Retroperitoneal and Mediastinal Emphysema after Sigmoid Colon Resection.

Retroperitoneal and mediastinal emphysema after colon resection is extremely rare, especially in the absence of anastomotic leakage. The feasibility and safety of conservative treatment for this complication are unknown. We report a patient who underwent open sigmoid colon resection for colon cancer and developed retroperitoneal and mediastinal emphysema that was not caused by anastomotic leakage. Retroperitoneal and mediastinal emphysema occurred as a result of diverticular perforation. We were able to treat this patient successfully with conservative management.

A calcitonin-producing pancreatic neuroendocrine neoplasm treated with distal pancreatectomy a lengthy time after a left trisectionectomy for liver metastases: a case report.

BACKGROUND: Calcitonin-producing pancreatic neuroendocrine neoplasms (PanNENs) are extremely rare. There have been no reports of a patient in whom liver metastases were the presenting finding, and a calcitonin-producing PanNEN was subsequently detected after a lengthy period. CASE PRESENTATION: A 53-year-old man had diarrhea for several years. Computed tomography (CT) revealed multiple liver tumors. We performed a left trisectionectomy with a bile duct resection. The histologic examination showed neuroendocrine tumors G1. Immunohistochemistry was positive for calcitonin and the serum calcitonin level was elevated. Neuroendocrine neoplasms of hepatic origin are extremely rare, so a systemic exploration was performed, but no tumor was detected. CT showed a 4-mm calcification in the pancreatic body, but no contrast-enhanced mass was noted. Although the liver tumors were resected, the diarrhea and high serum calcitonin level persisted. Serial examinations were performed for 6 years, but no tumor was identified; however, 6.5 years after the hepatectomy the serum calcitonin level increased. CT showed a 10-mm contrast-enhanced mass in the calcified area of the pancreatic body. A distal pancreatectomy was performed. The histologic examination showed a neuroendocrine tumor G1, which mimicked the liver tumors. Immunohistochemistry was positive for calcitonin. After the distal pancreatectomy, the serum calcitonin level decreased and diarrhea resolved. The calcitonin-producing neuroendocrine neoplasm was considered the pancreatic primary and the hepatic tumors were metastases. CONCLUSIONS: Calcitonin-producing PanNENs may be initially recognized as liver tumors and may become evident after a lengthy period, thus long-term observation is recommended. Aggressive surgeries may contribute to long-term survival.

[Case Report of an Elderly Patient with Interstitial Pneumonia Caused by the Administration of Trastuzumab plus Anastrozole for the Treatment of Inflammatory Breast Cancer].

An 83‒year‒old woman received trastuzumab plus anastrozole as first‒line chemotherapy for inflammatory breast cancer in her left breast. Following the treatment, the induration and redness in her breast gradually improved; however, 2 days after receiving the 5th course of chemotherapy, she developed dyspnea and was referred to the emergency room. Her SpO2 was 88%; her KL‒6 level had increased to 2,613 U/mL; and a chest CT scan showed ground‒glass opacity in the bilateral lung fields, yielding a diagnosis of interstitial pneumonia requiring steroid pulse therapy. The dyspnea improved immediately after steroid administration, and the patient was discharged 20 days after hospitalization. Thereafter, the steroid dosage was gradually lowered to 5 mg/day. We discontinued steroid therapy after a chest CT confirmed the reduction of ground‒glass opacity. However, she was later readmitted for interstitial pneumonia for which she was readministered steroid pulse therapy. Trastuzumab‒induced interstitial pneumonia is rare, but we must be aware of the possibility that patients may develop severe pulmonary disorders or experience cardiotoxic effects.

Pancreaticoduodenectomy with malrotation following reoperation due to torsion of efferent loop: a case report.

BACKGROUND: Malrotation is a congenital anomaly during the development of the embryonic intestine. Although it is generally considered a pediatric surgical condition, it can have significant implications for adult surgery in terms of reconstruction. CASE PRESENTATION: The patient was an 85-year-old man with pancreatic cancer and intestinal malrotation. He underwent pancreaticoduodenectomy with modified Child's reconstruction. Because the ascending colon and efferent loop twisted easily, we fixed the ascending colon to the abdominal wall. Thereafter, right twist and stenosis of the efferent loop occurred. On the 22nd day after the initial surgery, detorsion and Braun anastomosis were performed for efferent loop fixation. Postoperative oral intake was good, and the patient was discharged from our hospital on the 24th day after the reoperation. CONCLUSIONS: This is a rare case of pancreaticoduodenectomy with malrotation following reoperation due to a complication after Child's reconstruction. In similar cases of intestinal malrotation, it is important to consider avoiding coaxial positioning of intestinal parts and an upper abdominal space while selecting a reconstruction method.

Long-term survival after surgical resection for recurrent hepatic and pulmonary metastases of intrahepatic cholangiocarcinoma: a case report.

