Single-incision laparoscopic totally extraperitoneal obturator hernia repair in a patient on antiplatelet therapy: a case report

An 83-year-old woman who complained of right lower limb discomfort was diagnosed with a right obturator hernia by CT scan. On examination, she had a soft and flat abdomen without signs of peritoneal irritation. The Howship-Romberg sign was present. She had a history of vasospastic angina and paroxysmal supraventricular tachycardia, and took aspirin and dipyridamole until she was admitted to the hospital. Exploratory laparoscopy identified a spontaneously reduced small bowel from the right obturator canal, but there were no signs of ischemic and necrotic bowel. The patient underwent SILS for totally extraperitoneal obturator hernia repair without a dissection balloon. The patient recovered without perioperative complications such as hemorrhage and thrombotic episodes. She remains well, and CT scans showed no signs of obturator hernia recurrence at the 7-month follow-up.

Multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor successfully treated by laparoscopic surgery: Report of a case

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Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer.

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Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

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This report is the first to describe multiple hepatic sclerosing hemangiomas treated by laparoscopic surgery.

Introduction

Hepatic sclerosing hemangioma is a very rare benign tumor, characterized by fibrosis and hyalinization occurring in association with degeneration of a hepatic cavernous hemangioma. We report here a rare case of multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor that was successfully treated using laparoscopic surgery.

Presentation of case

A 67-year-old woman with multiple liver tumors underwent single-incision laparoscopic sigmoidectomy under a diagnosis of advanced sigmoid cancer with multiple liver metastases. Examination of surgical specimens of sigmoid colon revealed moderately differentiated adenocarcinoma invading the serosa, and no lymph node metastases. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 remained within normal limits throughout the course. Two months after sigmoidectomy, the patient underwent laparoscopic partial hepatectomy of S1 and S6 of the liver and cholecystectomy. Histopathological examination showed that the tumors mainly comprised hyalinized tissue and collagen fibers with sporadic vascular spaces on hematoxylin and eosin-stained sections, yielding a diagnosis of multiple hepatic sclerosing hemangioma. No evidence of recurrence has been seen as of 21 months postoperatively.

Discussion

Differentiating multiple sclerosing hemangiomas from metastatic liver tumors was quite difficult because the radiological findings were closely compatible with liver metastases. Laroscopic hepatectomy provided less blood loss, a shorter duration of hospitalization, and good cosmetic results.

Conclusion

Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer. Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.

Totally extraperitoneal inguinal hernia repair during extraperitoneal laparoscopic radical prostatectomy: Report of a case

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TEP combined with ELRP appears to be a rational procedure and easy to perform.

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The incidence of complications related to either TEP or ELRP might not be increased.

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TEP combined with ELRP might be safely performed for recurrent inguinal hernia after non-mesh hernioplasty.

Introduction

The incidence of prostate cancer is increasing, and inguinal hernias are common in the age group of men with prostate cancer. Furthermore, inguinal hernias are now considered to be one of the long-term complications of radical prostatectomy. In this report, we present our experience with the performance of totally extraperitoneal inguinal hernia repair (TEP) along with extraperitoneal laparoscopic radical prostatectomy (ELRP).

Presentation of case

A 66-year-old man with prostate cancer and bilateral inguinal hernias was admitted to our hospital for surgery. He had a history of right inguinal hernioplasty without mesh placement and ascending colon diverticulitis. With a diagnosis of prostate cancer and bilateral inguinal hernia, concomitant TEP after ELRP was safely performed.

Discussion

TEP combined with ELRP appears to be a rational procedure and easy to perform. The incidence of complications related to either TEP or ELRP might not be increased. TEP combined with ELRP might be safely performed for recurrent inguinal hernia after non-mesh hernioplasty.

Conclusion

TEP combined with ELRP might be of use in prostate cancer patients with inguinal hernias.

Choroidal metastasis from early rectal cancer: Case report and literature review

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We report a case of choroidal metastasis from early rectal cancer.

