Laparoscopic approach as a safe and effective option for incarcerated femoral hernias.

INTRODUCTION: The laparoscopic approach for elective femoral herniorrhaphy is well established. However, femoral hernias often present as incarcerations and require emergency repair surgery, mainly using the open approach. This study aimed to retrospectively analyze the efficacy of the laparoscopic approach for incarcerated femoral hernias. METHODS: Data of patients who underwent emergency surgery for incarcerated femoral hernia between April 2016 and August 2021 were retrospectively analyzed. Laparoscopy was performed whenever possible; however, conversion to an open approach remained a fallback option for when laparoscopic repair was not possible. In laparoscopic repair, incarcerated femoral hernias reduced using traction, water pressure, and preperitoneal methods. Data of patients who underwent open repair and laparoscopy were then compared. RESULTS: During the observation period, 20 patients underwent emergency surgery for incarcerated femoral hernia. Eleven patients subsequently underwent repair using a laparoscopic approach, and eight underwent repair using an open approach. Only one patient underwent intestinal resection without hernia repair due to perforated bowel. Operative time for laparoscopic repair was longer. Mesh repair was performed in 18 patients. Four patients each in the laparoscopic repair and open group required intestinal resection. CONCLUSION: Incarcerated femoral hernias can be safely repaired using the laparoscopic approach.

A new technique to avoid unintentional adhesion while deploying ProGrip mesh and its utility in the laparoscopic repair of obturator hernia.

The ProGrip™ laparoscopic self-fixating mesh provides advantages such as low cost and reduced pain following tack-free fixation in laparoscopic hernia repair through a transabdominal preperitoneal approach. Obturator hernia repair needs adequate fixation around the hernial orifice without the use of tacking, and ProGrip™ mesh provides options for secure fixation. However, it is often difficult to adequately adjust the mesh placement to cover the obturator hernia orifice with a ProGrip™ mesh, due to adhesion of the grips to the surrounding tissues. We introduce our technique to avoid unintentional adhesion during ProGrip mesh repair and discuss its utility in the treatment of obturator hernias. We repaired seven obturator hernia lesions in five patients using this technique without any complications. The biggest advantage of our technique is that the position of the mesh can be adjusted after it is expanded, unless the sheet is completely removed, allowing the surgeons to fix the mesh without any unintended adhesion to surrounding tissue.

Perforation of small intestinal metastasis of lung adenocarcinoma treated with pembrolizumab: a case report.

BACKGROUND: Pembrolizumab is an immune checkpoint inhibitor and is an anti-human programmed cell death-1 (PD-1) monoclonal antibody. Pembrolizumab is used for non-small cell lung carcinoma with high programmed cell death ligand-1 (PD-L1) expression. It has been found that better overall survival can be obtained using pembrolizumab compared to the existing chemotherapy. We report a case of perforation of small intestinal metastasis after pembrolizumab treatment. CASE PRESENTATION: A 62-year-old man was treated by pembrolizumab for PD-L1 highly expressed lung adenocarcinoma, with multiple metastasis (small intestinal, lymph nodes, and bone). The treatment was stopped owing to drug-induced pneumonitis. One month after drug withdrawal, the patient visited the emergency department of our hospital with the complaint of severe stomachache. He had a rigid abdomen and generalized tenderness, and computed tomography scans showed free air within the abdomen. We diagnosed bowel perforation and performed emergency surgery. Surgical findings revealed multiple small intestine metastasis and mesenteric lymph node metastasis. Perforation was found in the metastatic site in the jejunum located around 40 cm anal to Treitz's ligament. This perforated part was resected, and functional end-to-end anastomosis was performed using linear staplers. The post-operative course was uneventful. Pathological examination revealed lung adenocarcinoma metastasis at the perforation site, and the effectiveness of pembrolizumab was grade 1b (Japanese Classification of the Colorectal Carcinoma, seventh edition). CONCLUSIONS: This is the first report of perforation of small intestinal metastasis of lung adenocarcinoma after pembrolizumab treatment. Because pembrolizumab causes some side effects, particularly autoimmune side effects, careful attention during treatment is warranted.

Long-term survival after repeated resection of metachronous lung metastases from pStage IA pancreatic adenocarcinoma.

