Cerebral infarction by paradoxical gas embolism detected after laparoscopic partial hepatectomy with an insufflation management system: a case report.

BACKGROUND: Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report a case of severe cerebral infarction presumably caused by paradoxical CO2 embolism in laparoscopic partial hepatectomy with an insufflation management system. CASE PRESENTATION: A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient's end-tidal CO2 and percutaneous oxygen saturation dropped from approximately 40-20 mmHg and 100-90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism. CONCLUSIONS: A patent foramen ovale is found in approximately 15-20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.

Benign multicystic peritoneal mesothelioma occurring in bilateral inguinal canals metachronously: a case report.

BACKGROUND: Benign multicystic peritoneal mesothelioma (BMPM) is a benign tumor that usually occurs in middle-aged females. Although several published studies have reported the occurrence of this tumor in the abdominal cavity, few have documented its development in the inguinal region. CASE PRESENTATION: We present a case of a 48-year-old female presenting with a bulge in her left inguinal region. Physical examination revealed a golf ball-sized nodule in the left inguinal region that could not be pushed back into the abdominal cavity. Contrast-enhanced computed tomography showed a multicystic tumor; therefore, the patient was diagnosed with inguinal hernia or hydrocele of the Nuck's canal. We performed surgical resection and hernia repair using the mesh plug method. The resected specimen was 80 mm in length and contained a multicystic tumor. Pathological examination showed that the cyst wall was lined by a single layer of cuboidal to single layer squamous epithelium. Immunohistochemistry revealed positivity for calretinin in the epithelial cells, for which a diagnosis of BMPM was established. The patient returned to our hospital after 5 years with symptoms similar to the previous episode, but this time in the right inguinal region. Imaging studies showed a tumor in the right inguinal region with the same characteristics as the previous one. The patient underwent tumor resection and hernia repair using the same technique. The resected tumor was 45 mm in length and had characteristics similar to the previously resected tumor. The presence of calretinin and D2-40 on immunohistochemistry led to the diagnosis of BMPM. There was no recurrence of BMPM for 33 months after the secondary surgery. CONCLUSIONS: Here we present the first report of metachronous BMPM occurring in bilateral inguinal canals. Although the pathogenesis of BMPM remains unclear, reactive changes have been suggested to cause tumors originating from the groin. The treatment of choice for BMPM is surgical resection. For diagnosis, pathological examination with immunostaining can be useful. The most appropriate postoperative follow-up for inguinal BMPM is controversial, and the accumulation of more inguinal BMPM cases is needed.

A case of gastrointestinal bleeding due to right hepatic artery pseudoaneurysm following total remnant pancreatectomy: A case report.

INTRODUCTION: Pseudoaneurysm is a serious complication after pancreatic surgery, which mainly depends on the presence of a preceding pancreatic fistula. Postpancreatectomy hemorrhage following total pancreatectomy is a rare complication due to the absence of a pancreatic fistula. Here we report an unusual case of massive gastrointestinal bleeding due to right hepatic artery (RHA) pseudoaneurysm following total remnant pancreatectomy. PRESENTATION OF CASE: A 75-year-old man was diagnosed with intraductal papillary mucinous carcinoma recurrence following distal pancreatectomy and underwent total remnant pancreatectomy. After discharge, he was readmitted to our hospital with melena because of the diagnosis of gastrointestinal bleeding. Gastrointestinal endoscopy was performed to detect the origin of bleeding, but an obvious bleeding point could not be detected. Abdominal computed tomography demonstrated an expansive growth, which indicated RHA pseudoaneurysm. Emergency angiography revealed gastrointestinal bleeding into the jejunum from the ruptured RHA pseudoaneurysm. Transcatheter arterial embolization was performed; subsequently, bleeding was successfully stopped for a short duration. Because of improvements in his general condition, the patient was discharged. DISCUSSION: To date, very few cases have described postpancreatectomy hemorrhage following total remnant pancreatectomy. We suspect that the aneurysm ruptured into the jejunum, possibly because of the scarring and inflammation associated with his two complex surgeries. CONCLUSION: Pseudoaneurysm should be considered when the fragility of blood vessels is suspected, despite no history of anastomotic leak and intra-abdominal abscess. Our case also highlighted that detecting gastrointestinal bleeding is necessary to recognize sentinel bleeding if the origin of bleeding is undetectable.