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Radiotherapy was initiated for the left eye and systemic chemotherapy is initiated for the multiple lung metastases.

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The patient is living 2 years and 3 months after the diagnosis of choroidal metastasis without signs of recurrence in the left eye.

INTRODUCTION

Choroidal metastasis from colorectal cancer is rare, and there have been no reported cases of such metastasis from early colorectal cancer. We report a case of choroidal metastasis from early rectal cancer.

PRESENTATION OF CASE

A 61 year-old-man experienced myodesopsia in the left eye 2 years and 6 months after primary rectal surgery for early cancer, and was diagnosed with left choroidal metastasis and multiple lung metastases. Radiotherapy was initiated for the left eye and systemic chemotherapy is initiated for the multiple lung metastases. The patient is living 2 years and 3 months after the diagnosis of choroidal metastasis without signs of recurrence in the left eye, and continues to receive systemic chemotherapy for multiple lung metastases.

DISCUSSION

Current literatures have few recommendations regarding the appropriate treatment of choroidal metastasis from colorectal cancer, but an aggressive multi-disciplinary approach may be effective in local regression.

CONCLUSION

This is the first report of choroidal metastasis from early rectal cancer. We consider it important to enforce systemic chemotherapy in addition to radiotherapy for choroidal metastasis from colorectal cancer.

Laparoscopic distal pancreatectomy for multiple epithelial cysts in an intrapancreatic accessory spleen. A case report and review of literature

CONTEXT

Accessory spleen is a congenital abnormality consisting of normal splenic tissue in ectopic sites that is found in approximately 10-15% of the general population. However, an intrapancreatic accessory spleen has seldom been reported and multiple epithelial cysts in the intrapancreatic accessory spleen are extremely rare.

CASE REPORT

A 37-year-old woman with no clinical manifestations presented with two cystic lesions in the tail of the pancreas. The tumor markers CA 19-9 (251 U/mL) and SPAN-1 (38 U/mL) were increased. Computed tomography showed a multilocular cyst, 40 mm in size, and a unilocular cyst, 20 mm in size, in the tail of the pancreas and gallstones. The cystic component was hypointense on T1-weighted magnetic resonance images and hyperintense on T2-weighted magnetic resonance images. A laparoscopic distal pancreatectomy was performed with the presumptive diagnosis of a mucinous cystic neoplasm or an intraductal papillary mucinous neoplasm with gallstones. The pathological examination showed that the walls of the two cysts were covered with non-keratinized stratified squamous epithelium, surrounded by normal splenic tissue. The final pathological diagnosis was two epithelial cysts originating from an intrapancreatic accessory spleen.

CONCLUSIONS

Even though multiple masses were detected in the pancreatic tail, the possibility of epithelial cysts originating from an accessory spleen should be considered. Laparoscopic distal pancreatectomy might be a safe and effective procedure and provide good cosmetic result for a benign or low-grade malignant tumor in the pancreas.

The effects of chemotherapy on primary small bowel cancer: A retrospective multicenter observational study in Japan

Small bowel cancer is relatively rare among gastrointestinal tract cancers, including esophageal, gastric and colorectal cancers. The majority of cases of small bowel cancer are diagnosed at an advanced stage, resulting in poor outcomes. The clinical effects of chemotherapy on small bowel cancer have been investigated in a limited number of studies from Europe and the USA. However, they have not yet been fully investigated in Asian countries, including Japan. This retrospective multicenter observational study was designed to investigate the efficacy of chemotherapy on small bowel cancer. A questionnaire survey was conducted in 28 hospitals affiliated with the Osaka University Hospital. We retrospectively reviewed the medical records of 61 patients with small bowel cancer (32 patients who were unable to undergo curative resection or had unresectable distant metastases and 29 who underwent curative resection), treated between 1996 and 2009, to evaluate the outcomes and the efficacy of chemotherapy. There was no significant difference in the overall survival between the patients undergoing curative resection with postoperative adjuvant chemotherapy and those without postoperative adjuvant chemotherapy. In patients with non-curative resection or unresectable distant metastases, the response rate to chemotherapy was 31.6% and the overall survival was significantly higher compared to that without chemotherapy (P=0.008). The study results suggested that chemotherapy is effective for Japanese patients with small bowel cancer who cannot undergo curative resection or have unresectable distant metastases.

