[Simultaneous Resection of Mediastinal and Liver Hydatid Disease].

Cystic echinococcosis is an uncommon zoonosis in Japan. Typical location of the cyst is the liver and the lung. Mediastinal hydatidosis is found in less than 0.1% of all hydatid disease patients. We report a rare case of 68 years old male with mediastinal and liver hydatid cysts. Serological test confirmed the diagnosis of hydatidosis. The patient underwent complete resection of mediastinal and liver cysts successfully. Postoperative follow-up for two years has not shown any signs of recurrence. Simultaneous resection of the cysts in different sites including mediastinum is rare and has not been reported in Japan. Hydatid disease is an important differential diagnosis for patient who has cryptogenic liver cyst and history of contact to wildlife or unsterile water.

The incidence of cardiovascular thrombotic complications after laparoscopic resection in colorectal cancer in Japanese hospitals: A large-scale clinical study.

Aim: The aim of this retrospective study was to investigate the incidence of cardiovascular thrombotic complications after laparoscopic resection in colorectal cancer. Methods: This study involved 2017 patients with stages 0-III colorectal cancer who underwent laparoscopic surgery at 17 Japanese hospitals between January 2010 and December 2013. We assessed the incidence of postoperative cardiovascular thrombotic and haemorrhagic complications. Results: Laparoscopic surgeries were performed in 1152 men and 865 women with 1405 colon and 612 rectal cancers, respectively. Overall, 3%, 38%, 17%, 8%, and 9% of patients had comorbidities of heart failure, high blood pressure, diabetes, history of stroke, and vascular disease, respectively. Antithrombotic agents were being consumed by 17% of patients. The types (and perioperative rest periods) of the antithrombotic agents were aspirin in 58% (18.6 days), clopidogrel in 19% (21.1 days), cilostazol in 13% (13.3 days), and warfarin potassium in 21% (14.6 days) of cases with antithrombotic agents. Surgical time and blood loss in the total cohort were 234 minutes and 56 mL. Four cases (0.2%) had cardiovascular thrombotic complications, including one severe cardiac infarction and one stroke with major sequelae (CHADS2 scores were 2 points in both cases). Hemorrhagic complications occurred in 19 cases (0.9%). In particular, the incidence of the major gastroduodenal haemorrhagic ulcer was higher in cases with antithrombotic agents than without them (0.05% vs 0%, P = .02). Conclusion: The incidence of cardiovascular thrombotic complications was rare, although severe cardiac infarction and stroke could occur even after minimally invasive surgery in colorectal cancer.

The survival impact of preoperative FOLFOX for resectable locally advanced rectal cancer: the R-NAC-01 study.

PURPOSE: In this follow-up of the R-NAC-01 study, we assessed the long-term oncological benefit of four courses of modified leucovorin, 5-fluorouracil (FU), and oxaliplatin (mFOLFOX6) chemotherapy before rectal surgery. METHODS: In this prospective, multicenter study (UMIN 000012559) involving 11 hospitals in Japan, patients with lower rectal cancer underwent four cycles of mFOLFOX6 chemotherapy and subsequent surgery within four to six weeks. The 3-year recurrence-free survival and local recurrence rates were then reported. RESULTS: Of 41 patients (36 males, 5 females; mean age: 60.8 years old) who received 4 courses of chemotherapy, 40 underwent total mesorectal excision, and 1 underwent total pelvic exenteration. R0 resection was achieved in 40 patients, but none showed a pathological complete response. Twenty-nine patients received adjuvant chemotherapy for an average of 4 months. The 3 year recurrence-free survival and local recurrence rates in patients undergoing curable resection were 72.8% and 8.5%, respectively. cStage III patients with adjuvant chemotherapy had a significantly higher 3 year recurrence-free survival than those without adjuvant chemotherapy (76.6 vs. 40.0%, log-rank p = 0.03). CONCLUSION: Four courses of mFOLFOX6 chemotherapy before surgery may be a promising treatment strategy for locally advanced rectal cancer. Adjuvant chemotherapy might be needed for cStage III patients, even after four courses of neoadjuvant mFOLFOX6.

