Ultrasonic Cleaning for Irrigating Purulent Substances during Laparoscopic Gastrointestinal Surgery.

To improve the outcome of laparoscopic gastrointestinal surgery, improvement in the technology for removing purulent substances from the abdominal cavity is required. Ultrasonic cleaning technology may be suitable for the task. However, it is necessary to examine cleaning efficiency and safety through model tests that can lead to clinical trials for practical use. Nine surgical specialists first estimated the distribution of the actual attachment of purulent substances using videos of removing pus-like model dirt as an evaluation scale. Subsequently, cleaning tests were conducted using a small-size shower with model dirt that was somewhat difficult to remove, and its suitability as a model sample was confirmed. A mixture of miso and other substances was attached to a silicon sheet to prepare a test sample. The model dirt could be removed within a few seconds by cleaning using a probe-type ultrasonic homogenizer while the test sample was submerged in water. This performance greatly surpassed that of water flow cleaning under increased water pressure. An ultrasonic cleaner that is useful for irrigation during laparoscopic surgery will be suitable for practical use in laparoscopic surgery.

[A Case of Laparoscopic Repair for Hiatal Hernia Occurred Five Years after Esophagectomy for Esophageal Cancer].

A 70s man underwent minimally invasive esophagectomy and gastric conduit reconstruction via the posterior mediastinal route for early esophageal cancer 5 years ago. Three days prior to hospital visit, he presented with abdominal fullness, left chest pain, and vomiting. A CT revealed a postoperative hiatal hernia, and emergency surgery was performed laparoscopically. The laparoscopic findings showed that the transverse colon had prolapsed into the left thoracic cavity through the esophageal hiatus on the left side of the gastric conduit. The transverse colon had no sign of necrosis. The diaphragmatic defect was closed with unabsorbable suture. Increased bowel motility due to postoperative fat loss in the mesentery and intra-abdominal pressure are thought to be causes of the hernia. In addition, decreased adhesion formation due to endoscopic surgery may be a contributing factor. Although there is no unanimous opinion regarding the suture fixation of the conduit to the diaphragm after esophagectomy, it should be performed to prevent a herniation. Postoperative hiatal hernia occurs more than 5 years after the surgery is relatively rare, but its occurrence should be noted.

Perihepatic Abscess due to a Liver Suture with Pledgets Used to Treat a Penetrating Liver Injury.

BACKGROUND: Selective nonoperative management has become the standard for liver injuries. Accordingly, we cannot perform surgery for liver injuries as frequently as in the past. This report is aimed at sharing a valuable experience of postoperative complications after surgery for a liver injury. Case Presentation. A 40-year-old man was stabbed in his abdomen and underwent an emergency laparotomy for a severe liver injury. Five months after the operation, he developed fever, and purulent discharge was observed from an abdominal fistula. He was diagnosed with a perihepatic abscess and duodenal perforation due to the pledgets used for the operation. He underwent a second surgery to remove the pledgets and the abscess cavity for infection control and was discharged in good condition. CONCLUSION: The intra-abdominal environment should be considered contaminated due to bile leakage in surgeries following liver injury. Furthermore, nonabsorbable agents should not be used in these contaminated areas.

[A Case of Intrahepatic Cholangiocarcinoma Confused with a Recurrent Hepatocellular Carcinoma Treated by RFA at Diagnosis].

