Laparoscopic transabdominal preperitoneal repair for inguinal hernia in a patient with an adult Still's disease receiving anti-interleukin-6 receptor monoclonal antibody therapy.

Tocilizumab, a monoclonal antibody drug against interleukin-6 receptor, has been reported to cause wound infection and delayed wound healing. Therefore, surgeries using artificial materials in patients receiving tocilizumab require careful observation. A 75-year-old man who had been receiving tocilizumab and steroids for the treatment of adult Still's disease was diagnosed with an inguinal hernia and underwent laparoscopic transabdominal preperitoneal repair. Tocilizumab administration was discontinued for 3 weeks before surgery and was restarted 2 weeks after the surgery. Postoperatively, there was no fever, and the C-reactive protein level was marginally elevated. The patient was discharged from the hospital on the fourth day without any postoperative complications, and no delayed infection or delayed wound healing 1 year after the surgery. A few weeks withdrawal of tocilizumab administration before and after surgery permitted safe laparoscopic hernia surgery using a surgical mesh without infection or delayed wound healing.

Surgical Laparotomy for Repeated Delayed Arterial Hemorrhage after Pancreaticoduodenectomy.

Postpancreatectomy hemorrhage is one of the major life-threatening complications of pancreatic surgery. Radiological intervention is used as a first-line approach for the initial treatment of late arterial hemorrhage. However, rehemorrhage has a high risk for mortality, and it is undecided which urgent intervention provides optimal management for rehemorrhage. We experienced a successful surgical laparotomy for the repeated delayed arterial hemorrhage caused by a pancreaticoduodenectomy (PD) for chronic pancreatitis. A 57-year-old man had undergone PD with pancreaticogastrostomy for tumor-forming pancreatitis with possible pancreatic cancer. A delayed massive hemorrhage from the drain developed 11 days after surgery. Although angiography was done, the bleeding site was not clearly detected. Therefore, urgent surgical laparotomy was performed. Arterial bleeding was detected from the stump of the gastroduodenal artery. Surgical ligation, using the suture technique, was performed for hemostasis, and a closed drain was placed in the area due to drainage of pancreatic juice and an abscess. However, rehemorrhage from the drain developed 7 days after the initial hemorrhage. Relaparotomy was performed immediately. The surgical ligation and compression hemostasis with absorbable hemostatic cotton was done. After relaparotomy for rehemorrhage, there was no hemorrhage or fatal hepatic failure. He left our hospital 64 days after initial surgery. Surgical laparotomy is one of the feasible procedures for hemostasis of a massive arterial hemorrhage. Proper blood vessel ligation is necessary for reliable hemostasis and proper drainage of pancreatic juice and abscesses to prevent hemorrhage.

Effects of Enteral Immunonutrition in Esophageal Cancer.

BACKGROUND: Immunonutrition (IN) significantly reduces the incidence of postoperative infectious complications and the length of hospitalization in patients undergoing major elective surgery for gastrointestinal malignances. However, the clinical benefit of IN in patients who have undergone esophagectomy for esophageal cancer is unclear. Moreover, the effect of enteral IN in patients during preoperative adjuvant chemoradiotherapy and in patients treated with concurrent chemoradiotherapy for advanced esophageal cancer is unknown. SUMMARY: This review analyzes the evidence supporting the enteral administration of IN in patients who have undergone esophagectomy and/or chemoradiotherapy for esophageal cancer. Twelve trials that evaluated IN exclusively in patients who underwent esophagectomy were published between January 1980 and August 2017. Two trials concerning IN during chemoradiotherapy for esophageal cancer were identified in the same period. However, the evidence is insufficient to recommend enteral IN in patients who have undergone esophagectomy and/or chemoradiotherapy for esophageal cancer. KEY MESSAGE: Further evidence from well-designed randomized controlled trials is required to verify the clinical benefits of enteral IN in patients undergoing esophagectomy and/or chemoradiotherapy for esophageal cancer. PRACTICAL IMPLICATIONS: Resolvins, which are generated from EPA, are novel anti-inflammatory lipid mediators and may play a key role in the resolution of acute inflammation when IN is supplemented with EPA in patients undergoing severely stressful operations.

Utility of Inflammatory Marker- and Nutritional Status-based Prognostic Factors for Predicting the Prognosis of Stage IV Gastric Cancer Patients Undergoing Non-curative Surgery.