Effectiveness of Intraoperative Indocyanine Green Fluorescence-Navigated Surgery for Superior Mesenteric Vein Thrombosis that Developed During Treatment for Intravascular Lymphoma: A Case Report.

BACKGROUND Superior mesenteric vein thrombosis (SMVT) is a relatively rare form of acute abdominal disease; less than 0.1% of laparotomy surgeries are performed for SMVT. In the presence of severe intestinal ischemia or necrosis caused by SMVT, immediate surgical intervention is required. Macroscopic diagnosis of intestinal viability is sometimes difficult; its over-resection may carry the risk of short bowel syndrome. A near-infrared fluorescence imaging system with indocyanine green (ICG) has recently been developed for intraoperative, real-time evaluation of intestinal perfusion. This is the first report on the use of ICG fluorescence imaging during surgery for intestinal ischemia caused by venous thrombosis. CASE REPORT A 70-year-old man presented with a general feeling of weariness. On examination, he was diagnosed with intravascular large B cell lymphoma. R-CHOP therapy was initiated. On day 3 of initial R-CHOP therapy, the patient experienced sudden severe abdominal pain while in the hospital. Contrast-enhanced computed tomography revealed SMVT and loss of contrast effect in the small intestine. We diagnosed small bowel necrosis caused by SMVT, and exploratory laparotomy was performed, which revealed a continuous ischemia of 150 cm. Intraoperative ICG fluorescence imaging was utilized, and the color boundary was consistent with the ischemic area detected by visualization. The necrotic small intestine was excised and anastomosed. The patient was transferred to the hematology department on postoperative day 10 with no severe complications such as anastomotic leakage or re-thrombosis, and re-embolization was not observed 6 months later. CONCLUSIONS Venous thrombosis should be listed as a differential diagnosis when acute abdominal disease presents during chemotherapy for malignant lymphoma. ICG fluorescence imaging may be useful in the evaluation of intestinal blood flow for venous thrombosis.

A Benign Appendiceal-Colonic Fistula, Diagnosed and Managed Laparoscopically: A Case Report.

BACKGROUND Treatment methods for appendiceal-colonic fistulas differ greatly depending on whether lesions are benign or malignant. If the tumor is malignant, appendectomy with lymph node resection (ileocecal resection or right hemicolectomy) should be performed. There is no consensus on the method of surgery for organs infiltrated by appendiceal cancer. Furthermore, there are no reported laparoscopic cases that could be prevented from over-surgery by laparoscopy examination or rapid intraoperative pathological examination. CASE REPORT A 76-year-old man presented with positive fecal occult blood. Lower endoscopy revealed a 10-mm tumor in the rectosigmoid colon accompanied by white moss. A biopsy showed inflammatory granulation and no malignancy. Fluorodeoxyglucose-positron emission tomography showed highly increased accumulation at the tip of the appendix, and the standardized uptake value max was 7.3. We suspected a benign lesion rather than appendiceal cancer with infiltration into the rectosigmoid colon; therefore, we performed laparoscopic appendectomy and wedge-shaped resection of the rectum of the sigmoid colon. An intraoperative rapid pathological examination showed no appearance of malignancy; therefore, additional resection was omitted, and an ileostomy was created in the right lower quadrant. A permanent pathological examination showed complicated appendicitis, with no appearance of malignancy. The ileostomy was closed on postoperative day 25, and the patient was discharged on postoperative day 32. CONCLUSIONS In cases where there is difficulty in identifying whether the appendiceal-colonic fistula lesion is benign or malignant, laparoscopy and intraoperative rapid pathological examination may be useful in avoiding excessive treatment.

