[A Resected Case of Leiomyosarcoma Originating from the Ovarian Vein].

We present a 46-year-old female patient who underwent resection of a retroperitoneal tumor, which was found by medical check-up. The tumor which was elastic hard and had good mobility displaced the duodenum to her abdominal wall. Since her right ovarian vein adhered to the tumor, we removed the tumor with the ligated vein. Pathological findings showed the tumor consisted of spindle-shaped cells with pleomorphic nucleus and it presented the fascicular growth pattern. Additional immunostaining showed positive for HHF35, h-caldesmon. Because the leiomyosarcoma connected with the smooth muscle of the right ovarian vein, we considered the vascular smooth muscle was the origin of the tumor. It is 2 years after the operation, there has been no local recurrence or metastasis.

[A Case of Advanced Rectal Cancer Successfully Treated with Preoperative Radiochemotherapy].

An 80-year-old woman who visited our hospital with chief complaints of decreased appetite and diarrhea. Lower gastrointestinal endoscopy showed a type 2 tumor in the rectal Ra, and biopsy revealed a well-differentiated adenocarcinoma. The patient had locally advanced rectal cancer with widespread contact with the sacrum, and preoperative radiochemotherapy (S-1 100 mg/day plus radiotherapy 50 Gy/25 Fr)was performed. After the treatment was completed, the tumor was remarkably reduced, but the surgery was strongly rejected, and therefore chemotherapy became the policy. XELOX plus bevacizumab therapy was started, but in the second course was performed, obstructive symptoms appeared, so a semi-urgent lower anterior resection and ileostomy were performed. Postoperative pathological findings showed only a small amount of tumor cells in the mucosa, suggesting that preoperative treatment was effective.

[A Case of Small Bowel Perforation Due to Lung Cancer Metastasis].

A 79-year-old man was diagnosed with Stage ⅢB(T4N2M0)adenocarcinoma of the lung, administered. He suddenly developed abdominal pain with muscle guarding and rebound tenderness. An abdominal computed tomography scan revealed a thickened small bowel wall and mesenteric mass, as well as massive ascites and free air. He underwent an emergency laparotomy following a diagnosis of pan-peritonitis due to intestinalperforation. A partialresection of the smallintestine and abdominal drainage were performed. The resected specimen included an ulcerative lesion on the mucosal surface. The pathological diagnosis was a metastasis of lung cancer. The patient died in hospice 29 days postoperatively. In the present case, however, surgery improved the patient's quality of life. Although lung cancer metastasis to the small bowel is associated with a poor prognosis, palliative surgery is indicated in otherwise fatal circumstances.

[A Clinical Study of Seven Cases of LECS for Gastric Submucosal Tumors].

Laparoscopy and endoscopy cooperative surgery(LECS)is a surgical technique to resect a tumor with minimal invasion, using both a laparoscope and endoscope. Twenty-eight surgeries for gastric submucosal tumors(SMT)were performed between 2009 and 2019. Seven of those cases were performed using LECS. Two male and 5 female patients underwent LECS; their mean age was 53 years. The tumors were located at the anterior wall of the fornix in 1 case, anterior wall of the subcardia in 2 cases, anterior wall of the upper gastric body in 3 cases, and anterior wall of the lower gastric body in 1 case. Two cases were intraductal growing types, and 5 cases were intramural growing types. No postoperative complications have occurred. The mean size of the tumors was 21.1 mm. In pathological findings, 5 cases were gastrointestinal stromal tumor (GIST); 1 case was high risk, 2 cases were low risk, and 1 case was very low risk as classified using the modified-Fletcher's classification. Imatinib was administered to the high risk case, and there have been no recurrences in any cases.

[A Case of Small Cell Carcinoma of the Pancreas].

A 55-year-old man was admitted to our hospital for jaundice. Magnetic resonance cholangiopancreatography showed a mass in the pancreatic head as well as biliary obstruction. We strongly suspected invasive ductal carcinoma of the pancreas. We performed pancreaticoduodenectomy with partial resection of the portal vein. The histopathological diagnosis was small cell carcinoma of the pancreas. We detected metastasis of the right hilar lymph node in PET-CT scan performed 2 months after the surgery and started chemotherapy with cisplatin(CDDP)plus irinotecan(CPT-11). However, we observed recurrent metastasis of the right hilar lymph node 12 months after the surgery. We started second-line chemotherapy with amrubicin( AMR)and radiotherapy. Unfortunately, the patient died from multiple metastases of the left adrenal gland and brain 26 months after the surgery. The prognosis of small cell carcinoma of the pancreas is extremely poor. Multimodal treatment such as chemotherapy, radiotherapy, and curative operation are required for long-term survival.

