Pancreaticoduodenectomy after distal gastrectomy: A case series.

INTRODUCTION: Pancreatoduodenectomy (PD) after gastrectomy requires more attention during surgery than ordinary PD due to anatomical variation with different types of gastrointestinal anastomoses, the complication of anatomical dissection, and the extent of adhesions present. Herein, we describe the PD strategies we used in three patients who strategy for three patients who had previously undergone distal gastrectomy for gastric cancer treatment. DISCUSSION: Generally, reconstruction following PD in patients who have undergone a prior Billroth I reconstruction is simple, as there is no previous afferent loop. By comparison, reconstruction after a Billroth II or R-Y reconstruction requires special consideration of the point of circulation and length of the remnant intestine used for pancreaticojejunostomy, choledochojejunostomy or gastrojejunostomy. CONCLUSION: There is no consensus regarding the best method for performing PD and reconstruction in patients with a prior history of gastrectomy. The appropriateness of using the existing afferent loop for reconstruction depends on whether the jejunum is of sufficient length for bile duct and pancreatic anastomosis. Regardless of the approach used, it is necessary to avoid excessive tension during reconstruction. Based on our experience and previous studies published in the English literature, we propose that reconstruction needs to be considered on a case-by-case basis.

Secondary aorto-duodenal fistula successfully treated with a novel surgical method: A case report.

INTRODUCTION: Secondary aorto-duodenal fistula (sADF) is a complication of abdominal aorta artificial blood vessel replacement that often leads to death. However, an optimal operative method has not yet been established. We describe a patient who underwent artificial blood vessel reimplantation and duodenectomy after endovascular aneurysmal repair (EVAR) with positive outcomes. PRESENTATION OF CASE: An 84-year-old man underwent artificial blood vessel replacement in 2015. In September 2016, he visited our emergency department and was diagnosed with sADF based on computed tomography. Urgent EVAR was performed, followed by duodenal segmental resection on the next day without opening the syringeal part to minimize the pollution of the operative field. Artificial blood vessel reimplantation and omental flap transposition were performed. As of 2020, about 3 years after surgery, there has been no relapse of the infection. DISCUSSION: Using our novel operative method, we can minimize exposure of the artificial blood vessel and surrounding tissue to intestinal juice and pus. We believe that this reduces the risk of postoperative artificial blood vessel reinfection. CONCLUSION: Controlling bleeding by EVAR and resection of the duodenum and artificial blood vessels as a group without opening the syringeal part can contribute to positive long-term results as this method minimizes the pollution of the duodenectomy surgical field.

Repair of a perforated duodenal diverticulum using intraduodenal suture in 94 year old woman: A case report.

INTRODUCTION: In case of gastrointestinal diverticula, the duodenal type is quite frequent; duodenum is the second most common site for diverticula following the colon (Glener et al., 2016). However, duodenal diverticular perforation is rare, so the appropriate surgical treatment for this condition is yet unclear (Simoes et al., 2014). This literature has been written in line with the SCARE criteria (Agha et al., 2018). PRESENTATION OF CASE: A 94-year-old woman emergently presented to our department with diffuse abdominal tenderness and guarding, indicating pan-peritonitis. Computed tomography revealed pneumoretroperitoneum; Therefore, gastrointestinal perforation was suspected. Emergency surgery was performed; we detected the perforated diverticulum located at the posterior wall of the duodenum with accompanying inflammation. Considering the location, postoperative leakage, and the patient's advanced age, we placed trans-section on duodenal wall against the lesion and resected the diverticulum, The lumen was then manually sutured from within. The anterior wall was closed using linear staplers. The patient recovered uneventfully and was discharged 24 days after surgery. DISCUSSSIONS: As perforated duodenal diverticulum is rare, the ideal management is unclear. Several studies mention various surgical procedures. However, actual treatment varies based on the patient's situation and surgeon's assessment. Almost all cases that require surgery present emergently; therefore, simpler and more effective treatment methods are required (Simoes et al., 2014; Philip et al., 2019; Fujisaki et al., 2014). CONCLUSION: We used a unique surgical technique; intraduodenal suture for perforated diverticulum. This technique can be a feasible alternative for managing this condition.

Separation of D-amino acid-containing peptide phenylseptin using 3,3'-phenyl-1,1'-binaphthyl-18-crown-6-ether columns.