Difficult Diagnosis and Surgical Procedure for Scirrhous Gastric Cancer Complicated by Upside-Down Stomach: A Case Report.

BACKGROUND The upper stomach can be involved in 1 type of esophageal hiatal hernia in which the degree of stomach insertion is considerable and accompanied by a twist in the shaft of the stomach. The diagnostic accuracy of upper endoscopy or barium meal examination decreases in patients with upside-down stomach, thus making diagnosis of stomach lesions very difficult. No previous reports have described scirrhous gastric cancer in a patient with upside-down stomach. CASE REPORT An 85-year-old woman presented with loss of appetite and vomiting after eating oxalic acid-containing food 2 months previously. Computed tomography revealed an upside-down stomach, and upper endoscopy revealed loss of distensibility and superficial gastritis of the entire stomach. Upside-down stomach was diagnosed; accordingly, laparoscopic hernia repair was planned. Laparoscopic exploration revealed retention of serous fluid (i.e., ascites) containing gastric carcinoma cells (pathologically identified intraoperatively) and induration of the entire stomach. After converting to laparotomy, induration of the stomach was confirmed, continuing to the adjacent 4 cm of the distal esophagus. The patient was diagnosed with scirrhous gastric cancer. Esophageal hiatus hernia repair was performed due to the patient's age and the risks associated with esophagojejunostomy. Preoperative complaints of symptoms disappeared. The patient was transferred to the medical hospital on postoperative day 52 with no complications. CONCLUSIONS Specific symptoms of gastric cancer can mimic those of esophageal hiatal hernia in patients with hernia. In cases of upside-down stomach with loss of distensibility and increased wall thickness, physicians should be aware of the possibility of scirrhous gastric cancer.

Preoperative FOLFOX in resectable locally advanced rectal cancer can be a safe and promising strategy: the R-NAC-01 study.

PURPOSE: The aim of this study was to assess the safety of rectal surgery after 5-fluorouracil-leucovorin-oxaliplatin chemotherapy (FOLFOX6). METHODS: This was a prospective, multicenter study in 11 Japanese hospitals. We included patients with rectal cancer who received 4 courses of modified FOLFOX6 (mFOLFOX6) before rectal surgery and examined the postoperative complication rate, the clinicopathological response, and the rate of chemotherapy-related adverse events (UMIN 000012559). RESULTS: The study population included 36 men and 5 women. The average age of the patients was 60.8 years and the average body mass index was 23.1 kg/m2. After 4 courses of chemotherapy, grade 2 peripheral nerve disorder and other grade 3 adverse events were seen in 3 patients each (7.3%). Twenty-eight (73.7%) and 8 (21.1%) patients underwent low anterior resection and abdominoperineal resection, respectively. The pelvic nerves were preserved in 35 patients. Surgical morbidity (grade ≥ 3) occurred in 4 patients (10.5%). Anastomotic leakage occurred after surgery in 2 patients (7.1%). No patients achieved pathologically complete remission. However, downstaging of the clinical stage and N stage was seen in 17 (41.5%) and 22 (53.7%) patients, respectively. CONCLUSIONS: Surgery after four courses of mFOLFOX6 chemotherapy can be a safe and promising strategy for patients with locally advanced rectal cancer.

[Thymic basaloid carcinoma].

This is a case of a 72-year-old male whose chest computed tomography (CT) revealed a 2.0 x 1.6 cm anterior mediastinal solid tumor during follow-up of an abnormal shadow of the lung. The tumor increased its size during preoperative follow-up, and multilocular cyst was also observed. Radical thymectomy was performed, and histopathologically the tumor was diagnosed as thymic basaloid carcinoma. Thymic basaloid carcinoma is a rare tumor and is often associated with multilocular thymic cyst. There are only 32 cases reported both locally and internationally. Surgical resection is the general treatment for this disease. Adjuvant radiotherapy can be considered in cases of incomplete resection and invasive tumor. In our case, no recurrence of the tumor was noted 12 months post-operative. Generally, the malignancy of thymic basaloid carcinomas are regarded as low-grade compared with other thymic carcinomas, however, since mortality and recurrence have been reported, careful follow-up is required.

