[A case of granulocyte-colony stimulating factor-producing gallbladder adenosquamous carcinoma with rapidly-growing recurrence of liver metastasis in early postoperative period].

An 82-year-old male with a gallbladder mass was diagnosed with gallbladder carcinoma through various examinations. Cholecystectomy, gallbladder bed resection, and lymph node dissection were performed. The histological examination revealed a gallbladder adenosquamous carcinoma, and this tumor showed positive staining for granulocyte-colony stimulating factor (G-CSF). Recurrence of multiple liver metastases was detected on 25th day postoperatively. Unfortunately, the patient died on 97th day postoperatively. Here, we report a case of G-CSF-producing adenosquamous carcinoma of the gallbladder with rapid recurrence of liver metastases in the early postoperative period.

[A Case of Primary Anal Fistula Cancer with Extensive Intrapelvic Spreading That Was Successfully Treated with Bevacizumab plus mFOLFOX6].

The patient was a 68-year-old man who had an anal fistula for>10 years. He was referred to our institution after visiting a local physician with left femoral pain as the main complaint and received a diagnosis of high inflammatory response. We then found discharge of pus in the perianal region during a medical examination. We also found an extensive intrapelvic tumor during a computed tomography(CT)/magnetic resonance imaging examination. In addition, the level ofa tumor marker and inflammatory response were high. To control the inflammation, we performed seton drainage and sigmoid colostomy. On the basis of the pathological findings from the mucus component, we confirmed a diagnosis of fistula cancer. Considering that the progressive lesion had extensively spread, we decided to initiate chemotherapy alone because ofthe absence ofan indication for radiotherapy. We administered bevacizumab plus mFOLFOX6, and partial response was observed on a CT scan. We could control the progression ofthe disease for>6 months. The present case suggests that bevacizumab plus mFOLFOX6 can be an effective regimen for unresectable advanced fistula cancers.

A patient with cystic duct remnant calculus treated by laparoscopic surgery combined with near-infrared fluorescence cholangiography.

BACKGROUND: The recurrence of symptoms present before cholecystectomy may be caused by a cystic duct remnant. The resolution of cystic duct remnant syndrome may require surgical resection, but identification of the duct remnant during laparoscopic surgery may be difficult because of adhesions following the previous procedure. Open surgery, which is more invasive than laparoscopic surgery, is frequently chosen to avoid bile duct injury. CASE PRESENTATION: The patient was a 24-year-old woman with previous laparoscopic cholecystectomy for chronic cholecystitis and repeated attacks of biliary colic. The postoperative course was uneventful, but computed tomography revealed a remnant cystic duct calculus. Ten months after surgery, the patient returned to our department for right hypochondriac pain. Laparoscopic remnant cystic duct resection was performed with intraoperative near-infrared (NIR) fluorescence cholangiography to visualize the common bile duct and remnant cystic duct. The postoperative course was uneventful and the patient was discharged on day 3 after surgery. At the 6-month follow-up, she had no recurrence of pain. CONCLUSION: Laparoscopic surgery with NIR cholangiography is a safe and effective alternative for the removal of a cystic duct remnant calculus after cholecystectomy.

Transumbilical Hidden-Scar High Anterior Resection for Sigmoid Colon Cancer Using GelPOINT® Through an Umbilical Zigzag Skin Incision.

Introduction: Hidden-scar surgery is a new method by which surgeons perform abdominal operations through one incision made in the folds of the patient's umbilicus. However, with a straight incision in the umbilicus, the maximal opening of the fascia is 2 cm. The 2-cm fascial opening is not enough to allow for the triangulation of instruments, the removal of specimens, and the performance of anastomosis, particularly during gastrectomy and colectomy. To overcome this problem, we developed an umbilical zigzag skin incision with a 6-cm opening of the fascia and peritoneum in collaboration with plastic surgeons and used Gelport® to maintain pneumoperitoneum, which resulted in a scarless wound.1 Plastic surgeons modified this technique from umbilicoplasties for umbilical deformities.2,3 We have performed gastrectomies, colectomies, cholecystectomies, and transabdominal preperitoneal hernia repairs using this method without any complications and have succeeded in hiding scars in the umbilicus. GelPOINT® is a newly developed device for minimally invasive surgery that provides a flexible, air-tight fulcrum to facilitate the triangulation of standard instrumentation. By offering an increased range of motion and maximum retraction and exposure, the GelPOINT platforms assure maximum versatility and access for a wide range of abdominal procedures. We report herein a video (559 seconds) describing a new method of transumbilical hidden-scar surgery using GelPOINT through an umbilical zigzag skin incision. Materials and Surgical Technique: A 64-year-old woman underwent laparoscopic sigmoidectomy for sigmoid colon cancer. The procedure was performed as previously described1; after marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPOINT double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The GelPOINT was latched to the wound retractor ring, and the pneumoperitoneum was then inflated using CO2. One additional port was inserted in the right-lower abdomen for safety. Laparoscopic high anterior resection with lymph node dissection was performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical zigzag incision, and the double-staple technique was used for anastomosis without any complications. The wound in the umbilical region was virtually hidden in the bottom of the umbilicus after surgery. Results and Conclusion: We performed an umbilical zigzag skin incision technique using GelPOINT for laparoscopic high anterior resection without any complications. We consider that this zigzag skin incision technique is one way to lessen the technical difficulties of laparoscopic surgery, resulting in a hidden scar in the umbilicus. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 9 mins 19 secs.