Osamu Komine

Two successful curative operations using stomach-preserving distal pancreatectomy with celiac axis resection for the treatment of locally advanced pancreatic body cancer

Large vessel invasion is a serious factor determining whether an operation for pancreatic body cancer is feasible. The Appleby operation is a radical operation for the treatment of pancreatic body cancer that has infiltrated the celiac axis. Since this procedure includes a total gastrectomy, the operation is associated with a high morbidity, mortality, and deteriorating postoperative quality of life (QOL). We experienced two cases in which radical operations consisting of a stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric artery were performed. The use of adjuvant chemotherapy in these cases led to a good postoperative QOL.

Granulocyte-colony stimulating factor-producing esophageal carcinosarcoma: a case report

An 80-year-old man presented at our hospital with chest oppression and vomiting. An endoscopic examination revealed a tumor in the lower portion of the esophagus, and the patient was diagnosed as possibly having esophageal carcinosarcoma based on a histological examination of endoscopic biopsy specimens. During the initial medical examination, the patient had a high leukocyte count and a high level of serum granulocyte-colony stimulating factor (G-CSF). Moreover, immunohistochemical examination revealed cells that were positive for antibodies against G-CSF. Therefore, we diagnosed the patient as possibly having a G-CSF-producing esophageal carcinosarcoma. The patient died of tumor 4 months after the initial diagnosis.

Single-incision Laparoscopic Cholecystectomy with an Additional Needle Grasper: A Novel Technique

BACKGROUND Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, the technique remains technically challenging for most surgeons. We developed a new technique utilizing a needle grasper held in the surgeons left hand as an alternative to conventional single-incision laparoscopic cholecystectomy (SILC). PATIENTS AND METHODS From August 2011 through May 2013, 29 patients at Nippon Medical School Musashi Kosugi Hospital, with gallbladder stones or polyps underwent single-incision laparoscopic cholecystectomy (SILC) with an additional needle grasper that was held in the surgeons left hand (SILCAN) and introduced in the right subcostal region without a trocar. We analyzed intraoperative and postoperative outcomes of 29 patients for whom SILCAN was performed and retrospectively compared these outcomes to those of 32 patients who underwent conventional 4-port laparoscopic cholecystectomy (CLC) from January 2011 through May 2013. RESULTS No differences in patient characteristics or intraoperative/postoperative outcomes were observed between the groups. None of the patients in either group required conversion to an open procedure or additional ports. In the SILCAN group, no patients had complications within the first 4 weeks after surgery, with the exception of 1 patient with severe chronic cholecystitis in whom bile duct stenosis developed due to inadvertent clipping of the common hepatic duct. The frequency of postoperative analgesic use was similar in both groups, although none of the patients in the SILCAN group received analgesics for pain from the small, inconspicuous wound in the right subcostal region. CONCLUSIONS SILCAN is a safe and feasible alternative to SILC which does not compromise the qualities of CLC. It is less technically challenging, and postoperative pain and cosmesis are comparable to those of conventional SILC.

Surgical resection of late solitary locoregional gastric cancer recurrence in stomach bed.

Summary Background Late-onset and solitary recurrence of gastric signet ring cell (SRC) carcinoma is rare. We report a successful surgical resection of late solitary locoregional recurrence after curative gastrectomy for gastric SRC carcinoma. Case Report The patient underwent total gastrectomy for advanced gastric carcinoma at age 52. Seven years after the primary operation, he visited us again with sudden onset of abdominal pain and vomiting. We finally decided to perform an operation, based on a diagnosis of colon obstruction due to the recurrence of gastric cancer by clinical findings and instrumental examinations. The laparotomic intra-abdominal findings showed that the recurrent tumor existed in the region surrounded by the left diaphragm, colon of splenic flexure, and pancreas tail. There was no evidence of peritoneal dissemination, and peritoneal lavage fluid cytology was negative. We performed complete resection of the recurrent tumor with partial colectomy, distal pancreatectomy, and partial diaphragmectomy. Histological examination of the resected specimen revealed SRC carcinoma, identical in appearance to the previously resected gastric cancer. We confirmed that the intra-abdominal tumor was a locoregional gastric cancer recurrence in the stomach bed. The patient showed a long-term survival of 27 months after the second operation. Conclusions In the absence of effective alternative treatment for recurrent gastric carcinoma, surgical options should be pursued, especially for late and solitary recurrence.