Short-term outcome of single-incision laparoscopic totally extra-peritoneal inguinal hernia repair

We performed single-incision laparoscopic surgery for totally extra-peritoneal (SILS-TEP) repair using a lightweight mesh fixed by absorbable tacks and without balloon dilation. Thirty-four patients (mean age, 66.5 years) underwent SILS-TEP repair in our hospital between September 2011 and April 2012; 30 patients had unilateral hernia and 4 had bilateral hernias. Mean operative time was 85.6 min for unilateral hernia and 137.7 min for bilateral hernias. All patients underwent successful SILS-TEP repair. Mean hospital stay was 3.4 days. Mean duration of follow-up was 7.1 months. Four seromas were observed, but no recurrences or major complications occurred. SILS-TEP is an economical and useful method for decreasing postoperative complications, such as neuralgia and recurrence, and it could be an attractive approach for inguinal hernia.

Gallbladder metastasis from hepatocellular carcinoma: Report of a case and review of literature

INTRODUCTION

The incidence of metastasis of hepatocellular carcinoma (HCC) to the gallbladder is low. Here, we report a case of HCC with metastasis to the gallbladder and discuss the pattern of spread and the treatment.

PRESENTATION OF CASE

A 74-year-old man was diagnosed with advanced hepatocellular carcinoma. Computed tomography and magnetic resonance imaging demonstrated a tumor in the right lobe of the liver with a thrombus in the bifurcation of the portal vein. Because intraoperative ultrasonography showed portal vein tumor thrombosis from the main tumor reaching the umbilical portion, we performed only a cholecystectomy for the elimination of postoperative cholecystitis. Pathological examination showed gallbladder vein tumor thrombosis from poorly differentiated hepatocellular carcinoma.

DISCUSSION

A preoperative diagnosis of metastatic HCC to the gallbladder is difficult because there are no specific findings in the imaging tests. Cancer cells in the liver were thought to migrate to the gallbladder via the connection between the portal system and the cholecystic veins, and grow in the lumen of the veins in our case. The survival rate, in all reported cases including the present case, was increased in patients who underwent radical resection, compared to patients who underwent palliative surgery.

CONCLUSION

The resection of metastatic HCC to the gallbladder might appear to prolong survival.

Six months versus twelve months of capecitabine as adjuvant chemotherapy for stage III (Dukes' C) colon cancer: Initial safety report for the open-label randomized phase III study (JFMC37-0801)

