[A case of biliary panperitonitis due to intrahepatic bile duct rupture with intrahepatic bile duct tumor].

An 87-year-old man visited his previous doctor because of jaundice, abdominal pain, and disturbance of consciousness. He was diagnosed with cholangitis and panperitonitis and was referred to our hospital. Emergency laparotomy revealed biliary peritonitis. However, the bile leak point was unclear. Two days after surgery, endoscopic retrograde cholangiopancreatography was performed and revealed hilar bile duct stenosis, slight dilation of the intrahepatic bile duct, and bile leakage from the peripheral left intrahepatic bile duct to the abdominal free space. Endoscopic nasobiliary drainage was performed, and bile leakage decreased. He was discharged from our hospital with improvement from jaundice and peritonitis. Intrahepatic bile duct rupture with neoplastic obstruction of the bile duct is extremely rare. To date, only two cases of intrahepatic bile duct rupture with intrahepatic cholangiocarcinoma have been published.

Long-Term Outcomes of Conversion Hepatectomy for Initially Unresectable Colorectal Liver Metastases.

BACKGROUND: Chemotherapy, including molecular targeted agents, for metastatic colorectal cancer has greatly improved recently and offers an increased chance of conversion hepatectomy for patients with initially unresectable liver metastases. However, the long-term outcomes of conversion hepatectomy remain controversial. METHODS: We retrospectively assessed a consecutive series of 210 patients with colorectal liver metastases to evaluate the long-term outcomes of patients who underwent conversion hepatectomy and to clarify the predictive factors related to the conversion rate. RESULTS: Ninety-four cases were initially resectable and underwent primary hepatectomy. Of the 116 patients with initially unresectable liver metastases, 104 patients underwent chemotherapy (systemic or hepatic artery infusion). Twenty-four percent (11/46) of the initially unresectable liver-limited metastases that became resectable after chemotherapy were subsequently treated with conversion hepatectomy; however, there were no cases of conversion among the patients with extrahepatic metastases. The final resection rate of liver metastases was 50 % (105/210), including conversion hepatectomies. The predicted 5-year survival rate in the conversion hepatectomy group was 76 %. The conversion rate was significantly (P < 0.05) higher in patients with liver-limited metastases (24 %), patients with no LN involvement (27 %), the hepatic arterial infusion chemotherapy group (33 %), patients treated with anti-EGFR agents (21 %), and patients with a complete or partial response (33 %). CONCLUSIONS: Twenty-four percent of the patients with initially unresectable liver-limited metastases became resectable after chemotherapy, and the survival rate after conversion hepatectomy was not inferior to that of the primary hepatectomy cases. Chemotherapy regimens with high response rates are needed to achieve a higher conversion rate.

The Oncologic Outcomes of Inferior Mesenteric Artery-Preserving Laparoscopic Lymph Node Dissection for Upper-Rectal or Sigmoid Colon Cancer.

BACKGROUND: The standard procedure of lymph node (LN) dissection for rectal or sigmoid colon cancer remains controversial. Many laparoscopic surgeons cut the inferior mesenteric artery (IMA) at the root; however, this may cause bowel ischemia around the site of anastomosis. We performed D3 or D2 LN dissection with the preservation of the IMA. The aim of this study was to evaluate the oncologic outcomes of IMA-preserving LN dissection. PATIENTS AND METHODS: We retrospectively analyzed 142 consecutive patients with upper-rectal or sigmoid colon cancer who underwent laparoscopic LN dissection with the preservation of the IMA. The number of LNs dissected and the overall and disease-free survival rates were retrospectively evaluated. RESULTS: Laparoscopic D3 (n = 92) or D2 (n = 50) LN dissection were performed with the preservation of the IMA. The left colic artery was preserved in all cases, the superior rectal artery was also preserved in 30 cases. The mean number of LNs dissected was 19.6 in the D3 group and 12.9 in the D2 group. The median operative time was 230 minutes, and the median volume of blood loss was 17 mL. There was no treatment-related mortality. The estimated 5-year disease-free survival rates of the stage I, II, and III patients were 93%, 83%, and 74%, respectively. No patients developed LN recurrence. CONCLUSIONS: Laparoscopic surgery with IMA-preserving LN dissection is an oncologically acceptable treatment strategy in patients with upper-rectal or sigmoid colon cancer.