[Radical Surgery Following Chemotherapy in a Patient with Mesenteric Recurrence Associated with Hematoma upon ESD for Rectal Cancer Three Years Six months Later].

A63 -year-old man complaining of anal pain visited our hospital. Three years 6 months previously, the patient underwent endoscopic submucosal dissection(ESD)for early-stage rectal cancer. Based on the pathological findings, adenocarcinoma with invasion to the submucosal layer(2,000 mm)and lymphovascular invasion were diagnosed. Abdominal computed tomography( CT)revealed a solid tumor 50mm in diameter and hematoma measuring approximately 90mm in length adjoining the tumor in the mesorectum. We performed exploratory laparoscopy. Ahematoma was confirmed in the mesentery from the sigmoid colon and rectum. After the surgery, endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)revealed well-differentiated adenocarcinoma. We diagnosed a hematoma associated with mesenteric recurrence following ESD for rectal cancer. The patient received chemotherapy first because of the large size of the recurrent cancer. Four courses of mFOLFOX6(5-FU: bolus 400mg/m / / / 2,2,400mg/m2,oxaliplatin 85 mg/m2) and panitumumab(6 mg/kg)were administered. Based on the CT findings following chemotherapy, the hematoma had disappeared, and the size of the recurrent cancer in the mesorectum reduced to 28 mm. The patient underwent laparoscopic lower anterior resection with D3 lymph node dissection and ileostomy. The postoperative course was uneventful. Currently, the patient has no recurrence.

[A Case of Mesenteric Malignant Lymphoma Treated Using Single-Port Surgery and an Umbilical ZigZag Incision].

A 73 -year-old man was found to have a mesenteric tumor on abdominal ultrasonography and computed tomography (CT). Single-port laparoscopic surgery using an umbilical ZigZag incision was performed. Operative findings revealed that the tumor involved the mesentery. The tumor and a section of small intestines were resected. Pathological examination diagnosed follicular lymphoma. Single-port laparoscopic surgery using an umbilical ZigZag incision is superior for manipulation of forceps and evisceration. This operative method may be useful for resection or biopsy of mesenteric tumors.

The Risk Factors for Refractory Fistula after Esophagectomy with Gastric Tube Reconstruction in Patients with Esophageal Cancer.

BACKGROUND/AIMS: Anastomotic leakage (AL) after esophagectomy is associated with high rates of postoperative morbidity and mortality. In cases with leakage, a refractory fistula (RF) is sometimes recognized after esophagectomy. The aim of this study was to evaluate the risk factors for RF after esophagectomy with gastric tube reconstruction. METHODS: This study enrolled 244 consecutive esophageal cancer patients who had undergone esophagectomy with gastric tube reconstruction. RF was defined as a noncurative anastomotic site-cutaneous fistula that had been present for more than 2 months. We evaluated the risk factors for RF. RESULTS: AL occurred in 30 patients (12.3%). There was one mortality case (0.4%) due to mediastinitis caused by AL in the present series. A multivariate analysis revealed that the subcutaneous route was an independent risk factor for AL (OR 4.42, 95% CI 1.42-13.8, p = 0.01), and that the subcutaneous route was an independent risk factor for RF (OR 13.30, 95% CI 2.50-71.30, p = 0.0024). CONCLUSION: The results of this retrospective study suggest that subcutaneous route was associated with an increased risk of RF after esophagectomy with gastric tube reconstruction. The preoperative identification of risk factors may contribute to the prevention of postoperative AL and RF.

Randomized Controlled Study to Evaluate the Efficacy of a Preoperative Respiratory Rehabilitation Program to Prevent Postoperative Pulmonary Complications after Esophagectomy.

BACKGROUND/AIMS: Patients with postoperative pulmonary complications after esophagectomy often have increased mortality. The purpose of the study was to examine the efficacy of preventing postoperative pulmonary complications by an intensive preoperative respiratory rehabilitation (PR) program for esophageal cancer patients. METHODS: This study was a prospective randomized controlled study. Thirty patients in the PR group and 30 patients in the no preoperative respiratory rehabilitation (NPR) group were included. The PR group received preoperative rehabilitation for more than 7 days, while the NPR group did not receive any preoperative rehabilitation. All patients underwent postoperative rehabilitation from the first postoperative day. The postoperative pulmonary complications were evaluated using the Clavien-Dindo classification (CDC) and the Utrecht Pneumonia Scoring System (UPSS). RESULTS: The CDC grade in the PR group was significantly lower than that in the NPR group (p = 0.014). The UPSS score in the PR group was significantly lower than that in the NPR group at postoperative day 1 (p = 0.031). In the multivariate analysis, NPR was an independent risk factor for postoperative pulmonary complications greater than CDC grade II (OR: 3.99, 95% CI: 1.28-12.4, p = 0.017). CONCLUSIONS: This study showed that the intensive PR program was capable of reducing the postoperative pulmonary complications in esophageal cancer patients.

