Pancreaticoduodenectomy after distal gastrectomy: A case series.

INTRODUCTION: Pancreatoduodenectomy (PD) after gastrectomy requires more attention during surgery than ordinary PD due to anatomical variation with different types of gastrointestinal anastomoses, the complication of anatomical dissection, and the extent of adhesions present. Herein, we describe the PD strategies we used in three patients who strategy for three patients who had previously undergone distal gastrectomy for gastric cancer treatment. DISCUSSION: Generally, reconstruction following PD in patients who have undergone a prior Billroth I reconstruction is simple, as there is no previous afferent loop. By comparison, reconstruction after a Billroth II or R-Y reconstruction requires special consideration of the point of circulation and length of the remnant intestine used for pancreaticojejunostomy, choledochojejunostomy or gastrojejunostomy. CONCLUSION: There is no consensus regarding the best method for performing PD and reconstruction in patients with a prior history of gastrectomy. The appropriateness of using the existing afferent loop for reconstruction depends on whether the jejunum is of sufficient length for bile duct and pancreatic anastomosis. Regardless of the approach used, it is necessary to avoid excessive tension during reconstruction. Based on our experience and previous studies published in the English literature, we propose that reconstruction needs to be considered on a case-by-case basis.

Repair of a perforated duodenal diverticulum using intraduodenal suture in 94 year old woman: A case report.

INTRODUCTION: In case of gastrointestinal diverticula, the duodenal type is quite frequent; duodenum is the second most common site for diverticula following the colon (Glener et al., 2016). However, duodenal diverticular perforation is rare, so the appropriate surgical treatment for this condition is yet unclear (Simoes et al., 2014). This literature has been written in line with the SCARE criteria (Agha et al., 2018). PRESENTATION OF CASE: A 94-year-old woman emergently presented to our department with diffuse abdominal tenderness and guarding, indicating pan-peritonitis. Computed tomography revealed pneumoretroperitoneum; Therefore, gastrointestinal perforation was suspected. Emergency surgery was performed; we detected the perforated diverticulum located at the posterior wall of the duodenum with accompanying inflammation. Considering the location, postoperative leakage, and the patient's advanced age, we placed trans-section on duodenal wall against the lesion and resected the diverticulum, The lumen was then manually sutured from within. The anterior wall was closed using linear staplers. The patient recovered uneventfully and was discharged 24 days after surgery. DISCUSSSIONS: As perforated duodenal diverticulum is rare, the ideal management is unclear. Several studies mention various surgical procedures. However, actual treatment varies based on the patient's situation and surgeon's assessment. Almost all cases that require surgery present emergently; therefore, simpler and more effective treatment methods are required (Simoes et al., 2014; Philip et al., 2019; Fujisaki et al., 2014). CONCLUSION: We used a unique surgical technique; intraduodenal suture for perforated diverticulum. This technique can be a feasible alternative for managing this condition.

Unresectable Advanced Gastric Cancer with Skin Invasion followed by Total Gastrectomy after Second-Line Chemotherapy.

Conversion surgery has been reported but few cases have undergone surgical R0 resection after second-line chemotherapy. We report a case of an unresectable locally advanced gastric cancer in a patient who finally underwent the operation (R0) after second-line chemotherapy. The 77-year-old male was diagnosed with gastric cancer (cT4 [SI; Skin, Liver] N0M0 c Stage IIIA) with invasion to the skin of the abdominal wall, and chemotherapy was initially performed because of his poor performance status and due to the large defect in the abdominal wall that might occur if an operation was performed. Partial response (PR) was observed after S-1+CDDP (SP) therapy, which was then stopped after which progressive disease (PD) was observed. Ramucirumab+Paclitaxel (RAM/PTX) therapy was chosen as second-line therapy, and PR was obtained again, following which total gastrectomy was performed (D2 dissection of lymph nodes, Roux-en-Y reconstruction, and combined resection of the partial skin and the affected region of the liver). At 30 months postoperatively, no recurrence has occurred and the patient is alive after the operation without chemotherapy.

[Effectiveness of Ramucirumab Therapy for Advanced Gastric Cancer after Stent Placement for Esophagogastric Junction Carcinoma Obstruction-A Case Report].

