Masashi Hirota

Carcinosarcoma of the gallbladder producing α-fetoprotein and manifesting as leukocytosis with elevated serum granulocyte colony-stimulating factor: Report of a case

A 69-year-old man was referred to our hospital for investigation of leukocytosis and a persistent fever of 38°C, but we could find no evidence of a specific infection. The leukocyte count was 18 000/mm3, and the serum granulocyte colony-stimulating factor (G-CSF) and α-fetoprotein (AFP) levels were both elevated, at 66.3 pg/ml and 1,495 ng/ml, respectively. Computed tomography (CT) showed a gallbladder tumor and we performed extended cholecystectomy. Postoperatively, the fever subsided and the leukocyte count, serum G-CSF and AFP level normalized. Histologically, the tumor was a carcinosarcoma of the gallbladder. Immunohistochemical staining of the tumor cells was positive for AFP, but negative for G-CSF. This is the first report of a carcinosarcoma of the gallbladder producing AFP. The laboratory findings and clinical course strongly suggested that the tumor produced not only AFP, but also G-CSF.

A novel endoscopic submucosal dissection technique with robust and adjustable tissue traction.

BACKGROUND AND STUDY AIMS A novel esophageal endoscopic submucosal dissection (ESD) technique was devised using a newly developed overtube to achieve adequate tissue traction. The aim of this study was to evaluate the feasibility and safety of this new full-traction ESD (tESD) technique. METHODS The key feature of tESD is tissue traction by grasping forceps, which is passed through the built-in side channel of the overtube. The strength and direction of traction is controlled by rotating the overtube and by adjusting its depth. The en bloc resection rate, procedure time, adverse events, and dissected area per minute were evaluated in a porcine model (n = 10) and compared with those of conventional ESD (n = 10). RESULTS tESD provided robust and adjustable tissue traction during the procedure. En bloc resection was accomplished in all lesions with no complications. Median procedure time was similar to that of the conventional technique (25 vs. 27 minutes; P = 0.4723) but the submucosal injection catheter was used less often (1.5 vs. 6; P < 0.01). CONCLUSIONS tESD might contribute to more efficient esophageal ESD by providing adequate tissue traction. This inexpensive technique may become an attractive option in esophageal ESD.

Esophageal submucosal dissection under steady pressure automatically controlled endoscopy (SPACE): a clinical feasibility study.

BACKGROUND AND STUDY AIMS Steady pressure automatically controlled endoscopy (SPACE) is a new insufflation system that provides constant carbon dioxide (CO2) insufflation pressure during prolonged procedures. The system consists of an overtube, a surgical insufflator, and a newly developed leak-proof valve. The aims of this study were to validate the feasibility and safety of SPACE for esophageal endoscopic submucosal dissection (ESD). PATIENTS AND METHODS This was a clinical phase I trial, involving 10 patients who underwent esophageal ESD. The primary end point was the rate of adverse events within 30 days (grade 0 to 4). Secondary end points were changes in partial pressure of carbon dioxide (PaCO2) and vital signs during ESD, completion rate of ESD, and degree of abdominal distension by patient assessment and radiographic grading. RESULTS All adverse events were Grade 2 or less. Mild PaCO2 elevation after ESD was noted; however, no associated symptoms were reported. The procedure was completed under SPACE alone in 8 of 10 patients. Minimal post-procedural bowel distension was observed. CONCLUSIONS In this small pilot study, SPACE was feasible and appeared to be safe. Further study with larger case numbers is required to demonstrate efficacy and safety. CLINICAL TRIAL REGISTRATION UMIN000005434.

Dynamic article: steady pressure CO2 colonoscopy; its feasibility and underlying mechanism.

