Usefulness of a novel, slim long syringe-like device for applying surgical mesh through a 5-mm trocar.

We developed a device for introducing surgical mesh through a 5-mm trocar during transabdominal preperitoneal hernia repair. This device is like a slim long syringe; it has a polypropylene outer sheath (outer diameter, 5.8 mm; inner diameter, 5.6 mm; length, 2500 mm) and inner rod, and is made in a similar manner to a drinking straw. Therefore, the manufacturing costs are low. To use the device, folded mesh is placed inside it with a grasper before surgery. The device is then inserted through the trocar, and the mesh is pushed out by the inner rod and applied. The folded mesh extrudes smoothly pubis side to lateral side along the inguinal curve. It reinforces the area without any contamination and expands in a manner that makes it easy for the surgeon to place and fix the mesh. Our device allows mesh to be applied smoothly, comfortably, and economically, and it may reduce the risk of infection.

[A Case of Resected Reactive Lymphoid Hyperplasia of Liver Suspected of Hepatocellular Carcinoma].

A 64-year-old woman who had chronic type C viral hepatitis was referred with a liver tumor detected by magnetic resonance imaging(MRI). She had a history of rheumatoid arthritis which was treated by methotrexate. Ethoxybenzyl-MRI(EOBMRI) showed a low signal in the T1-weighted imaging, a high signal in the T2-weighted imaging and a low signal in the hepatobiliary phase. The tumor was 7 millimeters in diameter at S4, and exhibited enhancement in the arterial phase and wash out in the portal phase by contrast enhanced CT. Imaging findings suggested hepatocellular carcinoma, and we performed partial hepatectomy of S4. Histopathological examination confirmed reactive lymphoid hyperplasia(RLH)of liver. RLH of liver is a rare benign lesion and it is necessary to consider RLH as a differential diagnosis of the liver tumor.

Impact of nutritional status on outcomes in laparoscopy-assisted gastrectomy.

BACKGROUND: There is a high morbidity rate after digestive surgery in patients with nutritional disorders such as high body mass index and depletion of skeletal muscle. MATERIALS AND METHODS: The ratio of psoas muscle area to trunk area was defined as the Psoas and All trunk Ratio (PandA Ratio) and used as an index of the balance between muscle and adipose tissue. This ratio was determined in 77 patients undergoing laparoscopy-assisted gastrectomy (LAG) for gastric cancer. Patients were classified into groups with and without postoperative complications. Clinicopathological factors were compared between the groups, and relationships of PandA Ratio with other nutritional indices were examined. PandA Ratios were also analyzed in males and females in each Clavien-Dindo grade. RESULTS: Complications developed in 22 patients (28.6%) after LAG. The PandA Ratio was significantly lower in patients with complications in univariate (2.76 ± 0.22% versus 3.66 ± 0.14%, P = 0.0009) and multivariate (P = 0.0064) analyses. A low PandA Ratio was also associated with more severe complications in males. CONCLUSIONS: Measurement of the areas of the psoas muscle and trunk on CT is useful for evaluation of the balance between skeletal and adipose tissue. The PandA Ratio derived from these measurements is a predictor of the clinical course after LAG in males.

A novel procedure for introducing large sheet-type surgical material with a self-expanding origami structure using a slim trocar (chevron pleats procedure).

BACKGROUND: Large sheet-type surgical materials (e.g., absorbable hemostat, adhesion barrier membranes, and flat surgical mesh) are difficult to introduce into a corporeal cavity using a 5-mm trocar; however, laparoscopic surgeries that use mainly 5-mm trocars are increasing. Furthermore, it is necessary not only to introduce but also to secure the applied surgical material and expand it from the original surgical site. To address these challenges, we developed a novel procedure for introducing such surgical materials into a corporeal cavity using a 5-mm trocar and a self-expanding origami structure, called the "chevron pleats procedure (CPP)". METHODS: We used CPP in 114 cases of laparoscopic surgery for gastrointestinal diseases. The chevron folding pattern is an excellent origami structure and compactly folds a large sheet of material for use with a slim trocar. Surgical materials were folded using a chevron pleats pattern and inserted into a novel, slim, long syringe-type device, which was made from a specially ordered precision polypropylene tube, for introduction into a corporeal cavity. When the surgical material was used, the end of the device was placed above the surgical site and the inner rod was pushed. The surgical material was securely injected and expanded over the surgical site. RESULTS: Surgical materials were introduced smoothly and securely using a 5-mm trocar to a site of intraoperative bleeding, the incisional surface of the liver, and defects of the abdominal wall or peritoneum. Efficient hemostasis was attained, the introduction and expansion of surgical mesh was made simpler, and the covering of defects of the peritoneum with adhesion barrier membranes, which is typically difficult during laparoscopic surgery, was easily performed. CONCLUSIONS: CPP is a basic utility procedure for introducing several sheet-type surgical materials into a corporeal cavity with a 5-mm trocar and might help ensure efficient and safe laparoscopic surgery.