A case-matched comparison of single-incision versus multiport laparoscopic right colectomy for colon cancer.

PURPOSE: To minimize the parietal trauma associated with multiple surgical access sites, single-incision laparoscopic surgery for colectomy has been emerging with the improvements in instrumentation and surgical techniques. The purpose of this study was to compare the clinicopathological outcomes between single-incision laparoscopic right colectomy (SILC) and multiport laparoscopic right colectomy (MLC) for right colon cancer. METHODS: Thirty-five consecutive patients undergoing SILC from a prospective single-institution database were case matched according to demographic data to an equivalent number of patients who underwent MLC. RESULTS: The SILC patients had decreased scores for maximal pain assessed by a visual analog scale on postoperative days 1 and 3, and used fewer postoperative systemic narcotics. The median length of the hospital stay for the SILC patients was significantly shorter compared with the MLC patients. The postoperative morbidity rates were similar between the groups. The oncological findings were not significantly different between the groups. CONCLUSION: SILC is a feasible and safe alternative to conventional MLC for patients with right colon cancer.

Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy.

BACKGROUND: One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20%. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD. METHODS: Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007-March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010-September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. RESULTS: The incidence of DGE was 21.3% in the SSPPD-ETS group and 2.5% in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. CONCLUSIONS: The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD.

Lesser curvature approach in laparoscopic distal pancreatectomy.

Laparoscopic distal pancreatectomy (LDP) has entailed ventrally retracting the stomach to afford adequate visualization. The retracted stomach commonly droops over the pancreas and obstructs the surgical field, thus forcing the assistant surgeon to repeatedly lift the stomach out of the way ventrally and cranially. We herein reported LDP using the "lesser curvature approach" in which the pancreas was approached cephalad to the lesser curvature of the stomach in underweight patients with a coincidental low hanging stomach. An excellent view of both the distal pancreas and the spleen could be afforded, enabling complete mobilization of these organs from the retroperitoneum and easy ligation of the splenic vessels, without needing to retract the stomach ventrally and cranially. The lesser curvature approach in LDP could be performed safely and efficiently as an alternative to the conventional greater curvature approach in underweight patients with a low hanging stomach.

Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: a randomized controlled trial.

BACKGROUND: In colorectal surgeries, surgical site infections (SSIs) frequently cause morbidity; an incidence of up to 20% has been shown in previous studies. Recently, to prevent microbial colonization of suture material in operative wounds, triclosan-coated polyglactin suture materials with antimicrobial activity have been developed; however, their significance in colorectal surgery remains unclear. This randomized controlled trial was conducted to assess the value of triclosan-coated polyglactin sutures in colorectal surgery. METHODS: A total of 410 consecutive patients who had undergone elective colorectal operations were enrolled in this trial. Of those patients, the 206 in the study group underwent wound closure with triclosan-coated polyglactin 910 antimicrobial sutures, and the 204 patients in the control group received conventional wound closures with polyglactin 910 sutures. RESULTS: The study group and the control group were comparable regarding risk factors for SSIs. The incidence of wound infection in the study group was 9 of 206 patients (4.3%), and that in the control group was 19 of 204 patients (9.3%). The difference is statistically significant in the 2 groups (P = .047). The median additional cost of wound infection management was $2,310. The actual entire additional cost, therefore, of 9 patients in the study group was $18,370, and that of 19 patients in the control group was $60,814. CONCLUSION: Triclosan-coated sutures can reduce the incidence of wound infections and the costs in colorectal surgery.

[Long-term survival of a patient with giant liver metastatic breast cancer treated with trastuzumab].