BACKGROUND/AIM: The present study aimed to compare the utility of various inflammatory marker- and nutritional status-based prognostic factors, including many previous established prognostic factors, for predicting the prognosis of stage IV gastric cancer patients undergoing non-curative surgery. PATIENTS AND METHODS: A total of 33 patients with stage IV gastric cancer who had undergone palliative gastrectomy and gastrojejunostomy were included in the study. Univariate and multivariate analyses were performed to evaluate the relationships between the mGPS, PNI, NLR, PLR, the CONUT, various clinicopathological factors and cancer-specific survival (CS). RESULTS: Among patients who received non-curative surgery, univariate analysis of CS identified the following significant risk factors: chemotherapy, mGPS and NLR, and multivariate analysis revealed that the mGPS was independently associated with CS. CONCLUSION: The mGPS was a more useful prognostic factor than the PNI, NLR, PLR and CONUT in patients undergoing non-curative surgery for stage IV gastric cancer.

[Primary Tumor Resection in Incurable Stage IV Colorectal Cancer].

The influence of primary tumor resection on the prognosis of patients with incurable Stage IV colorectal cancer is unclear. We retrospectively analyzed 30 patients with incurable Stage IV colorectal cancer who underwent primary tumor resection. Postoperative complications occurred in 13 patients(43.3%)classified as grades greater than Clavien-Dindo classification II . There was no mortality. Median duration of hospital stay after surgery was 23 days. Fourteen patients(46.7%)underwent chemotherapy after surgery, of which 12 were administered molecular targeted therapy. The median number of chemotherapy regimens was 2(range, 1 to 3). The median time between start and end of chemotherapy was 11.8 months. The median survival time(MST)of all patients was 16.9 months. The MST of patients treated with chemotherapy combined with molecular targeted therapy(60.6 months)was significantly longer than those who did not undergo chemotherapy(10.9 months). Chemotherapy combined with molecular targeted therapy contributes to survival after primary tumor resection in patients with incurable Stage IV colorectal cancer.

[Report of a Successful Case of Combined Modality Therapy for a Patient with Local Recurrence of Rectal Cancer].

A 67-year-old man underwent abdominoperinealresection for rectalcancer (Rb, tub2>muc, A, N1, H0, P0, M0, Cy1, Stage III a). We administered mFOLFOX6 as adjuvant chemotherapy for 6 months. Twenty-seven months after surgery, his serum tumor marker level was increased, and local recurrence in the left rear of the prostate was detected by pelvic CT. The patient selected radiation(50 Gy/25 Fr), after rejecting resection for the local recurrence. After radiation, we performed chemotherapy combined with bevacizumab. Seventeen months from the start of chemotherapy, 47 months after surgery, chemotherapy was stopped because his tumor maker levels normalized and pelvic CT revealed a partial response. At present, his progression-free survival is 7 months after completion of chemotherapy. We conclude that combined modality therapy is an option for a patient with locally recurrent rectal cancer.

Adenocarcinoma arising from heterotopic pancreas at the third portion of the duodenum.

A 62-year-old Japanese man presented to our hospital with a history of weight loss of 6 kg in 4 mo. Imaging examinations revealed a tumor located on the third portion of the duodenum with stenosis. We suspected duodenal carcinoma and performed pancreas-preserving segmental duodenectomy. Adenocarcinoma arising from a heterotopic pancreas at the third portion of the duodenum was finally diagnosed by immunohistochemical staining. Malignant transformation in the duodenum arising from a heterotopic pancreas is extremely rare; to our knowledge, only 13 cases have been reported worldwide, including the present case. The most common location of malignancy is the proximal duodenum at the first and descending portion. Herein, we describe the first case of adenocarcinoma arising from a heterotopic pancreas, which was located in the third portion of the duodenum, with a review of the literature.

Glasgow prognostic score is a useful predictive factor of outcome after palliative gastrectomy for stage IV gastric cancer.