Several D-amino acid-containing peptides (DAACPs) with antimicrobial, cardio-excitatory, or neuronal activities have been found in several species. Here, we demonstrated the chiral separation of the antimicrobial peptide diastereomers, D-phenylseptin and L-phenylseptin using (S) and (R) 3,3'-phenyl-1,1'-binaphthyl-18-crown-6-ether columns (CR-I (+) and CR-I (-), respectively) and also investigated the underlying mechanism. First, using D-amino acid-containing tripeptide Phe-Phe-Phe-OH, we found that CR-I (+) could be used to recognize diastereomeric tripeptides containing an L-amino acid as the first residue. On the contrary, CR-I (-) enabled separation of a series of diastereomers with D-amino acid as the first residue. Therefore, we achieved separation of the stereoisomers using the chiral columns depending on the position of the D- amino acid in the peptide and demonstrated the orthogonality of separations of the chiral columns. Then, using CR-I (+), we separated amphibian antimicrobial peptide diastereomers, L- and D-phenylseptin, which have the sequences, L-Phe-L-Phe-L-Phe and L-Phe-D-Phe-L-Phe at their N-termini, respectively. In order to understand the host-guest interactions, we performed molecular dynamics simulations for L-Phe-L-Phe-L-Phe tripeptide-CR-I molecule complex systems. Three hydrogen bonds between the N-terminal amine group -NH3+ and the crown ether oxygens were the dominant interactions. The hydrophobic interactions between phenyl-rings in the chiral selector unit of CR-I (+) and the side chains of 2nd and 3rd residues of the peptide also contributed to the affinity. Our results show that the CR-I (+)-column can be applied for the separation of endogenous DAACPs generated by the post-translational modification.

Unresectable Advanced Gastric Cancer with Skin Invasion followed by Total Gastrectomy after Second-Line Chemotherapy.

Conversion surgery has been reported but few cases have undergone surgical R0 resection after second-line chemotherapy. We report a case of an unresectable locally advanced gastric cancer in a patient who finally underwent the operation (R0) after second-line chemotherapy. The 77-year-old male was diagnosed with gastric cancer (cT4 [SI; Skin, Liver] N0M0 c Stage IIIA) with invasion to the skin of the abdominal wall, and chemotherapy was initially performed because of his poor performance status and due to the large defect in the abdominal wall that might occur if an operation was performed. Partial response (PR) was observed after S-1+CDDP (SP) therapy, which was then stopped after which progressive disease (PD) was observed. Ramucirumab+Paclitaxel (RAM/PTX) therapy was chosen as second-line therapy, and PR was obtained again, following which total gastrectomy was performed (D2 dissection of lymph nodes, Roux-en-Y reconstruction, and combined resection of the partial skin and the affected region of the liver). At 30 months postoperatively, no recurrence has occurred and the patient is alive after the operation without chemotherapy.

[Effectiveness of Ramucirumab Therapy for Advanced Gastric Cancer after Stent Placement for Esophagogastric Junction Carcinoma Obstruction-A Case Report].

According to the REGARD and RAINBOW trials, ramucirumab(RAM)was introduced as second-line therapy for advanced or metastatic gastric cancer. Endoscopic metallic stent placement and angiogenesis inhibitor administration carry the risk of gastrointestinal perforation. The outcomes of patients who undergo endoscopic placement of metallic stents during RAM treatment have not yet been fully assessed. A 60's man was diagnosed with advanced esophagogastric junction cancer(por) with Virchow's lymph node metastases. His tumor was classified as cT4a(SE), N1(#1), M1, stage Ⅳ. He received chemotherapy, but the size of the primary tumor and metastases increased. After stenting for gastric outlet obstruction, he received a paclitaxel(PTX)plus RAM regimen as third-line treatment. Because of CTCAE Grade 2 peripheral neuropathy, PTX was discontinued after 10 courses. For 11 months, tumor control without adverse events was maintained. The patient was then switched to CPT-11 as fourth-line treatment.

Thoracoscopic Oesophagectomy Using Prone Positioning for Oesophageal Cancer With Right Aortic Arch: A Case Report.

BACKGROUND/AIM: Right aortic arch (RAA) is a rare abnormality of the aortic arch that forms a vascular ring. Oesophageal cancer (EC) accompanied with RAA is even rarer, and in such cases, it is very important to understand the anatomical structure in the upper mediastinum in order to perform a safe and curative operation. PATIENTS AND METHODS: A 67-year-old man who presented with pharyngeal discomfort was admitted to our hospital. Further examinations revealed advanced thoracic EC accompanied with RAA and aortic diverticulum. RESULTS: After neoadjuvant chemotherapy, we successfully and safely performed thoracoscopic oesophagectomy and lymphadenectomy using the prone positioning. CONCLUSION: There exist only a few reports of thoracoscopic oesophagectomy for EC with RAA. Sufficient preoperative preparation and sharing an adequate strategy for the surgical approach with the surgical team are definitely necessary. Although the thoracoscopic approach for EC with RAA is useful, more considerations are needed for some issues.

Augmented rectangle technique for Billroth I anastomosis in totally laparoscopic distal gastrectomy for gastric cancer.