We report the long-term survival of a patient with metastatic breast cancer treated with trastuzumab and chemoendocrine therapy. The patient was a 60-year-old female. She underwent right mastectomy with axillary lymphadenectomy I c for advanced right breast cancer in 1999. In 2007, she consulted our hospital for treatment of recurrent giant liver metastasis. A giant liver metastasis up to 15 cm in diameter was detected by CT upon arrival. After 4 years of trastuzumab and chemoendocrine therapy, she was diagnosed as in progressive remission with good quality of life. Breast cancer with liver metastasis often can be life-threatening. Therefore, an optimal chemotherapy should be applied as soon as possible. Trastuzumab and chemoendocrine therapy showed efficacy for the treatment of a HER2-positive breast cancer with recurrent giant liver metastasis.

Clinically relevant pancreas-related infectious complication after pancreaticoenteral anastomosis could be predicted by the parameters obtained on postoperative day 3.

OBJECTIVES: Pancreatic fistula or pancreas-related infectious complications are one of the most common surgical complications after pancreatic surgery. The aims of this study were, first, to reveal the risk factors for clinically relevant pancreas-related infectious complications and, second, to identify those risk factors that are obtainable within the first 3 postoperative days. METHODS: One hundred seven consecutive patients who underwent pancreaticoenteral anastomosis between October 2007 and November 2010 were enrolled. RESULTS: There were 36 patients with clinical pancreas-related infectious complications among 107 in this series of patients. Univariate and multivariate analyses revealed that a narrow main pancreatic duct diameter (<3 mm) was an independent risk factor for clinically relevant pancreas-related infectious complication. Univariate and multivariate analyses also revealed that a body temperature of 38°C or higher on postoperative day 3 (POD3), a leukocyte count of 9.8 × 10(9)/L or greater on POD3, and a drain fluid amylase level of 3000 IU/L or higher on POD3 were significant predictive factors for clinically relevant pancreas-related infectious complication for 58 patients with a narrow main pancreatic duct. CONCLUSIONS: In view of the clinical variables obtained on POD3, such as amylase levels in drain effluent, body temperature, and leukocyte count, clinically relevant pancreas-related infections could be predicted well.

Laparoscopic pancreaticoduodenectomy combined with minilaparotomy.

Laparoscopic pancreatic surgery is evolving rapidly; however, the surgical treatment of periampullary tumors is still fraught with challenges, such as technical difficulty and the appropriateness of oncologic treatment for these patients. We describe how we performed laparoscopic pancreaticoduodenectomy (LPD) combined with minilaparotomy successfully in six consecutive patients. This procedure consisted of two surgical phases: safe laparoscopic surgery, including the Kocher maneuver, tunneling behind the pancreatic neck, and dissecting along the uncinate process with magnified vision; and a secure open approach with complete skeletonization of the hepatoduodenal ligament and alimentary tract reconstruction, performed similarly to conventional pancreaticoduodenectomy, under direct visualization through the minilaparotomy. By performing this procedure, we combined a safe and secure minilaparotomy approach under direct vision with a less invasive laparoscopic approach providing a magnified image. Our experience demonstrates that LPD combined with minilaparotomy is technically feasible for selected patients with periampullary tumors.

ENBD tube placement prior to laparoscopic cholecystectomy may reduce the rate of complications in cases with predictably complicating biliary anomalies.

BACKGROUND: The risk factors predisposing to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) include the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct of Luschka. One method to prevent bile duct injury is preoperative placement of an endoscopic nasobiliary drainage tube (ENBD assisted LC). The aims of this investigation are first, to report the incidence of bile duct anomalies according to the classification system proposed by Wakayama Medical University and second, to evaluate the efficacy of ENBD assisted LC with regard to prevention of intraoperative bile duct injury and postoperative bile duct injury or leakage. METHODS: A total of 1,835 consecutive LCs performed at our institution during a recent 10-year period were reviewed. RESULTS: Anomalous cystic duct confluence was detected in 11 cases and an accessory hepatic duct was detected in 37 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery, conversion rate to laparotomy, or frequency of bile duct injury or leakage between the standard LC group and ENBD assisted LC group. CONCLUSION: A bile duct anomaly was seen in 2.6% of LC cases. Placement of an ENBD tube prior to LC in predictably complicating bile duct anomalies may have successfully decreased the incidence of complications.