[Solitary Splenic Hilar Nodes Metastasis from Ovarian Cancer Managed by Splenectomy with Pancreas Tail].

Solitary splenic metastasis from cancer is known as a rare disorder in cancer patients. In the present study, we report our experience regarding pathophysiology and treatment tactics of the splenic metastasis caused by ovarian cancer after perioperative chemotherapy. A 50s female presented to our clinic complaining of growing solitary splenic hilar node in CT. Hysterectomy, bilateral oophorectomy, omentectomy and adjuvant therapy was performed after neoadjuvant therapy with TC regimen. Five years and 3 months after surgery, she presented growing solitary splenic hilar nodule in CT. After staging laparoscopy, this lesion is judged to be able to be resected absolutely. Splenectomy and pancreas tail resection was performed. She has survived 39 months after 2nd surgery without recurrence. She recieved a diagnosis of solitary splenic metastasis from past ovarian cancer with whitch pattern of immunostaining was accord closely. Therapeutic tactics for solitary splenic metastasis is splenectomy because of the prognosis after complete resection is thought to be well.

Prognostic Impact of a Nutritional Index Including Muscle Volume in Stage 4 Colorectal Cancer.

BACKGROUND: Nutritional status influences cancer prognosis. Measurement of the area of the psoas muscle on computed tomography is useful for evaluation of skeletal muscle mass and prediction of prognosis. PATIENTS AND METHODS: The psoas muscle index (PMI) was determined in 42 patients undergoing surgery for stage 4 colorectal cancer. Patients were classified into high and low PMI groups using a cutoff of 5.5×10-4 cm2 m-2 Relationships of PMI with prognosis, chemotherapy period, and postoperative complications were examined. RESULTS: The 3-year overall survival rate was 24.0%. PMI was significantly associated with 3-year OS in univariate (high vs. low PMI: 43.0% vs. 12.9%, p=0.0415) and multivariate (p=0.0146) analyses. A low PMI was associated with a shorter period of chemotherapy. A reduction in PMI was a predictor of a poor prognosis. CONCLUSION: PMI status is related to the period of chemotherapy and is an independent prognostic factor in patients with stage 4 colorectal cancer.

[A Case of Trousseau's Syndrome Caused by CA19-9-Producing Gastric Cancer].

Trousseau's syndrome is a coagulation disorder occurring in cancer patients. In the present study, we report our experience regarding the pathophysiology and treatment strategies of this syndrome that is caused by CA19-9-producing gastric cancer during long term chemotherapy. A 60s male presented to our clinic; he was found to have a high level of CA19-9. An advanced gastric cancer was identified by gastric scope. A totalgastrectomy was performed. Severalcourses of chemotherapy were administered, and the level of CA19-9 was measured over a long period. Three years and 2 months after the surgery, he presented to the emergency room complaining of acute onset of aphasia and paresis of the extremities. Brain MRI showed multiple cerebral infarctions. He was diagnosed with Trousseau's syndrome. Although decision making is difficult in the treatment of this syndrome, owing to the complex medicalhistory associated with it, it is essentialthat strategies be established for achieving successfultreatment results in the future.

[Diagnostic problems in gastric cancer patients with sarcoidosis-case report and literature review].

Sarcoidosis is an idiopathic systemic disease with non-caseating granuloma that is reported to occur concomitantly with various malignant tumors. We report here a case of advanced gastric cancer with sarcoidosis, for which precise preoperative diagnosis was difficult. A 69-year-old woman was diagnosed with a far-advanced gastric cancer because multiple intra-abdominal and intra-thoracic lymph node swellings and a tumorous lesion in the spleen were detected by multidetector computed tomography and fluorodeoxyglucose positron emission tomography. However, these multiple changes might be derived from sarcoidosis, because the multiple lymph node swellings were nonspecific changes for gastric cancer. With appropriate informed consent, surgery was selected in order to accurately confirm the stage of progression. Consequently, these changes were shown to not be metastatic, and curative surgery was performed. In conclusion, careful examination and a reasonable treatment strategy are important for avoiding the risk of overdiagnosis in gastric cancer patients with sarcoidosis.