BACKGROUND: Steady pressure automatically controlled endoscopy is a new insufflation concept, achieving a laparoscopy-like steady environment in the upper GI tract, recently reported in the esophagus. OBJECTIVE: The purpose of this work was to validate the feasibility and safety of steady pressure automatically controlled endoscopy in the lower GI tract and to identify major factors that enable it. DESIGN: This was a nonsurvival animal study using canine models. SETTINGS: The study was conducted in an academic center. PATIENTS: Canine models were used in this study. INTERVENTIONS: In experiment 1, steady pressure automatically controlled endoscopy was attempted in the cecum with insufflation pressures of 4, 8, and 12 mm Hg. We assessed performance by video review and continuous intracecal pressure monitoring. Next, steady pressure automatically controlled endoscopy was performed for 20 minutes under optimal pressure, 8 mm Hg (n = 10). In experiment 2, steady pressure automatically controlled endoscopy was attempted in the rectum with or without artificial colonic flexure and with either low (8 mm Hg) or high (16 mm Hg) insufflation pressure to assess the effects of anatomic flexure and insufflation pressure on the establishment of steady pressure automatically controlled endoscopy (n = 6). MAIN OUTCOME MEASURES: We measured multipoint intraluminal pressure monitoring in the upstream bowel, as well as cardiopulmonary parameters. RESULTS: For experiment 1, steady pressure automatically controlled endoscopy in cecum was successful at all of the tested insufflation pressures; 8 mm Hg provided the optimal result. Steady pressure automatically controlled endoscopy was safely performed for 20 minutes at 8 mm Hg without any cardiopulmonary parameter changes or intraluminal pressure elevation in the upstream bowel. For experiment 2, confinement of the steady pressure environment to the rectum was achieved only with the assistance of colonic flexure and at 8 mm Hg insufflation pressure. In other conditions, the insufflated gas extended throughout the entire colon. LIMITATIONS: This study was limited by being an animal study. CONCLUSIONS: Steady pressure automatically controlled endoscopy is feasible and safe in the lower GI tract under the optimized insufflation pressure and in the presence of anatomical flexure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A150).

Pancreatic intraductal tubulopapillary neoplasm with associated invasive cancer successfully treated by total pancreatectomy: A case report

A 74-year-old male was admitted to Departments of Surgery, Toyonaka Municipal Hospital (Osaka, Japan) for treatment of a pancreatic tumor. Contrast enhanced computed tomography (CT) revealed a mass with small cystic lesions in the pancreatic head and body. Fluorodeoxyglucose-positron emission tomography/CT revealed an abnormal uptake of fluorodeoxyglucose, corresponding to the mass lesions. Upper gastrointestinal endoscopy revealed rough mucosa near the opening of the accessory pancreatic duct, and the mucosa biopsy exhibited adenocarcinoma with no mucin observed. The preoperative diagnosis was pancreatic intraductal tubulopapillary neoplasm (ITPN) with cancerous lesions, and a total pancreatectomy with splenectomy was performed. The resected tissue specimen revealed a solid tumor occupying the entire pancreas with intraductal growth into the main pancreatic duct. Histological examination revealed high-grade dysplastic cells in a tubulopapillary growth pattern without overt mucin production beyond the pancreatic duct. Immunohistochemical staining analysis of the tumor was positive for cytokeratin (CK)7, CK19 and mucin (MUC)1, and negative for MUC2, MUC5AC, MUC6 and caudal type homeobox 2. The tumor was finally diagnosed as pancreatic ITPN with associated invasive cancer. The patient remains well without evident recurrence nine months post-surgery. ITPN is a rare type of epithelial neoplasm of the pancreas, and is characterized by intraductal tubulo-papillary growth, ductal differentiation, limited intracellular mucin production, and cellular dysplasia. The present case report may contribute to improved understanding of how to effectively treat patients with ITPN.

Feasibility of laparoscopic cholecystectomy in patients with cerebrospinal fluid shunt

Previous reports of laparoscopic surgery in patients with cerebrospinal fluid (CSF) shunts for intracranial hypertension described shunt‐related complications. Thus, the shunts have been considered a contraindication for laparoscopic procedures. However, with the implementation of recent improvements in surgical techniques, perioperative management, and shunt technology, laparoscopic surgery may now be safe in cases with shunts. The aim of the present study was to examine the safety of such procedures based on our own experiences with laparoscopic surgery in patients with CSF shunts.

Simultaneous automatic insufflation and smoke-evacuation system in flexible gastrointestinal endoscopy.

