Impact of Straight Stomach Reconstruction on Delayed Gastric Emptying and Nutritional Recovery After Pancreaticoduodenectomy

BACKGROUND

The aim of this study was to evaluate the effectiveness of a modified reconstruction technique-anchored straight stomach reconstruction-in reducing the incidence of delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) and its impact on postoperative nutritional recovery.

METHODS

A case series analysis of 125 consecutive PD patients was conducted: 104 of them had undergone anchored straight stomach reconstruction (SSR group) and the remaining 21 without (Non-SSR group). The incidence of DGE and the change in postoperative nutritional status (body weight and serum albumin level during 12 months post-surgery) were compared.

RESULTS

The incidence of DGE in the SSR group (13%) was significantly lower than that in the Non-SSR group (33%) (P = .018); further the significant DGE (grade B or C) was only 5%. Comparison of nutritional status showed that SSR facilitated a prompt recovery of body weight and serum albumin level at 6 months after PD. At 12 months after surgery, body weight gain was significantly better in the SSR group than in the Non-SSR group (P = .006), and albumin level tended to be higher in the SSR group (P = .071).

CONCLUSION

Straight stomach reconstruction is able to reduce DGE in patients after PD and also improves their postoperative nutritional recovery.

Safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in pioneering hospitals in Japan: A nationwide retrospective cohort study

INTRODUCTION

We aimed to evaluate the safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in 12 pioneering hospitals in Japan.

METHODS

Clinical data of patients who underwent robotic-assisted transabdominal preperitoneal repair between September 1, 2016, and December 31, 2021 were collected. Primary outcome measures were intra-operative adverse events and post-operative complications, whereas secondary outcomes were surgical outcomes, including chronic pain, recurrence, and learning curve.

RESULTS

In total, 307 patients were included. One case of inferior epigastric arterial injury was reported; no cases of bowel or bladder injury were reported. Thirty-five seromas were observed, including four (1.3%) cases that required aspiration. The median operative time of a unilateral case was 108 minutes (interquartile range: 89.8-125.5), and post-operative pain was rated 1 (interquartile range: 0-2) on the numerical rating scale. In complicated cases, such as recurrent inguinal hernias and robotic-assisted radical prostatectomy-associated hernias, dissection and suture were safely achieved, and no complications were observed, except for non-symptomatic seroma. All patients underwent robotic procedures, and there was no chronic post-operative inguinal pain, although one case of hernia recurrence was reported. Regarding the learning curve, plateau performance was achieved after 7-10 cases in terms of operative time (P < .001).

CONCLUSION

Robotic-assisted transabdominal preperitoneal repair can be safely introduced in Japan. Regardless of the involvement of many surgeons, the mastery of robotic techniques was achieved relatively quickly. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases.

A Case of a Grade 3 Gallbladder Neuroendocrine Tumor With Rapid Recurrence After Curative Resection

Primary gallbladder neuroendocrine tumor (GB-NET) is extremely rare. Therefore, tumor behavior and adequate treatment in GB-NETs are still unclear. A 74-year-old man without any specific complaints was referred to our hospital cause of gallbladder tumor. Abdominal ultrasonography examination revealed a 22-mm non-pedunculated tumor in the gallbladder body. Contrast-enhanced computed tomography showed a polyp that was enhanced in the arterial phase. The patient underwent gallbladder bed resection and radical lymphadenectomy with a diagnosis of gallbladder carcinoma. Macroscopically, the resected specimen showed a nodular expanding tumor measuring 32×15 mm in the gallbladder body. From the pathological findings, a grade 3 GB-NET was diagnosed. Only cystic lymph node metastasis was observed. The patient was discharged uneventfully, but bone and lymph node metastasis were detected eight months after surgery. We conclude that grade 3 GB-NET shows occasionally malignant biological behavior although NET G3 is distinguished from neuroendocrine carcinoma in the current WHO 2019 classification of NET.