Intrahepatic cholangiocarcinoma(ICC)is the second most common malignant liver tumor after hepatocellular carcinoma (HCC). ICC is usually ischemic; however, it has variable findings and may be difficult to differentiate from HCC. We report about a case of ICC that was difficult to distinguish from HCC treated by radiofrequency ablation(RFA). A 79‒year‒old woman underwent RFA for HCC of the caudate lobe. Two years after RFA, a spindle‒shaped tumor was identified near the previous treatment site using contrast‒enhanced MRI. Images showed posterior segment bile duct dilation, posterior segment atrophy of the liver parenchyma, and posterior segmental portal vein disruption. We performed surgery because of the suspicion of a recurrent HCC invading into the bile duct. Intraoperative findings showed posterior segment atrophy. Intraoperative echocardiography could not identify the tumor but revealed a tumor plug and portal vein disruption in the posterior segment. The patient underwent post‒enlargement segmentectomy, caudate lobectomy of the liver, and biliary neoplastic resection. Histopathological findings showed no malignant findings in the hepatocytes. A moderately differentiated adenocarcinoma was found in the expanded bile duct, which was diagnosed as an intrahepatic cholangiocarcinoma. Here, we report about the case along with a discussion and a bibliographical consideration.

[A Case of Internal Hernia into a Reconstructed Pelvic Floor and Torsion of Jejunum near the Treitz Ligament after Laparoscopic Abdominoperineal Resection].

A 50s women underwent laparoscopic abdominoperineal resection(APR)for rectal cancer. Laparotomy was performed on the 8th postoperative day because of intestinal obstruction. An internal hernia was observed at the pelvic floor and the hernia orifice was found at the retroperitoneum that was sutured in the initial operation. On the other hand, the jejunum near the Treitz ligament was twisted, resulting in ischemic necrosis. The reason of the internal hernia is considered that a suction drain placed during the initial operation may have caused the rupture of the fragile part of the sutured peritoneum. Furthermore, increase of intra-abdominal pressure due to the internal hernia may have exacerbated the torsion of the jejunum near the Treitz ligament. This is probably due to the failure to the adequate reposition of the small intestine at the end of the initial operation. There is no consensus of the need for retroperitoneal sutures for APR. Currently, we only spray anti-adhesion agents on the pelvic floor without retroperitoneal reconstruction. Although the mobilization of small intestine is important to provide a good operative view in laparoscopic colorectal surgery, it is also important to confirm the reposition of the small intestine at the end of surgery.

[Gastric Complications in Stomach-Preserving Procedures on Total Pancreatectomy].

Whether the stomach should be preserved during total pancreatectomy(TP)is controversial. Therefore, we examined the correlation between stomach-preserving procedures on TP and postoperative gastric complications. Seven consecutive cases underwent TP(standard TP: 1 case, SSPTP: 3 cases, PPTP: 3 cases)for pancreatic cancer during the time period 2011-2019 at our hospital. There was no clinical case of postoperative gastric ulcer nor bleeding. Delayed gastric emptying(DGE)was observed in 4 cases of Grade A and 2 cases of Grade C. One of the Grade C cases was considered to be secondary DGE due to postoperative intestinal necrosis. The other was SSPTP case whose left gastric artery(LGA)was ligated. The patient had difficulty of food intake after the surgery and gastrointestinal endoscopy showed widespread hemorrhage and erosion of the gastric mucosa, considered to be ischemic gastropathy. Regarding primary DGE, most of cases were within Grade A even in stomach-preserving cases. Whereas, stomach-preserving procedure should be avoided when the LGA is ligated, because ischemic gastropathy may occur.

[Adenosquamous Carcinoma in the Remnant Pancreas after Pancreatoduodenectomy for Invasive Pancreas Cancer-A Resected Case with Five-Year Relapse-Free Survival].

A 52-year-old man underwent pancreatoduodenectomy(PD)for invasive cancer of the pancreatic head, with a histopathological diagnosis of moderately to poorly differentiated invasive ductal carcinoma. One year and 2 months after PD, follow- up CT revealed a mass 3 cm in diameter in the remnant pancreas without distant metastasis. Therefore, total remnant pancreatectomy was performed with a histopathological diagnosis of adenosquamous carcinoma. Five years after re-excision, the patient remains alive without recurrence. Although no tumor component was found at the anastomotic site of the pancreatojejunostomy, squamous metaplasia with chronic inflammation with carcinogenic potential was diffusely observed in the main pancreatic duct. Clinical cases of remnant pancreatic resection after PD for invasive cancer are relatively rare. Furthermore, this case of adenosquamous carcinoma with long-term recurrence-free survival is extremely rare.