According to the REGARD and RAINBOW trials, ramucirumab(RAM)was introduced as second-line therapy for advanced or metastatic gastric cancer. Endoscopic metallic stent placement and angiogenesis inhibitor administration carry the risk of gastrointestinal perforation. The outcomes of patients who undergo endoscopic placement of metallic stents during RAM treatment have not yet been fully assessed. A 60's man was diagnosed with advanced esophagogastric junction cancer(por) with Virchow's lymph node metastases. His tumor was classified as cT4a(SE), N1(#1), M1, stage Ⅳ. He received chemotherapy, but the size of the primary tumor and metastases increased. After stenting for gastric outlet obstruction, he received a paclitaxel(PTX)plus RAM regimen as third-line treatment. Because of CTCAE Grade 2 peripheral neuropathy, PTX was discontinued after 10 courses. For 11 months, tumor control without adverse events was maintained. The patient was then switched to CPT-11 as fourth-line treatment.

Thoracoscopic Oesophagectomy Using Prone Positioning for Oesophageal Cancer With Right Aortic Arch: A Case Report.

BACKGROUND/AIM: Right aortic arch (RAA) is a rare abnormality of the aortic arch that forms a vascular ring. Oesophageal cancer (EC) accompanied with RAA is even rarer, and in such cases, it is very important to understand the anatomical structure in the upper mediastinum in order to perform a safe and curative operation. PATIENTS AND METHODS: A 67-year-old man who presented with pharyngeal discomfort was admitted to our hospital. Further examinations revealed advanced thoracic EC accompanied with RAA and aortic diverticulum. RESULTS: After neoadjuvant chemotherapy, we successfully and safely performed thoracoscopic oesophagectomy and lymphadenectomy using the prone positioning. CONCLUSION: There exist only a few reports of thoracoscopic oesophagectomy for EC with RAA. Sufficient preoperative preparation and sharing an adequate strategy for the surgical approach with the surgical team are definitely necessary. Although the thoracoscopic approach for EC with RAA is useful, more considerations are needed for some issues.

Mesh-Airtight-Preperitoneum: a simple method for confirming mesh placement in transabdominal preperitoneal repair of inguinal hernia.

We devised a method for confirming the position of mesh placed during transabdominal preperitoneal repair (TAPP) of an inguinal hernia. The preperitoneum is sufficiently detached, and the mesh is fixed in place as usual. Before completely closing the peritoneum, pressure is applied from outside the body and inside the abdominal cavity to remove as much air as possible from the detached preperitoneum; the peritoneum is then sutured using a V-Loc(TM) closure device so that it does not constrict. By releasing the pressure all at once, the airtightness of the preperitoneum is maintained, and the position of the mesh can be observed through the translucent peritoneum. This method, called Mesh-Airtight-Preperitoneum (MAPP), could become widely used as a simple technique for confirming mesh position in TAPP. J. Med. Invest. 63: 270-273, August, 2016.

Short-Term Outcomes of Laparoscopic Distal Gastrectomy for Advanced Gastric Cancer.

The purpose of this study was to investigate the oncologic outcomes of laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC). Between April 2003 and March 2014, LDG was performed for 392 patients, 91 patients (23.2%) had histopathologically diagnosed AGC beyond T2 depth. The clinicopathological features, postoperative outcomes, mortality, morbidity, recurrence rate, and survivals of those patients were reviewed. The TNM stages of the tumor were IB in 26 patients (28.5%), IIA in 20 (21.9%), IIB in 18 (19.7%), IIIA in 13 (14.2%), IIIB in 6 (6.5%), IIIC in 6 (6.5%), and IV in 2 (2.1%). Major morbidity occurred in 14 patients (15.3%), with no postoperative mortality. Median follow-up was 24.5 months; 10 patients developed recurrence during the follow-up period, and 10 patients died, including 6 cancer deaths. The 5-year overall and disease-free survival rates were 76.8% and 72.6%, respectively. By stage, OS/DFS was 92.3%/91.8% in stage IB, 85.4%/85.4% in stage II, and 49.3%/26.9% in stage III. Oncologic outcomes were good in patients with AGC, especially with stage IB-IIB, who underwent LDG. LDG appears to be an effective approach for treating stage IB and II gastric cancer.

Three-dimensional CT for preoperative detection of the left gastric artery and left gastric vein in laparoscopy-assisted distal gastrectomy.

