Osteosynthesis using scorpion plate for nonunion of distal clavicle fracture with small distal bone fragment: A case report.

Distal clavicle nonunion is a relatively common complication of unstable, displaced distal clavicle fractures; however, its standard surgical procedure has not been fully established. We describe a case of symptomatic nonunion of a distal clavicle fracture with a very small distal bone fragment that was treated with a scorpion plate. A 63-year-old man presented with left shoulder pain after a bicycle fall 5 months earlier. Plain radiographs and computed tomography revealed atrophic nonunion of the distal clavicle with a small distal bone fragment measuring 12 mm in length. Shoulder pain interfered with his work and daily life; therefore, we scheduled surgery. After releasing the nonunion site, cancellous bone was grafted from the iliac crest. We placed a scorpion plate with two grasping arms that fixed the distal clavicular fragment without straddling the acromioclavicular joint. One year postoperatively, his pain subsided, and bone union was confirmed. Our case presents a surgical procedure for treating the nonunion of distal clavicle fractures using a scorpion plate and an autologous bone graft. This procedure is especially beneficial for cases with small distal bone fragments, because the grasping arms of the scorpion plate allow secure fixation of the distal bone fragment and bone graft without further fragmentation.

[A Case of Laparoscopic Resection Following Preoperative Chemoradiotherapy of a Locally Recurrent Rectal Cancer after a Prior Endoscopic Curative Resection].

A man in his seventies underwent endoscopic mucosal resection(EMR)of a rectal cancer 3 years ago. Histopathological examination showed that the specimen had been resected curatively. However, a routine follow-up colonoscopy revealed a submucosal mass on the EMR scar. Computed tomography imaging revealed a mass in the posterior wall of the rectum, with suspected invasion of the sacrum. We performed a biopsy during endoscopic ultrasonography and diagnosed a local recurrence of the rectal cancer. After preoperative chemoradiotherapy(CRT), laparoscopic low anterior resection with ileostomy was performed. Histopathological examination revealed invasion of the rectal wall from the muscularis propria to the adventitia and tissue fibrosis at the radial margin, which was devoid of cancerous cells. Subsequently, the patient received adjuvant chemotherapy with uracil/tegafur and leucovorin for 6 months. No recurrence has been reported over a postoperative follow- up period of 4 years. Preoperative CRT may be an effective treatment for locally recurrent rectal cancer after endoscopic resection.

Plate fixation using parallelogram prism iliac bone grafts for clavicle oblique nonunion with shortening deformity: a case report.

BACKGROUND: Plate fixation using a tricortical iliac bone graft can provide a high ratio of bone union and restore clavicle length in cases of atrophic nonunion. However, the surgical treatment of clavicle oblique nonunions with marked shortening deformity remains challenging and unresolved. Here, we describe a case of clavicle oblique nonunion with shortening that was treated using plate fixation with parallelogram prism iliac bone grafts. CASE PRESENTATION: A 46-year-old man presented to our hospital with severe medial scapular pain. He had been diagnosed with a right clavicle mid-shaft fracture in a motorcycle accident 9 months earlier. He underwent conservative treatment, but radiographs and computed tomography showed clavicle oblique nonunion with marked shortening. Physical examination revealed no pain at the nonunion site; however, tenderness was noted on the medial side of the right scapula and protrusion of the inferior scapular angle was prominent. His symptoms interfered with daily life and required surgery. After release of the nonunion, we harvested the parallelogram prism bone grafts from the iliac crest. We inserted these bone grafts into the fracture ends and fixed them with lag screws, after which we performed plate fixation. Immediately after surgery, right medial scapular pain and scapula winging subsided. Bone union was achieved, and the length of the clavicle was restored at 9 months postoperatively. CONCLUSIONS: This case report provides new information on the surgical treatment of clavicle oblique nonunion with shortening deformity. The presence of medial scapular pain and winging scapula can be clinically problematic in cases of clavicle nonunion with marked shortening. Our case revealed that reliable bone union and clavicle length recovery can be achieved with plate fixation and iliac bone grafts.

[A Case Report of Rectal MiNEN Laparoscopic Resection].

A 74-year-old woman underwent colonoscopy for positive fecal occult blood test. A colonoscopy revealed a Type 1 tumor in the rectosigmoid region. The tumor was diagnosed as well-differentiated adenocarcinoma(tub1)by biopsy. Laparoscopic high anterior resection was performed. The final diagnosis was MiNEN(adenocarcinoma:NEC=6:4), RS, pT4a(SE), INF c, Ly1c, V1b, Pn1b, BD2, pN2a(5/28), cM0, pStage Ⅲc. All lymph node metastases were of NEC origin. This case was considered to be at high risk of recurrence and require adjuvant chemotherapy focused on NEC. She was referred to an advanced medical institution for carboplatin and etoposide therapy. MiNEN is a rare disease, and has a poor prognosis. In order to establish a therapeutic strategy of MiNEN, it is important to accumulate further cases and evidence.