[Third-line CPT-11 chemotherapy for gastric cancer cases of non-curative gastrectomy or recurrence].

BACKGROUND: There have been few case reports of 3rd-line chemotherapy for gastric cancer. So we reported the results of CPT-11 therapy as the 3rd-line chemotherapy for gastric cancer. PATIENTS AND METHODS: 549 cases underwent gastrectomy from Jan. 2004 to Aug. 2007 in our hospital. In 76 of these cases, which underwent non-curative resection or evidenced a recurrence until July 2009, were analyzed in this study. CPT -11 3rd-line chemotherapy was administered to 11 cases. RESULTS: The mean survival time of non-curative or recurrent cases was 16.9 months. Mean survival times of the non-chemotherapy group, the group administered only 1st-line chemotherapy, the group administered until 3rd-line chemotherapy, the group administered 3rd-line chemotherapy were 7.9 , 11.3 , 21.4 and 28.9 months, respectively(p=0.000 ). Adverse effects occurred in 90.9% of 3rd-line CPT-11, however, all cases were categorized in GradeI. CONCLUSION: The group administered 3rd-line chemotherapy survived the longest. It is probably correct to administer 3rd-line chemotherapy, if the patient maintains a good performance status.

Comparison of respiratory function recovery in the early phase after laparoscopy-assisted gastrectomy and open gastrectomy.

BACKGROUND: Laparoscopic gastrectomy (LAG) is recognized as a less invasive surgery, but no advantage in terms of respiratory function recovery has been demonstrated. We investigated respiratory function recovery in the early period after LAG compared with open gastrectomy (OG) for measuring the recovery of oxygen saturation level (SaO(2)). METHODS: The study population comprised 454 patients who underwent distal gastrectomy or total gastrectomy for preoperatively diagnosed T1N0 gastric cancer: 192 underwent laparoscopy-assisted distal gastrectomy (LADG), 190 underwent open distal gastrectomy (ODG), 42 underwent laparoscopy-assisted total gastrectomy (LATG), and 30 underwent open total gastrectomy (OTG). RESULTS: The number of days until SaO(2) reached 95% or higher in room air was significantly smaller in the LADG group (1.54 days) than in the ODG group (1.81 days; p = 0.010) and also significantly smaller in the LATG group (1.48 days) than in the OTG group (2.03 days; p = 0.043). CONCLUSIONS: LAG patients recovered their oxygenation earlier than OG patients. The laparoscopic procedure might confer a respiratory benefit for gastrectomy patients.

A sodium hyaluronate carboxymethylcellulose bioresorbable membrane prevents postoperative small-bowel adhesive obstruction after distal gastrectomy.

PURPOSE: It is predictable that since distal gastrectomy (DG) with Billroth I anastomosis involves no procedures caudal to transverse colon, the effects of the surgical wound are the main cause of adhesive obstruction. Thus, it is an appropriate operation to test the efficiency of a synthetic absorbable adhesion barrier (Seprafilm). METHODS: The subjects were 282 patients diagnosed with gastric cancer who underwent open DG with Billroth I anastomosis between 2001 and August, 2005. Seprafilm was not used in any patients operated on before April, 2003 (n = 169), but it was used in all patients operated on from May 2003 onward (n = 113). We retrospectively compared the incidences of adhesive obstruction in the Seprafilm group and the non-Seprafilm group. RESULTS: The cumulative incidence of adhesive obstruction was significantly lower in the Seprafilm group than in the non-Seprafilm group (P = 0.021). The respective incidences of adhesive obstruction 2 years after surgery were 0.9% and 6.5%. Multivariate analysis of the occurrence of adhesive obstruction revealed no significant differences in sex, age, body mass index, operation time, blood loss, or degree of lymph-node dissection; however, it revealed a significant difference in relation to the use of Seprafilm (P = 0.049). CONCLUSION: In this series, Seprafilm reduced the incidence of adhesive obstruction after DG significantly; however, a prospective randomized study will be necessary to confirm this result.

