Long-term outcomes of single-incision laparoscopic colectomy for right-sided colon cancer utilising a craniocaudal approach.

INTRODUCTION: This study aimed to evaluate the short- and long-term outcomes of single-incision laparoscopic colectomy (SILC) for right-sided colon cancer (CC) using a craniocaudal approach. PATIENTS AND METHODS: The data of patients who underwent SILC for right-sided CC at our hospital between January 2013 and December 2022 were retrospectively collected. Surgery was performed using a craniocaudal approach. Short- and long-term operative outcomes were analysed. RESULTS: In total, 269 patients (127 men, 142 women; median age 74 years) underwent SILC for right-sided CC. The cases included ileocaecal resection (n = 138) and right hemicolectomy (n = 131). The median operative time was 154 min, and the median operative blood loss was 0 ml. Twenty-seven cases (10.0%) required an additional laparoscopic trocar, and 9 (3.3%) were converted to open surgery. The Clavien-Dindo classification Grade III post-operative complications were detected in 7 (2.6%) cases. SILC was performed by 25 surgeons, including inexperienced surgeons, with a median age of 34 years. The 5-year cancer-specific survival (CSS) was 96.1% (95% confidence interval [CI] 91.3%-98.2%), and CSS per pathological disease stage was 100% for Stages 0-I and II and 86.2% (95% CI 71.3%-93.7%) for Stage III. The 5-year recurrence-free survival (RFS) was 90.6% (95% CI 85.7%-93.9%), and RFS per pathological disease stage was 100% for Stage 0-I, 91.7% (95% CI 80.5%-96.6%) for Stage II and 76.1% (95% CI 63.0%-85.1%) for Stage III. CONCLUSIONS: SILC for right-sided CC can be safely performed with a craniocaudal approach, with reasonable short- and long-term outcomes.

Aplastic Anemia with Epstein-Barr Virus Reactivation after Anti-thymocyte Globulin Therapy.

Lymphoproliferative disorders and Epstein-Barr virus reactivation (EBV-LPDs) have various forms of onset, ranging from infectious mononucleosis-like syndrome (IM-like) to lymphoma, although whether or not IM-like progresses to lymphoma remains unclear. A 61-year-old man was diagnosed with aplastic anemia (AA). Polyclonal atypical B-lymphocytes were observed in the peripheral blood, and IM-like was diagnosed. Atypical lymphocytes disappeared, but a gastrointestinal examination revealed diffuse large B-cell lymphoma (DLBCL). Rituximab was initiated but later discontinued because of severe acute respiratory syndrome coronavirus 2 infection. Pancytopenia due to AA exacerbation recurred. The patient ultimately died of multiple organ failure due to bacterial infection.

Inguinal single-port approach of endoscopic component separation for abdominal wall defects: A case series.

Background: The component separation (CS) technique is widely used for abdominal wall defects, particularly in infected wounds. CS is associated with many wound complications due to subcutaneous blood flow disturbance. Endoscopic component separation (ECS) has fewer wound complications compared to CS and has been performed recently. However, there are various port required placements for ECS, and this technique requires proficiency. One approach for ECS is the inguinal single-port approach, which can be performed from an inguinal incision similar to that used in open surgery for inguinal hernias. Case presentation: We performed ECS with an inguinal single-port approach in three older adults. All patients had abdominal wall defects with infection at the central abdominal wound site. A 2-3-cm incision was created in the middle of the inguinal ligament, and a single-port surgical device with two 5-mm trocars was placed in the incision. The external oblique muscle was separated from the internal oblique muscle, and the external oblique aponeurosis was released. The muscle flap of the abdominal wall was moved to the central line. Tension-free abdominal wall closure was possible using a one-handed approach. Conclusions: ECS, which has fewer wound complications, requires proficiency. This procedure is a simple and easy-to-perform procedure using an inguinal incision that surgeons are familiar with.

Development of a systematic telesimulation curriculum for laparoscopic inguinal hernia repair.