[Occult Breast Carcinoma and Recurrent Tumor in the Breast 14 Years after Axillary Dissection-A Case Report].

We report a patient with occult breast cancer who underwent axillary dissection as primary surgery. The patient, a 68-yearold woman, noticed a tumor measuring approximately 3 cm in diameter, in her left axilla. Biopsy of the axillary tumor revealed adenocarcinoma. Imaging studies did not detect primary lesions in the mammary gland or other organs. The patient was diagnosed with occult breast cancer and underwent axillary dissection but did not desire mastectomy or radiation therapy. The patient was closely observed thereafter. Tamoxifen was prescribed for 5 years but left breast cancer was detected 14 years after the operation. A simple mastectomy was performed. She died of respiratory failure 1 year later. Occult breast cancer may require axillary lymph node dissection and systemic therapy. Breast preservation could be an alternative treatment if followed by adequate systemic therapy and close observation.

[A Rare Case of Gastric Metastasis from Cholangio Carcinoma].

An 80-year-old man was referred to our hospital because of jaundice and fatigue. Abdominal computed tomography(CT) scan revealed an extrahepatic bile duct tumor, and biliary cytology detected adenocarcinoma; therefore, subtotal stomachpreserving pancreaticoduodenectomy was performed. Histological analysis showed that the tumor was a well-differentiated adenocarcinoma without lymph node metastasis. Two years after the initial surgery, blood examination detected an elevated serum CA19-9 level and submucosal tumor which is 2.5 cm diameter with an ulcer at the gastrojejunostomy anastomosis. Tumor biopsy was performed, and histological analysis revealed a recurrent cholangiocarcinoma. The tumor directly invaded the transverse colon mesentery; therefore, distal gastrectomy and right hemicolectomy were performed. The patient survived 12 months postoperatively without recurrence. Gastric metastasis from cholangiocarcinoma rarely occurs. Intraoperative exposure of bile juice may have caused gastric metastasis in this case.

[A Case of Pancreatic Mixed Acinar-Neuroendocrine Carcinoma with Main Pancreatic Duct Development].

A 78-year-old man was referred to our hospital owing to a pancreatic tumor detected on ultrasonography. He showed weight loss, and his diabetes mellitus had worsened over 3 months. Abdominal contrast-enhanced computed tomography revealed a 3 cm diameter pancreatic head tumor with peripheral enhancement and a dilated pancreatic duct. He underwent subtotal stomach-preserving pancreaticoduodenectomy. Examination of intraoperative frozen sections did not indicate cancer involvement at the edge of the resected pancreatic duct. The tumor was histologically diagnosed as mixed acinar-neuroendocrine carcinoma(MANEC). It was mainly detected in the pancreatic head and was accompanied by intra-ductal growth in the pancreatic duct. The patient has survived for 21 months without recurrence. MANEC is a rare disease associated with intraductal growth. Intraoperative diagnosis of tumor involvement at the edge of the pancreatic duct may be useful for R0 resection in surgery for MANEC.

[Surgical Resection of a Solitary Pulmonary Nodule in a Patient with Breast Cancer-A Case Report].

Solitary lung tumors after radical surgery for breast cancer often present difficulty in diagnosis and treatment. This report describes the case of a patient with a previous history of radicalsurgery for breast cancer who underwent lung surgery. Solitary pulmonary nodules should be diagnosed in patients with breast cancer, because treatments and prognoses differ between metastatic and primary tumors. At the age of 43 years, this patient underwent surgicaltreatment for breast cancer. Eighteen years later, a solitary mass was observed in the middle lobe of the right lung. Right middle lobectomy was performed using video-assisted thoracic surgery. The diagnosis was primary lung carcinoma. In case of primary lung carcinoma, radical treatment is possible through surgical resection. On the contrary, breast cancer metastasis has been known to have subtypes with characteristics that may often be different from those of the originall esions; therefore, surgicalresection helps in the reevaluation of receptor expression. Thus, early pathological diagnosis using surgical resection is useful for early diagnosis and treatment.

