Severe induction of aberrant DNA methylation by nodular gastritis in adults

BACKGROUND

Nodular gastritis (NG) is characterized by marked antral lymphoid follicle formation, and is a strong risk factor for diffuse-type gastric cancer in adults. However, it is unknown whether aberrant DNA methylation, which is induced by atrophic gastritis (AG) and is a risk for gastric cancer, is induced by NG. Here, we analyzed methylation induction by NG.

METHODS

Gastric mucosal samples were obtained from non-cancerous antral tissues of 16 NG and 20 AG patients with gastric cancer and 5 NG and 6 AG patients without, all age- and gender-matched. Genome-wide methylation analysis and expression analysis were conducted by a BeadChip array and RNA-sequencing, respectively.

RESULTS

Clustering analysis of non-cancerous antral tissues of NG and AG patients with gastric cancer was conducted using methylation levels of 585 promoter CpG islands (CGIs) of methylation-resistant genes, and a large fraction of NG samples formed a cluster with strong methylation induction. Promoter CGIs of CDH1 and DAPK1 tumor-suppressor genes were more methylated in NG than in AG. Notably, methylation levels of these genes were also higher in the antrum of NG patients without cancer. Genes related to lymphoid follicle formation, such as CXCL13/CXCR5 and CXCL12/CXCR4, had higher expression in NG, and genes involved in DNA demethylation TET2 and IDH1, had only half the expression in NG.

CONCLUSIONS

Severe aberrant methylation, involving multiple tumor-suppressor genes, was induced in the gastric antrum and body of patients with NG, in accordance with their high gastric cancer risk.

Cutaneous Metastasis of Transverse Colon Cancer with an Aberrant Pattern of CK7/CK20/CDX2 and High Microsatellite Instability

A 79-year-old woman was diagnosed with transverse colon cancer, moderately differentiated adenocarcinoma. She underwent surgery and postoperative adjuvant chemotherapy. At 80 years old, the patient exhibited changes in skin tone at the chest and abdomen with CK7+/CK20-/CDX2- immunostaining that was later identified as poorly differentiated adenocarcinoma. The diagnosis was cancer of unknown primary origin. The patient passed away three months after the detection of the skin lesion. Autopsy revealed recurrence at the transverse colon, multiple organ metastases, a similar postmortem immunostaining pattern, and high-frequency microsatellite instability (MSI-high). We herein report this case of CK7+/CK20-/CDX2- and MSI-high transverse colon cancer showing cutaneous metastasis.

Preoperative prognostic predictors and treatment strategies for surgical procedure focused on the sequential organ failure assessment score in nonocclusive mesenteric ischemia: a multicenter retrospective cohort study

BACKGROUND

Several large-scale studies have assessed endovascular and surgical treatment methods for nonocclusive mesenteric ischemia (NOMI); however, the prognostic factors for NOMI remain unclear. Therefore, this study aimed to evaluate risk factors for in-hospital mortality among patients with NOMI who underwent laparotomy and to examine therapeutic strategies that may improve the prognosis.

MATERIALS AND METHODS

In this multicenter retrospective study, the authors reviewed the electronic medical records retrieved from the inpatient database of patients with NOMI at eight district general hospitals between January 2011 and January 2021. A total of 88 patients who underwent laparotomies were divided into survivor and nonsurvivor groups, and statistical analysis was performed to determine clinical and physiological factors.

RESULTS

Exploratory laparotomy based on second-look surgery was the first treatment choice. The overall mortality rate was 48.8%, with a male-to-female ratio of 1.1:1. The median Sequential Organ Failure Assessment (SOFA) score was 8 [interquartile range: 3.75-14.2], and the median SOFA scores were 5 [3-7] in the survivor group and 13 [9-17.5] in the nonsurvivor group. Univariate analysis revealed a significant difference in BMI ( P <0.001), hypoglycemia ( P =0.0012), previous cardiovascular surgery ( P =0.0019), catecholamine use ( P <0.001), SOFA score ( P <0.001), platelet count ( P =0.0023), and lactate level ( P <0.001). Logistic regression analysis using the factors with significant differences revealed that SOFA score ≥10 (odds ratio 23.3; 95% CI: 1.94-280.00; P =0.013) was an independent prognostic factor. In addition, catecholamine use was suggested as a factor with a SOFA score greater than or equal to 10.

CONCLUSION

This study confirmed that a SOFA score of greater than or equal to 10 may be associated with increased mortality. While closely monitoring low blood pressure and renal dysfunction, survival rates may be improved if surgical intervention is performed before the SOFA score reaches greater than or equal to 10.

Clinical features and progress of ischemic gastritis with high fatalities: Seven case reports

BACKGROUND

Ischemic gastritis is a clinically rare and highly fatal disease that occurs when the hemodynamics of a patient with vascular risk is disrupted. Early diagnosis and treatment are possible only with upper endoscopy after symptom appearance. We report seven cases of ischemic gastritis and its clinical features, prognosis, and indicators that may help in early detection.