T tube drainage for spontaneous perforation of the extrahepatic bile duct.

Summary Background Spontaneous perforation of the extrahepatic bile duct is very rare. We report a patient with a spontaneous perforation of the left hepatic bile duct who was diagnosed preoperatively. Case Report A 65-year-old woman was admitted to our hospital complaining of a right upper quadrant pain lasting for two days. She was diagnosed as having a perforated bile duct and peritonitis and underwent a laparotomy. After a cholecystectomy, T-tube drainage of the left hepatic duct was performed. The postoperative course was uneventful. The T tube was removed 25 days after the surgery. Conclusions A more noninvasive procedure, such as endoscopic treatment, should play a central role in the management of extra bile duct perforation. For this case, however, we chose to perform a laparotomy based on the patient’s general condition and the presence of peritonitis. T tube decompression is effective and a safe and reliable method. The goal of treatment is to stop the bile leakage, resolve the choledocholithiasis and cholangitis, and reconstruct the bile duct.

Primary Volvulus of the Small Intestine Exhibiting Chylous Ascites: A Case Report

BACKGROUND Primary volvulus of the small intestine associated with chylous ascites is very rare, with only four reported cases. In this paper, we report a new case of primary volvulus associated with chylous ascites. CASE PRESENTATION The patient was a 70-year-old man. After experiencing bloating and abdominal pain for several hours, he called an ambulance and underwent an emergency examination at our hospital. Abdominal distension, pressure pain, and rebound tenderness were observed throughout his entire abdomen. The patient had a history of hypertension for which he was receiving oral treatment. Abdominal contrast-enhanced computed tomography (CT) revealed an edematous change in the intestinal membrane and volvulus of the small intestine. As findings suggestive of ischemia were observed in part of the intestines, emergency surgery was performed on the day of admission. Open surgery revealed approximately 500 mL of chylous ascites in the abdominal cavity. The small intestine had twisted 180° in a counter-clockwise direction at the root of the superior mesenteric artery, and the mesentery appeared milky white with edematous changes extending 75 to 240 cm from the ligament of Treitz. There was no evidence of intestinal necrosis; therefore intestinal resection was not performed. The volvulus of the small intestine was corrected. Moreover, because there was no other underlying disease observed, surgery was completed. The ascites collected during surgery revealed high levels of triglycerides at 332 mg/dL, and chylous ascites was diagnosed. An abdominal CT performed on the third day after surgery showed an improvement in intestinal edema, and primary volvulus of the small intestine associated with chylous ascites was diagnosed. Postoperative progress was good, and the patient was discharged on hospital day 10.

Time‐dependent changes in endoscopic findings of intestine in patient with acute superior mesenteric arterial thrombosis after pancreaticoduodenectomy

Superior mesenteric arterial thrombosis (SMAT) is a disorder with high mortality because of extensive necrosis of the intestine.Even if necrosis does not occur, subsequent stricture with sclerosis and the impairment of intestinal absorption are common. We report a case of SMAT in a woman in which time-dependent changes of small intestinal endoscopy could be observed. She had previously undergone anastomosis of the stomach and small intestine during subtotal stomachpreserving pancreaticoduodenectomy. She suddenly developed abdominal pain 10 days after the operation.At 24 h after the onset, she was diagnosed with SMAT, and per-catheteric thrombus aspiration was carried out.After 2 days, endoscopy was carried out for the first time since the onset. The color of the intestinal lumen was cyanotic and dark. A pseudomembrane appearance was observed. Hunter green mucosal nodules were apt to drop off from the wall. Petechial hemorrhages interspersed with pale areas were visible (Fig. 1a,b). Seven days after the onset, the small intestine had a bloody pink color with a wet glossy appearance. After 14 days, the color of the lumen improved significantly. Kerckring folds and local regeneration of the mucosa were observed (Fig. 1c,d). The passage through the intestine was good. After 3 weeks, the patient developed mild stricture(Fig. 1e,f).After 4 weeks, strong stricture was formed with massive sclerosing fibrosis, and Kerckring folds had disappeared. Furthermore, regeneration of the mucosa stopped, and erosive mucosa was seen in the tongue fur (Fig. 1g,h). A contrast examination demonstrated multiple apple-core like lesions throughout the small bowel. After 1 month, no progressive stricture has been observed. This case provides us with interesting endoscopic findings of SMAT in a timedependent manner.