BACKGROUND: A few reports to date have described the effectiveness of surgical resection for recurrent intrahepatic cholangiocarcinoma (ICC). We report in this study a patient who achieved long-term survival after surgical resection for recurrent hepatic and pulmonary metastases of ICC. CASE PRESENTATION: A 62-year-old man was referred to our hospital for examination of a tumor in the left lobe of the liver. Computed tomography (CT) scans of the abdomen revealed a hypovascularized tumor, 30 mm in hepatic segment 2 (S2). The patient was diagnosed with a mass-forming type of ICC. A left lateral sectionectomy with regional lymph node dissection was performed. Histopathological examination showed moderately differentiated adenocarcinoma in the hepatic S2 with lymph node metastasis. There were two intrahepatic metastases around the main tumor. The pathological stage of the ICC was pT2pN1M0pStageIIIB. The patient did not receive adjuvant chemotherapy after surgery. Twelve months after surgery, liver lesions in S4/S8 and S7 were detected on CT scans. A partial hepatectomy was performed. The histopathological features were similar to those of the previous ICC. The patient did not receive adjuvant chemotherapy after the repeat hepatectomy. Four years and four months after this repeat hepatectomy, CT scans showed multiple nodes in S4 and S10 of the left lung and in S1 of the right lung. Wedge resection of the left upper lobe and sectionectomy in S10 of the left lung were performed. Histopathological findings of the resected lung nodules were compatible with metastatic ICC. The nodule in S1 of the right lung was too small to be diagnosed as metastasis; therefore, it was not resected. After pulmonary resection, the patient was treated with gemcitabine and cisplatin for 6 months. After chemotherapy, the size of the nodule in S1 increased gradually. One year and ten months after the pulmonary resection, we performed wedge resection of S1 of the right lung, and the histopathological findings were compatible with metastatic ICC. The patient is alive without evidence of disease 8 years after the initial surgery and 8 months after the last pulmonary resection. CONCLUSIONS: ICC with poor prognostic factors can frequently recur; however, surgical resection for recurrent ICC might, for selected patients, enable long-term survival.

A long-term survival case after resection of the pancreatic metastasis from lung cancer.

INTRODUCTION: Pancreatic metastasis from lung cancer is not an indication for surgical resection because patients with such a condition present with multiple-organ metastases. Therefore, the significance of resection in patients with pancreatic metastasis from lung cancer remains unclear. Here we report a case of a long-term survivor of pancreatic metastasis from lung cancer after pancreatectomy. CASE PRESENTATION: A 67-year-old woman presented with a pancreatic mass. She had undergone left lower lobectomy for stage IIIA lung adenocarcinoma 6 years prior to presentation. Following surgery, she received adjuvant treatment with gefitinib for 7 months. However, this treatment was discontinued due to its side effects. The patient received radiation therapy for mediastinal lymph node metastasis 2 years after resection and she became cancer-free. Six years after the initial pulmonary resection, the patient's tumor marker level increased, and abdominal computed tomography (CT) revealed a 20-mm tumor in the pancreatic tail. Positron emission tomography-CT revealed an abnormal uptake in the pancreatic tail. However, no other abnormal lesions were observed. The diagnosis was primary pancreatic cancer or metastasis from lung cancer. Distal pancreatectomy with lymph node dissection was performed, and the pathological diagnosis was metastasis from lung cancer. The patient survived for more than 5 years without recurrence but she died of acute renal failure after acquiring pneumonia. CONCLUSION: Surgical treatment should be considered for pancreatic metastasis from lung cancer if the disease is localized and the patient's condition is good. Additionally, combined therapy, including surgical resection, may be effective for repeated recurrence.

Cholangiographic Tumor Classification for Simple Patient Selection Prior to Hepatopancreatoduodenectomy for Cholangiocarcinoma.

BACKGROUND: Hepatopancreatoduodenectomy (HPD) is employed for patients with laterally advanced cholangiocarcinoma. However, the survival benefit of this extended approach remains controversial. The aim of this study is to identify a tumor feature benefiting from HPD from the standpoint of long-term survival. PATIENTS AND METHODS: Patients with cholangiocarcinoma who underwent HPD with curative intent between 2001 and 2017 were retrospectively analyzed. Tumors were radiologically classified by preoperative cholangiogram. Diffuse type was defined as significant tumor/stricture located from the hilar to intrapancreatic duct; localized type was defined as tumor otherwise. Univariable and multivariable analyses were performed to identify prognostic indicators. RESULTS: Of 100 study patients, 28 (28%) patients had diffuse tumor type, while the remaining 72 (72%) patients had localized tumors. The former group showed significantly longer lateral length (43 versus 22 mm, P < 0.001) and more frequent pancreatic invasion (50% versus 32%, P = 0.110), advanced T classification (64% versus 49%, P = 0.185), and nodal metastasis (57% versus 47%, P = 0.504), compared with the latter group. The survival for patients with diffuse tumor type was significantly worse than that for patients with localized tumor type, with 5-year survival rates of 59.0% versus 26.3%, respectively (P = 0.003). Multivariable analysis identified four independent factors deteriorating long-term survival: cholangiographic diffuse tumor (P = 0.021), higher age (P = 0.020), percutaneous biliary drainage (P = 0.007), and portal vein resection (P = 0.007). CONCLUSIONS: Presurgical cholangiographic classification, diffuse or localized type, is a tumor-related factor closely associated with survival probability; therefore, it may be a useful feature for patient selection prior to HPD for cholangiocarcinoma.