CASE SUMMARY

Of the seven patients, six had vascular risk and five died within 2 wk of diagnosis. Their symptoms included hematemesis and hypotension. Although surgery is a choice for radical treatment, not all patients were tolerant. For such patients, conservative treatment was selected, but all of them died. In contrast, patients who underwent repeat endoscopy showed improved mucosal findings, suggesting that this improvement may not affect prognosis. Some ischemic changes such as wall thickening, mural emphysema, and fluid retention in the stomach were observed before diagnosis through endoscopy and computed tomography (CT). The CT scan can be effective for early detection, and improvement in circulatory failure and aggressive treatment may save the lives of patients with this disease.

CONCLUSION

The characteristic CT findings enable early detection of ischemic gastritis. Early diagnosis increases the chance of survival if early therapeutic intervention and improvement of circulatory dynamics can be achieved in this highly fatal disease.

Liver cyst with biliary communication treated with endoscopic ultrasound-guided drainage: A case report

RATIONALE

Simple liver cysts are common, and usually benign and asymptomatic, requiring little to no treatment. Liver cysts with biliary communication, however, are rare and require effective treatment to avoid recurrence.

PATIENT CONCERNS

A 70-year-old woman with breast cancer visited our hospital for treatment. Physical examination revealed abdominal distension and bilateral lower leg edema.

DIAGNOSIS

Abdominal contrast-enhanced computed tomography revealed a giant liver cyst, inducing inferior vena cava compression that was causing her edema.

INTERVENTIONS

Percutaneous transhepatic cyst drainage was performed. Since the bilirubin level in the drained fluid was high, the patient was diagnosed with a liver cyst with biliary communication. After the procedure, her symptoms improved and the cyst decreased in size. However, the drainage volume did not decrease after approximately 2 weeks. Sclerotherapy with minocycline was ineffective. Thus, endoscopic retrograde cholangiopancreatography was performed, and an endoscopic nasobiliary drainage tube was inserted. The percutaneous drainage tube was clamped, and the cyst showed increase in size. Therefore, endoscopic ultrasound-guided cyst drainage, which is less invasive than surgery, was performed.

OUTCOMES

The cyst tended to decrease in size even after the percutaneous drainage tube had been removed. At 3years follow-up, the cyst has almost disappeared.

LESSONS

Endoscopic ultrasound-guided drainage can treat liver cyst with biliary communication.

Spontaneous pneumothorax with coronavirus disease 2019 in non-ventilated patients: A single-center retrospective case series

Background

Pneumothorax is a rare complication of coronavirus disease 2019, and many of its associated factors are related to mechanical ventilation. We investigated the incidence and clinical features of patients with pneumothorax and coronavirus disease 2019 at a field hospital for patients who did not require intubation.

Materials and methods

An isolated field hospital for COVID-19 patients who did not require ventilation was constructed. Patients who developed pneumothorax were extracted and reviewed retrospectively.

Results

Between May 2020 and February 2021, 1061 patients were admitted to this field hospital. Among them, eight patients (0.75%, three men and four women) developed pneumothorax. The mean age at incidence was 79.9 (range: 20–96) years; all patients were over the age of 80 years, except one 20-year-old woman. Six of these eight patients (75%) died.

Conclusion

Although pneumothorax is a rare complication of coronavirus disease-2019, it is predictive of a poor prognosis in older-adult patients.

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Incidence of pneumothorax in patients without mechanical ventilation was 0.75%.

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The mean age was 79.9 years and six of eight (75%) died.

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Pneumothorax is rare and predictive of poor prognosis patients with COVID-19.

Monitoring the Sequential Organ Failure Assessment score in nonocclusive mesenteric ischemia increases the survival rate: A single-center observational study

Several large-scale studies have assessed the endovascular and surgical treatments for nonocclusive mesenteric ischemia (NOMI); nonetheless, the prognostic factors for NOMI remain unclear.In this single-center study, we retrospectively reviewed the electronic medical records of 197, 149 patients were retrieved from the inpatient database of our hospital from January 2011 to January 2020; 79 patients with NOMI were observed. A total of 44 patients who underwent laparotomy were statistically analyzed and divided into the survivor and non-survivor groups. Prognostic factors were compared between the 2 groups. Exploratory laparotomy based on a second-look surgery was the first treatment choice.The overall mortality rate was 61.3%, with a male-to-female ratio of 1.6:1. The median Sequential Organ Failure Assessment (SOFA) score was 11.06 [5.75-17.25]. The median SOFA score was 5 [interquartile range: 3-8] in the survivor group and 14.8 [interquartile range: 10.5-19] in the non-survivor group. The log-rank test showed a significant difference in the presence of diabetes mellitus (P = .025), hypoglycemia (P = .001), SOFA score ≥10 (P < .001), hemoglobin levels ≥11 g/dL (P = .003), platelet count ≥12.9 × 104/μL (P = .01), lactate levels ≥2.6 mmol/L (P = .005), and base excess <-3.0 (P < .023). Multivariate analysis using the factors with significant differences revealed that SOFA score ≥10 (hazard ratio for death, 1.199; 95% confidence interval, 1.101-1.305; P < .001) was an independent prognostic factor.The SOFA score can be used to assess disease severity. A SOFA score of ≥10 may be associated with increased mortality.