BACKGROUND/AIM: The Glasgow prognostic score (GPS) is a predictor of outcome for several cancer types. The present study examined the significance of modified GPS (mGPS) in the prognosis of patients undergoing palliative surgery for stage IV gastric cancer. PATIENTS AND METHODS: A total of 42 patients with stage IV gastric cancer treated with palliative gastrectomy and gastrojejunostomy were included in the study. Univariate and multivariate analyses were performed to evaluate the relationship between clinicopathological factors and cancer-specific survival (CS). RESULTS: Among patients who underwent palliative surgery including gastrectomy and gastrojejunostomy, univariate analysis of CS identified the following significant risk factors: surgical treatment, chemotherapy and mGPS, and multivariate analysis revealed that mGPS was independently-associated with CS. In particular, among patients who underwent palliative gastrectomy, mGPS was shown to be the strongest independent predictive factor for CS. CONCLUSION: The mGPS was an independent predictive factor for survival in patients who underwent palliative surgery for stage IV incurable gastric cancer, especially for those who underwent palliative gastrectomy.

Simultaneous laparoscopic Nissen fundoplication and percutaneous endoscopic gastrostomy to treat an elderly patient with a large paraesophageal hernia: a case report.

Laparoscopic Nissen fundoplication (LNF) and gastrostomy are often performed in children with gastroesophageal reflux disease. With a population that is increasingly aging, the number of elderly patients with paraesophageal hernia who have a nutritional disorder due to dysphagia has increased. In these patients with feeding difficulties, LNF and percutaneous endoscopic gastrostomy (PEG) are effective procedures for providing nutritional support. Here, we describe the case of an 82-year-old woman with paraesophageal hernia and certain comorbidities. She was receiving enteral feeding through a nasogastric tube, which was discontinued because aspiration pneumonia occurred. Therefore, LNF and crural repair without mesh placement were performed. The PEG tube was placed using the Ponsky pull technique under direct visualization with a laparoscope and gastroscope. The patient's nutritional status improved after she received enteral nutrition through the PEG tube. Thus, LNF and PEG may be useful techniques for nutritional support in elderly patients with a large paraesophageal hernia.

Gastric Cancer Arising from an Upside-Down Stomach through a Paraesophageal Hiatal Hernia.

We report the rare case of an elderly patient with an advanced gastric cancer arising from an upside-down stomach through a paraesophageal hiatal hernia (PEH). An 82-year-old man presented with appetite loss and anemia. Upper gastrointestinal endoscopy revealed a type 1 tumor located in the middle body of the stomach. An upper gastrointestinal series and computed tomography showed organoaxial rotation of the stomach, which was located in the mediastinum, through a PEH, indicating an upside-down stomach. The preoperative diagnosis was gastric cancer arising from an upside-down stomach through a PEH. The patient underwent total gastrectomy with lymph node dissection and closure of the hernial orifice. Although a large PEH is a chronic disorder, gastric malignancies should be considered in patients with PEH manifested as an upside-down stomach due to its anatomical characteristics, and careful preoperative diagnosis is mandatory.

Chemotherapy for liver metastasis originating from colorectal cancer with portal vein tumor thrombosis: a case report.

The patient was a male in his 70s with a history of chronic renal failure and dilated cardiomyopathy. In January 2011, he underwent abdominoperineal resection of the rectum, right hepatic lobectomy, and resection of a portal vein tumor thrombus with a diagnosis of rectal cancer and metastatic liver cancer accompanied by portal vein tumor thrombosis. Although 5-fluorouracil + l-leucovorin therapy (RPMI regimen) was carried out as postoperative adjuvant chemotherapy, the tumor marker (CEA and VA19-9) levels increased 8 months after surgery. Since the functions of major organs were impaired, UFT(®) + UZEL(®) therapy was started. The tumor marker levels decreased temporarily, but increased again 12 months after surgery, and so intravenous instillation of panitumumab was initiated. Nine administrations have been performed to date, with no increase in tumor marker levels or exacerbation of the condition. Also, no grade 2 or severer adverse event has been noted according to CTCAE v.4.0. The experience with this patient suggests the possibility that exacerbation of the condition of patients with liver metastasis of colorectal cancer accompanied by portal vein tumor thrombosis with abnormalities in the functions of major organs can be controlled temporarily by the administration of panitumumab alone.

Killian-jamieson diverticula presenting synchronously with thyroid adenoma.