[Severe Therapy-Related Pancytopenia Caused by UFT and LV in a Patient with Ascending Colon Cancer].

We report a case of a 79-year-old man who developed severe therapy-related pancytopenia from tegafur uracil(UFT)and Leucovorin(LV)as adjuvant chemotherapy for ascending colon cancer. Laparoscopic right hemicolectomy resection was performed for the ascending colon cancer. Pathohistological analysis revealed that the ascending colon tumor was moderately differentiated tubular adenocarcinoma(T3, N1, M0, and Stage III a). Postoperative adjuvant chemotherapy with UFT and LV was administered. After 2 courses of chemotherapies, severe thrombocytopenia(Grade 4)and neutropenia(Grade 4)were noted. Platelet and granulocyte-colony stimulating factor(G-CSF)were transfused. Furthermore, red blood cell transfusions were given for anemia(Grade 3). Dihydropyrimidine dehydrogenase(DPD)deficiency was suspected as the cause of the pancytopenia, and the ratio of dihydrouracil(DHU)and uracil(URA)was measured. However, the result was negative for DPD deficiency. Bone marrowaspiration revealed that therapy-related leukemia(TRL)and therapy-related myelodysplastic syndrome(T-MDS)were not the causes of the pancytopenia either. A total of 230 units of platelet transfusions and 20 units of red blood cell transfusions have been given for 32 weeks, and the patient currently requires routine blood transfusions. Fortunately, infection and bleeding never occurred. Subsequently, the patient should be monitored carefully.

[Examination of Resection for Pulmonary Tumors after Breast Cancer Surgery].

There are many arguments about whether surgical resection or drug therapy is better for pulmonary metastasis after breast cancer surgery. Here, we examine 9 cases of resection for pulmonary tumors suspected of being metastases from breast cancer, at our institution. The preoperative diagnosis was difficult, with nodules less than 20 mm in all cases. Of the 9 cases, 2 cases were primary lung cancer, 4 cases were metastatic pulmonary tumors, 1 case was comorbid with lung cancer and metastatic pulmonary tumors, and 2 cases were benign pulmonary tumors. The median disease-free interval (DFI) was 6.1 (1.3-8.9) years, and the median survival time was 12.5 (2.3-17.8) years after metastasectomy. There were no changes in the hormone receptors or HER2 status between primary breast tumors and metastases. Both cases of primary lung cancer were Stage ⅠA, and they were treated with radical resection. The 2 benign pulmonary tumors did not receive any unnecessary additional treatment. If a difficult-to-diagnose pulmonary tumor occurs after an operation for breast cancer, a pneumonectomy should be considered, not only for diagnosis but also for treatment.

[A Case of Resected Lymph Node Recurrence of Cancer of the Papilla of Vater].

We report the successful resection of lymph node recurrence of cancer of the papilla of Vater after pancreatoduodenectomy (PD). A 67-year-old man had undergone PD for adenocarcinoma of the papilla of Vater, and histopathological examination revealed well differentiated papillotubular adenocarcinoma, ly1, v0, T1, n (0), pStage ⅠB. One year after surgery, abdominal computed tomography revealed a mass at the left side of the residual inferior pancreaticoduodenal artery (IPDA). We resected the mass, which was diagnosed as lymph node recurrence of cancer of the papilla of Vater. The patient remains alive without any evidence of recurrence 5 years since the second operation. We suggest that complete resection of lymph node surrounding the IPDA is an important surgical procedure for cancer of the papilla of Vater. There still is only limited experience with resection for recurrence of cancer of the papilla of Vater, but our case shows that it may provide for long-term survival from recurrence of cancer of the papilla of Vater.

