a setting for vessel erosion and delayed intra-abdominal hemorrhage (DIH). With the aim of protecting vessels near the pancreatic stump from potential pancreatic fistulas, we have adopted a surgical option by which these vessels are wrapped using a pedicled falciform ligament. METHODS: After completing DP, the pedicled falciform ligament is spread out widely on major vessels exposed during resection near the pancreatic stump, and fixed to the surrounding retroperitoneal connective tissue. These procedures allow the complete separation of these vessels from the pancreatic stump. We reviewed the cases of 8 patients who underwent DP including these procedures. RESULTS: The mobilization of the falciform ligament and the wrapping of the vessels were successfully performed without any complications. Although 2 patients (14.5%) developed pancreatic fistulas, DIH did not occur in any of the patients. CONCLUSIONS: The wrapping of the skeletonized and divided vessels using a pedicled falciform ligament is simple and easy, and may be an effective prophylactic measure against DIH following DP.

Key factors for successful en bloc endoscopic submucosal dissection of early stage gastric cancer using an insulation-tipped diathermic knife.

BACKGROUND/AIMS: En bloc endoscopic mucosal resection (EMR) is presently considered to be the treatment of choice for endoscopically resectable early stage gastric cancer (EGC). Although a new EMR technique using an insulation-tipped diathermic knife (endoscopic submucosal dissection using an IT knife: IT knife-ESD) is reportedly suitable for en bloc resection, a failure in en bloc resection (piecemeal resection) can occur. We retrospectively analyzed factors affecting the success rate of en bloc resection by IT knife-ESD. METHODOLOGY: A total of 71 gastric lesions were treated by IT knife-ESD. En bloc/piecemeal resection rates were investigated. Twelve potential factors associated with clinicopathological characteristics or procedures were analyzed univariately and multivariately. RESULTS: IT knife-ESD was successfully performed in all 71 lesions. En bloc resection was achieved in 63 lesions (91%), while eight lesions (9%) were removed as two or more fragments (piecemeal resection). The multivariate analysis identified only one independent factor affecting the success rate of en bloc resection: the second-half period of procedure application. The en bloc resection rate was not associated with the tumor location/site, tumor size, specimen size, and ulceration within the tumor. CONCLUSIONS: Much experience with IT knife-ESD may resolve the tumor-related technical difficulties. It is true for this advanced procedure that endoscopist experience is highly likely to be a critical factor for treatment success. We consider that IT knife-ESD for EGC is feasible and safe when performed by experienced endoscopists.

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic fistula development after distal pancreatectomy.

BACKGROUND AND OBJECTIVE: Pancreatic fistula is a common complication of distal pancreatectomy (DP). Although various surgical procedures have been proposed for DP in an attempt to decrease the high incidence of pancreatic fistula, the prevention of pancreatic fistula remains a major problem in DP. Endoscopic pancreatic stenting for the treatment or prophylaxis of such a fistula has been rarely described. METHODS: We reviewed 9 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after DP. RESULTS: Preoperative endoscopic pancreatic stenting was successfully performed with a 7F stent in all the 9 patients. Two patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the 9 patients developed pancreatic fistula. The pancreatic stent was removed from 8 to 28 days (mean 11 days) postoperatively. CONCLUSIONS: Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP in selected patients.

Laparoscopic lymph node dissection after endoscopic submucosal dissection: a novel and minimally invasive approach to treating early-stage gastric cancer.

BACKGROUND AND OBJECTIVE: Endoscopic submucosal dissection (ESD), a newly developed endoscopic mucosal resection (EMR) technique, can completely cure a differentiated mucosal gastric cancer smaller than 2 cm. For early-stage gastric cancers (EGCs) deviating from the above-mentioned criterion, gastrectomy with lymph node dissection is performed for potential risk of lymph node metastasis (LNM). However, many of surgical EGC cases actually do not have LNM, indicating this surgery may not be necessary for many cases of EGC. To avoid this unnecessary surgery, we have introduced laparoscopic lymph node dissection (LLND) after ESD. Standard gastrectomy with extended lymph node dissection is indicated for patients if LLND reveals LNM. We present our novel approach and the preliminary results of EGC patients having potential risk of LNM. METHODS: Five patients with EGC deviating from the EMR criterion underwent the combination of ESD and LLND. ESD was performed using a newly developed insulation-tipped diathermic knife. Lymph nodes, which were determined on the basis of the location of the primary tumor and lymphatic drainage of the stomach, were removed laparoscopically. The lymphatic drainage was visualized by submucosally injecting indocyanine green (ICG) around the post-ESD ulcerative scars during intraoperative gastroscopy. RESULTS: The ESD enabled en bloc resection without any complications. The resected margins of all the lesions were free of cancer cells vertically and horizontally. LLND was successfully performed without any complications. The mean number of the dissected lymph nodes was 15 (range 6 to 22). In 4 of the 5 patients, the dissected lymph nodes were free of cancer cells, and therefore, the combination of ESD and LLND was considered a definitive treatment. The remaining patient was found to have LNM but chose not to undergo any surgery. During follow-ups, the patients' previous quality of life was restored without any tumor recurrence. CONCLUSIONS: The combination of ESD and LLND enables the complete resection of the primary tumor and the histologic determination of lymph node status. This combination treatment is a potential, minimally invasive method, and may obviate unnecessary gastrectomy without compromising curability for EGC patients having the potential risk of LNM.

En bloc endoscopic mucosal resection of a large early stage gastric cancer by combined use of an insulation-tipped diathermic knife and a grasping forceps percutaneously inserted into the gastric lumen.

A new endoscopic mucosal resection using an insulation-tipped diathermic knife (IT knife-EMR) is a promising procedure for en bloc resection of an early stage gastric cancer. However, the use of this procedure for a large lesion on the greater curvature of the gastric middle-upper body is technically difficult. With the help of a grasping forceps percutaneously inserted into the gastric lumen, which allowed traction to be applied to the lesion, a 66-year-old man with a large tumor (49mm in diameter) on the greater curvature of the gastric middle body underwent IT knife-EMR. This approach enabled easy dissection between the submucosa and the muscle layer by the IT knife under direct vision. The lesion was completely removed as a single piece. This new technique, employing IT knife-EMR in cooperation with a percutaneously inserted grasping forceps, could be a potential procedure to make original IT knife-EMR easier. This approach may enhance the utility of original IT knife-EMR for selected tumors, that is, large tumors on the greater curvature of the middle-upper body of the stomach and/or ulcerated tumors. We propose that the present approach may provide an important alternative to laparoscopic intragastric surgery.