Purpose: Telesimulation, whereby learners telecommunicate and use simulator resources to receive education at an off-site location, has been used to educate surgical trainees about how to perform basic surgical procedures. However, it has not yet been used for advanced surgical procedures. We aimed to develop a telesimulation curriculum to teach a common laparoscopic procedure called transabdominal preperitoneal (TAPP) repair and to explore the feasibility of its use. Methods: Learning objectives were created to develop a telesimulation curriculum that included didactic telelecture and telesimulation training. Pre-tests and post-tests to assess the didactic materials were developed and assessed among surgeons with various experiences. We assessed the feasibility of the telelecture and telesimulation separately. Pre-tests, post-tests, and questionnaires were used to assess the telelectures. We created a TAPP repair telesimulation system and checked for problems during training. Trainees were assessed to determine their skill improvement using previously published assessment tools and questionnaires. Results: A didactic telelecture was developed based on the learning objectives using an expert consensus and pilot-tested among five participants. After the lecture, their test scores improved and they expressed positive opinions about the usefulness of telelectures. The TAPP repair telesimulation training was pilot-tested among three trainees. No technical problems occurred during training. All trainees improved their skills after the telesimulation training and agreed that the training was useful for learning the TAPP repair procedure. Conclusions: We systematically developed a telesimulation curriculum for the TAPP repair procedure and demonstrated its feasibility among learners.

Resection of mediastinal goiter extending to the carina with use of artificial pneumothorax, two-lung ventilation, and thoracoscopy, with the patient in a prone position.

A 67-year-old woman was presented with a mediastinal tumor extending from the left lobe of the thyroid and passing through the posterior trachea, causing displacement of the esophagus to the left side of the patient and then descending into the right side of the mediastinum to below the carina. Surgery was performed under two-lung ventilation with the patient in a prone position; general anesthesia was performed with a single-lumen tube combined with artificial pneumothorax. In thoracoscopic surgery, we were able to confirm and preserve anatomical structures. After detachment of the tumor at the level of the left and right subclavian arteries, the patient was placed supine, a cervical incision was added, and the tumor was extracted. The tumor was diagnosed as a nonmalignant mediastinal goiter (MG). No such surgical report was found in the literature, and one would be useful for this new approach to MG removal.

Development of a novel training system for laparoscopic inguinal hernia repair.

Background: Laparoscopic inguinal hernia repair is considered technically difficult. Although a simulation-based curriculum has been developed to help trainees, access to simulation training outside North America is limited. This study aimed to develop an educational system for the transabdominal preperitoneal (TAPP) approach based on the TAPP checklist, an assessment tool we had developed and validated earlier. Material and methods: Consensus within the TAPP education working group consisting of local TAPP experts, hernia experts and a surgical educator to develop educational tools and the educational system based on the TAPP checklist. The system was piloted in several institutes, and participants were surveyed on its efficacy. Results: We systematically developed an educational video and training manual explaining each item of the TAPP checklist and conveying basic knowledge of the procedure. We integrated the training tool with evaluation and feedback to develop an educational system. In a pilot study, seven trainees at five hospitals were trained using this system and found it very useful for mastering the TAPP procedure. Conclusions: We have developed a training system for TAPP procedure and successfully implemented it in several hospitals. Further research will focus on the educational value of this tool.

Atypical presentation of a cushion sign-positive stomach gastrointestinal stromal tumor with cystic formation: A case report.

Gastrointestinal stromal tumors (GIST) typically appear as solid masses, and cystic formation is uncommon. Most stomach GISTs with cystic formation progress outside the gastric wall and are frequently misdiagnosed as epigastric cystic tumors derived from pancreas or liver. An asymptomatic 72-year-old male underwent esophagogastroduodenoscopy, which revealed a submucosal tumor (SMT), approximately 50 mm in diameter, at the anterior wall of the gastric angle. The SMT was very soft with positive cushion sign. Endoscopic ultrasonography and contrast-enhanced computed tomography revealed that the SMT was a cystic tumor with solid component. Laparoscopic and endoscopic cooperative surgery were performed to remove the tumor. Histopathological analysis revealed that the tumor was a GIST with cystic formation. To the best of our knowledge, this the first documented case of a cushion sign-positive stomach GIST with cystic formation, which had mainly developed inside the stomach. This case suggests that we should keep in mind the possibility of cystic formation of GIST when the tumor has a solid component, even if it appears as a cushion sign-positive SMT.