BACKGROUND AND AIMS Automatic smoke evacuation has not been feasible inside the gastrointestinal tract as evacuation collapses pneumoviscera. As previously reported, steady pressure automatically controlled endoscopy (SPACE) may resolve this problem. The aims of this study were to clarify the potential dangers of surgical smoke, and to evaluate the feasibility and potential usefulness of automatic smoke evacuation in flexible gastrointestinal endoscopy. METHODS Seven pigs were enrolled. SPACE was established by using a flexible endoscope, an overtube, and a surgical CO2 insufflator. Smoke was generated by gastric mucosal ablation for component analysis and was evacuated by a commercially available surgical-use smoke evacuator connected to an additional line attached to the endoscope. Endoscopic images with evacuation were evaluated subjectively in comparison to those from cases without evacuation. After each session, the residual intraluminal smoke was collected by a smoke testing device for objective evaluation. RESULTS Ten chemical compounds were detected. Smoke evacuation was achieved without collapse of the pneumostomach. Smoke was significantly reduced with the use of evacuation. CONCLUSIONS Surgical smoke generated inside the gut lumen was potentially hazardous. Automatic evacuation was feasible and potentially useful in conjunction with SPACE technology.

A case of simultaneous transvaginal NOTES gastrectomy and vaginal hysterectomy in a patient with gastric submucosal tumor and uterine prolapse.

A 5‐cm gastric submucosal tumor was incidentally found through abdominal CT as a preoperative work‐up for hysterectomy in a 62‐year‐old woman with uterine prolapse. NOTES using a flexible gastrointestinal endoscope via the transvaginal route was indicated to accomplish concomitant partial gastrectomy and hysterectomy. Perigastric dissection was performed, followed by stapled partial gastrectomy using transvaginal NOTES technique with two transabdominal ports. The specimen was delivered transvaginally by enlarging the initial vaginal entry site. Vaginal hysterectomy was then accomplished by utilizing the enlarged vaginal wound. The patient showed rapid and uneventful postoperative recovery without any narcotic need. No complication was noted, her cosmetic result was satisfactory, and there was complete resolution of preoperative gynecological symptoms. Female patients with concomitant gastrointestinal and gynecological conditions requiring large specimen retrieval would potentially be suitable candidates for the transvaginal NOTES approach.

Surgical outcomes of laparoscopic cholecystectomy for acute cholecystitis in elderly patients: Lap cholecystectomy in the elderly

The clinical significance of laparoscopic cholecystectomy (LC) for acute cholecystitis in elderly patients aged 80 years or older has not been determined. This study aimed to investigate surgical outcomes of LC for acute cholecystitis in elderly patients compared to non‐elderly patients.

Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review

Patient: Male, 90 Final Diagnosis: Ruptured cystic artery pseudoaneurysm Symptoms: Epigastric pain • Fever Medication: — Clinical Procedure: Open cholecystectomy Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Cystic artery pseudoaneurysm is rare, and some cases are associated with inflammation of the gallbladder. There is limited information regarding this condition, and the clinical features remain unclear. This report is a case of ruptured cystic artery pseudoaneurysm diagnosed by computed tomography (CT) imaging and treated with urgent cholecystectomy and is supported by a literature review of previous cases. Case Report: A 90-year-old man, who had developed acute cholecystitis due to a gallstone one month previously, was referred to our hospital. He developed fever and epigastric pain while waiting for a scheduled elective cholecystectomy. Laboratory investigations showed elevated markers of inflammation and elevated hepatobiliary enzyme levels. Computed tomography (CT) imaging showed cholecystitis and pseudoaneurysm of the cystic artery. The pseudo-aneurysm had ruptured and was accompanied by the formation of a hematoma within the gallbladder that involved the liver bed. Having made the preoperative diagnosis, an urgent open laparotomy was performed, during which the gallbladder was found to have perforated. The hematoma penetrated into the liver bed. Cholecystectomy was performed, and the pseudoaneurysm of the cystic artery was extirpated. There were no serious postoperative complications. A literature review identified 50 previously reported case of cystic artery pseudoaneurysm. Conclusions: A case of ruptured cystic artery pseudoaneurysm, successfully treated with urgent cholecystectomy is reported, supported by a literature review of previous cases and characterization of the clinical features of this rare condition.