Multimodal treatment for acute empyema based on the patient's condition, including patients who are bedridden: A single center retrospective study

Background

The incidence of acute empyema has increased in various countries; some elderly patients with acute empyema have contraindications for surgery under general anesthesia. Therefore, suitable management based on a patient's clinical condition is required.

Methods

We evaluated the different surgical and nonsurgical therapeutic approaches available for patients with acute empyema. This was a retrospective study of 57 patients with acute empyema who received treatment in our department between May 2015 and February 2019. For patients who did not initially improve with drainage or drainage combined with fibrinolytic therapy, surgery, or additional percutaneous drainage was performed based on their general condition. We compared several clinical factors pertaining to the patients who underwent surgical versus nonsurgical treatment.

Results

Our study showed that the patients with a performance status of 0-2 and an American Society of Anesthesiologists physical status classification of class II or lower underwent surgery safely without major operative complications. The combination of repeated drainage of the pleural cavity and fibrinolytic therapy appeared to be a reasonable nonsurgical management option for patients in poor overall condition.

Conclusion

For an aging population, we think that the combination of repeated pleural cavity drainage procedures and fibrinolytic therapy is a reasonable nonsurgical strategy for the management of patients with acute empyema.

Advanced Colon Cancer after Curative Resection of Intramucosal Adenocarcinoma with Endoscopic Submucosal Dissection

Endoscopic resection, particularly endoscopic submucosal dissection (ESD), for colorectal cancers enables a precise pathological diagnosis and safe R0 resection. The recurrence rate after ESD is generally extremely low, with annual surveillance colonoscopy recommended. However, surveillance may not be considered for super-elderly patients owing to their condition. This is a case report of an 85-year-old man in whom curative resection was achieved for an intramucosal adenocarcinoma with ESD. The patient presented with a hypoechoic mass located in his lower right abdomen, diagnosed via surveillance abdominal ultrasound. He had undergone curative ESD for intramucosal cecal cancer 2 years prior. Colonoscopy revealed a type 2 epithelial tumor at the proximal aspect of the ESD scar. Ileocolic resection with lymph node dissection was performed. An epithelial tumor and well-differentiated adenocarcinoma but not a submucosal tumor was detected in the mucosal layer. The lesion was diagnosed not as a local recurrence after ESD but as a newly emerged original advanced cancer. After ESD for colorectal cancer, a newly developed advanced cancer may occur at the site of the ESD scar in a shorter term than usual. Surveillance colonoscopy after ESD is necessary even for super-elderly patients.

Sigmoid colon strangulation caused by bilateral fallopian tubes: A case report

INTRODUCTION

There are no reports regarding sigmoid colon strangulation caused by bilateral fallopian tubes, which is a rare type of large bowel obstruction. Herein, we report a case of successful laparoscopic treatment of sigmoid colon strangulation.

PRESENTATION OF CASE

A 54-year-old woman presented to our hospital with intermittent abdominal pain. Her medical history was significant for endometriosis; however, there was no surgical history. The physical examination revealed tenderness over the lower abdomen. CT scan shows closed loop obstruction of sigmoid colon. Exploratory laparoscopy was performed, and a sigmoid colon strangulated by bilateral fallopian tubes was detected. The adhesions consisting of bilateral fallopian tubes were dissected laparoscopically. The patient's postoperative course was uneventful, with no complications.

DISCUSSION

The most common cause of large bowel obstruction (LBO) is colorectal cancer, including volvulus and diverticulitis. In this case, the adhesion of both the right and left fallopian tubes caused LBO, and it is conceivable that the etiology involved is endometriosis. Few cases have reported bowel obstruction associated with a fallopian tube, and the laparoscopic approach is very rare. In our case, we immediately performed laparoscopic exploration before colon strangulation led to necrosis or perforation. Therefore, we succeeded in releasing the strangulation laparoscopically.

CONCLUSION

We report a case of sigmoid colon strangulation that was treated laparoscopically. This approach can be the treatment of choice for sigmoid colon strangulation.

Laparoscopic treatment for renal paratransplant hernia: A case report

INTRODUCTION

There are limited reports regarding renal paratransplant hernia (RPH), which is a rare type of internal hernia. Herein, we report a case of successful laparoscopic treatment of RPH.