Immunoglobulin G4-related disease presenting as a pulmonary nodule with an irregular margin.

We report a case of immunoglobulin G4 (IgG4)-related lung disease presenting as a solitary pulmonary nodule with an irregular margin on computed tomography. The nodule showed a high standardized uptake value on positron emission tomography. A malignant pulmonary tumour could not be excluded. Middle lobectomy was performed. Histological analysis revealed marked lymphoplasmacytic infiltration and storiform fibrosis. Immunostaining indicated the presence of IgG4-positive plasma cells. A definitive diagnosis of IgG4-related disease was confirmed.

[Surgical Treatment for Refractory Metastatic Lung Tumors from Urachal Carcinoma after Chemotherapy].

A 33-year-old man underwent radical surgery for urachal cancer. Histology of the cancer revealed an adenocarcinoma of the urachus, Sheldon stage ⅢA. He developed a right lung nodule 23 months after the surgery. Partial lobectomy was performed;it revealed an adenocarcinoma compatible with urachal carcinoma. Additionally, 2 right lung metastases measuring 0.5 cm and 1.6 cm in diameter were found 12 months after partial lobectomy. The patient was treated with 4 different chemotherapy regimens including TS-1 and cisplatin, paclitaxel, folinic acid・fluorouracil・oxaliplatin(FOLFOX), and folinic acid・fluorouracil・irinotecan (FOLFIRI). Computed tomography reports showed progression of the pulmonary nodules, now measuring 1.4 cm and 10 cm in diameter. There was no evidence of distant metastasis except for in the lung and local recurrence. Right pneumonectomy was performed;the histology of the specimen confirmed urachal adenocarcinoma. Three months later, he developed cerebellar metastasis. The tumor was removed by neurosurgeons. The patient died of widespread metastases 6 months after the pneumonectomy.

Development and validation of a checklist for assessing recorded performance of laparoscopic inguinal hernia repair.

BACKGROUND: Despite a need for video assessment for the performance transabdominal preperitoneal procedure (TAPP), the present assessment tools have not been validated for the use of evaluation of the recorded performance. We aimed to develop a checklist for the evaluation of the recorded performance of TAPP. METHODS: The TAPP checklist was developed by hernia experts from multiple institutes. Thirty unedited TAPP videos were rated by 3-blinded hernia experts. Inter-rater reliability and construct and concurrent validities were evaluated. RESULTS: The inter-rater reliability for 3 raters was .75 (95% confidence interval .60 to .86). The median total score of each group demonstrated a significant difference among experienced (>50 TAPP), intermediate (≥10 TAPP, <50), and novice (<10 TAPP) surgeons (P < .001). The checklist score showed a high correlation with TAPP experience and previously validated global scale for laparoscopic inguinal hernia repair. CONCLUSIONS: The TAPP checklist is a valid metrics for the assessment of the recorded TAPP performance.

[A case of stomal variceal hemorrhage successfully treated using sclerotherapy].

A 72-year-old man underwent transverse colostomy for sigmoid colon cancer with multiple liver metastases. Subsequent chemotherapy effectively reduced liver metastases, and sigmoidectomy was performed. However, the liver metastases recurred and the patient developed stomal varices due to portal hypertension. To control the resulting massive variceal bleeding, we performed percutaneous sclerotherapy through a varicose vein, which was puncutured directly under ultrasound (US) guidance. Although the patient recovered from variceal bleeding, he eventually died due to the primary cancer.

[A Well-differentiated Mediastinal Liposarcoma that Expanded into the Right Thoracic Cavity with Dedifferentiation].

