Kenji Mimatsu

Preventing delayed gastric emptying in pancreaticogastrostomy by a modified subtotal-stomach-preserving pancreaticoduodenectomy: Oida modification.

BACKGROUND/AIMS Delayed gastric emptying (DGE) is one of the most troublesome complications of pylorus-preserving pancreaticoduodenectomy (PPPD). In Japan, since the 1990s, subtotalstomach- preserving pancreaticoduodenectomy (SSPPD) has been performed as an alternative to PPPD. Here, we evaluated the efficacy of our modification of the original SSPPD technique as compared to PPPD with an aim to decrease the incidence of DGE. METHODOLOGY We retrospectively analyzed 67 patients who underwent PD with pancreaticogastrostomy (PG). They were divided into 2 groups on their basis of the surgical treatment: the PPPD group and the modified SSPPPD (MSSPPD) group. The incidence of DGE was determined and compared between the 2 groups. RESULTS In the MSSPPD group, 98%, 2%, and 0% of the cases developed class A, class B, and class C DGE, respectively; the corresponding values in the PPPD group were 4%, 52%, and 44%, respectively. The incidence of DGE differed significantly between the 2 groups (p<0.0001). CONCLUSIONS We consider that our reconstruction procedure is useful for preventing DGE in patients who have undergone SSPPD with PG.

Long-term outcome of laparoscopic cystogastrostomy performed using a posterior approach with a stapling device.

Background: Internal drainage of an acute pancreatic pseudocyst is indicated 6 weeks after its first detection. Laparoscopic treatment of pancreatic pseudocysts enables definitive drainage with faster recovery. Pseudocysts located adjacent to the posterior gastric wall are best drained by pseudocyst gastrostomy. Although the anterior approach for drainage has frequently been reported, reports on the posterior approach are rare. Methods: Seven patients underwent laparoscopic cystogastrostomy for pancreatic pseudocysts. The posterior approach that enables the direct visualization of the posterior gastric wall and pseudocyst was used, and the cyst was drained with a needle. After creating a sufficient drainage orifice, the cyst was thoroughly debrided. Cystogastrostomy was performed using the posterior approach with a stapling device. The insertion site of the stapling device closed using a hernia stapler. Results: Cystogastrostomy was performed using the posterior approach with a stapling device in all patients, without requiring conversion to the anterior approach or open surgery. There were neither operative complications nor late recurrences during the follow-up period (median 65 months). Conclusion: Laparoscopic cystogastrostomy using the posterior approach, which facilitates adequate internal drainage, is a safe and feasible procedure for pancreatic pseudocyst, and it is not accompanied with a risk of recurrence in the long term.

Protection of major vessels and pancreaticogastrostomy using the falciform ligament and greater omentum for preventing pancreatic fistula in soft pancreatic texture after pancreaticoduodenectomy.

BACKGROUND/AIMS Pancreatic fistula is one of the major causes of morbidity in patients undergoing pancreaticoduodenectomy. Protection of the skeletonized vessels and the anastomotic site of pancreaticoenterostomy is one of the surgical options to prevent the development of a pancreatic fistula. The aim of this study was to describe an operative technique to protect the vessels and anastomotic site by wrapping them with the falciform ligament and the greater omentum. METHODOLOGY After a modified subtotal stomach-preserving pancreaticoduodenectomy reconstruction with pancreaticogastrostomy was performed, the falciform ligament and greater omentum was used on the skeletonized major vessels and wrapped around the anastomotic site of pancreaticogastrostomy. Twenty consecutive patients were enrolled in this prospective study. RESULTS The entire procedure did not result in any operative complications. Postoperative pancreatic fistula developed in 2 cases (10%). According to the international postoperative pancreatic fistula criteria, grade A and grade B was observed in 1 case each. No intra-abdominal hemorrhage and late intra-abdominal abscess were observed. CONCLUSIONS This procedure is a convenient and safe technique, and may be helpful in preventing major complications caused by pancreatic fistula.

Aggressive progression of granulocyte colony-stimulating factor producing squamous cell carcinoma of the esophagus: case report and literature review

We report a case of a 69-year-old man who was diagnosed to have granulocyte colony-stimulating factor (G-CSF)-producing esophageal squamous cell carcinoma, based on a histological examination of endoscopic biopsy specimens. A high serum level of leukocytes and G-CSF was noted. Moreover, immunohistochemical examination revealed that the tumor cells were positive for antibodies against G-CSF. Palliative radiation therapy was performed because of existing distant metastasis at the time of presentation, and the patient died of tumor progression 7 months after the initial diagnosis. To the best of our knowledge, only five cases with G-CSF-producing squamous cell carcinoma have been described in the English literature, including our present case. Because many cytokines induced by G-CSF-producing tumors contribute to tumor growth and aggressive inflammation, these patients might have a poor prognosis. G-CSF-producing tumor is extremely rare; however, we should consider a differential diagnosis for such disease when a patient shows a high leukocyte count with no evidence of systemic infection or hematological disease.

