Hidehiko Kitagami

A Case Report of Multiple Early Gastric Cancer with Submucosal Gastric Gland Heterotopia

症例は61 歳の男性で, 検診で異常を指摘され受診した. 上部消化管内視鏡検査にて, 胃体上部後壁にIIb型病変を認めた. 生検の結果, Group V (中分化型管状腺癌) と診断された. 超音波内視鏡検査では, びまん性に粘膜下層の数mm大の嚢胞状変化を認めた. 以上より, びまん性胃粘膜下異所腺に併存した早期胃癌と診断した. 患者の強い希望を受け, 手術は胃全摘術を施行した. 病理学的検索では, 粘膜下のびまん性異所性胃腺, 内視鏡的に認められた胃体上部後壁の癌病変に加え, 前庭部にも癌病変を認め, びまん性胃粘膜下異所腺に併存した多発早期胃癌と診断された.びまん性胃粘膜下異所腺に合併した胃癌症例においては, 術前診断が困難な微小病変が存在する可能性があるため, そのことを念頭に置いた注意深い診断に加え, 多発胃癌, 残胃癌を考慮した治療法の選択と経過観察が必要であると考えられた.

Laparoscopic-assisted total gastrectomy for early gastric cancer with situs inversus totalis: report of a first case

BackgroundSitus inversus totalis is a relatively rare condition and is an autosomal recessive congenital defect in which an abdominal and/or thoracic organ is positioned as a “mirror image” of the normal position in the sagittal plane. We report our experience of laparoscopic-assisted total gastrectomy with lymph node dissection performed for gastric cancer in a patient with situs inversus totalis.Case presentationA 58-year-old male was diagnosed with cT1bN0N0 gastric cancer. There were no vascular anomalies on abdominal angiographic computed tomography with three-dimensional reconstruction. laparoscopic-assisted total gastrectomy was performed with D1+ lymph node dissection, in accordance with the Japanese Gastric Cancer Treatment Guidelines. There were no intraoperative issues, and no postoperative complications.ConclusionsThis was the first report describing laparoscopic-assisted total gastrectomy with the standard typical lymph node dissection in the English literature. We emphasize that the position of trocars and the standing side of the primary surgeon during the lymph node dissection are critical.

A post operative complication of foramen of Winslow hernia with left to right herniation of the small intestine: An extremely rare case report

Highlights • A foramen of Winslow hernia is rare and difficult to diagnose.• We report a post operative complication of foramen of Winslow herniation from left to right.• There are no previous reports of a foramen of Winslow hernia with this presentation.• It has been thought that closure of the foramen is not necessary.• However, as there are no reports about the complications due to closing the Foramen of Winslow, the foramen should be closed, whenever possible.

A Giant Duodenal Leiomyoma Showing Increased Uptake on 18F-Fluorodeoxyglucose Positron Emission Tomography

Background Although 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) is now widely used in their differential diagnosis, it is sometimes difficult to distinguish between benign and malignant diseases. Case Presentation A 44-year-old woman was found to have abnormalities on health screening. Magnetic resonance imaging for detailed examination showed an intra-abdominal tumor measuring 12 cm in the major axis near the cranial end of the uterus. Upper gastrointestinal tract endoscopy showed a tumor with an ulcer in the third part of the duodenum, involving half the circumference. Heterogeneous uptake was observed within the tumor on FDG-PET/CT. Based on these findings, the patient underwent surgery for suspected primary malignant lymphoma of the duodenum or gastrointestinal stromal tumor. Laparotomy revealed a 12 cm tumor in the third part of the duodenum. Partial duodenectomy and end-to-end duodenojejunostomy were performed. Pathological findings showed a solid tumor growing from the muscle layer of the duodenum to outside the serous membrane; based on immunostaining, it was diagnosed as a leiomyoma. Conclusions Duodenal leiomyomas are originally benign; to date, there have been no reports of uptake in duodenal leiomyomas on FDG-PET/CT; therefore, our case is rare. Leiomyomas should be considered in the differential diagnosis of duodenal neoplastic diseases.

Technique of totally robotic delta-shaped anastomosis in distal gastrectomy

Background: We aimed to clarify the utility of delta-shaped anastomosis (Delta), an intracorporeal Billroth-I anastomosis-based reconstruction technique used after laparoscopy-assisted distal gastrectomy (LADG), in robot-assisted distal gastrectomy (RADG). Methods: RADG was performed in patients with clinical Stage I gastric cancer, and reconstruction was performed using Delta. The Delta procedure was the same as that performed after LADG, and the operator practiced the procedure in simulated settings with surgical assistants before the operation. After gastrectomy, the scope and robotic first arm were reinserted from separate ports on the right side of the patient. Then, a port on the left side of the abdomen was used as the assistant port from which a stapler was inserted, with the robotic arm in a coaxial mode. The surgical assistant performed functional end-to-end anastomosis of the remnant stomach and duodenal stump using a powered stapler. Results: The mean anastomotic time in four patients who underwent Delta after RADG was 16.5 min. All patients were discharged on the post-operative day 7 without any post-operative complications or need for readmission. Conclusions: Pre-operative simulation, changes in ports for insertion of the scope and robotic first arm, continuation of the coaxial operation, and use of a powered stapler made Delta applicable for RADG. Delta can be considered as a useful reconstruction method.

Retroperitoneal and Mediastinal Pancreatic Pseudocyst Accompanied by Pancreas Divisum

症例は 68歳のアルコール多飲歴のある男性で,呼吸困難を主訴に近医を受診し,右胸水貯留を指摘さ れ,当院紹介となった.当院初診時の単純 CTで右胸水貯留に加え,後腹膜から縦隔内の低吸収域,膵石 を認めた.胸水中のアミラーゼは高値であった.胸水ドレナージ後の造影 CTで,後腹膜から縦隔内の低 吸収域は囊胞性病変と判断した.また,膵体尾部頭側には膵仮性囊胞を認めた.以上から,慢性膵炎に伴 う,後腹膜・縦隔内膵仮性囊胞と診断した.膵管癒合不全のため,ERCPで縦隔内,肝背側囊胞への内瘻 を描出できなかったが,MRCPでは膵体尾部頭側の囊胞から後腹膜囊胞への内瘻の存在を疑った.脾合併 膵体尾部切除術を施行し,術後 4か月の CTでは後腹膜,縦隔内囊胞は消失した.膵管癒合不全のため, 縦隔内膵仮性囊胞への内瘻が ERCPで確認困難な症例であったが,MRCPではその存在を疑うことがで き,治療方針の決定に有用であった.

Rectal arteriovenous fistula resected laparoscopically after laparoscopic sigmoidectomy: A case report

We report a very rare case of rectal arteriovenous fistula following sigmoidectomy and discuss this case in the context of the existing literature. In April 2011, the patient, a man in his 60s, underwent laparoscopic sigmoidectomy with lymph node dissection for sigmoid colon cancer. Beginning in February 2012, he experienced frequent diarrhea. Abdominal contrast‐enhanced CT revealed local thickening of the rectal wall and rectal arteriovenous fistula near the anastomosis site. Rectitis from the rectal arteriovenous fistula was diagnosed. No improvement was seen with conservative treatment. Therefore, surgical resection was performed laparoscopically and the site of the lesion was confirmed by intraoperative angiography. The arteriovenous fistula was identified and resected. Postoperatively, diarrhea symptoms resolved, and improvement in rectal wall thickening was seen on abdominal CT. No recurrence has been seen as of 1 year postoperatively.