Acceptability of laparoscopy-assisted gastrectomy for patients with previous intra-abdominal surgery.

PURPOSE: This study assessed the acceptability of laparoscopy-assisted gastrectomy (LAG) for patients with previous intra-abdominal surgery (PIS). METHODS: Sixteen patients with PIS had undergone LAG; 9 of laparoscopy-assisted distal gastrectomy, 2 of laparoscopy-assisted total gastrectomy and 5 of laparoscopy-assisted remnant gastrectomy (LARG). Difficulty, safety, and accuracy of LAG were compared between patients with PIS and with no previous intra-abdominal surgery. An independent group of 11 cases with open remnant gastrectomy (ORG) was used for comparing with LARG. RESULTS: No significant difference was observed in conversion rate, intraoperative complication, operation time, blood loss, dissected lymph nodes, postoperative complications and hospital stay between PIS, and no PIS. There was no significant difference in operative time, dissected lymph nodes, and postoperative complications between LARG and ORG. Blood loss was lesser and postoperative hospital stay was shorter in LARG than in ORG. CONCLUSION: LAG for patients with PIS is acceptable.

Comparison of invasiveness between laparoscopy-assisted total gastrectomy and open total gastrectomy.

BACKGROUND: Because only a few studies have been performed to date on the invasiveness of laparoscopy-assisted total gastrectomy (LATG) compared with open total gastrectomy (OTG), the minimal invasiveness of LATG has been unclear. METHODS: The OTG cohort contained 35 cases, which were performed from April 2003 to October 2005. The LATG cohort contained 46 cases, which were performed from November 2005 to November 2008. Postoperative changes over time in various parameters relating to minimal invasiveness were evaluated. We used the Wong-Baker FACES Pain Rating Scale to evaluate pain. Vital signs and a face scale were analyzed using daily maximum values on postoperative days (POD) 1-7. A hematological examination was performed on the preoperative day and POD 1, 4, 7, and 10. The number of days until oxygen saturation level (SaO2) was 95% or more in room air was used to evaluate respiratory function. RESULTS: Significantly lower pain scores were obtained in the LATG group on POD 1, 4, 5, and 7. There was a significantly lower body temperature in the LATG group on POD 7. A significantly lower white blood cell count was revealed for LATG patients on POD 10, and for C-reactive protein on POD 1. Significantly higher serum total protein values were observed in the LATG group on POD 1, 4, and 7. Significantly lower blood sugar level was found in the LATG group on POD 4 and 7. The number of days until SaO2 was 95% or more in room air was significantly fewer in the LATG group. CONCLUSIONS: LATG seems to be a less invasive procedure than OTG.

Assessment of pain by face scales after gastrectomy: comparison of laparoscopically assisted gastrectomy and open gastrectomy.

BACKGROUND: Laparoscopic gastrectomy is reported to cause little pain. However, only the total number of analgesics used has been studied to date. Because pain is a subjective experience, its evaluation requires indicators for the subjective assessment. METHODS: Pain was evaluation for patients after open distal gastrectomy (ODG, 52 cases), laparoscopically assisted distal gastrectomy (LADG, 112 cases), open total gastrectomy (OTG, 18 cases), and laparoscopically assisted total gastrectomy (LATG, 33 cases). The patients were administered continuous epidural anesthesia for 2 days after the surgery. The Wong-Baker FACES pain rating scale was used to evaluate the differences in pain. Each patient was evaluated from postoperative day (POD) 1 to POD 7, and temporal changes in pain were studied comparatively between ODG and LADG and between OTG and LATG. RESULTS: Peak pain scores were recorded on POD 3 for both distal and total gastrectomy. The scores decreased over time after POD 3. There was no significant difference in scores between open and laparoscopic gastrectomy up to POD 2, but lower scores were shown on PODs 3, 4, and 5 for LADG and on days 3 and 4 for LATG. CONCLUSIONS: The pain score for laparoscopic gastrectomy was low. There was no significant difference in pain between procedures while epidural anesthesia was in effect. Pain subsided earlier with laparoscopic than with open gastrectomy. The same characteristics were observed with both LADG and LATG.