Mixed neuroendocrine carcinoma and hepatocellular carcinoma in the liver

BACKGROUND

Mixed neuroendocrine carcinoma (NEC) and hepatocellular carcinoma (HCC) is extremely rare, thus radiological features have not been fully clarified.

CASE

A male patient (age: 70 years) visited our hospital due to a tumor in the liver. Examination using contrast-enhanced computed tomography (CT) revealed a tumor (diameter: 5.0 cm) in hepatic segment 5, with early enhancement of the peripheral area and slight internal heterogeneous enhancement in the arterial and delayed phases, respectively. F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT revealed intratumoral heterogeneity, characterized by increased uptake (standardized uptake value, 12.10) in the corresponding low-density area detected using enhanced CT relative to the surrounding areas of the tumor. On magnetic resonance imaging, diffusion-weighted imaging also showed high intensity in the corresponding low-density area detected using CT. Preoperatively, the patient was diagnosed with HCC and underwent anterior sectionectomy. Pathological findings revealed both HCC and NEC components, and the patient was diagnosed with mixed NEC and HCC. Comparison of component distribution with FDG-PET/CT revealed an increased uptake area was congruent with the NEC component in the tumor.

CONCLUSION

In this case, the difference in tumor components affected the uptake in FDG-PET/CT. Such heterogeneous uptake with an enhanced spot may be useful for suspecting the presence of mixed NEC and HCC in patients with atypical HCC.

Assessment of laparoscopic inguinal hernia repair using the classification for single port laparoscopy in adolescents and young adults

BACKGROUND

Inguinal hernia repair is one of the most common operations performed worldwide. No consensus currently exists regarding the most appropriate operation for inguinal hernia in adolescent and young adult (AYA) patients. This study aimed to evaluate the outcomes in AYA patients undergoing high ligation or mesh repair under laparoscopy by examining the location and size of the hernia orifice defect.

METHODS

We retrospectively reviewed all patients aged 15 to 40 years old who underwent laparoscopic hernia repair. Under single port laparoscopy, we classified the anatomic location (lateral, medial, or femoral) and size of the hernia orifice according to the classification by the European Hernia Society (EHS). A laparoscopic percutaneous extraperitoneal closure (LPEC) was performed on the patients with a lateral hernia with a hernia orifice defect size of ≤1.5 cm (L1). Transabdominal preperitoneal (TAPP) repair was performed on the patients with a lateral hernia with a hernia orifice defect size of >1.5 cm (L2 or 3).

RESULTS

Overall, 40 patients underwent the mentioned surgical procedures. We performed LPEC on 22 patients, and TAPP on 18 patients. There were no intraoperative or postoperative complications and recurrences.

CONCLUSIONS

This is the first report that evaluated the outcomes of AYA patients who underwent high ligation or mesh repair under laparoscopy by examining the location and size of the hernia orifice defect. Our data indicated that LPEC were effective and safe for AYA patients with small hernia orifice defect.

[Late recurrence of gastric cancer diagnosed 10 years after curative gastrectomy: a review of 30 Japanese case reports]

A woman in her 50s was referred to our hospital with intestinal obstruction. Ten years prior, she had been treated for gastric cancer, pathologically confirmed as stage IIIA poorly differentiated adenocarcinoma with signet-ring cell carcinoma. Intraoperatively, a 4-cm hard white tumor was found in the mesoileum and around the ileum. Pathological examination revealed poorly differentiated adenocarcinoma with signet-ring cell carcinoma and infiltration and fibrosis. Late peritoneal recurrence of gastric carcinoma was diagnosed. Recurrence of gastric carcinoma more than 10 years after curative gastrectomy is extremely rare. A review of 30 cases reported in Japan revealed recurrence was more frequent in females (60%) and the mean age was around 50 years at the time of primary surgery. Poorly differentiated adenocarcinoma and/or signet-ring cell carcinoma was the primary gastric cancer in 82% of cases and bone metastasis was the most frequent site of recurrence.

