[A case of pulmonary tuberculosis developed during chemotherapy for local advanced colon cancer].

We report a case of pulmonary tuberculosis developed during chemotherapy for colon cancer. A 78-year-old man with dyspnea was referred to our hospital for the treatment of transverse colon cancer with duodenal invasion. Chemotherapy was initiated for severe respiratory dysfunction associated with emphysema. After 3 months of chemotherapy, the patient required hospitalization because of severe general fatigue and appetite loss. Pneumonia occurred on the 9th hospital day. Antibiotic therapies with cefotiam hydrochloride or tazobactam/piperacillin were ineffective, his respiratory condition gradually decreased, and thus, endotracheal intubation was required. The patient was finally diagnosed with pulmonary tuberculosis by acid-fast staining of the sputum. Antituberculosis therapy with rifampicin, isoniazid, and streptomycin was effective, and acid-fast staining became negative after 2 weeks of antituberculosis therapy. However, he could not withdraw from the ventilator support and died of cancer progression on the 94th hospital day. Because chemotherapies induce immunosuppression, a targeted screening for latent tuberculosis infection should be performed in patients with colorectal cancer who are highly at risk for tuberculosis before starting chemotherapy, and pulmonary tuberculosis should be ruled out when a patient develops symptoms of pneumonia during chemotherapy.

A case of indirect inguinal bladder hernia treated with laparoscopic transabdominal preperitoneal repair with high peritoneal incisional approach.

BACKGROUND: Inguinal herniation of the urinary bladder is uncommon and those descending into the scrotum are even rarer. Although open anterior repair has been used for inguinal bladder hernia, the efficacy of laparoscopic herniorrhaphy has been reported in recent years. CASE PRESENTATION: A 63-year-old man presented with an irreducible right groin and scrotal bulge associated with voiding difficulty. Abdominal ultrasonography showed a dislocation of the urinary bladder descending into the right scrotum. Abdominal CT imaging revealed that a part of the bladder and small intestine was herniating into the scrotum through the internal inguinal ring and running laterally to the inferior epigastric artery. Under the diagnosis of indirect inguinal bladder hernia, the patient underwent trans-abdominal preperitoneal hernia repair (TAPP). The bladder herniated into the scrotum through the internal inguinal ring was replaced to the original position. Then the myopectineal orifice was exposed and covered with polypropylene mesh, where a horizontal peritoneal incision 4 cm above the hernia orifice, i.e., the high peritoneal incision approach (HPIA), allowed an easy peeling of the peritoneum and hernia sac. The patient's postoperative course was uneventful and the voiding difficulty resolved. The patient continued to do well without recurrence at 20 months after surgery. CONCLUSION: Preoperative evaluation with abdominal ultrasonography and CT scan allowed a precise diagnosis of a groin hernia with voiding difficulty. TAPP with HPIA was useful in the treatment of inguinal bladder hernia because this technique facilitated a quick confirmation of the hernia contents, secure dissection of the whole protruded bladder, and adequate replacement of the bladder to the original position without any injury.

Duplicate left gastric artery identified during robot-assisted distal gastrectomy: a case report.

BACKGROUND: Duplicated left gastric artery (LGA) is a rare anomaly. With an incidence of only 0.4%, its clinical significance remains largely unrecognized. CASE PRESENTATION: A 65-year-old man underwent robot-assisted distal gastrectomy for early gastric cancer. After division of the left gastric vein in the left gastropancreatic fold, a slim LGA (LGA-1) was identified and dissected. Careful dissection of the left gastropancreatic fold toward the root of the celiac artery revealed another LGA (LGA-2), which was dissected without difficulty. Postoperative reevaluation of the three-dimensional-computed tomography (CT) angiography reconstructed using the preoperative CT scan identified a 2.7 mm LGA-1, branching from the splenic artery, and a 3.0 mm LGA-2, branching from the celiac artery. To the best of our knowledge, this is only the third reported case of a duplicate LGA in a patient who underwent laparoscopic gastrectomy. Our case is the first to report the use of robot surgery. CONCLUSIONS: Although duplicate LGA is rare and receives little clinical attention, surgeons should keep this vascular anomaly in mind during preoperative evaluation since there is an increased risk for intraoperative bleeding during gastrectomy.

Rational Gastric Conduit Stump Closure Method Using Endo GIA Radial Reload in End-to-Side Anastomosis of the Esophagogastric Conduit.

Background: The lack of tension at the anastomosis site and the blood flow of the gastric conduit are important to prevent anastomotic leakage in the anastomosis of the esophagogastric conduit. This study reports a gastric conduit stump closure method using Endo GIA™ Radial Reload in end-to-side anastomosis of the esophagogastric conduit, especially focusing on blood flow. Methods: A 4-cm conduit was created to ensure an intramural vascular network. The gastric conduit was elevated to the neck through the posterior mediastinal route, and end-to-side anastomosis of the esophagus and gastric conduit was performed using a circular stapler. Closure of the gastric stump with an Endo GIA Radial Reload was performed 2 cm proximal to the anastomosis on the end side of the esophagogastric conduit. The lesser curvature of the stump of the gastric conduit is the most frequent site of anastomotic leakage as it has the least blood flow, and the pressure is highest when the pressure inside the gastric conduit increases. Therefore, the gastric conduit stump was closed using the Endo GIA Radial Reload to resect the intersection of the gastric stump and lesser curvature from which the gastric conduit was created. The gastric conduit stump is gently curved; therefore, the pressure applied to the gastric conduit stump could be dispersed when the intragastric pressure increases. Results: No anastomotic leakage was observed among the 21 patients who underwent this method. Conclusion: This method is a novel anastomosis method to prevent anastomotic leakage in an end-to-side anastomosis of the esophagogastric conduit.