[A Case of Squamous Cell Carcinoma of the Lung from Gastrointestinal Perforation Due to Small Intestinal Metastasis].

An 80s male, with a medical history of hypertension, hyperuricemia, and atrial fibrillation, visited our emergency outpatient department with vomiting and diarrhea as the chief complaint in August 2017. The blood examination revealed a high level of inflammatory reaction. The plain abdominal CT revealed fluid retention contacting the small intestine and intraabdominal free gas. We diagnosed the case as a small intestinal perforation, following which we performed emergency surgery. The small intestine was perforated, and an abscess cavity was formed between the transverse mesocolon and mesentery proper. Thus, the abscess was removed, and about 30 cm of the small intestine, including the perforated site, was resected, followed by the reconstruction. The resected specimens revealed squamous cell carcinoma at the small intestinal perforated site. Lung squamous cell carcinoma was diagnosed by subsequent chest CT and immunostaining. We administered 3 courses of chemotherapy combined with carboplatin and albumin-bound paclitaxel. Although the effect was partially observed, interstitial pneumonia occurred, which was inferred to be drug-induced. The patient died in 195 days following the surgery. Herein, we reported a case of lung cancer, which was diagnosed on the detection of gastrointestinal perforation caused by a small intestinal metastasis.

[Two Cases of Laparoscopic Partial Resection of Stomach Using a Trans-Gastric Wall Approach for Submucosal Tumors].

We performed laparoscopic partial resection of the stomach with a trans-gastric wall approach for submucosal tumors. Case 1: A 67-year-old woman was referred to our hospital because of tarry stool. Upper gastrointestinal endoscopy revealed a well demarcated, round, 45mm intraluminal-type submucosal tumor with delle on the anterior wall of the gastric upper body. Case 2: An 86-year-old woman was referred to our hospital because of anemia. Upper gastrointestinal endoscopy revealed a well demarcated, round, 25mm intraluminal-type submucosal tumor on the posterior wall of the gastric upper body. Laparoscopic partial resection of the stomach with a trans-gastric wall approach was performed. The operation times were 58 minutes and 73 minutes, respectively, and blood loss was low in both cases. This operative procedure is safe and easy and allows for resection resected with a direct view for surgeons without endoscopists.

[Two Cases of Resectable Intra-Abdominal Desmoid Tumor after Laparoscopic Gastrectomy for Gastric Cancer].

Case 1: A 52-year-old man underwent laparoscopic total gastrectomy for gastric cancer. After 2 years, a follow-up computed tomography(CT)scan showed a large, solid 10 cm-sized mass in his left upper abdomen. Under the diagnosis of a suspected mesenchymal tumor, a tumor resection with a partial resection of the upper jejunum and transverse colon was performed. Case 2: A 61-year-old man underwent laparoscopic pylorus-preserving gastrectomy for gastric cancer. After 1.5 years, follow-up CT showed a tumor of 2 cm in diameter near the greater curvature side of the upper stomach. Under the diagnosis of a suspected gastrointestinal stromal tumor(GIST), a laparoscopic partial resection of the stomach was performed. Histologically, spindle-shaped cells without atypia and rich collagen fibers were observed, and the sample was positive for b-catenin by immunostaining in both cases; from this evidence, the patients were diagnosed with desmoid tumors. Desmoid tumors have invasive proliferation characteristics, and treatment requires consideration of the balance between securing a surgical margin and increasing surgical stress.

Atlantoaxial Stabilization Using C1 and C2 Laminar Screw Fixation.

We describe the use of a C1 laminar screw in combination with a C2 laminar screw as a salvage technique to treat two patients, one with persistent first intersegmental artery and the other with vertebral artery occlusion after cervical spine fracture. The combined use of C1 and C2 laminar screws allows for good fixation of the atlantoaxial joint with a lower risk of vertebral artery injury; therefore, it can be an alternative surgical procedure for patients with congenital or traumatic anomalous vertebral artery.

[Laparoscopic Lymphadenectomy without Gastrectomy for Lymph Nodes Recurrence after Endoscopic Submucosal Dissection (ESD)].

A case oflaparoscopic lymphadenectomy in a patient with lymph node recurrence after endoscopic submucosal dissection (ESD)is presented. A 77-year-old man underwent ESD for gastric cancer. After 2 years, the patient was referred to our hospital with the diagnosis of lymph node recurrence. We offered radical surgery, including gastrectomy and lymphadenectomy; however, this suggestion was denied by the patient because ofstrong anxiety for gastrectomy. As an alternative therapy, laparoscopic lymphadenectomy for the limited area of high recurrence, without gastrectomy, was performed. Postoperative course was uneventful. The patient was discharged on the 10th postoperative day and remains cancer-free over 2 years after the operation. Laparoscopic lymphadenectomy for high risk area of recurrence may be considered in frail elderly patients to avoid the high burden ofgastrectomy.