INTRODUCTION: We evaluated 3-D CT imaging for preoperative classification of the left gastric artery and vein in patients with early gastric cancer and estimated its clinical benefit. METHODS: Between April 2009 and March 2014, 279 patients underwent preoperative 3-D CT using a 64-row multi-detector CT scanner, followed by laparoscopy-assisted distal gastrectomy. The 3-D CT images of the arterial and portal phases were reconstructed and fused. The operative outcomes were compared between patients who had not undergone 3-D CT (2007-2008) and who had undergone 3-D CT (2009-2011). RESULTS: According to Adachi's classification, the numbers of type I, II, III, IV, V, and VI arterial patterns were 253, 15, 1, 3, 3, and 1, respectively. Three cases could not be classified. According to the Douglass classification, the left gastric vein flowed into the portal vein, splenic vein, junction of the portal vein and splenic vein, and left branch of the portal vein in 119, 111, 36, and 5 patients, respectively. The left gastric vein could not be visualized in six patients, and two patients could not be classified. In addition, the relation was absent for an Adachi type I vein and one of the "other" types of veins. The total operative time was significantly shorter with 3-D CT than without it (P = 0.01), and the degree of lymph-node dissection was significantly higher (P = 0.01). Inflammatory parameters and operative morbidity tended to decrease with 3-D CT. CONCLUSION: Three-dimensional CT is a useful modality to visualize the vessel anatomy around the stomach, and it improves clinical effectiveness and reduces the invasiveness of surgery.

[A Case of Complete Pathological Response in a Patient with Locally Advanced Sigmoid Colon Cancer after FOLFOX IRI Chemotherapy].

A 61-year-old man with advanced sigmoid colon cancer was admitted to our hospital. Abdominal computed tomography (CT) revealed locally advanced sigmoid colon cancer, with suspected invasion of the bladder and small intestine. The clinical stage of the disease was T4b, N1, M0, and Stage III a, with wild-type KRAS expression. A transverse colostomy was performed because of the presence of a bowel obstruction. The patient received 4 courses of Leucovorin, 5-fluorouracil, oxaliplatin, and irinotecan (FOLFOXIRI). The size of the tumor and lymph nodes decreased noticeably after chemotherapy and laparoscopic high anterior resection with lymph node dissection. During this phase, the pathological stage of the disease was ypT0, N0, and Stage 0(no viable carcinoma cells, Grade 3). This result suggested that preoperative FOLFOXIRI chemotherapy is a useful regimen for the treatment of locally advanced colon cancer.

[A case of gastric cancer in which grade 2 treatment effects were obtained with preoperative two-week S-1 administration].

In our hospital, a clinical trial on the effects of preoperative 2-week S-1 administration for advanced gastric cancer is being conducted. A7 5-year-old man presented to our hospital with a type 2 tumor(poorly differentiated adenocarcinoma)in the pyloric antrum. Subpyloric lymph node enlargement and a c-T2(MP), N1, M0, Stage II A tumor (according to the gastric cancer handling agreement, 14th edition)were diagnosed, and S-1(100mg/day)was subsequently administered for 14 days. On day 15, we performed laparoscopy-assisted distal gastrectomy, with D2 dissection. Analysis of the resected specimen, ie the primary tumor and metastatic lymph nodes, confirmed the effect of the treatment as Grade 2, and revealed a type 2 gastric cancer of 30×20mm in size; this tumor was downstaged to yp-T1b(SM), N1, Stage I B. No adverse events associated with perioperative S-1 were observed, and the postoperative course was good. At the latest follow-up(6 years after treatment), no recurrence was observed.

[A case of long-term survival after resection of metastatic lymph nodes along the superior mesenteric vein from early gastric cancer].

A 63-year-old man underwent distal gastrectomy and D1 + beta lymph node dissection for type II c early gastric cancer in the posterior wall of the antrum. In the fifth postoperative month, a mass appeared in the epigastric region, and serum tumor marker levels rose. Abdominal CT revealed a 4-cm mass anterior to the superior mesenteric vein. He was diagnosed with recurrence in the lymph nodes along the superior mesenteric vein (No. 14v). Since there was no evidence of recurrence elsewhere, the patient underwent resection of the lymph nodes and transverse colectomy, followed by five courses of chemotherapy with S-1 + cisplatin. At present, more than 38 months after surgery, he is alive without recurrence. Generally, chemotherapy is the first-line treatment for recurrent gastric cancer; however, surgery appears to be a treatment option if the tumor is localized and resectable.

Adenomyoma of the small intestine in an adult: report of a case.

We report a case of adenomyoma in the small intestine, which is an extremely rare entity. An 81-year-old woman presented to our hospital with a history of three episodes of vomiting accompanied by abdominal pain. Upper gastrointestinal examination via a long tube found intestinal obstruction caused by a tumor of the small intestine. Laparotomy revealed a hard mass, 160 cm distal to the Treitz ligament. Pathological examinations of the resected tumor confirmed a diagnosis of adenomyoma originating in the small intestine. To our knowledge, this is only the second report of an adenomyoma of small intestine causing intestinal obstruction in an adult.