Killian-Jamieson diverticulum is a rare hypopharyngeal diverticulum, less commonly encountered compared with Zenker's diverticulum. These hypopharyngeal diverticula that cause dysphagia often mimic a thyroid tumor incidentally detected on neck ultrasonography. However, to our knowledge, Killian-Jamieson diverticula complicated by a thyroid tumor have not been previously described. We experienced a rare case of bilateral Killian-Jamieson diverticula synchronously complicated by a thyroid adenoma in a 74-year-old woman who became aware of dysphagia and a tumor in the left side of her neck. Pharyngoesophagography revealed bilateral diverticula protruding from the lateral wall of the esophagopharyngeal junction, but the appearance of the cricopharyngeal bar representing the cricopharyngeus muscle above the diverticula had become unclear because the thyroid tumor was pressing on the diverticula and the cervical esophagus. However, the diverticula were diagnosed as Killian-Jamieson diverticula because cervical computed tomography showed bilateral diverticula arising from the cervical esophagus just below the level of the cricoid cartilage, and operative finding showed that the diverticula were located above the upper esophageal longitudinal muscle. Radiographic imaging is useful for diagnosis as cause of dysphagia and cervical tumor.

Delayed gastric emptying after pancreaticoduodenectomy in diabetes mellitus.

INTRODUCTION: Delayed gastric emptying (DGE) is one of the most troublesome complications of pancreaticoduodenectomy (PD). Diabetes mellitus (DM) is one of the risk factors for pancreatic cancer. Moreover, several studies have shown that diabetic patients tend to have a high incidence of upper gastrointestinal symptoms such as nausea, vomiting and DGE. Here, we compared the influence of DM on the incidence of DGE after PD. METHODS: We retrospectively analysed 67 cases of PD with pancreaticogastrostomy. These patients were categorized into the following two groups: the DM group included patients with DM, and the NDM group included patients without DM. The incidence of DGE was determined and compared between the two groups. RESULTS: In the DM group, 76.5%, 5.9% and 17.6% of the subjects developed classes A, B and C DGE, respectively; the corresponding values in the NDM group were 58%, 22%, and 20%. The incidence of DGE did not differ between the two groups (P < 0.2771). CONCLUSIONS: DM does not accelerate DGE in patients who have undergone PD. Preoperative DM does not appear to play a key role in post-operative DGE after PD.

Minimal incision based on measurement of the to-be-resected specimen in laparoscopic hepatectomy.

Recent technological improvements in laparoscopic devices have significantly extended the surgeon's ability to perform laparoscopic liver surgery safely. Hand-assisted laparoscopy has been proposed in order to achieve greater safety and accessibility in laparoscopic liver surgery. Moreover, in order to expand the indications of minimally invasive liver resection and improve its safety, the "hybrid procedure" or "laparoscopy-assisted resection" has been proposed. Hand-assisted laparoscopic liver resection consists of the placement of a gas-tight port through an 8cm incision that enables a hand to be introduced into the abdomen. The "hybrid procedure" is performed through an 8-12cm midline or subcostal incision. Such a minimal abdominal incision is preferred not only for cosmetic reasons but also for obtaining adequate surgical margin. We performed laparoscopic liver resection via a minimal incision that was based on the measurement of the to-be-resected specimen intraoperatively by ultrasonography. Here, we have described our procedure and evaluated its efficacy.

Horizontal vs. vertical incision on the anterior gastric wall in pancreaticogastrostomy.

BACKGROUND/AIMS: Pancreaticogastrostomy during pancreaticoduodenectomy is associated with a very low rate of anastomotic leakage. However, gastric peristalsis is disturbed by pancreaticogastrostomy, which stabilizes the posterior stomach at that point leading to delayed gastric emptying. We evaluated which anterior gastrostomy, i.e. horizontal or vertical incision on the anterior gastric wall, is better for maintaining peristaltic movement of the anterior stomach to prevent delayed gastric emptying after pancreaticogastrostomy. METHODOLOGY: We retrospectively studied 50 patients who underwent subtotal stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy. These patients were divided into 2 groups depending on the type of anterior gastrostomy: horizontal incision (H group) and vertical incision (V group). RESULTS: The observed grade of delayed gastric emptying was lower in the V group than in the H group; however, the difference was not significant. CONCLUSIONS: We conclude that a vertical incision on the anterior gastric wall is preferable for preventing delayed gastric emptying after a pancreaticogastrostomy.

Diffuse Peritonitis due to Perforated Gastric Ectopic Pancreas.