CASE REPORT: A 70-year-old woman with pancreatic ductal adenocarcinoma was initially treated by distal pancreatectomy (DP). Thirty-five months later, another tumor appeared in the pancreatic head and was treated by pancreaticoduodenectomy. Histopathological findings identified both tumors as pancreatic ductal adenocarcinoma pStage IA. Computed tomography (CT) of the chest 16 months after the second pancreatectomy revealed a ground-glass opacity in segment 3 of the right lung. Chest CT 23 months after the second pancreatectomy revealed a nodular shadow in segment 1a of the right lung. Chest CT 39 months after the second pancreatectomy revealed a nodular shadow in segment 5 of the left lung. These lesions were treated by video-assisted thoracoscopic surgery partial resection. Histopathological and immunohistochemical features (positive for cytokeratin (CK)7 and CK20, negative for transcription factor-1) for these three lesions and the secondary pancreatic ductal adenocarcinoma were similar, indicating a diagnosis of lung metastasis from the second pancreatic ductal adenocarcinoma. The patient has remained alive and free of new metastases for 8 years after initial DP, 3 years after the last lung resection. CONCLUSION: This patient has survived over the long term after undergoing three resections of lung metastases from resected pancreatic ductal adenocarcinoma.

Impact of elemental diet on early recovery after laparoscopic colectomy: findings of a randomized controlled trial.

PURPOSE: An amino acid-containing elemental diet (ED) does not require digestion for nutritional absorption, making it a good option for patients with gastrointestinal malabsorption. We conducted a randomized trial to confirm that perioperative ED enhanced the recovery of patients undergoing laparoscopic colectomy. METHODS: Patients in the intervention arm received commercially available ED from the day prior to surgery until postoperative day (POD) 3, whereas patients in the control group received a conventional perioperative diet program. To verify the endpoints, "estimated minimum length of stay in hospital after surgery" (emLOS) was defined as the number of days necessary to reach all the five criteria; namely, "sufficient oral intake", "sufficient pain control", "withdrawal of intravenous alimentation", "no abnormal findings in routine examinations", and "no rise in fever". RESULTS: A total of 102 patients were randomized, 94 of whom were analyzed (ED 45, control 49). There was no morbidity or mortality. Shorter emLOS (POD 4 vs. POD 7; p = 0.018), earlier resumption of sufficient oral intake (POD 3 vs. POD 4; p = 0.034) and faster recovery to defecation (2.2 vs. 3.1 days; p = 0.005) were observed in the ED group vs. the control group. CONCLUSIONS: The perioperative ingestion of ED by patients undergoing laparoscopic colectomy is safe and can reduce the postoperative hospital stay by supporting the acceleration of oral intake.

Noninvasive management for iatrogenic splenic injury caused by chest tube insertion: a case report.

Splenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management. However, noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event.

Risk Factors for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis.

BACKGROUND AND OBJECTIVES: Factors that contribute to difficult laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) that would affect the performance of early surgery remain unclear. The purpose of this study was to identify such risk factors. METHODS: One hundred fifty-four patients who underwent LC for AC were retrospectively analyzed. The patients were categorized into early surgery and delayed surgery. Factors predicting difficult LC were analyzed for each group. The operation time, bleeding, and cases of difficult laparoscopic surgery (CDLS)/conversion rate were analyzed as an index of difficulty. Analyses of patients in the early group were especially focused on 3 consecutive histopathological phases: edematous cholecystitis (E), necrotizing cholecystitis (N), suppurative/subacute cholecystitis (S). RESULTS: In the early group, the CDLS/conversion rate was highest in necrotizing cholecystitis. Its rate was significantly higher than that of the other 2 histopathological types (N 27.9% vs E and S 7.4%; P = .037). In the delayed-surgery group, a higher white blood cell (WBC) count and older age showed significant correlations with the CDLS/conversion rate (P = .034 and P = .004). CONCLUSION: In early surgery, histopathologic necrotizing cholecystitis is a risk factor for difficult LC in AC. A higher WBC count and older age are risk factors for delayed surgery.

Blood stasis may cause thrombosis in the left superior pulmonary vein stump after left upper lobectomy.

BACKGROUND: We previously reported that arterial infarction of vital organs after lobectomy might occur only after left upper lobectomy and be caused by thrombosis in the left superior pulmonary vein stump. We hypothesized that changes in blood flow, such as blood stasis and disturbed stagnant flow, in the left superior pulmonary vein stump cause thrombosis, and this was evaluated by intraoperative ultrasonography. METHODS: From July 2013 to April 2014, 24 patients underwent lobectomy in the Steel Memorial Muroran Hospital. During the procedure, an ultrasound probe was placed at the pulmonary vein stump and the velocity in the stump was recorded with pulse Doppler mode. The peak velocity and the presence of spontaneous echo contrast in the stump were evaluated. After the operation, the patients underwent contrast-enhanced CT within 3 months. RESULTS: The operative procedures were seven left upper lobectomies, four left lower lobectomies, seven right upper lobectomies, and six right lower lobectomies. Blood flow was significantly slower in the left superior pulmonary vein stump than in the right pulmonary vein stumps. However, that was not significantly slower than that in the left inferior pulmonary vein stump. Spontaneous echo contrast in the pulmonary vein stump was seen in three patients who underwent left upper lobectomy. Of the three patients with spontaneous echo contrast, two patients developed thrombosis in the left superior vein stump within 3 months after the operation. There was no patient who developed arterial infarction. CONCLUSIONS: In patients who underwent left upper lobectomy, intraoperative ultrasonography to evaluate blood flow and the presence of spontaneous echo contrast in the left superior pulmonary vein stump may be useful to predict thrombosis that may cause arterial infarction.