Effect of excessive acute-phase response on liver regeneration after partial hepatectomy in rats.

BACKGROUND/AIMS: Acute-phase response (APR) is known to have a protective role against infection and tissue injury including partial hepatectomy (HTX). In this study, the effect of excessive APR on liver regeneration was investigated using a rat hepatectomized model. METHODOLOGY: Experimental APR was induced by subcutaneous injection of turpentine oil, immediately, 24 h and 48 h after 50% HTX. Serum IL-6 and hepatic alpha2-macroglobulin mRNA was evaluated in rats receiving turpentine or saline as control after HTX. DNA synthesis and PCNA labeling index in the remnant liver was also investigated. Furthermore, in vitro total hepatic protein synthesis (TPS) and secretory protein synthesis (SPS) in the remnant liver were measured. RESULTS: Liver regeneration was significantly inhibited after HTX in the turpentine group, compared to the control. DNA synthesis and PCNA labeling index was also significantly decreased on days 1 and 2. A remarkable increase in the serum IL-6 and hepatic alpha2-macroglobulin mRNA was found in the turpentine group. Furthermore, SPS was significantly upregulated in the turpentine group, although TPS was almost similar between the groups. CONCLUSIONS: Induction of excessive APR after HTX inhibits liver regeneration. Acute phase protein synthesis is remarkably upregulated within the capacity of hepatic protein synthesis, most probably by a reduction in replicative protein synthesis, suggesting that APR may be more appropriate biological response for ensuring immediate survival.

[A case of liver metastatic recurrence of bile duct cancer completely responding to single-drug S-1 chemotherapy].

A 65-year-old man with common bile duct cancer was treated by pylorus-preserving pancreaticoduodenectomy with D2 lymph node dissection. Three months after surgery, tumor marker was increasing, and CT demonstrated multiple liver metastatic tumors. Single drug chemotherapy with S-1(100 mg/body/day)was administered. After 6 months, the liver metastatic tumors could not be visualized by CT. S-1 may be the chemotherapy of choice for recurrence of bile duct cancer.

Angiopoietin-2 levels in the hepatic vein as a useful predictor of tumor invasiveness and prognosis in human hepatocellular carcinoma.

BACKGROUND AND AIM: Hepatocellular carcinoma (HCC) is characteristically a hypervascular tumor and its progression is known to be closely related to angiogenesis. In this study, we investigated angiopoietin-2 (Ang-2) and vascular endothelial growth factor (VEGF) levels in the hepatic vein draining from HCC, as well as in the peripheral vein, to evaluate their relation to clinicopathological features and prognosis. METHODS: To obtain hepatic venous blood samples, a catheter was placed into the main branch of the hepatic vein draining from HCC in 21 patients. The Ang-2 and VEGF levels in both the hepatic and peripheral veins were investigated. Furthermore, Ang-2 mRNA expression in surgically resected HCC was evaluated by quantitative reverse-transcription polymerase chain reaction (RT-PCR), as well as microvessel density (MVD) by CD34 immunostaining. RESULTS: Ang-2 levels in the hepatic vein significantly correlated with Ang-2 mRNA expression in HCC, but Ang-2 levels in the peripheral vein did not correlate. Furthermore, a significant correlation was found between hepatic venous Ang-2 and MVD levels, whereas there was no significant correlation with hepatic venous VEGF levels. When hepatic venous Ang-2 levels were compared with clinicopathological features, a significant relationship was found between high Ang-2 levels and portal vein invasion. The survival for patients in the high hepatic venous Ang-2 group was significantly poorer when compared with the low group. CONCLUSION: Preoperative hepatic venous Ang-2 levels may be a good predictor for portal vein invasion and also prognosis in patients with HCC.