A laparoscopic approach is associated with a decreased incidence of SSI in patients undergoing palliative surgery for malignant bowel obstruction.

BACKGROUND: Several authors have reported on the utility of a laparoscopic approach for the palliation of malignant bowel obstruction (MBO); however, the advantages of laparoscopic surgery for MBO have not yet been confirmed. METHODS: We retrospectively reviewed the medical records of patients who underwent palliative surgery for MBO between 2007 and 2015. Laparoscopic procedures have been performed when technically possible since 2014. Successful palliation was defined as the ability to tolerate solid food (TSF) for at least 2 weeks. RESULTS: Twenty-two patients underwent laparoscopic palliative surgery, and 171 patients underwent conventional open palliative surgery to relieve the symptoms of MBO. Laparoscopic palliative surgery was performed for patients with MBO due to colorectal cancer (n = 12), uterine cancer (n = 3), and other types of cancers (including gastric, prostate, and renal cancer). The following laparoscopic procedures were performed: stoma placement (n = 18), palliative resection (n = 3) and bypass (n = 2). The median operative time was 100 min and the median operative blood loss was 9 ml. The laparoscopic palliative operation allowed 91% (20/22) of the patients to consume a solid diet for more than 2 weeks, and be discharged from hospital. There were no significant differences between laparoscopic surgery and open surgery with regard to the ability to TSF or the postoperative mortality rate. The postoperative morbidity (Clavien-Dindo Grade ≥ II) rates in the laparoscopic and open surgery groups were 14% and 32%, respectively. Laparoscopic surgery led to a significantly lower rate of postoperative surgical site infection (SSI) in comparison to open surgery (4.5% vs 32%; P = 0.0053). CONCLUSION: A laparoscopic approach in palliative surgery for MBO was safe and feasible, and was associated with a lower incidence of SSIs. By minimizing the postoperative morbidity rate, the laparoscopic approach may provide significant benefits to patients with MBO who have a limited life expectancy.

Gastrointestinal Stromal Tumor of the Stomach with an Abscess Excised by Laparoscopic Surgery.

Gastrointestinal stromal tumors (GISTs) of the stomach presenting as an intra-abdominal abscess are extremely rare. We herein report a case that underwent successful laparoscopic resection of gastric GIST presenting with an intra-abdominal abscess. A 70-year-old man presented with a 3-day history of acute upper abdominal pain with a fever. Laboratory data showed an elevated white blood cell count and C-reactive protein level. A CT scan revealed a mass of mixed solid and fluid components, measuring 5.5 cm, in the adjacent lesser curvature of the stomach. He was diagnosed as having an intra-abdominal abscess, and antibiotic therapy was administered. Consequently, his symptoms were relieved and a CT scan on the 7th day showed that the mass reduced and became homogenous. According to the results of a fine-needle aspiration biopsy, the tumor was suspected to be a GIST. Laparoscopic surgery with the 5-port approach was performed. The tumor existed in the lesser curvature of the stomach, and was excised en bloc with the omentum and gastric wall by wedge resection. The tumor measured 3.0 cm in diameter and originated from the serosal layer of the stomach. Histological findings showed spindle cells with a stromal growth pattern that was positive for c-kit (CD 117) and CD 34. The postoperative course was uneventful, and no recurrence has been noted in the 2 years since the operation. This is the first report of a case with gastric GIST with an intra-abdominal abscess that was successfully treated by laparoscopic surgery.

Survival benefit of surgical treatment for liver metastases from gastric cancer.

BACKGROUND AND OBJECTIVES: Indications for the resection of liver metastases from gastric cancers (GLM) remain controversial, and few previous studies have reported subsequent surgical outcomes. Thus, the present retrospective study was designed to clarify the benefits of surgical treatment and identify prognostic factors. METHODS: Outcomes of 47 patients with or without hepatectomy for GLM were retrospectively compared. RESULTS: A total of 22 patients received surgical treatment for GLM, and overall 1-, 3-, and 5-year survival rates were 86, 26, and 26 %, respectively, and the median survival time (MST) was 22 months. Among 25 patients who did not receive hepatic surgical treatment, the overall survival rates were 24, 8.0, and 4.0 % at 1-, 3-, and 5-years, respectively, with an MST of 7 months. A significant difference was observed between patients with and without the liver surgical treatment (P < 0.001). Univariate and multivariate analyses of recipients of surgery, only the number of liver metastases (solitary or multiple) was significantly predictive of survival (HR = 0.26, P = 0.029) following hepatic resection for GLM. CONCLUSIONS: Surgical treatment of GLM should be considered when complete excision including the primary tumor appears to be possible, particularly in cases of solitary hepatic metastases.