Video-assisted thoracoscopic surgery using mobile computed tomography: new method for locating of small lung nodules.

BACKGROUND: The O-arm is an intraoperative imaging device that can provide computed tomography images. Surgery for small lung tumors was performed based on intraoperative computed tomography images obtained using the O-arm. This study evaluated the usefulness of the O-arm in thoracic surgery. METHODS: From July 2013 to November 2013, 10 patients with small lung nodules or ground glass nodules underwent video-assisted thoracoscopic surgery using the O-arm. A needle was placed on the visceral pleura near the nodules. After the lung was re-expanded, intraoperative computed tomography was performed using the O-arm. Then, the positional relationship between the needle marking and the tumor was recognized based on the intraoperative computed tomography images, and lung resection was performed. RESULTS: In 9 patients, the tumor could be seen on intraoperative computed tomography images using the O-arm. In 1 patient with a ground glass nodule, the lesion could not be seen, but its location could be inferred by comparison between preoperative and intraoperative computed tomography images. In only 1 patient with a ground glass nodule, a pathological complete resection was not performed. There were no complications related to the use of the O-arm. CONCLUSIONS: The O-arm may be an additional tool to facilitate intraoperative localization and surgical resection of non-palpable lung lesions.

Left upper lobectomy can be a risk factor for thrombosis in the pulmonary vein stump.

BACKGROUND: Thrombosis in the left upper pulmonary vein stump after left upper lobectomy is a very rare but important complication because it occurs in the systemic circulation system. We previously made the first ever report on the frequency and risk factors of thrombosis in the pulmonary vein stump after lobectomy. In this study, we conducted an investigation in a different hospital to determine whether this was a common complication. METHODS: From 2008 to 2012, 151 patients who underwent lobectomy and following enhanced CT within 2 years after the operation were studied. Postoperative contrast-enhanced CT imaging was retrospectively checked. RESULTS: We found thrombosis in the pulmonary vein stump in 5 of the 151 patients (3.3%). All 5 patients underwent left upper lobectomy (17.9% of the patients who underwent left upper lobectomy). These 5 patients did not have infarction of any vital organ. The thrombus was disappeared several months later on contrast-enhanced CT in 3 patients and followed in 2 patients. On univariate analysis, there was a significant difference only in the operative procedure (p<0.001). CONCLUSIONS: Thrombosis in the pulmonary vein stump occurred with high frequency in patients who underwent left upper lobectomy. Because the frequency of thrombosis in this study was the same as in our previous report, this might be a common complication.

[Clinicopathological features of intestinal complications in non-Hodgkin's lymphoma -a single institution analysis-].

We evaluated the clinicopathological features of patients who developed intestinal complications following surgery for gastrointestinal non-Hodgkin's lymphoma (NHL) and determined the risk factors for complications. We retrospectively analyzed 28 patients with gastrointestinal NHL who were treated at our institution between January 2007 and June 2012. Seven patients (25.0%) underwent surgery for bleeding, perforation, or ileus caused by the gastrointestinal NHL, particularly those with involvement of the jejunum or ileum. Half the patients with small intestinal NHL required surgery for complications; patients with this form of NHL were therefore considered to be at a high risk of complications. Those with semicircular ulcerative lesions, a protruding deformity, or systemic NHL involving the small intestine were also considered to be at a particularly high risk of intestinal complications.

[A case of serous cystadenoma of the pancreas communicating with the main pancreatic duct synchronously diagnosed with pancreatic ductal carcinoma].

A 65-year-old woman who had been followed up for a cystic lesion of the tail of the pancreas was found to have cancer of the body of the pancreas. ERP showed stenosis of the main pancreatic duct (MPD) with dilatation of the distal side of the duct, and communication between the cystic lesion and MPD. She underwent distal pancreatectomy under a diagnosis of intraductal papillary-mucinous neoplasm associated with cancer of the body of the pancreas. Clinicopathologic investigation revealed that the diagnosis of the cystic lesion was serous cystadenoma having the communication with MPD. It was also indicated by the histopathologic findings that inflammatory changes of MPD caused by stenosis might contribute to the development of serous cystadenoma.