PRESENTATION OF CASE

A kidney transplant recipient presented to our emergency department with a 6-h history of abdominal pain and vomiting. The patient had received a living-related donor kidney transplantation and native nephrectomy in our hospital last year. Computed tomography (CT) confirmed a diagnosis of RPH. We performed laparoscopic exploration, and the findings showed an incarcerated small bowel in the retroperitoneal space through a peritoneal defect. Short laparotomy was performed to resect the non-viable bowel. The peritoneal defect was opened adequately. The patient's postoperative course was uneventful, with no complications.

DISCUSSION

RPH is an uncommon variant of internal hernia, which is a rare surgical complication after kidney transplantation. Early diagnosis and treatment are important once RPH develops. Due to immunosuppression in kidney transplant recipients, typical signs of peritonitis were not observed. This event can be critical to the patient. Laparoscopic surgery has recently become a treatment option for small bowel obstructions. We believe that this surgical procedure is useful for patients with RPH.

CONCLUSION

We report a case of RPH treated laparoscopically. This approach can be a treatment of choice for RPH.

Clinical and endoscopic features of aorto-duodenal fistula resulting in its definitive diagnosis: an observational study

Background

Upper gastrointestinal (GI) bleeding is the most important presentation of an aorto-duodenal fistula (ADF). Early diagnosis is difficult, and the disease is associated with high mortality. The present study aimed to examine the clinical and the endoscopic characteristics of ADF in eight patients who presented to our hospital. We also sought to clarify the diagnostic approach towards the disease.

Methods

The present study examined the clinical and the endoscopic/computed tomography (CT) characteristics of ADF in eight patients who were definitively diagnosed with this condition in a 12-year period at our hospital.

Results

The patients comprised of five men and three women, with a mean age of 69.8 years. Upper gastrointestinal bleeding was the chief complaint for all the patients. Out of these, two patients presented with shock. The patients’ mean haemoglobin at presentation was 7.09 g/dL, and the mean number of blood transfusions was 7.5. All patients had undergone intervention to manage an aortic pathology in the past. As the first investigation, an upper GI endoscopy in 5 and a CT scan in 3 patients were performed. In cases where CT scan was performed first, no definitive diagnosis was obtained, and the diagnosis was confirmed by performing an upper GI endoscopy. In cases where endoscopy was performed first, definitive diagnosis was made in only one case, and the other cases were confirmed by the CT scan. In some cases, tip attachments, converting to long endoscopes, and marking clips were found useful.

Conclusions

In patients who have undergone intervention to manage an aortic pathology and have episodes of upper gastrointestinal bleeding, ADF cannot be definitively diagnosed with only one investigation. In addition, when performing upper GI endoscopy in cases where an ADF is suspected, tip attachment, converting to a long endoscope, and using marking clips can be helpful.

Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding

Aim

Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites.

Methods

This retrospective study analyzed contrast‐enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3–5 mL indocyanine green was injected through the microcatheter. The green‐stained segment of the small bowel was resected.

Results

Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred.

Conclusions

Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.

A Surgical Case of Bronchial Artery Aneurysm Connecting to a Pulmonary Artery and Vein Complicated by Racemose Hemangioma

We report a surgical case of bronchial artery aneurysm (BAA) that directly connected to a pulmonary artery and a pulmonary vein through an abnormal vessel. It was complicated by racemose hemangioma. This is a rare vascular malformation. An 82-year-old female had a large BAA that was found incidentally. First, we consider treating the BAA with embolization by interventional radiology (IVR). However, because of strong meandering of the bronchial artery, we could not advance a microcatheter into the BAA. Therefore, a surgical operation was performed through a standard posterior lateral thoracotomy. The BAA was located between the upper and lower lobes and directly connected to the pulmonary artery. Some bronchial artery branches that provided inflow to the aneurysm were ligated, and the abnormal vessel that connected the BAA to the upper pulmonary vein was ligated easily. A fistula between the BAA and pulmonary artery was sutured by the cardiovascular surgeon using an artificial cardiopulmonary device, with permissive stenosis of A2b (ascending A2).

Association of pre-operative chronic kidney disease and acute kidney injury with in-hospital outcomes of emergency colorectal surgery: a cohort study

BACKGROUND

Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery.

METHODS

We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality.

RESULTS

We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90-3.40), 1.29 (0.90-1.85), 2.86 (1.54-5.32), and 2.76 (1.55-4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60-89, 30-59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results.

CONCLUSIONS

The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Successful treatment of hepatic gas gangrene by open drainage: A case report and review of the Japanese literature

INTRODUCTION

Liver gas gangrene is rare and has a low prognosis. This case, reports a successful treatment of hepatic gas gangrene using an open drainage technique, followed by antibiotics and hyperbaric oxygen therapy (HBO).