Is the Geriatric Nutritional Risk Index a Significant Predictor of Postoperative Complications in Patients with Esophageal Cancer Undergoing Esophagectomy?

BACKGROUND: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting the risk of nutrition-related complications. The GNRI has mainly been reported as a simple and accurate tool to assess the nutritional status and prognosis of elderly patients. So far, there have been no reports of the GNRI in patients with gastrointestinal cancer. Our objective was to examine the association between the GNRI and short-term outcomes, especially postoperative complications, in patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. MATERIALS AND METHODS: The present study enrolled 122 consecutive patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin in g/l) + (41.7 × present/ideal body weight). The characteristics and short-term outcomes were compared between two groups: the high (GNRI ≥90) and the low (GNRI <90) GNRI group. The mortality and morbidity rates, especially the rates regarding respiratory complications and anastomotic leakage, were investigated. RESULTS: The mean age of the 122 patients was 63.9 ± 9.1 years (range 43-83). There were no significant differences in either patient or operative characteristics. The low GNRI group had a significantly higher rate of respiratory complications (p = 0.002). A multivariate analysis demonstrated that the GNRI was the only independent significant factor predicting respiratory complications (hazard ratio 3.41, 95% confidence interval 1.19-9.76; p = 0.022). CONCLUSION: The GNRI is considered to be a clinically useful marker that can be used to assess the nutritional status and predict the development of postoperative respiratory complications in patients with esophageal cancer undergoing esophagectomy and gastric tube reconstruction.

The high-sensitivity modified Glasgow prognostic score is superior to the modified Glasgow prognostic score as a prognostic predictor in patients with resectable gastric cancer.

AIM: The aim of the present study was to evaluate the superiority of the high-sensitivity modified Glasgow prognostic score (HS-mGPS) before surgery in patients with gastric cancer. PATIENTS AND METHODS: The participants of this retrospective study comprised 552 patients with gastric cancer who underwent gastrectomy at the Fukuoka University Hospital. The HS-mGPS was calculated before surgery based on cutoff values of 0.3 mg/dl for C-reactive protein and 3.5 g/dl for albumin, and correlations between the HS-mGPS and the clinicopathological parameters and prognosis were evaluated. In addition, the superiority of the HS-mGPS to the mGPS as a prognostic indicator was examined in detail. RESULTS: The mGPS was 0 in 494 patients, 1 in 24 patients and 2 in 34 patients. In contrast, the HS-mGPS was 0 in 411 patients, 1 in 75 patients and 2 in 66 patients. Both the mGPS (p < 0.0001) and HS-mGPS (p < 0.0001) were good prognostic predictors in gastric cancer patients who underwent gastrectomy. Of the 494 patients with an mGPS of 0 before surgery, 51 and 32 exhibited an HS-mGPS of 1 and 2, respectively. The patients who exhibited migration in the HS-mGPS demonstrated a significantly more unfavorable prognosis than the patients with an HS-mGPS of 0 (p < 0.0001). The prognostic impact of the HS-mGPS was especially clear in stage I and IV patients (p = 0.0027, p = 0.017). The HS-mGPS was found to be a superior prognostic predictor compared to the mGPS in a multivariate analysis (p = 0.0002). CONCLUSIONS: The HS-mGPS before surgery is a superior prognostic predictor in patients with gastric cancer.

Long-term survival after excision of a giant esophageal gastrointestinal stromal tumor with imatinib mesylate resistance: report of a case.

A 69-year-old woman underwent 4 months of imatinib mesylate chemotherapy for a diagnosed gastrointestinal stromal tumor of the esophagus. This treatment was suspended because of its side effects and because radiological examinations showed that the tumor had not changed or had even increased slightly in size. Thus, we performed esophagectomy via left thoracotomy and removed a tumor that measured 18 × 17 × 10 cm. Immunohistochemical examination revealed positive reactions for c-kit and CD34, suggestive of a high-risk malignancy. The patient was discharged from hospital on postoperative day 30, and has remained well with no sign of tumor recurrence for more than 5 years, without adjuvant chemotherapy.