Application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament: Preliminary experience.

An 82-year-old woman was diagnosed with cholecystitis with a right-sided round ligament. We planned a single-incision laparoscopic cholecystectomy. Based on the findings of fluorescent cholangiography, the running course of the common bile duct was confirmed before dissection of Calot's triangle, and the confluence between the cystic duct and the common bile duct was exposed after the dissection of Calot's triangle. The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery. Application of fluorescent cholangiography during a laparoscopic cholecystectomy for the patients with a right-sided round ligament should be widely accepted.

Single-Incision Laparoscopic Splenectomy for an Unruptured Aneurysm of the Splenic Artery.

OBJECTIVE: We describe our experience of single-incision laparoscopic splenectomy (SILS) for an unruptured aneurysm of the splenic artery. CLINICAL PRESENTATION AND INTERVENTION: A 73-year-old woman was diagnosed as having a splenic aneurysm which grew from 14 to 22 mm in diameter within 2 years. Due to a contrast agent allergy, transcatheter arterial embolization could not be performed; therefore, SILS was performed with a 4-cm Z-shaped incision. The operative time and intraoperative blood loss were 132 min and 27 mL, respectively. The patient was discharged 4 days after surgery. CONCLUSION: In selected cases, SILS is a suitable and safe procedure for an unruptured aneurysm of the splenic artery.

Laparoscopic surgery for the treatment of a ruptured aneurysm of the right gastric artery: a case report.

Laparoscopic surgery for the treatment of a ruptured visceral artery aneurysm is recognized as a challenging procedure. Here, we describe our experience with laparoscopic surgery to treat a ruptured aneurysm of the right gastric artery. A 72-year-old woman was diagnosed with intra-abdominal hemorrhage caused by a ruptured aneurysm of the right gastric artery. Transcatheter arterial embolization failed because the right gastric artery could not be cannulated. Therefore, we performed laparoscopic surgery. Using laparoscopy, we detected that the bleeding from the aneurysm had ceased; thus, the planned procedure was successful. The operative time and intraoperative blood loss were 100 min and 5 mL, respectively. The patient was discharged 7 days after surgery. Laparoscopic surgery after the failure of transcatheter arterial embolization is a suitable and safe procedure for ruptured visceral artery aneurysms, provided the circulatory dynamics are stable as a result of the temporary cessation of bleeding from the ruptured aneurysm.

Application of Fluorescent Cholangiography for Determination of the Resection Line During a Single-Incision Laparoscopic Cholecystectomy for a Benign Lesion of the Cystic Duct: Preliminary Experience.

BACKGROUND: To avoid bile leakage from the stump of a cystic duct that is closed at edematous and/or involved areas, the decision regarding the location of the resection line during a laparoscopic cholecystectomy for benign lesions extending into the cystic duct is important and requires technical ingenuity. For these situations, we used fluorescent cholangiography. METHODS: Our procedure for single-incision laparoscopic cholecystectomy utilized the SILS-Port, and an additional pair of 5-mm forceps was inserted via an umbilical incision. As a fluorescence source, 1 mL of indocyanine green was intravenously injected after endotracheal intubation of patients in the operating room. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. RESULTS: Fluorescent cholangiography could be used to identify the border of the lesion in the cystic duct. According to the fluorescent cholangiography results, a location for the resection line of the cystic duct could be identified; therefore, the planned resection was successful and produced a histologically negative margin. CONCLUSIONS: Application of fluorescent cholangiography in the determination of the location of the resection line location during a laparoscopic cholecystectomy for benign lesions of the cystic duct should be widely accepted.

Practical design for compact image scanner with large depth of field by compound eye system.

We designed a new image scanner using the reflective optics of a compound eye system that can easily assemble plural imaging optical units (called imaging cells) and is compact with a large depth of field (DOF). Our image scanner is constructed from 32 reflective imaging cells, each of which takes an image of approximately a 10-mm field of view (FOV) that slightly overlap the adjacent imaging cells. The total image is rebuilt by combining the 32 images in post processing. We studied how to fold the optical path in the imaging cells and simplified the structure, resulting in the following three advances of our previous work: 1) greater compactness (50 × 31 mm2 in the cross section), 2) less variable optical characteristics among the imaging cells, and 3) easy assembly thanks to small number of optical components constructing the imaging cell.