PRESENTATION OF THE CASE

An 82-year-old male with a history of left hepatectomy and bile duct resection for hilar cholangiocarcinoma presented with chilling, lethargy and dyspnea. He had a history of diabetes mellitus, hypertension, atrial fibrillation, and angina pectoris. Physical examination revealed scleric icterus, right hypochondrium tenderness and percussion tenderness of the liver, with warm extremities. Laboratory findings revealed leukocytosis and increased levels of hepatobiliary enzymes. A computed tomography (CT) scan showed gas accumulation in an S8 lesion with portal vein gas. Percutaneous drainage was performed immediately, and broad-spectrum antibiotics were started, but the drainage was insufficient. Consequently, laparotomy drainage was carried out, followed by HBO. No abscess was detected at one-year of follow-up.

DISCUSSION

Hepatic gas gangrene progresses rapidly and has a high mortality rate. Malignant disease and diabetes mellitus may be predisposing factors. While half of non-clostridial cases survive, most cases of hepatic gas gangrene are associated with clostridial infection and have a fatal outcome.

CONCLUSION

All survival cases of hepatic gas gangrene were treated by laparotomy drainage, thus immediate laparotomy seems essential to prevent a fatal outcome.

Small intestinal metastases from esophageal carcinoma presenting as a perforation: A case report and review of the literature

INTRODUCTION

Small intestinal metastasis from oesophageal carcinoma is rare. We report a case of small intestinal metastases from oesophageal carcinoma presenting as a perforation and discuss the aetiology with other cases of small intestinal metastasis from oesophageal carcinoma reported in previous literature.

PRESENTATION

An 86-year-old man presented with fever and coughing. He had choked while eating and had history of weight loss. He was diagnosed with aspiration pneumonia. Two days after the admission, he complained of abdominal pain. Physical examination revealed guarding and rebound tenderness in the upper abdomen. A contrast computed tomography of the abdomen showed ascites, free air, and irregular thickness of the small intestinal walls. Small intestinal perforation was noted, and surgical resection of the small intestine was performed. The pathological findings of the resected small intestine revealed ulcers with squamous cell carcinoma, and upper gastrointestinal endoscopy demonstrated oesophageal tumour, whose biopsy revealed squamous cell carcinoma. A diagnosis of small intestinal metastases from oesophageal carcinoma was made, but the patient died one month after the diagnosis.

DISCUSSION

Most cases found in the literature of oesophageal tumour involve squamous cell carcinoma with male patients, and specific symptoms are divided into obstruction and perforation. All patients with small intestinal metastasis from oesophageal carcinoma who survived were treated by a combination of resection and radiation and/or chemotherapy; thus, immediate treatments seem essential to improve the prognosis.

CONCLUSION

Physicians should keep in mind the possibility of small intestinal metastasis when patients with a history of oesophageal cancer have abdominal symptoms.

Lumbar Arterial Bleeding Treated with Endovascular Aneurysm Repair: A Report of 4 Patients

BACKGROUND

Lumbar arterial bleeding is a severe condition. Surgical exploration is not indicated because of its rich collateral flow. Transarterial embolization (TAE) is reportedly effective, but there have been cases of failure. It may be a time-consuming procedure for patients with multiple bleeding sources or those with poor vital signs. In this case series, we used endovascular aneurysm repair (EVAR) instead of TAE.

METHOD

In this case series, we described 4 male patients (2 with traumatic injury, 1 with iatrogenic injury, and 1 with drug-induced hypocoagulability) with lumbar arterial bleeding. The reasons we chose EVAR are because 2 patients had poor vital signs, one patient was a technically difficult case for selective cannulation, and one patient had accompanying aortic dissection.

RESULT

In all patients, EVAR was performed successfully, and hemostasis was obtained although one patient died of pneumonia on postoperative day 23.

CONCLUSIONS

EVAR is an effective alternative for lumbar arterial bleeding although TAE is a first choice of treatment.

Stomach resection with intraoperative fluoroscopy in laparoscopic distal gastrectomy for early gastric cancer

Background:

In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG.

Patients and Methods:

A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures.

Results:

No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13–60) mm.

Conclusion:

Stomach resection with intraoperative fluoroscopic guidance was safe and effective.

Scarless surgery for a huge liver cyst: A case report

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Fenestration is the definitive treatment for symptomatic/complicated liver cysts.

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NOTES, which has been reported recently, enables surgery without scars.

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Multiple clinical and technological barriers impede further progress with NOTES.

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Our safe and unique method enables minimally invasive surgery with small incisions.

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This “scarless surgery” is expected to yield some clinical benefits.

Introduction

Symptomatic or complicated liver cysts sometimes require surgical intervention and laparoscopic fenestration is the definitive treatment for these cysts. We performed minimally invasive surgery, hybrid natural orifice transluminal endoscopic surgery (NOTES) without scarring, for a huge liver cyst.