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Background: The standard treatment duration of adjuvant chemotherapy (CT) in patients (pts) with stage III colon cancer is 6 months. On the other hand, no clinical trial showed the optimal treatment duration of oral chemotherapeutic agents in adjuvant setting for colon cancer. Sargent et al have reported that 83% of recurrences in stage II and III pts have occurred within the first 3 years after surgery and peak was observed around one year after surgery. Therefore, to clarify the benefit of 12 months administration of Capecitabine, we designed randomized phase III trial for a comparison of 6 months treatment and 12 months treatment of capecitabine as adjuvant CT for stage III colon cancer. Methods: JFMC37 is a multicenter, randomized Phase III trial. Patients with fully resected Stage III colon or recto sigmoid cancer were eligible. Capecitabine was administered orally as tablets, 2,500 mg/m²/day for 14 days followed by a 7-days rest. Treatment is continued to 8 cycles (6 months) in arm A (A) or 16 cycles (12 months) in arm B (B). Patients were randomized 1:1 to A or B. Data size was estimated by disease free survival as primary endpoint. The statistical design is based on superiority hypothesis; 5-yrs DFS is 60% in arm A, 67% in arm B ;unilateral α=0.05, 1-β=0.8;and planed accrual is 1200 pts. Results: Between September 2008 to December 2009, 1304 patients were enrolled and then randomized. Both arms were well balanced for mean age: (A) 64.1, (B) 63.8; ECOG PS (%0/1): (A) 95.0/5.0, (B) 97.1/2.9; involvement of lymph nodes (%N0/N1/N2): (A) 77.1/19.9/3.1, (B) 76.6/19.7/3.7. Treatment completion rate for A and B were 68.2% and 43.4%. Incidences of serious adverse events (SAEs) over 1% were neutropenia: (A) 2.6%, (B) 3.8%, diarrhea: (A) 2.9%, (B) 2.1%, loss of appetite: (A) 1.3%, (B) 1.0%, fatigue: (A) 1.8%, (B) 1.2%, hand-hoot syndrome: (A) 16.4%, (B) 22.1%. Conclusions: There were no obvious differences in SAEs between arm A and arm B. Although twelve months of capecitabine showed a tendency to increase G3/4 hand-foot syndrome, we concluded that incidence of SAEs were acceptable and comparable to previously report.

Infected pancreatic necrosis occurring in a jejunal aberrant pancreas: report of a case

Acute pancreatitis occurring in an aberrant pancreas (acute aberrant pancreatitis) is a rare clinical condition. A 67-year-old male was referred to the emergency department complaining of severe epigastralgia. He was evaluated by computed tomography, and the findings suggested jejunal penetration into the mesentery and abscess formation. We performed emergency surgery and found a mass located in the jejunal mesentery. Intraoperatively, we diagnosed it to be a malignant tumor complicated by penetration, and we performed a partial resection of the jejunum to remove the mass. Based on the pathological results, it was evident that this was a case of acute aberrant pancreatitis occurring on a background of chronic pancreatitis. The patient had an uneventful postoperative course. This report is the first presentation describing the possible mechanism that contributes to the process of infected pancreatic necrosis in an aberrant pancreas.

Intracorporeal circular-stapled Billroth I anastomosis in single-incision laparoscopic distal gastrectomy

PURPOSE

The intracorporeal anastomotic procedure is one of the most difficult components in single-incision laparoscopic gastrectomy. We describe a simple surgical technique for intracorporeal circular-stapled Billroth I gastroduodenostomy with transumbilical introduction of the instrument.

SURGICAL TECHNIQUE

After standard laparoscopic mobilization of the distal stomach using a mini-loop retractor (diameter, 2 mm), a semi-circumference duodenotomy was made just distal to the pyloric ring. The anvil of a circular stapling device, secured with a Prolene suture with a needle, was introduced via the duodenotomy. The suture was advanced anteriorly such that an anvil shaft transfixed the anterior duodenal wall. The duodenum was staple-transected at this point, and the anvil shaft was removed from the duodenum by pulling the thread. The anvil shaft was advanced against the posterior wall of the stomach and tightly grasped by the mini-loop retractor to avoid slippage. After the cartridge-carrying instrument was introduced transumbilically with the pneumoperitoneum maintained using a surgical glove, the anvil shaft was connected with the center rod of the instrument under fine laparoscopic view. The instrument was fired to complete the circular-stapled gastroduodenostomy.

RESULTS

We employed this technique in 20 patients. Neither postoperative complications, including anastomotic leakage and stricture, nor postoperative mortality were observed.

CONCLUSIONS

Our modified technique for intracorporeal Billroth I reconstruction in single-incision laparoscopic distal gastrectomy is safe and feasible. This technique could be an attractive surgical option for all laparoscopic reconstructive procedures using circular stapling devices.