[Pedunculated carcinoid tumor of the gallbladder--analysis of the relationship between location and morphology in carcinoid tumor of the gallbladder].

Laparoscopic cholecystectomy was performed in a 54-year-old man because of gallbladder neck cancer suspected on endoscopic ultrasonography and computed tomography. The pathological diagnosis was carcinoid tumor of the gallbladder. Our case had the pedunculated morphology which was distinguishing characteristic. We analyzed the relationship between location and morphology in previously reported cases of gallbladder carcinoid tumor in Japan. The result indicated that carcinoid tumor of the gallbladder neck became pedunculated or subpedunculated more frequently than in the rectum or stomach.

Long-term results following thoracoscopic surgery for esophageal leiomyoma in four patients.

For esophageal leiomyoma, surgical enucleation is accepted as the standard procedure when the tumor is symptomatic or large in size without malignant findings. The aim of this study is to clarify the long-term results following thoracoscopic surgery. Four patients with esophageal leiomyoma were subjected to thoracoscopic surgery. The indications for surgical resection of esophageal leiomyoma were as follows: 1) tumor size greater than 3cm or appearance of enlargement; 2) symptomatic patients. In one case of a larger tumor, hand-assisted thoracoscopic surgery was performed in order to ensure both minimal invasion and a wide operative area. There was no mortality and one postoperative complication. No local recurrence, port site recurrence, pleural dissemination or distant metastases were detected between 35 and 96 months after the operation. The advantages of thoracoscopic surgery for esophageal leiomyoma include its safety and long-term prevention of recurrence.

Intraductal oncocytic papillary neoplasm having clinical characteristics of mucinous cystic neoplasm and a benign histology.

CONTEXT: An intraductal oncocytic papillary neoplasm is a rare pancreatic tumor which was first described by Adsay et al. in 1996. It has been defined as a new subgroup of IPMN. CASE REPORT: We report the case of a 76-year-old woman who presented with nausea. Imaging studies revealed a cystic mass in the body of the pancreas. She underwent a successful distal pancreatectomy and splenectomy, and has subsequently remained well. Microscopically, the cyst was lined by columnar epithelium similar to pancreatic duct epithelium, and the nodular projection consisted of arborizing papillary structures, lined by plump cells with abundant eosinophilic cytoplasm. These eosinophilic cells were immunohistochemically positively stained with anti-mitochondrial antibody. The cellular atypism was mild and the proliferating index was low, compatible with adenoma of an intraductal oncocytic papillary neoplasm. Although no ovarian type stroma was identified, in our case, no communication to main pancreatic duct (located in the pancreatic body) and rapid growth by intracystic hemorrhage were clinical characteristics of a mucinous cystic neoplasm, but not IPMN. CONCLUSION: With only 17 cases reported to date, the clinical and pathological details of an intraductal oncocytic papillary neoplasm are still unclear. We herein add one case with different characteristics from those of the past reports. To our knowledge, this is the first case report of an intraductal oncocytic papillary neoplasm with the clinical characteristics of a mucinous cystic neoplasm.

Feasibility of en-bloc wedge resection of the pancreas and/or the duodenum as an alternative to pancreatoduodenectomy for advanced gallbladder cancer.

Pancreatoduodenectomy has been described as a possible treatment for gallbladder cancer that presents with evidence of direct invasion to the pancreas and/or the duodenum. This procedure does, however, carry a significantly higher morbidity and mortality if performed with a hepatectomy. An alternative procedure, therefore, of wedge resection of the invaded organ(s) was investigated in this study. On recognition of infiltration of the tumor into the pancreas and/or the duodenum, an en-bloc wedge resection of the organ(s) combined with the original tumor was the intended procedure. However, a pancreatoduodenectomy was performed if the tumor was not resectable by an attempted wedge resection. Operative and long-term outcomes were compared between patients who underwent wedge resection (n = 9) and pancreatoduodenectomy (n = 8). One patient in each group was incorrectly diagnosed preoperatively as having cancer invasion, as opposed to inflammatory changes, as recognized by subsequent histology. All tumors were excised with tumor-free pancreatic and duodenal margins. Postoperative complications occurred in one patient with wedge resection and four with pancreatoduodenectomy. One in-hospital death occurred in each group; one patient died with wedge resection of sepsis and one patient with pancreatoduodenectomy died of a pancreatic leak. No local recurrence occurred in either group. There was no difference in cumulative survival rates between the groups. Wedge resection was considered to be a feasible surgical procedure, in terms of morbidity, respectability, and long-term outcome.