Presentation of case

An 82-year-old female presented with a month-long history of right upper abdominal pain. We diagnosed her condition as a huge liver cyst by morphological studies. She denied any history of abdominal trauma. Her serum CEA and CA19-9 were normal and a serum echinococcus serologic test was negative. Laparoscopic fenestration, using a hybrid NOTES procedure via a transvaginal approach, was performed for a huge liver cyst because we anticipated difficulty with an umbilical approach, such as single incision laparoscopic surgery (SILS). Her post-operative course was uneventful and she was discharged from our hospital three days after surgery. Pain killers were not required during and after hospitalization. No recurrence of the liver cyst or bulging was detected by clinical examination two years later.

Discussion

A recent trend of laparoscopic procedure has been towards minimizing the number of incisions to achieve less invasiveness. This hybrid NOTES, with a small incision for abdominal access, along with vaginal access, enabled painless operation for a huge liver cyst.

Conclusion

We report a huge liver cyst treated by hybrid NOTES. This approach is safe, less invasive, and may be the first choice for a huge liver cyst.

Comparison of efficacies of the self-expandable metallic stent versus transanal drainage tube and emergency surgery for malignant left-sided colon obstruction

BACKGROUND/OBJECTIVE

Patients with left-sided malignant colorectal obstruction require emergency treatment. Emergency stoma surgery has traditionally been recommended, however many stomas became permanent, decreasing patient quality of life. Recently, self-expandable metallic stents (SEMS) and transanal decompression tubes (TDT) have become widely used decompression methods to avoid stoma surgery. In this study, we evaluated: 1) the efficacy of SEMS compared with TDT and emergency surgery (ES) to avoid permanent stomas; and 2) the safety and success rate of each treatment.

METHODS

We retrospectively reviewed data from 56 patients who underwent SEMS, TDT, or emergency surgery for malignant left-sided colon obstruction. We compared the permanent stoma rate of each group, and assessed whether or not each treatment was an independent risk factor for permanent stomas. We compared morbidity and mortality for each treatment group (SEMS, TDT, ES), and the success rate of the decompression procedures (SEMS and TDT).

RESULTS

The permanent stoma rates in the SEMS, TDT, and ES groups were 5.3%, 50.0%, and 56.0%, respectively. Emergency surgery (vs. SEMS) and TDT (vs. SEMS) were independent risk factors for permanent stomas, as was age ≥ 75 years. Operative morbidity, mortality, and hospital stay were not different between groups. The success rate of SEMS was significantly higher than TDT; however, two deaths, including one perforation, occurred in the former group.

CONCLUSION

SEMS seems to be effective in avoiding permanent stomas, but caution should be taken to avoid complications.

Fatal liver gas gangrene after biliary surgery

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Liver gas gangrene is a rare condition with a highly mortality rate.

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Development of liver gas gangrene is associated with host conditions such as malignancy and immunosuppression.

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We report a case of liver gas gangrene after biliary surgery which is one of the risks of the liver parenchymal infection.

Introduction

Liver gas gangrene is a rare condition with a highly mortality rate. It is mostly associated with host factors, such as malignancy and immunosuppression.

Presentation of case

A 57-year-old female was admitted to our hospital with abnormalities of her serum hepato-biliary enzymes. She had a history of hypertension, diabetes mellitus, cerebral infarction, and chronic renal failure. She was diagnosed with bile duct cancer of the liver hilum and a left hepatectomy was carried out, with extrahepatic bile duct resection. Initially her post-operative state was uneventful. However, she suddenly developed melena with anemia on post-operative day (POD) 18. A Computed tomography (CT) examination on POD 19 revealed a massive build up of gas and portal gas formation in the anterior segment of the liver. Although we immediately provided the drainage and a probe laparotomy, she died on POD 20 due to shock with disseminated intravascular coagulation.

Discussion

Liver gas gangrene is rare and has a high mortality rate. This case seems to have arisen from an immunosuppressive state after major surgery with biliary reconstruction for bile duct cancer and subsequent gastrointestinal bleeding, leading to gas gangrene of the liver.

Adventitial cystic disease of the popliteal artery treated by bypass graft utilizing the short saphenous vein: A case report

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CT or MRI scan is crucial in the diagnosis of adventitial cystic disease (ACD).

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Surgery is the first line in the treatment of ACD at the popliteal artery.

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The short saphenous vein was successfully employed in bypass graft surgery.

Introduction

Adventitial cystic disease is relatively rare vascular disease, frequently occurred in the popliteal artery. No definitive treatment has been established yet.