[A Case of Curatively Resected Goblet Cell Carcinoid of the Appendix Diagnosed via Intraoperative Frozen Sectional Examination].

A 52-year-old patient presented with epigastric pain.An enhanced CT scan showed a strongly enhanced appendix with abscess formation.Appendectomy was performed under the diagnosis of acute appendicitis with perityphlitic abscess.The stump of the appendix was white and hard, suggesting malignant transformation.Intraoperative frozen sectional examination indicated goblet cell carcinoid(GCC)of the appendix.Thereafter, we performed ileocecal resection with lymphadenectomy (D3).The final pathological diagnosis was GCC, pSS, pN1, Stage III a by the Japanese classification of colorectal carcinoma. Immunohistochemical examination was consistent with GCC including synaptophysin(+), chromogranin A(+), somatostatin receptor(SSTR)2(±), SSTR5(+), and cytokeratin 20(+).The patient received adjuvant chemotherapy and remains cancer-free over 5 years after the operation.

[Simultaneous Laparoscopic Resection of Gastric Cancer and Hepatocellular Carcinoma].

A report of simultaneous laparoscopic resection for a patient with synchronous gastric cancer and hepatocellular carcinoma (HCC)is presented.A 76-year-old man was referred to our hospital for gastric cancer located in the antrum.In the preoperative examination, enhanced CT and MRI revealed a liver tumor located at S2 that had high contrast enhancement in the arterial phase but that was not washed out in the delayed phase.An early HCC was suspected, and simultaneous laparoscopic distal gastrectomy and partial resection of the liver was performed.The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day.Simultaneous laparoscopic resection of gastric cancer and HCC is possible with special attention to surgical procedures and port settings.

[A Case of Advanced Gastric Cancer with Extensive Lymph Node Metastases Treated by Capecitabine plus Cisplatin plus Trastuzumab Chemotherapy,Followed by Conversion Surgery].

An 82-year-old woman underwent upper gastrointestinal endoscopy to evaluate upper abdominal pain.A type 2 tumor (adenocarcinoma, por, HER2+)was found in the lesser curvature of the gastric antrum.Abdominal CT showed bulky lymph node metastases and pancreatic invasion of lymph node No.6 , resulting in a diagnosis of cT3N3M0, Stage III B.Radical resection was not possible by gastrectomy, and chemotherapy(capecitabine plus cisplatin plus trastuzumab)was administered. The primary lesion and lymph node showed significant regression on CT after the administration of 8 courses of chemotherapy, which also clarified the border between the lymph node and pancreas.At this stage, it was determined that radical resection was feasible; distal gastrectomy(Roux-en-Y reconstruction)and D2 dissection and cholecystectomy were performed.No cancer cells were found in the primary lesion on histopathology.The therapeutic effect of preoperative chemotherapy was assessed as Grade 3, pCR, and retained tumor was only found in lymph node No.5 . On follow-up observation, the patient is alive 11 months after surgery, with no evidence of recurrence without neoadjuvant chemotherapy.

Numerical analyses of the sound absorption of cylindrical microperforated panel space absorbers with cores.

Microperforated panels (MPPs) are next-generation absorption materials because they can provide wideband sound absorption without fibrous materials and can be composed of diverse materials to meet global environmental demands. The fundamental absorbing mechanism is Helmholtz-resonance absorption due to perforations and an air cavity. MPPs are typically backed by rigid flat walls, but to reduce the restrictions on the MPP absorber properties, one of the authors has proposed MPP space sound absorbers without backing structures, including three-dimensional cylindrical microperforated panel space absorbers (CMSAs). Advantages of MPPs without backing structures are design flexibility and ease of use. Besides, the absorption characteristics of a CMSA with a core, which has a rigid cylindrical core inside the CMSA, have been experimentally tested, but a method to predict the absorption characteristics is necessary to design CMSAs with cores. Herein the two-dimensional combined Helmholtz integral formulation method is employed, and its prediction accuracy is evaluated by comparing the measured and predicted absorption characteristics of a CMSA with a core. Furthermore, a parametric study with regard to the core size is carried out to investigate the transition of the absorbing mechanism.

[Synchronous Triple Malignant Tumors (Hilar Cholangiocarcinoma, Ascending Colon Cancer, Liposarcoma) Resected in a Two-Stage Procedure--A Case Report].