A huge hepatic angiomyolipoma with growth during 5 years of follow-up

A 45-year-old woman was referred to our hospital with a huge liver tumor that had been diagnosed as a hepatic angiomyolipoma (HAML) 5 years previously. At the time of referral, it had enlarged from 12 to 20 cm within the previous 5 years and become symptomatic. Enhanced computed tomography revealed a very large, well-defined, low-density mass occupying the entire right lobe of the liver. The patient underwent right hemi-hepatectomy. The resected specimen weighed 1620 g and measured 20 × 14 × 8 cm. The pathological diagnosis was confirmed as benign HAML. The estimated growth rate of this tumor was 44% per year with a doubling time of 826 days. Although the majority of HAMLs are stable lesions, resection should perhaps be considered when the tumor is known to be growing and exceeds 6 cm in diameter, even if it has been diagnosed as benign.

Primary anterior perineal hernia: A case report and review of the literature

Perineal hernia is a type of pelvic floor hernia and an extremely rare pathologic state. Perineal hernias can be classified into anterior and posterior types according to their positional relationship to the superficial transverse perineal muscle. A 49-year-old woman presented with bulging of the right labium major while standing. Standing external ultrasonography revealed a mass in the bulge, which could not be identified by transvaginal ultrasonography, CT, or MRI. Although hernia content could not be identified preoperatively, the patient was given a diagnosis of primary perineal hernia and underwent laparoscopic repair. Symptoms resolved postoperatively, and no sign of relapse has been noted for 8 months postoperatively. Here, we report the case details and review previous case reports.

[Spindle cell type anaplastic carcinoma of the pancreas: review of 27 Japanese case reports]

Spindle cell type anaplastic carcinoma of the pancreas is extremely rare and has a very poor prognosis. A previously healthy 68-year-old woman was referred to our hospital due to a large tumor in the body of the pancreas. Abdominal computed tomography revealed an irregular, well-enhanced 140-mm tumor containing a cystic component. The patient underwent distal pancreatectomy for a possible malignant tumor (e.g., mucinous cystic neoplasms). Histological examination showed that the tumor contained spindle-shaped cells and adenocarcinoma with nuclear atypia, and a definitive diagnosis of anaplastic carcinoma spindle cell type was made. A review of 27 cases reported in Japan revealed 43% of these lesions invaded other organs, and 26% were classified in Stage IV at the time of diagnosis. Postoperative recurrence rate was 78.2%, and mortality rate was 59.3%. Early diagnosis and sequential radial surgery would improve the poor prognosis.

Use of finger-piece method for indocyanine green clearance test

AIM

The indocyanine green (ICG) finger-piece method (FPM), which allows measurement of the ICG concentration by mounting a light sensor onto a finger, is used to assess liver function. We compared the ICG FPM with the conventional ICG blood sampling method (BSM) in patients with liver disorders.

METHODS

Ninety consecutive patients simultaneously underwent the ICG BSM and ICG FPM. After ICG administration, blood samples were collected at 5, 10, and 15 min for the ICG BSM. The ICG concentration was measured through the finger piece by an ICG clearance meter.

RESULTS

Seventy-one patients (78.9%) had Child-Pugh class A liver disease, and 19 (21.1%) had class B or C. The FPM-measured ICG plasma disappearance rate was positively correlated with the BSM-measured values (r = 0.886, P < 0.001). Bland-Altman analysis showed good agreement between the two methods (mean difference, 0.012 ± 0.018). The FPM-measured ICG plasma disappearance rate was positively correlated with the BSM-measured values both in patients with Child-Pugh class A liver disease (r = 0.821, P < 0.001) and class B or C liver disease (r = 0.859, P < 0.001).

CONCLUSION

The ICG FPM may be an alternative to the ICG BSM for liver function assessment.