Prentation of case

A 53-year-old woman presenting intermittent claudication of the right leg was diagnosed as adventitial cystic disease of popliteal artery. Percutaneous balloon dilation yielded an immediate recurrence. The disease was successfully treated by bypass grafting utilizing the short saphenous vein to replace the part of the popliteal artery containing the adventitial cyst. No postoperative complication was found six months after surgery.

Discussion

Comparing to a great saphenous vein, a short saphenous vein as a material of bypass graft has a significant advantage, as only a single surgical field is necessary.

Conclusion

We propose that bypass graft surgery employing a short saphenous vein is worth considering as a treatment of adventitial cystic disease at the popliteal artery.

A rare case of an infected tracheal diverticulum requiring emergency intervention: A case report

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A case of an infected tracheal diverticulum presenting as a paratracheal mass is demonstrated.

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An infected tracheal diverticulum can impair the airway and require emergency intervention including surgery.

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The most commonly described procedure of surgery is resection via a transverse or lateral neck incision and drainage of the abscess.

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A CT scan plays important roles to make a diagnosis and evaluate the necessity of intervention.

Introduction

Recent advancement in radiological imaging has revealed an increasing amount of asymptomatic abnormalities. Tracheal diverticula are relatively rare entities and are incidentally found on radiological imaging such as computed tomography. Here, we present a case of an infected tracheal diverticulum presenting as a paratracheal mass, which required emergency intervention.

Case presentation

A 65-year-old Japanese nonsmoker man presented with a fever, lower neck pain, and the aggravation of dyspnea for a week. An enhanced computed tomography scan demonstrated that the trachea was displaced by a paratracheal mass with a well-defined thin wall. His respiratory status was so urgent that emergency intubation and surgical drainage of the abscess were performed. A computed tomography scan performed 4 days after admission demonstrated shrinking of the abscess, and he was extubated and discharged 7 days after admission without any complications.

Conclusion

To the best of our knowledge, this is the first report to confirm an infected tracheal diverticulum presenting as a paratracheal abscess, which required emergency intervention. Moreover, computed tomography plays an important role in the differentiation of paratracheal masses.

An Autopsy Case of Amyotrophic Lateral Sclerosis with Diaphragm Pacing

Respiratory insufficiency is a critical problem in amyotrophic lateral sclerosis (ALS) patients. We herein present the case of an autopsied patient with sporadic ALS who underwent diaphragm pacing (DP). The pathology showed several localized adhesions with a markedly atrophied diaphragm. A marked loss of motor neurons with Bunina bodies and phosphorylated TDP-43 positive inclusions was found in the spinal cord and primary motor cortex. Mild hyalinization and a few multinucleated giant cells were present around the electrode tracks in the diaphragm. However, no infiltration of inflammatory cells was detected. Our findings suggest that full-time DP might not cause severe damage to adjacent diaphragm tissue.

[Successful Treatment of Empyema with Bronchial Fistulas by Filling under Thoracoscopic Observation; Report of a Case]

Empyema with fistula usually resists conservative treatment such as thoracic cavity drainage and administration of antibacterial agents, thus it often requires surgeries such as fenestration, omental/muscle filling, and thoracoplasty. However, due to advanced age and poor condition, conducting invasive surgeries is often difficult in elderly patients. We report a case with the improvement of empyema by bronchial filling with endobronchial Watanabe spigot (EWS) under thoracoscopic observation for an 89-year-old patient who had developed chronic empyema with a bronchial fistulas. After filling EWS, air-leakage from bronchial fistula disappeared and the patient could discharged from the hospital successfully.

[Early diagnosis of capecitabine-induced acute leukoencephalopathy by using diffusion-weighted MRI]

A 63-year-old woman with colon cancer who was treated with capecitabine as adjuvant chemotherapy presented with vertigo on day 5, and dysarthria and dysphagia on day 7 of the treatment. Diffusion-weighted magnetic resonance imaging of the brain revealed high signal intensity in the corpus callosum and corona radiata. The patient was diagnosed with acute leukoencephalopathy, and the capecitabine treatment was discontinued. Her symptoms recovered immediately. On the basis of these findings, it can be concluded that diffusion-weighted imaging is useful for the early detection and diagnosis of acute leukoencephalopathy.

Protocol-based strategy for endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVE

Compared with conventional open surgery (COS), endovascular aneurysm repair (EVAR) has been reported to decrease the 30-day mortality rate in patients with ruptured abdominal aortic aneurysms (rAAAs). We developed an EVAR-first strategy for rAAAs that incorporates the Shonan ruptured abdominal aortic aneurysm protocol (SRAP). We describe short-term results with this protocol at our institution and compare them with outcomes in patients who underwent COS.

METHODS

The records of all 57 patients in whom a rAAA was repaired during a 7-year period were reviewed retrospectively. Patients in the COS group (n = 30) were treated between January 2005 and December 2009; those in the SRAP group (n = 27) were treated between January 2010 and March 2012. The two groups were compared with respect to patient characteristics at admission, including severity of condition; operative and in-hospital variables; and 30-day mortality.

