Masamichi Matsuda

Concomitant Duodenal and Pancreatic Metastases from Renal Cell Carcinoma: Report of a Case

Abstract The pancreas and duodenum are uncommon sites for metastasis from renal cell carcinoma. Pancreatic or small intestinal metastases mainly occur when there is widespread nodal and visceral involvement and evidence of metastatic disease elsewhere in the body. We describe herein the case of a 68-year-old man in whom metastases arising from renal cell carcinoma developed concomitantly in the duodenum and pancreas. The patient presented with duodenal bleeding; but as no other metastatic lesions were observed at the time of surgery, total pancreatectomy with duodenetomy was performed. We believe that metastases may easily develop in the duodenum and pancreas owing to the similar tissue characteristics.

Macrocystic type of serous cystadenoma with a communication between the cyst and pancreatic duct.

Abstract A 42‐year‐old woman with a cystic lesion in the head of the pancreas was evaluated by using abdominal ultrasonography, a computed tomographic scan, magnetic resonance imaging and endoscopic retrograde pancreatography. Multiple cystic lesions, 5 cm in diameter, which had papillary protrusion inside the cyst in the head of the pancreas and had the communication between the cysts and pancreatic duct, were determined. Pylorus‐preserving pancreaticoduodenectomy was performed under the diagnosis of mucinous cystic neoplasm of the pancreas. Although the cut surface of the tumor showed a macrocystic tumor of 3 cm in diameter, part of the cyst wall was cavernous. A histopathological examination showed single‐layered cuboidal cells, which lead to the diagnosis as being serous cystadenoma of the pancreas. Serous cystadenoma is a rare, almost benign pancreatic tumor. The macrocystic subtype of serous cystadenoma is even more rare. We describe a patient who had this macrocystic subtype of serous cystadenoma with a communication between the cyst and pancreatic duct. This case illustrates the difficulty in the diagnosis of cystic lesions in the pancreas, and might support the single category of cystic lesions of the pancreas.

Case Report: Gastrointestinal bleeding from a hepatocellular carcinoma invading the transverse colon

A 72‐year‐old woman with cirrhosis of the liver was treated repeatedly by transcatheter arterial embolization for multifocal hepatocellular carcinomas. She developed gastrointestinal bleeding secondary to direct invasion of the wall of the transverse colon. The diagnosis was made pre‐operatively by colonoscopy and the patient was treated successfully. This rare complication of hepatocellular carcinoma was due to the protrusive type of growth exhibited by this tumour and may have been affected by the transcatheter arterial embolization.

Minimum resection margin should be based on tumor size in hepatectomy for hepatocellular carcinoma in hepatoviral infection patients.

In patients with hepatoviral infection, although a wide resection margin can eradicate the microsatellite lesions around hepatocellular carcinoma (HCC), a large‐volume hepatectomy may diminish remaining liver function and become an obstacle for treating recurrent HCC. The optimal width of the resection margin for these patients is still controversial. This study was conducted to investigate the optimal resection margin in hepatectomy for hepatoviral infection patients.

Resection of peritoneal metastases in patients with hepatocellular carcinoma

BACKGROUND Peritoneal metastases from hepatocellular carcinoma are common; they are found in as many as 18% of autopsy cases. Effective treatment for peritoneal metastases, however, has not yet been established. METHODS We resected peritoneal metastases 12 times in 9 patients with hepatocellular carcinoma. We assessed the clinical course and outcome of these patients to determine the effectiveness of resecting peritoneal metastases and the factors related to survival. RESULTS The 1-, 3-, and 5-year survival rates were 58%, 52%, and 42%, respectively. Four patients survived for longer than 2 years without recurrence or with controlled recurrence confined to the liver. Three patients receiving palliative resection had a poor prognosis, with survivals of only 4, 9, and 12 months. CONCLUSION Operative resection should be an option for selected patients with peritoneal metastases from hepatocellular carcinoma. Resection of peritoneal metastases should be considered in patients whose primary liver neoplasm is under control and who have no metastases in other organs.

Original method of transumbilical single-incision laparoscopic deroofing for liver cyst