Role of CT in detecting malignancy during follow-up of patients with branch-type IPMN of the pancreas.

BACKGROUND/AIMS: This retrospective study evaluated the suitability of computed tomography (CT) to detect malignancy while following patients with branch-type IPMN, most of which are benign and may be treated with observation alone. METHODOLOGY: Forty-two surgical specimens resected from patients with a diagnosis of branch-type IPMN were pathologically classified as benign (n=26), which included hyperplasia and adenoma, or malignant (n=16), including moderate dysplasia or adenocarcinoma. It was compared the differences in the sizes of the tumor and main pancreatic duct (MPD) and the presence of mural nodules on CT between the groups. RESULTS: In the malignant group, it was observed a larger tumor size (47.8 vs. 23.8 mm; p = 0.001) and increased dilation of the MPD (9.3 vs. 5.0 mm; p = 0.001) than those seen in the benign group. The accuracy of CT diagnosis of mural nodules, however, was only 62%. Tumor diameter > or =40 mm or MPD diameter >10 mm predicted malignancy with a sensitivity and negative predictive value of 93.8% and 95.7%, respectively. CONCLUSIONS: Either tumor size or MPD dilation detected by CT could predict the majority of malignant branch-type IPMNs. Increases in these morphological characteristics on CT images during the follow-up period would be an accurate method to predict a diagnosis of malignancy.

Laparoscopic pancreaticoduodenectomy is effective in a porcine model.

BACKGROUND: Laparoscopic pancreatic surgery is rapidly evolving due to improving instrumentation and surgical techniques. The challenges confronting laparoscopic pancreaticoduodenectomy (LPD), however, are its technical difficulty and its appropriateness for oncologic treatment. This study sought to develop a novel technique for LPD in an acute porcine model and to evaluate the safety and feasibility of LPD before clinical trials are undertaken. METHODS: The LPD procedure was performed in 10 pigs. Modified Child's reconstruction was performed intracorporeally. After the animals were killed, anastomotic sites were investigated by laparotomy. RESULTS: All the animals underwent LPD. The median operation time was 5 h, with minimal blood loss. One choledochojejunostomy had a small leak. CONCLUSIONS: The study proved LPD to be technically safe and feasible in an acute porcine model. Further studies and technical advances are necessary for transition of this clinical application of LPD to humans.

Treatment strategy for hilar cholangiocarcinoma, with special reference to the limits of ductal resection in right-sided hepatectomies.

The surgical anatomy of the hepatic hilar region is characterized by the three-dimensional formation of the branches of the bile duct, portal vein, and hepatic artery. The limit of ductal resection in hepatectomy for hilar cholangiocarcinoma is the most peripheral point where the hepatic ducts can be separated from the vasculature. The limit is different for each type of hepatectomy because the portal vein branches that should be preserved or divided vary with the extent of the hepatectomy, and therefore the limit of separation of the hepatic ducts differs. Surgeons are required to understand the surgical anatomy and to identify the precise area of cancer spread on a preoperative cholangiogram so as to choose the appropriate type of hepatectomy, and to ensure that the remnant ductal margin is cancer-negative.

Laparoscopic modified Devine exclusion gastrojejunostomy as a palliative surgery to relieve malignant pyloroduodenal obstruction by unresectable cancer.