Hepatectomy for liver metastases in non-colorectal, non-neuroendocrine cancer patients. The survival benefit in primary unresectable cases.

BACKGROUND: Although liver resection is widely accepted as a potentially curative treatment for colorectal liver metastases, there is an ongoing debate on the indications for hepatectomy for the treatment of liver metastases from non-colorectal primary tumors. The number of candidates for hepatectomy for non-colorectal liver metastases may increase due to advances in chemotherapy; however, the factors related to prognosis after hepatectomy for non-colorectal liver metastases have yet to be clearly elucidated. METHODS: The clinical outcomes of 59 patients who underwent hepatectomy for non-colorectal liver metastases at a single institute were retrospectively analyzed. RESULTS: The 5-year overall survival rate after hepatectomy for non-colorectal, non-neuroendocrine liver metastases was 30%, and 8 patients (gastric cancer (n = 2), ovarian cancer (n = 2), uterine cancer (n = 2) and breast cancer (n = 2)) survived for 5 years. The 5-year disease-free survival rate after hepatectomy was 28%. The postoperative morbidity rate was 25%; however, there were no cases of in-hospital mortality and no patients suffered liver failure. The presence of bilateral liver metastases was identified to be an independent predicting factor for poor prognosis by a multivariate analysis (P = 0.049). The survival rate of the conversion cases (initially unresectable and converted to resection after chemotherapy) was not inferior to that of primary resectable cases in terms of either overall survival or disease-free survival. CONCLUSION: The present study demonstrates that hepatectomy for liver metastases from non-colorectal tumors is safe and that it may be a promising strategy for prolonging survival and achieving a cure.

Laparoscopic resection aided by preoperative 3-D CT angiography for rectosigmoid colon cancer associated with a horseshoe kidney: A case report.

We herein report a case of laparoscopic high anterior resection with D3 lymph node dissection for rectosigmoid colon cancer with a horseshoe kidney. A 65-year-old Japanese man referred to our hospital for rectosigmoid colon cancer was found to have a horseshoe kidney on a CT scan. On 3-D CT angiography, an aberrant renal artery was visualized feeding the renal isthmus that arises from the aorta just below the root of the inferior mesenteric artery (IMA). Laparoscopic anterior rectal resection with D3 lymph node dissection was performed. During the operation, the IMA, left ureter, left gonadal vessels and hypogastric nerve plexus could be seen passing over the horseshoe kidney isthmus. With the aid of preoperative 3-D CT angiography, the root of the IMA was identified on the temporal side of the isthmus and divided safely just above the hypogastric nerve. As a horseshoe kidney is often accompanied by aberrant renal arteries and/or abnormal running of the ureter, 3-D CT angiography is useful for determining the location of these structures and avoiding intraoperative injury.

Neoplastic diseases of the papilla of Vater.

Although it is quite small, the papilla of Vater is an important part of the body. Carcinoma of the papilla may be one of the smallest cancers that can cause death. The 5-year survival rate after resection was 51%, which is not satisfactory. In this article, the topics discussed are (1) pathogenesis, (2) histological characteristics, and (3) the molecular biological characteristics of carcinoma of the papilla of Vater. From results obtained by the investigation of 576 autopsied and 51 resected cases, atypical epithelium was found most frequently in the common channel, where pancreatic juice and bile mix physiologically. Atypical epithelia may be a precursor of carcinoma of the papilla of Vater. Carcinoma of the papilla of Vater could be classified into two types histologically, an intestinal type and a pancreaticobiliary type. The prognosis of patients with the intestinal type was much better than that of patients with the pancreaticobiliary type. These two types of carcinoma should be treated by different operative procedures or adjuvant therapies. Regarding the molecular biological characteristics of carcinoma of the papilla of Vater; (1) K- ras mutation is mainly associated with the intestinal type, and carcinomas of the intestinal and pancreaticobiliary types may develop via different mechanisms; (2) p53 overexpression may play a role in tumor ulceration; and (3) p21/Waf1 overexpression was significantly correlated with a poor prognosis.