Laparoscopic resection of symptomatic nonparasitic liver cysts is a feasible and effective method to relieve the symptoms with minimal surgical trauma. Many laparoscopic deroofings have been performed, and the procedure is considered a standard approach to the liver cyst [1, 2]. Single-incision laparoscopic surgery (SILS) was developed with the aim of reducing the patient’s discomfort and improving cosmesis. Herein we report an original surgical approach of transumbilical single-incision laparoscopic deroofing for a nonparasitic liver cyst. The definition of single incision is still obscure, and achieving consensus is difficult. At the moment, we use the term ‘‘single incision’’ as including cases in which incision-less needle devices are used for retraction. The patients were placed in a low, modified lithotomy position, and the operator stood between the patient’s legs, with the scoopist standing on the left side of the patient. At first, the umbilicus was pulled out, and 1 cm of completely intra-umbilical skin was incised and the fascia exposed. First a 5-mm trocar for the 30 camera was inserted, then the second 5-mm trocar for the grasper and laparoscopic coagulating shears (LCS) was inserted above the first trocar. Two trocars were inserted from different peritoneal punctures, but from the same skin incision. Air leakage was entirely controlled by pursestring sutures. The liver cyst was seen on the surface of segment 4. The initial incision by LCS was made, and the resected cyst wall was grasped by a Mini Loop Retractor II (MLR, Tyco Health Care, Tokyo, Japan), which was inserted from the trans-abdominal wall with just a 2-mm needle scar. The technique for grasping with the MLR is shown in Fig. 1 [3]. During complete deroofing by LCS, the grasping position of the MLR could be changed at any time if needed. The operative time was just 1 h, and one-forth of operative time was spent for careful reconstruction of the umbilicus to achieve a completely invisible scar. There were no difficulties with handling the devices or with devices interfering with each other. By 3 months after surgery, the scars had virtually disappeared. Our original method of a transumbilical single-incision approach by inserting just two trocars and one wire retractor aimed to decrease the number of trocars used at the same skin incision. The problems of inserting three or more trocars and devices from the same incision were that the devices could interfere with each other and that the port site fascia could easily be torn. We reduced the number of inserted trocars to resolve these problems and adopted the use of a transabdominal wall wire retractor. Actually, in deroofing operations we have changed the grasper position several times since we started to use LCS. A wire retractor can replace the grasper. Considering the anatomical character of the umbilicus, it is better not to cause a large fascial tear, even if the feasibility of port site herniation in transumbilical SILS is not yet clear. We can convert this transumbilical SILS method consisting of two trocars with a wire retractor to surgery for cholecystectomy, appendectomy and colectomy. Actually, we perform cholecystectomy routinely by applying this method (two trocars with two wire retractors). K. Sasaki (&) G. Watanabe M. Matsuda M. Hashimoto T. Harano Hepato Pancreato Billiary Surgery Unit, Department of Digestive Surgery, Toranomon Hospital Tokyo, Tokyo, Japan e-mail: sasakikazunari1978@hotmail.com

Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

AIM To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG). METHODS One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis, respectively. A retrospective review was performed not only between SILC for AIG and non-AIG, but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period. RESULTS Comparison between SILC for AIG and non-AIG revealed that the operative time was longer in SILC for AIG (97.5 min vs 85.0 min, P = 0.03). The open conversion rate (2/26 vs 2/84, P = 0.24) and complication rate (1/26 vs 3/84, P = 1.00) showed no differences, but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82, P = 0.01). Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis. CONCLUSION Our original SILC technique was adequately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.

Single-incision laparoscopic cholecystectomy: comparison analysis of feasibility and safety.

To maintain operative safety, patient selection criteria for single-incision laparoscopic cholecystectomy (SILC) are more stringent than that for traditional laparoscopic cholecystectomy (TLC). No other method could demonstrate the same feasibility and safety as TLC because the patient selection criteria were too restrictive for SILC to compare with TLC. In this study, we conducted a comparative study between our original SILC and TLC for demonstrating similar feasibility and safety among patients who had the same selection criteria as that for TLC. A statistical comparison between 114 patients of SILC and 201 patients of TLC was conducted during the same time period. The preoperative patient characteristics for SILC and TLC showed no statistical difference. In the operative result analysis, a significant disadvantage of SILC was the prolongation of operative time by only 15 minutes. The original SILC was as feasible and safe as TLC and virtually scarless cholecystectomy could be performed without any selection criteria. This was performed using only 2 trocars from an umbilical incision and 2 incisionless extracorporeal retraction devices.

Abscesses caused by "dropped" stones after laparoscopic cholecystectomy for cholelithiasis: a report of three cases.

While laparoscopic cholecystectomy is a standard therapeutic option for gallbladder stones, it is associated with a significant risk of injury to the gallbladder wall, which may result in the dispersion of free stones within the peritoneal cavity. However, the incidence and consequences of these dropped stones remains unclear. We report herein the cases of three patients in whom abdominal abscesses developed as a result of dropped stones during this procedure. Of particular interest was the relatively long interval from the procedure to the onset of symptoms and the unusual progression of the inflammation. These case reports strongly reinforce the risk of dropped stones during laparoscopic cholecystectomy.

Factors associated with early cancer-related death after curative hepatectomy for solitary small hepatocellular carcinoma without macroscopic vascular invasion.

Unexpected early cancer‐related death (ECRD) within 2 years due to recurrence after curative hepatectomy for solitary small (<5 cm) hepatocellular carcinoma without macroscopic vascular invasion (SSHCC) is occasionally observed.