Inspection of safety and accuracy of D2 lymph node dissection in laparoscopy-assisted distal gastrectomy.

BACKGROUND: There is a consensus on the indication of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer that needs D1 + alpha or D1 + beta lymph node dissection. However, many gastrointestinal surgeons consider D2 lymph node dissection in LADG to be difficult, therefore, only a few medical institutions have performed D2 lymph node dissection in LADG. We examined the safety and accuracy of D2 dissection in LADG by comparing with open distal gastrectomy (ODG), as the first step to operate on advanced gastric cancer. METHODS: The study population comprised 53 and 67 patients who underwent D2 dissection in LADG or ODG, respectively; with the diagnosis of preoperative depth grade SM, between 2004 and 2006. In D2 lymph node dissection, difficult points are dissections of lymph node along the superior mesenteric vein (No. 14v), along the hepatic artery (No. 12a), and along the proximal splenic artery (No. 11p). We performed these lymph nodes dissection in a fixed process, which was achieved through all improvements. RESULTS: No significant difference was observed in age, sex, American Society of Anesthesiology (ASA) classification, body mass index (BMI), and operative time between two groups. Bleeding volume was significantly lower in LADG (96.5 +/- 126.3 ml) than in ODG (221.9 +/- 174.8 ml). There was no significant difference in number of dissected lymph nodes between ODG (44.8 +/- 15.6) and LADG (49.2 +/- 16.1), with no significant difference in degree of pathological stage. The postoperative complication rate was 16.4% for ODG and 5.7% for LADG, and postoperative hospital stay was significantly shorter for LADG (16.7 +/- 5.6 days) than for ODG (21 +/- 11.4 days). CONCLUSIONS: D2 dissection in LADG can be performed without problems with safety and accuracy, if the surgical team is skilled in the procedures of LADG.

Lipid peroxidation during ischemia depends on ischemia time in warm ischemia and reperfusion of rat liver.

Prolonged hepatic warm ischemia has been incriminated in oxidative stress after reperfusion. However, the magnitude of oxidative stress during ischemia has been controversial. The aims of the present study were to elucidate whether lipid peroxidation progressed during ischemia and to clarify whether oxidative stress during ischemia aggravated the oxidative damage after reperfusion. Rats were subjected to 30 to 120 min of 70% warm ischemia alone or followed by reperfusion for 60 min. Lipid peroxidation (LPO) was evaluated by amounts of phosphatidylcholine hydroperoxide (PC-OOH) and phosphatidylethanolamine hydroperoxide (PE-OOH) as primary LPO products. Total amounts of malondialdehyde and 4-hydroxy-2-nonenal (MDA + 4-HNE), degraded from hydroperoxides, were also determined. PC-OOH and PE-OOH significantly increased at 60 and 120 min ischemia with concomitant increase of oxidized glutathione. These hydroperoxides did not increase at 60 min reperfusion after 60 min ischemia, whereas they did increase at 60 min reperfusion after 120 min ischemia with deactivation of phospholipid hydroperoxide glutathione peroxidase and superoxide dismutase. The amount of MDA + 4-HNE exhibited similar changes, but the velocity of production dropped with ischemic time longer than 60 min. In conclusion, oxidative stress progressed during ischemia and triggered the oxidative injury after reperfusion. Secondary LPO products are less sensitive, especially during ischemia, which may cause possible underestimation and discrepancy.