A 77-year-old man was referred to our hospital because of massive opacification of the right hemithorax on chest radiography. Chest computed tomography (CT) revealed a 25×18-cm heterogeneous tumor in the right hemi-thorax. Chest CT scan obtained 6 years before the referral showed an 8×2-cm homogeneous lipomatous mass in the anterior mediastinum suggesting a well-differentiated liposarcoma. The follow-up chest CT scan obtained 12 months before the referral showed a 4×2-cm heterogeneous solid component within the lipomatous mass of the mediastinum suggesting the development of a dedifferentiated liposarcoma. The tumor was completely resected through a median sternotomy and anterior right thoracotomy. The pathological diagnosis was dedifferentiated liposarcoma originating from a well-differentiated liposarcoma of the anterior mediastinum.

[Successful Treatment of a Giant Emphysematous Bulla with Intracavity Drainage and Bronchial Occlusion in a Patient Receiving Home Oxygen Therapy].

A 74-year-old man was brought to our hospital for an acute exacerbation of respiratory failure. He had severe progressive dyspnea for a few days and had received home oxygen therapy for 4 years. Chest radiography revealed a giant bulla occupying the entire right hemithorax with a remarkable shift of the mediastinum to the left. Chest radiographies of previous 4 years had shown the bulla occupying half of the right hemithorax. It had expanded to its present size over the past month. Treatment consisted of immediate puncturing of the bulla followed by elective intracavity drainage. An urinary catheter was inserted into the bulla under local anesthesia. There was persistent aid leakage from the bulla. A histoacryl-lipiodol mixture was used for bronchial occlusion, and intracavity instillation of minocycline was performed to collapse the bulla. Air leakage from the bulla had ceased on the next day, and the bulla was completely eliminated.

[Simultaneous bilateral spontaneous pneumothorax; report of a case].

Simultaneous bilateral spontaneous pneumothorax (SBSP) occurred in a 16-year-old male. He presented with severe dyspnea. Chest X-ray showed bilateral pneumothorax. Computed tomography revealed bilateral apical bullas. Chest tubes were promptly inserted bilaterally. The patient underwent single-stage bilateral video-assisted thoracoscopic surgery( VATS). Bilateral bullectomy was performed sequentially. Saline poured in to test for air leakage did not escape to the opposite pleural cavity, suggesting no pleuro-pleural communication. Post-operative course was uneventful. A bilateral single-stage VATS by a conventional lateral approach with intra-operative patient repositioning is a safe, feasible and familiar technique for treatment of SBSP.

Efficacy and safety of artificial pneumothorax under two-lung ventilation in thoracoscopic esophagectomy for esophageal cancer in the prone position.

BACKGROUND: Thoracoscopic esophagectomy for esophageal cancer performed using two-lung ventilation in the prone position has many advantages, such as convenient anesthesia induction and maintenance, and good oxygenation. We examined the safety of surgery and anesthetic management by following chronological changes in intraoperative respiration and hemodynamics. METHODS: We focused on the most recent and consecutive 14 cases of thoracoscopic esophagectomy for esophageal cancer in the prone position performed from November 2010 until recently. We measured the following items by use of FloTrac system : cardiac index (CI), central venous pressure (CVP), mean arterial pressure, partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), peak airway pressure (APmax), and tidal volume. RESULTS: No major changes were observed in CI, systolic blood pressure, and TV after the start of pneumothorax (statically not significant). Conversely, CVP increased immediately after pneumothorax (p < 0.05) and decreased almost to its original level thereafter. The mean APmax value was 18-20 cm H2O [mean increase, 4.2 cm H2O; (p < 0.05)]. The mean P/F ratio and mean PaCO2 were 244.4 and 48.3 mmHg, respectively, during artificial pneumothorax. CONCLUSION: No excessive increases in airway pressure or clear circulatory depressions were observed because of artificial pneumothorax under two-lung ventilation in thoracoscopic esophagectomy for esophageal cancer in the prone position. These results suggest that artificial pneumothorax under two-lung ventilation is beneficial for maintaining stable hemodynamics and oxygenation in thoracoscopic esophagectomy in prone position.

[Reexpansion pulmonary edema following thoracentesis].