Radical operation for recurring gastric carcinoma.

BACKGROUND/AIMS: The effectiveness of surgical treatment for recurring gastric carcinoma is unclear. We conducted a retrospective review of our results with a radical surgical approach to the treatment of gastric cancer metastases. METHODOLOGY: Nine patients who underwent radical resection of recurring gastric cancer between 1990 and 2003 were examined and follow-up was completed by March 2003. RESULTS: The surgically removed recurring sites included local lesions (4 patients), as well as metastases in the liver (4 patients) and ovary (1 patient). There were no major complications or operative deaths. The mean operative time was 380 minutes; the mean intraoperative blood loss was approximately 525mL and the mean volume of transfused blood was 178mL. Re-recurrence appears in 8 patients between 1.5 and 26 months (average 8.5 months) following surgical resection. The sites of re-recurrence included the peritoneum, liver, lymph nodes, bone, as well as local lesions. One patient currently shows no evidence of disease more than 6 years after resection of the local recurrence. Two other patients remain alive, but presented with re-recurrence at 4 and 10 months postoperatively. The remaining 6 patients died of cancer between 2 and 28 months after surgery for recurring lesions. CONCLUSIONS: Radical surgery for recurring gastric cancer both liver and extrahepatic lesions is a safe treatment with a good prognosis for long-term survival in a select patient subpopulation.

Tumor-associated antigen recognized by the 22-1-1 monoclonal antibody encourages colorectal cancer progression under the scanty CD8+ T cells.

PURPOSE: The receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is a novel tumor-associated antigen. Although evidence suggests that RCAS1 suppresses immunity by inducing tumor-infiltrating lymphocyte (TIL) apoptosis, RCAS1 function in humans is controversial. RCAS1 overexpression leads to the generation of the Tn glycan antigen (N-acetyl-D-galactosamine, GalNAc) recognized by the 22-1-1 monoclonal antibody. The objective of this study is to examine Tn glycan antigen function in colorectal cancer and to determine its relationship to CD8+ T cells and prognosis. EXPERIMENTAL DESIGN: Immunohistochemical analyses examined Tn expression in tumor cells and CD8 on TILs in 146 surgically resected colorectal cancer. RESULTS: Of 146 samples, 68 tumors (47%) were Tn+; 72 tumors (49%) were CD8+. Using Cox multivariate analysis and the Kaplan-Meier method, Tn and CD8 positivity were determined to be mutually independent prognostic factors (P = 0.0266 and 0.0210, respectively). Tn+ patients with CD8+ TILs exhibited better survival than Tn+/CD8- patients (P = 0.0129). For CD8- patients, Tn positivity was associated with decreased survival from that seen in Tn- patients (P = 0.0097), suggesting that Tn exerts a function independent of CD8+ T cells in tumor progression. In all patients and cases with synchronous liver metastases (n = 29), the Tn+/CD8- survival rate was significantly lower than that seen for other groups (P = 0.0001 and 0.0063, respectively). The average number of liver metastases in Tn+/CD8- cases also increased (mean, 8.2 tumors; P = 0.0032). Multivariate analysis identified Tn+/CD8- status and Dukes' staging as independent prognostic factors (P = 0.0016 and < 0.0001, respectively). CONCLUSIONS: Tn may encourage invasion and innidiation through a mechanism independent of CD8+ T cells. Thus, Tn+/CD8- status is a risk factor for multiple liver metastases development and an independent negative prognostic factor for colorectal cancer.

Resection of lung metastasis from gallbladder carcinoma: immunohistochemistry of RCAS1 and CD8+T cells in primary and metastatic tumors.

Advanced Gallbladder cancer has an extremely poor prognosis. We examined a patient with resectable gallbladder cancer with associated lung metastasis. A 64-year-old female patient, diagnosed with gallbladder cancer and a solitary benign lung tumor by imaging, was subjected to extensive cholecystectomy and extrahepatic bile duct resection. After one year, a follow-up CT indicated enlargement of the lung tumor; video-assisted right middle lobectomy was then performed. The lung tumor was diagnosed as a metastasis derived from the gallbladder cancer by pathology and immunohistochemistry. Expression of RCAS1, an independent unfavorable prognostic indicator in gallbladder cancer, was observed in both the gallbladder and lung tumors. However, infiltration of CD8+T cells was only seen in the lung metastatic tumor. She has remained free of any evidence of recurrence in the 10 months and 4 years after the first surgery. The results that metastasis is solitary and infiltrated by CD8+T cells correspond with the present clinical history.