Open Abdomen Management After Massive Bowel Resection for Superior Mesenteric Arterial Occlusion

PurposeMassive bowel resection is often performed for superior mesenteric arterial (SMA) occlusion, resulting in short bowel syndrome. We conducted this study to evaluate the effectiveness of open abdomen management to monitor the blood flow of the remnant bowel and anastomoses.MethodsWe treated five of seven patients with SMA occlusion by open abdomen management, with or without mesh, using a zipper, which we opened daily to monitor the blood flow around the anastomotic site.ResultsNone of the five patients treated by open abdomen management required re-resection of the remnant bowel and they were all discharged from hospital in a stable condition.ConclusionOpen abdomen management proved extremely useful for monitoring blood flow to the anastomotic site and for allowing complete drainage into the abdominal space. Using this method would assist in leaving as much remnant bowel as possible after resection for SMA occlusion.

Adenocarcinoma arising from heterotopic pancreas at the third portion of the duodenum.

A 62-year-old Japanese man presented to our hospital with a history of weight loss of 6 kg in 4 mo. Imaging examinations revealed a tumor located on the third portion of the duodenum with stenosis. We suspected duodenal carcinoma and performed pancreas-preserving segmental duodenectomy. Adenocarcinoma arising from a heterotopic pancreas at the third portion of the duodenum was finally diagnosed by immunohistochemical staining. Malignant transformation in the duodenum arising from a heterotopic pancreas is extremely rare; to our knowledge, only 13 cases have been reported worldwide, including the present case. The most common location of malignancy is the proximal duodenum at the first and descending portion. Herein, we describe the first case of adenocarcinoma arising from a heterotopic pancreas, which was located in the third portion of the duodenum, with a review of the literature.

Long-term survival after resection of mass-forming type intrahepatic cholangiocarcinoma directly infiltrating the transverse colon and sequential brain metastasis: Report of a case.

MUC1 expression in cholangiocarcinoma is considered to be correlated with patient survival. We report a case of mass-forming type intrahepatic cholangiocarcinoma (ICC) with direct infiltration of the transverse colon and sequential brain metastasis. The patient was treated by curative right hepatectomy with right hemicolectomy followed by resection of the brain metastasis; there has been no evidence of recurrence in the 7 years since the hepatic resection. Thus, surgical resection may improve the prognosis of ICC involving the adjacent organs, even with brain metastasis. Immunohistochemical staining was performed for MUC1, MUC2, and MUC5AC. Although MUC1 expression was found in the liver tumor and metastatic brain tumor, the correlation between MUC1 expression and the prognosis of this patient was unclear. To clarify the correlation between immunohistochemical characteristics and prognosis, further studies on a greater number of cases of long-term survival of mass-forming type ICC are needed.

Preoperatively undetected solitary bile duct hamartoma (von Meyenburg complex) associated with esophageal carcinoma

Bile duct hamartomas, also known as von Meyenburg complexes, are benign neoplasms consisting of cystic dilatation of the bile duct surrounded by fibrous stroma. We report a rare case in a 60-year-old man who presented with coexistent von Meyenburg complex and esophageal carcinoma. Preoperative computed tomography did not reveal any liver tumors. Intraoperatively, a small lesion was discovered in segment III of the liver; the lesion was suspected to be a solitary liver metastasis from the esophageal carcinoma. Partial resection of the liver was performed, and pathological findings revealed bile duct hamartoma (von Meyenburg complex). As von Meyenburg complexes are small cystic lesions located throughout the liver, and as they do not present characteristic imaging findings, their preoperative morphological diagnosis and differential diagnosis from liver metastasis is extremely difficult. In conclusion, von Meyenburg complex should be considered in the differential diagnosis of intrahepatic cystic neoplasms.

Small intestinal perforation due to metastasis of breast carcinoma: Report of a case

A 79-year-old female patient underwent breast-conservation surgery following a diagnosis of right breast cancer in July 2007. In November 2008, the patient presented at our hospital with acute onset of lower abdominal pain. She was diagnosed with panperitonitis due to gastrointestinal perforation, and underwent an emergency operation. At the time of the operation, one site of free perforation was found in the small intestine, and a 2–3-cm nodule was found in the 50-cm anal side from the site of this perforation. Multiple metastases to the para-aortic lymph nodes and mesenteric lymph nodes were also found. The patient recovered without complications and was discharged from the hospital, but 3 months after surgery she succumbed due to multiple liver metastases. It is important to identify metastatic intestinal tumors in patients who have breast cancer.

Mediastinoscopy-assisted esophagectomy is useful technique for poor surgical-risk patients with thoracic esophageal cancer.

Elderly and poor surgical-risk patients with esophageal cancer experience several complications and often cannot undergo standard transthoracic esophagectomy. Mediastinoscopy-assisted esophagectomy (MAE) recently has been applied in patients with thoracic esophageal cancer. We herein report 2 poor surgical-risk patients of lower thoracic esophageal cancer treated with MAE. Patient 1 was a 60-year-old man with respiratory impairment due to pulmonary tuberculosis whereas patient 2 was an 80-year-old man with poor performance status and nutritional condition. In these patients, MAE was performed because standard esophagectomy by thoracotomy is too difficult to perform. We performed MAE using the mediastinoscope approaches via both the neck and hiatus. An approach via the hiatus is useful for mobilization of lower thoracic esophagus and via the neck is useful for direct visualization of recurrent nerve. These patients were successfully treated without complications. MAE enables the mobilization of the thoracic esophagus under the direct visualization in the mediastinum, and it may be considered to be safe and useful technique for elderly and poor surgical-risk patients.