BACKGROUND: Billroth I reconstruction is a means of anastomosis that is widely performed after surgical resection for distal gastric cancer. Interest has grown in totally laparoscopic gastrectomy, and several methods for totally laparoscopic performance of Billroth I reconstruction have been reported. However, the methods are cumbersome, and postoperative complications such as twisting at the site of anastomosis and obstruction due to stenosis have arisen. We developed an augmented rectangle technique (ART) by which the anastomosis is created laparoscopically with the use of three automatic endoscopic linear staplers, and the resulting anastomotic opening is wide and less likely to become twisted or stenosed. The technical details of our ART-based Billroth I anastomosis are presented herein along with results of the procedure to date. METHODS: The technique was applied in 160 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer between December 2013 and August 2017. Clinicopathological data, surgical data, and postoperative outcomes were analyzed. RESULTS: During surgery, there were no troubles associated with gastrointestinal reconstruction and there was no transition to laparotomy. There were no postoperative complications, including suture failure and stenosis, associated with the gastrointestinal reconstruction, and the average postoperative hospital stay was 12 days. CONCLUSION: Totally laparoscopic ART-based Billroth I reconstruction is both feasible and safe. We expect this technique to contribute to the spread of safe totally laparoscopic surgery for gastric cancer.

Mesh-Airtight-Preperitoneum: a simple method for confirming mesh placement in transabdominal preperitoneal repair of inguinal hernia.

We devised a method for confirming the position of mesh placed during transabdominal preperitoneal repair (TAPP) of an inguinal hernia. The preperitoneum is sufficiently detached, and the mesh is fixed in place as usual. Before completely closing the peritoneum, pressure is applied from outside the body and inside the abdominal cavity to remove as much air as possible from the detached preperitoneum; the peritoneum is then sutured using a V-Loc(TM) closure device so that it does not constrict. By releasing the pressure all at once, the airtightness of the preperitoneum is maintained, and the position of the mesh can be observed through the translucent peritoneum. This method, called Mesh-Airtight-Preperitoneum (MAPP), could become widely used as a simple technique for confirming mesh position in TAPP. J. Med. Invest. 63: 270-273, August, 2016.

Short-Term Outcomes of Laparoscopic Distal Gastrectomy for Advanced Gastric Cancer.

The purpose of this study was to investigate the oncologic outcomes of laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC). Between April 2003 and March 2014, LDG was performed for 392 patients, 91 patients (23.2%) had histopathologically diagnosed AGC beyond T2 depth. The clinicopathological features, postoperative outcomes, mortality, morbidity, recurrence rate, and survivals of those patients were reviewed. The TNM stages of the tumor were IB in 26 patients (28.5%), IIA in 20 (21.9%), IIB in 18 (19.7%), IIIA in 13 (14.2%), IIIB in 6 (6.5%), IIIC in 6 (6.5%), and IV in 2 (2.1%). Major morbidity occurred in 14 patients (15.3%), with no postoperative mortality. Median follow-up was 24.5 months; 10 patients developed recurrence during the follow-up period, and 10 patients died, including 6 cancer deaths. The 5-year overall and disease-free survival rates were 76.8% and 72.6%, respectively. By stage, OS/DFS was 92.3%/91.8% in stage IB, 85.4%/85.4% in stage II, and 49.3%/26.9% in stage III. Oncologic outcomes were good in patients with AGC, especially with stage IB-IIB, who underwent LDG. LDG appears to be an effective approach for treating stage IB and II gastric cancer.

[A Case of Complete Pathological Response in a Patient with Locally Advanced Sigmoid Colon Cancer after FOLFOX IRI Chemotherapy].

A 61-year-old man with advanced sigmoid colon cancer was admitted to our hospital. Abdominal computed tomography (CT) revealed locally advanced sigmoid colon cancer, with suspected invasion of the bladder and small intestine. The clinical stage of the disease was T4b, N1, M0, and Stage III a, with wild-type KRAS expression. A transverse colostomy was performed because of the presence of a bowel obstruction. The patient received 4 courses of Leucovorin, 5-fluorouracil, oxaliplatin, and irinotecan (FOLFOXIRI). The size of the tumor and lymph nodes decreased noticeably after chemotherapy and laparoscopic high anterior resection with lymph node dissection. During this phase, the pathological stage of the disease was ypT0, N0, and Stage 0(no viable carcinoma cells, Grade 3). This result suggested that preoperative FOLFOXIRI chemotherapy is a useful regimen for the treatment of locally advanced colon cancer.

Involvement of trefoil factor family 2 in the enlargement of intestinal tumors in Apc(Min/+) mice.

It is assumed that tumor size may be associated with malignant tumor conversion. However, the molecules responsible for determination of tumor size are not well understood. We counted the number of intestinal tumors in 8, 12 and 30-week-old Apc(Min/+) mice and measured tumor sizes, respectively. Genes involved in determining tumor size were examined using microarray analysis. Cultured cells were then, transfected with a mammalian expression vector containing a candidate gene to examine the functional role of the gene. The effect of forced expression of candidate gene on cell growth was evaluated by measuring the doubling time of the cultured cells and the growth of grafted cells in nude mice. Unexpectedly, microarray analysis identified trefoil factor family 2 (Tff2) rather than growth related genes and/or oncogenes as a most variable gene. Overexpressing Tff2 in cultured cells reduced doubling time in vitro and rapidly increased xenograft tumor size in vivo. We found Tff2 as a novel important factor that to be able to enlarge an intestinal tumor size.