A safe, reliable, and efficient robot-assisted port site closure for robot-assisted gastrectomy.

INTRODUCTION: The overall incidence of port site hernias in laparoscopy and robot-assisted surgeries ranges from 0% to 5.2%. Sufficient port site closure is essential to reduce and prevent the occurrence of port site hernia. However, complete fascial closure of 8-mm robot-port site appears to be difficult. In this study, we propose a safe and reliable robot-assisted port-site closure for robot-assisted gastrectomy. MATERIALS AND METHODS: The robotic arm was tilted 60-70° cranially or caudally to create a small gap between the port and the skin margin that was cut open for port insertion. While viewing through the robotic camera and grasping the polydioxanone (PDS) thread, the Lapa-Her-Closure was inserted into the peritoneal cavity through the gap. The Lapa-Her-Closure was removed after the PDS thread was grasped with robotic forceps. Subsequently, the Lapa-Her-Closure was inserted into the abdominal cavity by tilting the arm cranially or caudally, in contrast to the previous step. The PDS thread was inserted into the loop wire using robotic forceps. After tightening the loop wire and grasping the PDS thread, the Lapa-Her-Closure was removed, and the PDS thread was ligated to complete the abdominal wall closure, with total closure of the fascia and peritoneum. RESULTS AND CONCLUSIONS: We utilized this port site closure technique in 12 patients who underwent robot-assisted gastrectomy for gastric cancer. The procedure was accomplished safely and efficiently in all cases without any technical problems. In conclusion, our port site closure is safe, reliable, and efficient procedure that can be performed using basic surgical techniques.

Three-dimensional computed tomography image-oriented successful thoracoscopic subtotal esophagectomy for an esophageal cancer patient with an anomalous right superior pulmonary vein: A case report.

BACKGROUND: Subcarinal lymphadenectomy is an essential procedure in curative esophagectomy for esophageal cancer. The right superior pulmonary vein (RSPV) and its branches are usually located in front of the right main or intermediate bronchus. However, an anomalous posterior branch (aberrant V2) of RSPV passes behind the right intermediate bronchus, where the aberrant V2 may be embedded in the subcarinal nodal packet. This can lead to unanticipated bleeding when dissecting the subcarinal lymph node. We present a case study on the use of preoperative three-dimensional contrast-enhanced computed tomography (3D-CT) for performing a safe video-assisted thoracoscopic surgery-esophagectomy in lower thoracic esophageal cancer. CASE PRESENTATION: A 77-year-old man had esophageal cancer associated with an aberrant V2 passing behind the right intermediate bronchus. Esophagogastroduodenoscopy revealed a type 1 tumor in the lower thoracic esophagus. Contrast-enhanced and 3D-CT scans showed a space-occupying lesion with contrast enhancement and an aberrant V2 passing behind the right intermediate bronchus, respectively. The patient was then diagnosed with lower thoracic esophageal cancer (cT2cN1cM0 cStage II). As per the patient's request, he underwent a surgery-first approach followed by adjuvant chemotherapy. The patient underwent video-assisted thoracoscopic surgery-esophagectomy (VATS-E) with three-field lymphadenectomy, and a large aberrant V2 involving the subcarinal nodal packet was recognized behind the right intermediate bronchus. After the thoracoscopic subtotal esophagectomy with three-field lymph node dissection, laparoscopy-assisted reconstruction of the esophagus was performed with elevation of the gastric conduit to the neck. Recurrent laryngeal nerve palsy was not observed. He started to receive rehabilitation for swallowing on day 3 and resumed oral intake on day 10 after surgery. The final pathological diagnosis was squamous cell carcinoma of the esophagus (pT3N1M0 pStageIII). CONCLUSIONS: Preoperative contrast-enhanced 3D-CT clearly depicted the aberrant V2, which enabled us to perform a safe VATS-E with three-field lymphadenectomy. Thorough understanding of the anatomical configuration of the pulmonary vessels and bronchus is important for avoiding unexpected bleeding during subcarinal lymphadenectomy. 3D-CT imaging study is useful for recognizing the anomalous RSPV before surgery.

Percutaneous sonographically assisted endoscopic gastrostomy for difficult cases with interposed organs.

OBJECTIVES: The aim of this retrospective observational study was to clarify the usefulness and safety of percutaneous sonographically assisted endoscopic gastrostomy or duodenostomy (PSEGD) using the introduction method. METHODS: The information for the sequential 22 patients who could not undergo standard percutaneous endoscopic gastrostomy (PEG) and underwent PSEGD for 3 y was extracted and was reviewed. In standard PEG, we performed pushing out of the stomach from the mediastinum and full distention to adhere the gastric wall to the peritoneal wall without interposing of the intraperitoneal tissues by air inflation and a turning-over procedure of the endoscope, four-point square fixation of the stomach to the peritoneal wall by using a Funada-style gastric wall fixation kit under diaphanoscopy, extracorporeal thumb pushing, and in difficult cases extracorporeal ultrasound guidance, and if necessary confirmation of fixation of the gastric wall to the peritoneal wall and placement of the PEG tube without any interposed tissues by using ultrasound. RESULTS: Twenty-one patients (95.5%) successfully underwent PSEGD. Early complications (more than grade 2 in Clavien-Dindo classification) just after the procedure occurred in one case (active oozing). We did not encounter a case with mispuncture of the intraperitoneal organs and tissues. Delayed complications occurring within 1 mo were pneumonia in five patients, including death in three cases; bleeding from puncture site in two patients; and atrial fibrilation in one patient. CONCLUSION: PSEGD using the introduction method is a useful procedure for difficult patients in whom intraperitoneal organ or tissue is suspected to be interposed between the abdominal wall and stomach.