RESULTS

The baseline patient characteristics in the COS and SRAP groups were similar except that the SRAP group had a significantly higher rate of cerebrovascular disease. The 30-day mortality rate was significantly higher in the COS group (43% vs. 19%), as were the intraoperative mortality rate (27% vs. 5%) and the in-hospital mortality rate (57% vs. 26%; P < 0.05 for all comparisons). The technical success rate for EVAR was 96%; no conversions to open surgery were required.

CONCLUSIONS

Use of the SRAP is a promising strategy for improving initial outcomes in patients with rAAAs.

Histologic types of lung cancers among male Japanese copper smelter workers

This study was done to investigate which histologic type of lung cancer is prevalent among male Japanese copper smelter workers. A panel of eight pathologists was asked to diagnose uniformly prepared materials for 19 occupational series, 87 nonoccupational bronchogenic carcinomas, and 14 benign lesions. The consensus diagnosis was used as reference. The reference diagnoses and the originals without materials employed for verification were designated as finals. Squamous cell carcinoma was the most frequent cell type in the occupational group, which comprised 21 (75.0%) of 28 histologically proven cases. There were three (10.7%) small cell carcinomas, one (3.6%) large cell carcinoma, and three (10.7%) adenocarcinomas. The proportion of Kreyberg group I in the occupational cases was significantly larger than that of lung cancers in the population-based cancer registries in Japan. These findings are compatible with Kreyberg's hypothesis. Above all, squamous and small cell carcinomas were prominent and appeared to be environmentally related bronchogenic carcinomas.

Inter- and intra-pathologist variability in histologic diagnoses of lung cancer

To estimate variability and reliability in histologic diagnosis (Dx) of lung cancers, lung cancer preparations were divided into eight equal sets and diagnosed independently by an eight-man pathology panel. Majority Dx (Dx affirmed by more than 4 panelists) was regarded as the consensus Dx of each cancer. The consensus rate of each panelist ranged from 78.8% to 96.1% with an average of 89.4%. The consensus rates were not significantly different among the panelists. Relatively high inter-pathologist agreement was observed in squamous cell carcinoma, adenocarcinoma, and small cell carcinoma. However, regarding large cell carcinoma, there was occasional disagreement among the panelists. Forty-seven cancers were reexamined by the same panelists, with no preliminary announcement, 7 months after the first examination to study the intra-pathologist agreement. The rate of the intra-pathologist agreement ranged from 76.6% to 93.3%. Dx of large cell carcinoma was the most intra-changeable. It was concluded that the histologic Dx of large cell carcinoma was the most inter- and intra-changeable, and the most frequent dissenting Dx from it was poorly differentiated squamous cell carcinoma.

[Diagnostic variations among eight pathologists in the histologic classification of lung cancer]

In order to estimate the magnitude of variations among pathologists in histological diagnoses of lung cancer, eight doctors were asked to independently diagnose 73 preparations of the lung (16 biopsied cancers, 27 resected specimens, 21 autopsied specimens and nine benign autopsied cases). The rates of correct diagnoses by the pathologists ranged from 81.7% to 100%, averaging 91.8%. There was no significant difference between the lowest rate and mean or median of the rates. The variation of the diagnosis tended to be more prominent in large cell carcinoma than in adenocarcinoma or small cell and squamous cell carcinoma. It was suggested that the diagnostic criteria for large cell carcinoma varied to some extent among pathologists.

Malignant lymphoma in the Miyazaki district: analysis of 237 biopsy cases

Pretreatment biopsy specimens of 237 consecutive patients with malignant lymphoma, who presented to us from 1979 to 1982, were reviewed and reclassified. According to the new classification proposed by the Lymphoma Study Group of Japan (LSG), there were 226 patients with non-Hodgkin's lymphoma (NHL) which was further classified as diffuse lymphoma (216 cases), follicular lymphoma (4 cases), mycosis fungoides (4 cases), and others (2 cases). The 216 cases of diffuse NHL were subdivided into small cell (2 cases), medium-sized cell (71 cases), mixed (7 cases), large cell (92 cases), pleomorphic (40 cases), lymphoblastic (3 cases), and Burkitt's type (1 case) lymphoma. Cell surface marker studies using conventional methods were performed on 65 NHL patients, of whom 45 showed T-cell marker and 11 B-cell marker, and 8 had neither marker. The average survival periods were 13.1 mo for 107 patients with NHL, 27.9 mo for those with mycosis fungoides and 70.0 mo for 10 patients with Hodgkin's disease. Patients with adult T-cell leukemia survived for an average of only 5.5 mo. Histologically diffuse pleomorphic type had the worst prognosis. T-cell lymphoma appeared to have a poorer prognosis than B-cell lymphoma.