Postoperative portal vein thrombosis and gastric hemorrhage associated with late-onset hemorrhage from the common hepatic artery after pancreaticoduodenectomy

Portal vein thrombosis (PVT) is a rare but serious postoperative complication of pancreaticoduodenectomy (PD). We reported a case of late-onset postoperative PVT with hemorrhage from the common hepatic artery (CHA) in a 73-year-old man who underwent pylorus-preserving pancreaticoduodenectomy (PPPD) for duodenum papilla cancer, followed by reconstruction using the modified Child's technique. The pancreaticojejunostomy was achieved by end-to-side, 2-layer invagination anastomosis without pancreatic duct stenting. Drain removal and hospital discharge were scheduled on postoperative day (POD) 18, but blood-stained fluid in the drain and sudden hematemesis were noted. Emergency surgery was performed because PVT and imaging findings were suggestive of necrosis of the lifted jejunum. Although no jejunal necrosis was identified during surgery, bleeding from the side of the CHA was detected and the bleeding point was suture-closed to achieve hemostasis. We suspected late-onset postoperative arterial hemorrhage and subsequent hematoma formation, which caused portal vein compression and PVT formation. We chose a conservative treatment strategy for PVT, taking into account the operation time, intraoperative vital signs and blood flow in the portal vein. Despite the complicated postoperative course, he was discharged home in a fully ambulatory state on POD 167.

Results of pancreaticojejunal end-to-side anastomosis using the invagination method without a pancreatic stenting tube

BACKGROUND/AIMS

Perioperative management of pancreaticoduodenectomy (PD) is a constant dilemma and challenging for gastrointestinal surgeons. Postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) are of particular concern, and the onset of these conditions indicates a prolonged postoperative stay (POS). The procedure and postoperative outcomes of pancreaticojejunostomy performed at our hospital are reported.

METHODOLOGY

POPF, DGE, and POS were investigated in 54 patients who had undergone PD at our hospital since June 2007. Pancreaticojejunal end-to-side anastomosis using the invagination method without a stenting tube and without duct-to-mucosa anastomosis was performed in all patients, regardless of pancreatic duct diameter.

RESULTS

There were 26 patients (48.2%) without POPF, 24 (44.4%) with grade A, 4 (7.4%) with grade B, and none with grade C. The mean POS was 28.3 days. DGE was observed in 4 patients (7.4%) who underwent pylorus-preserving PD (PpPD). There were 34 patients with a soft pancreas. None of the patients experienced intraperitoneal bleeding or abscess, and no surgery-related deaths occurred.

CONCLUSIONS

The reconstructive pancreaticojejunostomy procedure performed at our hospital appears to be safe and convenient, and we plan to collect additional data, including assessments of the function of the remaining pancreas, in the future.

Numerical chromosomal abnormality in gastric MALT lymphoma and diffuse large B-cell lymphoma

BACKGROUND

We investigated numerical chromosomal abnormalities, using the fluorescence in situ hybridization (FISH) method, in gastric mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBL). We also compared the histopathological findings, including the presence or absence of Helicobacter pylori infection, with the analytical results.

METHODS

Sixteen patients who underwent operation for malignant gastric lymphoma in our department were divided into three groups: patients with low-grade gastric MALT lymphoma (l-MALT; n = 5), those with high-grade gastric MALT lymphoma (h-MALT; n = 8), and those with DLBL (n = 3). Numerical abnormalities of chromosomes 8, 9, 12, and 17 were investigated by the FISH method, and the presence or absence of H. pylori infection was microscopically examined.

RESULTS

Numerical abnormality was observed in chromosome 12 in 11 patients (68.8%), in chromosome 8 in 10 (62.5%), and in chromosome 17 in 5 (31.3%), showing a high frequency. H. pylori infection was detected in 80% and 50% of patients with l-MALT and h-MALT, respectively, but no H. pylori infection was observed in patients with DLBL.

CONCLUSIONS

A new biological characteristic of gastric MALT lymphoma was obtained, i.e., a high frequency of numerical abnormalities of chromosomes 12, 8, and 17. There was no correlation between the numerical chromosomal abnormalities and the clinicopathological findings.