Preventing an 8-mm Port Site Hernia in Robot-Assisted Laparoscopic Surgery: Insights From Two Rare Cases and Future Preventive Measures.

Port-site incisional hernia (PIH) is an uncommon complication that can arise subsequent to a laparoscopic procedure, potentially leading to severe adverse effects such as intestinal obstruction. We currently present two cases of incarcerated hernia that occurred at an 8-mm trocar site after robot-assisted laparoscopic surgery (RALS). While occurrences of an 8-mm port-site incisional hernia are infrequent, it is imperative to note that most PIH cases are due to inadequate fascial closure of the port site. Therefore, surgeons must pay attention to closing the fascia of an 8-mm trocar site following RALS.

Damage Control Surgery for Duodenal Ulcer Bleeding With Massive Hematoma and Perforation Due to Over-the-Scope Clip (OTSC).

Due to the advances in endoscopic technology, surgery for duodenal ulcer (DU) bleeding has decreased, although surgery is still necessary for more complicated cases. The concept of damage control surgery (DCS) has been established in the field of trauma, and a simple surgical approach may be preferable in serious cases such as uncontrolled DU bleeding. We present a successful case of bleeding with massive hematoma and perforation of the duodenum due to an over-the-scope clip that was treated by a less invasive surgical approach with consideration of the DCS.

Surgical resection for cancer located mainly in the lower esophagus.

BACKGROUND/AIMS: The aim of the present study was to clarify the results and feasibility of surgical approaches for cancer, which is mainly occupied by squamous cell carcinoma (SCC), of the lower esophagus. METHODOLOGY: Forty-four patients (34 men, 10 women) with cancer located at the lower esophagus were enrolled in this study. SCC was diagnosed in 36 cases and adenocarcinoma (ADC) in 8 cases. Thirteen patients underwent transhiatal esophagectomy, 18 underwent lower thoracic esophagectomy by left thoracotomy, and 13 underwent esophagectomy with a right thoracic approach by open thoracotomy or thoracoscopy. RESULTS: Ten cases (ADC, n = 2; SCC, n = 8) showed involvement of mediastinal lymph nodes, although lymph node dissection varied with each surgical approach. Five-year survival rates were 75% for ADC and 31.9% for SCC, and ADC tended to be associated with a more favorable prognosis than SCC (p = 0.058). Transhiatal esophagectomy was performed more often in older patients (p < 0.05), but no other clinicopathological parameters appeared to affect the selection of surgical approach. No significant prognostic differences existed between surgical approaches (p = 0.35), even though the examination was limited to SCC (p = 0.98). CONCLUSIONS: No significant prognostic differences were identified between transhiatal and left and right transthoracic approaches for lower esophageal cancer.

Massive Retroperitoneal Hematoma After Inguinal Hernia Repair Using Prolene® Hernia System: A Case Report.

Retroperitoneal hematoma is a possibly fatal condition that is frequently observed as a complication of procedures such as femoral artery catheterizations. We currently present a case of massive retroperitoneal hematoma after inguinal hernioplasty using Prolene® Hernia System mesh in a warfarin-treated patient. Especially in the case of inguinal hernioplasty in a patient receiving warfarin therapy, surgeons must pay close attention to prevent hemorrhage from the preperitoneal space, or they may opt for a different technique, such as the Lichtenstein method or laparoscopic approach.

Safety and Feasibility of Gastrectomy in Super Elderly Patients (Aged ≥ 80): A Propensity Score-Matched Analysis.

INTRODUCTION: The benefits of gastrectomy in elderly patients with gastric cancer (GC) remain unknown. This study was conducted to evaluate the short- and long-term outcomes of elderly patients with GC (≥ 80 years) who underwent gastrectomy. METHODS: We enrolled 479 patients (Stages I-IV) who underwent gastrectomy with R0-1 resection. The patients were divided into an elderly group (E group; age ≥ 80 years) (n = 115) and a non-elderly group (NE group; age < 80 years) (n = 364). After propensity score matching (PSM) was performed, the short- and long-term outcomes were compared between the groups. RESULTS: The rate of postoperative complications (Clavien-Dindo classification ≥ IIIa) in the two groups did not differ significantly (p = 0.657). Before PSM, the five-year overall survival (OS, 35.3% vs. 71.7%, p < 0.001) and disease-specific survival (DSS, 56.8% vs. 81.8%, p < 0.001) in the E group were significantly shorter than that in the NE group, respectively. On the other hand, significant differences between the E and NE groups were not shown in either the five-year OS (35.5% vs. 50.8%, p = 0.0985) or the five-year DSS (56.5% vs. 66.9%, p = 0.274) after PSM. CONCLUSION: Gastrectomy for elderly patients with GC can be considered safe based on short-term outcomes. In terms of long-term results, elderly patients are not inferior to non-elderly patients if the patients' backgrounds are the same. On the other hand, the long-term outcomes of elderly GC patients who have various comorbidities are not satisfactory, so we should carefully consider the indications for gastrectomy.