BACKGROUND: Malignant pyloroduodenal obstruction by an unresectable cancer makes ingesting food or liquids impossible for patients. The patient's quality of life deteriorates rapidly, leading to a dismal prognosis. The modified Devine exclusion (MDE) method of open laparotomy has been reported to be effective in such cases. METHODS: We performed laparoscopic MDE gastrojejunostomy in 8 cases. The patient data collected included surgical time, morbidity and mortality, length of stay, the state and duration of adequate oral ingestion, and outcome. RESULTS: The median surgical time was 191 minutes. There were no complications postoperatively. The median postoperative stay was 7 days. In that time, feeding conditions were restored to pre-illness levels. All patients were palliated successfully using this procedure. CONCLUSIONS: Laparoscopic MDE gastrojejunostomy allows patients to regain their ability to eat, significantly improving their quality of life. This alternative laparoscopic procedure is effective for patients whose prognosis is poor as a result of unresectable cancer.

Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results.

OBJECTIVE: To analyze the long-term results of distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body. SUMMARY BACKGROUND DATA: Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis and is regarded as an unresectable disease. We previously reported the feasibility and safety of DP-CAR in 10 patients and 3 preliminary cases; however, the long-term results are unknown. METHODS: Between May 1998 and September 2005, 23 patients underwent DP-CAR. No reconstruction of the arterial system was required because of early development of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery. We routinely used preoperative coil embolization of the common hepatic artery to enlarge the collateral pathways. RESULTS: The postoperative mortality rate was 0%, despite a high morbidity rate (48%). The chief postoperative complications were pancreatic fistula and ischemic gastropathy. Contrary to expectations, postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients (91%). The estimated overall 1- and 5-year survival rates were 71% and 42%, respectively, and the median survival was 21.0 months. The sites of recurrence were the liver in 6 patients and local recurrence in 2. CONCLUSIONS: DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The persisting early hepatic recurrence may indicate DP-CAR for the treatment of less advanced disease.

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.

Laparoscopic two-stage surgery for goblet cell carcinoid of the appendix: report of a case and review of the Japanese literature.

Goblet cell carcinoid of the appendix is a rare clinical entity exhibiting features of both carcinoid and adenocarcinoma. Here, we present the first report of laparoscopic 2-stage surgery for goblet cell carcinoid with a review of the Japanese literature. A 49-year-old man underwent laparoscopic appendectomy under the diagnosis of acute appendicitis. A pathologic diagnosis of goblet cell carcinoid, accompanied by the aggressive proliferation, with acute appendicitis was made. Subsequent laparoscopic ileocecal resection was performed, and it was verified that there were neither residual tumor nor lymph node metastases. The postoperative course was uneventful. Because goblet cell carcinoid may be difficult to clinically distinguish from acute appendicitis, pathologic examination is essential. Depending upon the grade of tumor proliferation, additional resection should be considered, and our experience with this case suggests that laparoscopic 2-stage surgery is feasible for the adequate treatment of goblet cell carcinoid without complications.

Number of lymph node metastases is better predictor of prognosis than level of lymph node metastasis in patients with node-positive colon cancer.

BACKGROUND: Lymph node metastasis is the most important prognostic factor for colon cancer patients. Survival is also related to the number and level of positive lymph nodes (PLNs). Definitions of degree of PLNs for colon cancer differ greatly between the number and level of PLNs. STUDY DESIGN: The aim of this study is to compare number and level of PLNs to see which is a better predictor of prognosis for node-positive colon cancer. One hundred eighteen patients underwent histologically curative resection for node-positive colon cancer. We calculated the cumulative 5-year survival rates and examined prognostic factors for multivariate analysis based on the number and level of PLNs and additional factors. The number of PLNs was classified as either one to three PLNs or more than four PLNs, and level of PLNs was classified as either Level I (pericolic lymph node metastasis) or Level II (lymph node metastasis along the major named vessel supplying the tumor, and that around the origin of a main artery). RESULTS: Cumulative 5-year survival rates were statistically different between the 1 to 3 PLNs group and the more than 4 PLNs group, but not significantly different between Level I group and Level II group. Multivariate analysis showed that number, not level, of PLNs was an independent prognostic factor. CONCLUSIONS: In node-positive colon cancer, number of PLNs predicted prognosis better than level of PLNs.