A 44-year-old female was presented to our department with a 4-day history of shortness of breath and chest pain. The chest X-ray showed pneumothorax with completely collapsed left lung. Thoracentesis was performed. She complained of dyspnea and the oxygen saturation decreased to 74% after thoracentesis. The 2nd chest X-ray and computed tomography demonstrated a left-sided pulmonary edema. A 67-year-old man came to our department complaining of persistent cough. The chest X-ray showed pneumothorax with collapsed right middle and lower lobes. Thoracentesis was performed. He complained of dyspnea and the oxygen saturation decreased to 87% after thoracentesis. The 2nd chest X-ray and computed tomography demonstrated an expanded right upper lobe, but also pulmonary edema in the right middle and lower lobes. Those patients were treated with supplemental oxygen without endotracheal intubation. Their oxygen saturation stabilized within 12 hours. They were successfully treated with the sole administration of oxygen.

[Diaphragmatic eventration with shock and respiratory distress requiring emergency plication; report of a case].

A 80-year-old female with an eventration of the left diaphragm, which had been noticed with routine chest roentgenogram in 2006, presented with severe dyspnea and shock vital in 2012. The chest X-ray on admission disclosed elevation of the left hemidiaphragm, dislocation of the heart to the right. The diagnosis of eventration of the diaphragm was confirmed with a computed tomographic scan. She underwent diaphragmatic plication with endostaplers by thoracoscopic surgery. The postoperative course was uneventful except for transient reexpansion pulmonary edema. The patient was extubated on the 5th postoperative day. Dyspnea has disappeared after the operation. She was in a good condition without requiring any additional oxygen.

Outcome of functional end-to-end esophagojejunostomy in totally laparoscopic total gastrectomy.

PURPOSE: Totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult. In fact, esophagojejunostomy is the most difficult surgical technique in TLTG. We adopted functional end-to-end anastomosis for esophagojejunostomy to simplify the procedure. The present study assesses the feasibility and surgical outcomes of TLTG with functional end-to-end esophagojejunostomy. METHODS: We assessed the intraoperative and postoperative outcomes of 65 consecutive patients who underwent TLTG with functional end-to-end esophagojejunostomy at Tonan Hospital between January 2006 and August 2011. RESULTS: The mean surgical duration was 271.5 ± 64.7 min, and the mean blood loss was 85.2 ± 143.2 g. One patient (1.5 %) was converted to open surgery, and two patients (3.1 %) required reoperation due to ileus because of an internal hernia and jejunojejunostomy leakage. No reoperation was associated with functional end-to-end esophagojejunostomy. The mean hospital stay was 21.4 ± 13.5 days. Ten patients (15.4 %) developed postoperative complications, of which three (4.6 %) were anastomotic stenosis associated with functional end-to-end esophagojejunostomy. All of these were resolved by endoscopic dilation. CONCLUSION: Functional end-to-end esophagojejunostomy in TLTG is safe and feasible.

A new marking technique for peripheral lung nodules avoiding pleural puncture: the intrathoracic stamping method.

While performing thoracoscopic wedge resection of the lung, the location of the lesion is generally identified by visual inspection or palpation. When difficulty in identification of the lesion by thoracoscopy is anticipated, preoperative marking is performed. However, complications and technical difficulties plague current marking techniques. To overcome this problem, we designed a new, safe and easy marking technique that avoids pleural puncture, called the intrathoracic stamping method.

[Lung carcinoma in a patient with rheumatoid arthritis treated with tumor necrosis factor antagonist].

A 65-year-old male was referred to our department because of an abnormal shadow on chest X-ray. He had been suffering from rheumatoid arthritis for 10 years. He had been treated with tumor necrosis factor antagonist(etanercept)for the past 3 years and 6 months. Computed tomography of the chest revealed an irregular shaped pulmonary nodule with the longest diameter of 4.3 cm in the left upper lobe. The diagnosis of lung carcinoma was made. He underwent video-assisted left upper lobectomy with lymph node dissection. Histological examination revealed poorly differentiated squamous cell carcinoma. The tumor was classified as stage ⅢA with T4(pm2)N1M0. No adjuvant chemotherapy was performed because he had recurrent arthralgia after operation and new anti-rheumatic-drug was required. He is free from disease with a follow-up period of 11 months.