Masakazu Takagi

Partial portal arterialization for the prevention of massive liver necrosis following extended pancreatobiliary surgery: Experience of two cases

Massive liver necrosis, which is a severe and highly fatal complication after extended pancreatobiliary surgery, may occur due to an interruption of the hepatic arterial flow caused by such events as an excision of the hepatic artery invaded by cancer, a ligation of the postoperatively ruptured hepatic artery, or a thrombotic obstruction of the reconstructed hepatic artery. In order to improve this ischemic state of the liver, we have performed a partial arterialization of the portal vein by making an arteriovenous shunt at the mesenteric vascular branches in two cases. Although a sufficient pathophysiological investigation could not be fully conducted, partial portal arterialization was considered to be effective in one patient, while no clinically noticeable adverse effects were revealed in the other patient.

Mesenteric arterioportal shunt after hepatic artery interruption

BACKGROUND Massive hepatic necrosis from hepatic artery (HA) interruption is a complication after extended pancreatobiliary operation. The effectiveness of a mesenteric arterioportal shunt in preventing liver failure after massive hepatic necrosis was evaluated. METHODS Of 98 patients who underwent pancreatic or hepatic resection for pancreatobiliary carcinoma between January 1989 and December 1995, six received a mesenteric arterioportal shunt. Clinical and hemodynamic analyses were done retrospectively. RESULTS The six patients were classified into groups: A, postoperative hepatic arterial occlusion and, B, main HA excision without reconstruction. One patient in group A and three patients in group B had good arterioportal shunt patency and favorable clinical courses. However, fatal hepatic necrosis after ligation of the HA proper occurred in one patient in group A from small portal flow despite a presumed patent shunt. In another patient in group A angiogram revealed shunt occlusion. CONCLUSIONS A mesenteric arterioportal shunt is beneficial when massive hepatic necrosis has occurred or is expected after main HA interruption under such conditions as postoperative hepatic arterial occlusion or HA excision without reconstruction. The procedure has the advantages of appropriate selection of artery size, a lower abdominal site apart from the primary operative field, and easy shunt closure by transarterial embolization.

Video-assisted thoracoscopic esophagectomy in the left lateral decubitus position in an esophageal cancer patient with pectus excavatum.

During thoracic cavity operations, it is difficult to obtain sufficient working space and good operative field visibility in patients with pectus excavatum because the space between the vertebral bodies and sternum is very narrow. Here, we report the successful treatment of esophageal cancer in a patient with pectus excavatum. A 77‐year‐old man with esophageal cancer was referred to our hospital for further treatment. He was diagnosed with multiple early esophageal squamous cell carcinomas. The patient had pectus excavatum, but because it was asymptomatic, a video‐assisted thoracoscopic radical esophagectomy in the left lateral decubitus position without pectus excavatum repair was selected. Despite the patients unusual anatomy, video‐assisted thoracoscopic esophagectomy in the left decubitus position allowed for good operative field visibility, as the videoscope was inserted from the side of the diaphragm. This operative procedure is useful in patients with esophageal cancer who also have pectus excavatum. To the best of our knowledge, this is the second report of video‐assisted thoracoscopic esophagectomy in an esophageal cancer patient with pectus excavatum.

Small bowel obstruction due to internal hernia caused by the ureter after laparoscopic radical cystectomy and ileal conduit: A case report: Small bowel obstruction due to hernia

A 74‐year‐old man presented at our hospital with complaints of abdominal pain, nausea, and vomiting. He had undergone laparoscopic radical cystectomy and ileal conduit for urinary bladder cancer 1 month earlier. The patient had abdominal distention, resonant sounds on percussion, and diffuse abdominal tenderness without rebound or guarding. Abdominal CT revealed dilated jejunal loops herniated through a cord‐like structure. Based on these findings, emergency surgery was performed, and intestinal dilatation into the space between the ureter, the ileal conduit, and the sacral bone was detected. The loops were released manually and were not resected. To the best of our knowledge, this is the first case report of small bowel obstruction due to internal hernia caused by the ureter after laparoscopic radical cystectomy and ileal conduit. Retroperitonealization and the minimum required mobilization of the ureters may be necessary when urinary diversion is constructed, especially in laparoscopic or robotic surgeries.

Resection of carcinoma in the cervical esophagus following prior removal of a thoracic esophageal carcinoma — A case report—

We report herein, a rare case of a patient who, having undergone resection of a thoracic esophageal cancer, underwent removal of a cervical esophageal cancer, for which a free jejunal graft with microvascular anastomoses was utilized. The tumor in the cervical esophagus had originated from a second primary squamous cell cancer, which had occurred synchronously but had unfortunately escaped detection before the first operation. Due to the high incidence of other multicentric neoplasma or metastatic skip lesions accompanying esophageal carcinoma, careful evaluation during preoperative examinations in order to avoid overlooking another lesion, especially in the cervical portion of the esophagus is imperative.