OSNA-based novel molecular testing for lymph node metastases in colorectal cancer patients: results from a multicenter clinical performance study in Japan

BACKGROUND

Lymph node (LN) metastasis in colorectal cancer (CRC) is a critical factor in making accurate prognoses and therapeutic decisions. This study evaluated the clinical performance of the one-step nucleic acid amplification (OSNA) assay in accurately diagnosing LN metastases in CRC patients through the specific detection of cytokeratin 19 mRNA levels in LNs.

METHODS

The OSNA assay was performed on 121 LNs dissected from early-stage CRC patients (pStage 0 or I) or from patients with benign colorectal disease (study 1). Separately, 385 LNs were dissected from 85 CRC patients (any stage); the OSNA assay was performed on half of each LN, and the results were compared with histopathological examination in 2-mm intervals of the other LN half (study 2).

RESULTS

In study 1, all 121 histopathologically negative LNs were also negative by the OSNA assay (concordance rate for metastasis negative: 1.0, 95% confidence interval [95% CI]: 0.976-1.0). In study 2, the concordance rate between the OSNA assay and the 2-mm-interval histopathological examination was 0.971 (95% CI: 0.950-0.984), with a sensitivity of 0.952 (95% CI: 0.881-0.987) and a specificity of 0.977 (95% CI: 0.953-0.991).

CONCLUSIONS

The OSNA assay provided a judgment performance equivalent to a 2-mm-interval histopathological examination, a more detailed assay than the common pathological examination. Therefore, the OSNA assay is considered a new molecular examination method for the diagnosis of LN metastases in CRC patients in clinical settings.

A case of Helicobacter pylori infection complicated with gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and idiopathic thrombocytopenic purpura successfully treated with laparoscopy-assisted total gastrectomy and splenectomy

Helicobacter pylori infection plays a key role in the pathogenesis of H. pylori-associated diseases, including gastroduodenal and non-gastroduodenal diseases. A 71-year-old man was evaluated for a positive fecal occult blood test by upper gastrointestinal endoscopy, which revealed H. pylori infection, two adenocarcinomas and two gastric mucosa-associated lymphoid tissue lymphomas. Hematological examination revealed low platelet-count, elevated platelet-associated immunoglobulin G and anti-H. pylori immunoglobulin G antibodies. We diagnosed H. pylori infection complicated by simultaneous occurrence of gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and idiopathic thrombocytopenic purpura. These diseases were successfully treated with laparoscopy-assisted total gastrectomy and splenectomy, and there was no evidence of recurrence for about 2 years. This is the first reported case of H. pylori infection complicated by these three diseases and cured with laparoscopic surgery.

Primary colorectal signet-ring cell carcinoma: clinicopathological features and postoperative survival

PURPOSE

The objective of this study was to investigate the clinicopathological features and postoperative survival of primary colorectal signet-ring cell carcinoma.

METHODS

Nineteen patients with primary colorectal signet-ring cell carcinoma were identified from a database of 5884 surgical patients with colorectal cancers treated surgically at Osaka University Hospital and affiliated hospitals between 1993 and 2007. The clinicopathological data of those patients were compared with those of 5792 patients with non-signet-ring cell colorectal carcinoma (5417 with well or moderately differentiated adenocarcinoma and 375 with poorly differentiated adenocarcinoma or mucinous carcinoma).

RESULTS

All patients showed a tumor depth of over T3. Lymph node involvement occurred in 14 patients. Seven of 19 patients presented with distant metastasis at the time of diagnosis. The overall 5-year survival rate in primary signet-ring cell carcinoma was significantly lower at 24.1%, in comparison to 77.5% in well or moderately differentiated adenocarcinoma and 57.7% in poorly differentiated adenocarcinoma or mucinous carcinoma. Likewise, the postoperative survival in Stage III was also significantly worse. On the other hand, no significant difference was observed in Stage II or IV.

CONCLUSION

The most important feature of primary colorectal signet-ring cell carcinoma is the advanced stage at the time of diagnosis. In addition, the postoperative survival is worse than for other types of colorectal cancer.