A 70-year-old man with a history of myocardial infarction (MI) and taking 2 antiplatelet drugs was diagnosed with anemia his 6-month post-MI checkup. A lower gastrointestinal endoscopy detected ascending colon cancer, and contrast-enhanced a computed tomography scan revealed hilar cholangiocarcinoma as well as lesions suspicious for gastrointestinal stromal tumors of the small intestine. The patient was given a preoperative diagnosis of synchronous triple malignant tumors. The decision to perform a two-stage procedure was made for the following reasons: the impossibility of discontinuing antiplatelet drugs 6 months after drug-eluting stent placement, continuous bleeding due to colon cancer and the possibility of suffering severe stress from surgery while at high risk for diseases such as hepatic failure. In the initial procedure, a right hemicolectomy and surgical resection of the mesenteric tumor (later diagnosed as a liposarcoma) were performed after portal vein embolization. Confirmation of an enlarged residual liver was confirmed 2 months after the initial procedure. The patient underwent right hepatectomy and resection of the extrahepatic bile duct and the biliary tract was surgically reconstructed. Safe resection of tumors was successfully performed by choosing a two-stage procedure for triple malignancy, including hilar cholangiocarcinoma, ascending colon cancer, and liposarcoma, in a single patient.

[A Case of Advanced Gastric Cancer for Which Curative Resection Was Performed, Despite CEA Elevation].

A 32-year-old man was admitted to our hospital with the complaint of epigastric pain. Gastrointestinal endoscopy revealed a type 5 advanced gastric cancer at the posterior wall of the antrum. Contrast-enhanced computed tomography (CT) and endoscopic ultrasonography showed a fluid collection, indicating peritoneal metastasis. CEA levels were elevated, at 16.5 ng/mL. A diagnosis was made of cStage Ⅳ (T4aN3H0P1M1), and he underwent first-line chemotherapy using CDDP and S-1. However, this immediately failed with the severe adverse effect of vomiting.Docetaxel and S-1 were adopted as second-line chemotherapy. Since progression of the disease was confirmed after 8 cycles of second-line chemotherapy, nab-paclitaxel was administered as third-line chemotherapy. Despite a trend of increasing CEA after 4 cycles of third-line chemotherapy, CT revealed a tumor volume reduction as well as the disappearance of the fluid collection, after which staging laparoscopy was performed. Based on the finding that non-curative factors such as fluid collection and peritoneal nodules were not observed, distal gastrectomy was performed. Histopathological examination showed a ypStage ⅠA (T1bN0H0P0M0)tumor with a grade 3 therapeutic response to chemotherapy.The patient is currently doing well with no recurrence 11 months after the operation.

[A Case of Pathological Complete Response after Primary Tumor Resection Followed by Hepatectomy-A Sigmoid Colon Cancer with Synchronous Liver Metastases].

The case is of a 62-year-old man with no medical history and no family history.A type 2 tumor was found in the entire circumference of the sigmoid colon by colonoscopy after a positive result on a fecal occult blood test, and 5 liver metastases were recognized in both lobes of the liver by using contrast-enhanced CT.He was first treated by primary tumor resection. Subsequently, 5-fluorouracil/l-leucovorin/oxaliplatin (mFOLFOX6) plus bevacizumab (BV) was started 1 month after the surgery and a total of 8 cycles of mFOLFOX6 plus BV were administered without any adverse events.On CT assessment after the chemotherapy, the patient was diagnosed with stable disease according to RECIST guidelines since the size of the tumor only showed a slight reduction.However, it was considered to be an optimal response based on the morphologic criteria. Thereafter, a medial segmentectomy and partial resection of the liver was performed.A mucus reservoir was found in the tumor site, and no viable tumor cells were detected pathologically, which confirmed the pathological complete response with mFOLFOX6 plus BV.

[A study of 10 patients with unresectable colorectal cancer who achieved long-term survival].

Appropriate evaluation and countermeasures against adverse events are important for the continuation of long-term chemotherapeutic treatment of patients with unresectable colorectal cancer. We studied 10 patients who were treated for advanced recurrent colorectal cancer at the outpatient chemotherapy unit of our department during the period from 2006 to 2010 and who survived with cancer for at least 3 years. In order to prevent grade 3 neuropathy caused by oxaliplatin (L- OHP), the duration and severity of adverse events were simultaneously assessed using a self-assessment form and a numeric rating scale( NRS) at the unit. In patients with an NRS score above 5 on or after the seventh day of treatment, L- OHP discontinuation was considered. In patients with long-term survival, the duration of FOLFOX or sLV5FU2 chemotherapy was significantly prolonged, and the L-OHP reintroduction rate was also high. Once non-hematological toxicities such as peripheral neuropathy occur, these can undermine the willingness to continue treatment and present considerable obstacles to ongoing therapy. Detailed assessment may prevent or at least reduce the incidence of grade 3 adverse events and thereby contribute to treatment continuation.