Ectopic pancreas is frequently found in the gastrointestinal tract. Lesions comprise well-developed and normally organized pancreatic tissue outside the pancreas, without anatomic or vascular connections with the true pancreas. Most patients with ectopic pancreas are asymptomatic or exhibit nonspecific symptoms. A 68-year-old Japanese woman had been experiencing intermittent pain in the right upper abdomen. Suddenly, the abdominal pain changed to intense pain in the right flank of the abdomen 2 days later. On initial medical examination, the abdomen exhibited rebound tenderness and distension. The results of laboratory tests revealed increased inflammatory reaction. Abdominal computed tomography showed free air and ascites on the surface of the liver and elevated levels of adipose tissue around the antrum and pylorus of the stomach. Perforation of the upper gastrointestinal tract was diagnosed and we performed urgent surgery. The site of perforation, whose size was 25 mm, was the lesser curvature of the antrum of the stomach. Since it was not possible to perform omentopexy, we performed extensive gastric resection. The reconstruction was a Billroth II operation. Microscopic analysis revealed pancreatic tissue within the ulceration, showing islets of Langerhans, acini, and ducts; the lesion was diagnosed as type I using Heinrich's criteria. The postoperative course was uneventful. The patient was discharged on day 13 and remains clinically healthy. Gastric perforation due to ectopic pancreas has been reported in 2 cases, including our patient, and is extremely rare. Once gastric perforation has been diagnosed, the presence of ectopic pancreas might be considered.

[A case of intussusception due to sigmoid colon cancer during mFOLFOX6 therapy].

We experienced a rare case of intussusception due to sigmoid colon cancer during chemotherapy. A-62-year-old female was started on mFOLFOX6 due to sigmoid colon cancer and hepatic metastases(stage IV). After 2 courses, she had abdominal pain and bloody stool. Abdominal ultrasonography showed a target sign, and abdominal CT showed edema of the mucosa of the sigmoid colon and invagination. She was diagnosed with intussusception due to sigmoid colon cancer, and underwent a bloodless reduction. However, because it was unavailable, we performed an emergency operation. The sigmoid colon invaginated 10 cm to the anal side. We then performed sigmoidectomy and lymphadenectomy(D2). The histopathological diagnosis was mucinous carcinoma, stage I. There was no report of intussusception with the chemotherapy. It is important to consider the intussusception of colon cancer even during chemotherapy.

Jejunal scarf-covering method in pancreaticojejunostomy after total gastrectomy.

Pancreatic fistula is the most serious postoperative complication after pancreaticoduodenectomy, and it leads to intra-abdominal abscess, sepsis, hemorrhage and high mortality. To prevent pancreatic fistula, wrapping of skeletonized vessels and the anastomotic site of the pancreaticoenterostomy using the round ligament, greater omentum, or both has been evaluated. However, the round ligament and greater omentum have already been resected in patients who have previously undergone total gastrectomy, making them unavailable in pancreaticoduodenectomy. Therefore, we developed a procedure for wrapping the anastomotic site of the pancreaticojejunostomy using the jejunum, namely the 'jejunal scarf-covering method' as a novel technique to prevent pancreatic fistula following pancreaticoduodenectomy in patients who have previously undergone total gastrectomy.

Spleen enlargement after distal gastrectomy in patients without hepatitis.

BACKGROUND/AIMS: Platelet count-to-spleen diameter ratio is reported to be the best non-invasive predictor of esophageal varices in cirrhotic patients. However, spleen enlargement is frequently detected during follow-up of patients after gastrectomy. Thus, we studied the relationship of the platelet count-to-spleen diameter ratio with the development of esophageal varices after distal gastrectomy in patients without liver cirrhosis or hepatitis. METHODOLOGY: We retrospectively studied 64 patients who underwent distal gastrectomy. Their platelet counts, spleen diameters and platelet count-to-spleen diameter ratios were correlated with the occurrence rate of esophageal varices after the surgery. RESULTS: Esophageal varices were not detected during the first 6 months after surgery; however, esophageal varices were detected in 2 patients (3%) at 12 months after surgery and their mean platelet count-to-spleen diameter ratio was 2,628 ± 409. CONCLUSIONS: The platelet count-to-spleen diameter ratio is a useful parameter for non-invasive prediction of esophageal varices after distal gastrectomy. In addition, we suggest that the occurrence rate of esophageal varices increases beyond 6 months after distal gastrectomy and when the platelet count-to-spleen diameter ratio is less than approximately 2600 and thus, endoscopy should be performed to determine the presence of esophageal varices.