Pancreatic injury in children: review of 7 cases and the pertinent literature.

BACKGROUND/AIMS: Treatment of blunt injury of the pancreas in children remains controversial. Some prefer non-surgical treatment, whereas others prefer surgical management in selected cases. This report reviews our management strategies of children with blunt pancreatic trauma and their outcomes. METHODOLOGY: Medical records of 7 children with traumatic pancreatic injury were retrospectively analyzed in our institutions. In addition, we reviewed the pertinent literature. RESULTS: There were 2 males and 5 females with a median age of 7.6 years. Pancreatic injury was classified in 3 patients as grade I, in 2 patients as grade II, and in 2 patients as grade III (AAST). The two grade III children underwent ERCP preoperatively. ERCP showed injury to the main pancreatic duct in both of these patients, and emergency surgery was performed for both of them. These operative methods were spleen-preserving distal pancreatectomy and only drainage at the margin of the pancreas with non-resection, respectively. All 7 cases survived. CONCLUSIONS: ERCP is helpful for the diagnosis of suspected cases in pancreatic injury with grade III. In hemorrhagic shock state, appropriate surgical procedures with only drainage at the margin of the pancreas are useful for the treatment of pancreatic fistula in children.

Clinical characteristics of 12 cases of appendiceal diverticulitis: a comparison with 378 cases of acute appendicitis.

PURPOSE: Previous authors have suggested that a diverticulum of the vermiform appendix has a higher risk of perforation than acute appendicitis. Therefore, this study compared appendiceal diverticulitis with acute appendicitis to explain the characteristics of appendiceal diverticulitis. METHODS: Data for this study came from a retrospective analysis at the Department of Surgery at Fukuoka Tokushukai Hospital from January 2005 to June 2008. Twelve cases of appendiceal diverticulitis and 378 cases of acute appendicitis were analyzed. RESULTS: The patients with appendiceal diverticulitis were older than those with acute appendicitis (42.7 ± 15.4 vs. 29.1 ± 17.7; p = 0.009). The white blood cell (WBC) level was lower (11332 ± 4658 vs. 14236 ± 3861; p = 0.011) and the CRP level was higher (8.65 ± 8.94 vs. 4.34 ± 6.34, p = 0.022) in those with appendiceal diverticulitis than in those with acute appendicitis. A preoperative diagnosis for appendiceal diverticulitis was made in 4 out of 12 (33.3%) by ultrasonography (US). The perforation rate was higher in appendiceal diverticulitis than that in acute appendicitis (33.3 vs. 9.8%; p = 0.009). CONCLUSIONS: Appendiceal diverticulitis is more likely to perforate over the progression of the clinical course, which would mandate appendectomy when appendiceal diverticulitis is detected by US, even if the patient has no severe abdominal pain.

Reduced port laparoscopic surgery using umbilical zigzag incision for Meckel's diverticulitis.

INTRODUCTION: Reduced port laparoscopic surgery using an umbilical zigzag incision is comparable to conventional multiport laparoscopic surgery. This method is associated with improved cosmesis and decreased wound pain. PRESENTATION OF CASE: A 67-year-old man visited our hospital. He presented emergency room with a chief complaint of right lower abdominal pain by walking. The patient was diagnosed Meckel's diverticulitis by computed tomography (CT). At first, antibiotics therapy and fasting were performed. Three months later, the patient underwent resection of Meckel' diverticulum with zigzag transumbilical laparoscopic surgery. The patient's postoperative course was good, and he rarely felt wound pain. The patient started oral intake three days after surgery, and was discharged 10 days after surgery. DISCUSSION: Zigzag transumbilical laparoscopic surgery is very useful for resection of the small intestine. This method is associated with improved cosmesis and decreased wound pain. In the case of Meckel's diverticulitis, we suggest that interval resection of Meckel's diverticulum was very useful as it was an operation that could be performed easily. CONCLUSION: Reduced port laparoscopic surgery using an umbilical zigzag incision is considered to be an excellent technique in terms of operability and aesthetic outcomes.