Ryosuke Kawai

True left-sided gallbladder with a portal anomaly: report of a case.

A 65-year-old female who presented with back pain was diagnosed to have the presence of biliary sludge in the gallbladder. Computed tomography showed that the round ligament connected to the left portal umbilical portion was in the normal anatomical position. However, the gallbladder was located to the left of the middle hepatic vein and the round ligament, attached to the left lateral segment of the liver. The right posterior portal vein diverged alone from the main portal vein, and there was a long stem from the right anterior and left portal veins. Laparoscopic cholecystectomy confirmed the abnormal location of the gallbladder. Most reported cases of left-sided gallbladder are caused by a right-sided round ligament, which is called a “false” left-sided gallbladder. A case of left-sided gallbladder with a normal left-sided round ligament, which is designated as a case of “true” left-sided gallbladder, is extremely rare.

Complications associated with postoperative adjuvant radiation therapy for advanced rectal cancer.

Preoperative management of advanced rectal cancer often includes chemoradiotherapy, but little is known about the late complications of radiotherapy. However, these are usually serious, making determination of the characteristics of late complications after radiation therapy critical. Accordingly, we investigated the complications occurring after adjuvant pelvic radiation therapy in patients with advanced rectal cancer. We enrolled 34 consecutive patients with TNM stage III rectal cancer who had undergone curative surgery with adjuvant pelvic radiation therapy. Data on the type of complication/organ involved, the number of complications, the phase of onset, and the treatments used were reviewed. Patients who experienced gut complications or edema were less likely to have their complications resolved than those with complications due to infection. Similarly, patients with multiple complications and late-onset complications were also less likely to have their complications resolved than those with single complications and those with early-onset complications, respectively. Adjuvant radiation therapy in patients with resected advanced rectal cancer was associated with various complications, characterized by late onset and impaired resolution. Therefore, patients indicated for radiation therapy should be selected with great caution.

Chylous leakage from a remaining duplicated left-sided thoracic duct after esophagectomy successfully treated by ligation of the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery with the patient in the prone position

A 69‐year‐old man who had undergone an esophagectomy was diagnosed with chylous leakage on postoperative day 2, and his pleural effusion output gradually increased daily. On postoperative day 6, intranodal lymphangiography using lipiodol demonstrated chylous leakage from branches of an incomplete duplicated left‐sided thoracic duct; it also indicated successful ligation of the right‐sided thoracic duct at initial operation. After lymphangiography, the chylous leakage did not heal and remained uncontrollable. Based on the preoperative lymphangiographic findings, we ligated the left‐sided thoracic duct with left‐sided video‐assisted thoracoscopic surgery, with the patient in the prone position, on postoperative day 9. The patient experienced no other postoperative complications. The use of the prone position with pneumothorax treatment was helpful in providing a wide operative field in the posterior mediastinum, thus allowing for a better chance for a successful postoperative outcome.

Curative resection of esophageal cancer with a double aortic arch.

Thoracic esophageal cancer with a double aortic arch is extremely rare. We herein report the case of a 63-year-old man with a double aortic arch who underwent an esophagectomy with a three-field lymphadenectomy for cancer in the lower thoracic esophagus. In such cases, it is important to recognize the relationship between the right and left aortic arches and the bilateral recurrent laryngeal nerves (RLNs). We were able to accurately understand the anatomical position of the RLNs using a precedent cervical procedure with partial resection of the manubrium to remove the nodes along the bilateral RLNs.

The Current Status of Emergency Operations at a High-Volume Cancer Center

This study aimed to assess the pathogenic causes, clinical conditions, surgical procedures, in-hospital mortality, and operative death associated with emergency operations at a high-volume cancer center. Although many reports have described the contents, operative procedures, and prognosis of elective surgeries in high-volume cancer centers, emergency operations have not been studied in sufficient detail. We retrospectively enrolled 28 consecutive patients who underwent emergency surgery. Cases involving operative complications were excluded. The following surgical procedures were performed during emergency operations: closure in 3 cases (10.7%), diversion in 22 cases (78.6%), ileus treatment in 2 cases (7.1%), and hemostasis in 1 case (3.6%). Closure alone was performed only once for peritonitis. Diversion was performed in 17 cases (77.3%) of peritonitis, 4 cases (18.2%) of stenosis of the gastrointestinal tract, and 1 case (4.5%) of bleeding. There was a significant overall difference (P = 0.001). The frequency of emergency operations was very low at a high-volume cancer center. However, the recent shift in treatment approaches toward nonoperative techniques may enhance the status of emergency surgical procedures. The results presented in this study will help prepare for emergency situations and resolve them as quickly and efficiently as possible.

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: A case report and literature review

The occurrence of intra‐abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74‐year‐old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine‐needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory‐white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Perioperative enteral supplementation with glutamine, fiber, and oligosaccharide reduces early postoperative surgical stress following esophagectomy for esophageal cancer

BackgroundWe clarified the effects of perioperative enteral supplementation with glutamine, fiber, and oligosaccharide (GFO) after an esophagectomy on preventing surgical stress.MethodsOf 326 patients with esophageal cancer, 189 received GFO administration (GFO group) and 137 did not (control group). The propensity score matching method was used to identify 89 well-balanced pairs of patients to compare postoperative laboratory parameters and clinical and postoperative outcomes.ResultsThe duration of the systemic inflammatory response syndrome (SIRS) was significantly shorter in the GFO group compared to the control group (p = 0.002). Moreover, the lymphocyte/neutrophil ratio (L/N ratio) had significantly recovered in the GFO group on postoperative day-3, and the CRP value was significantly lower in the GFO group than that in the control group on postoperative day-2.ConclusionsPerioperative use of enteral supplementation with glutamine, fiber, and oligosaccharide likely contributes to a reduction in early surgical stress after an esophagectomy. These beneficial effects can bring about early recovery from postoperative immunosuppressive conditions after radical esophagectomy.

Feeding catheter gastrostomy with the round ligament of the liver prevents mechanical bowel obstruction after esophagectomy

Jejunostomy, which requires the fixation of the jejunum to the abdominal wall, is commonly used as an enteral feeding access after esophagectomy. However, this procedure sometimes causes severe complications, such as mechanical bowel obstruction. In 2009, we developed a modified approach to insert an enteral feeding tube through the reconstructed gastric tube using the round ligament of the liver. The aim of this study is to investigate the usefulness of this approach as compared to the approach through jejunostomy. Between January 2005 and March 2015, 420 patients with thoracic esophageal cancer underwent esophagectomy via thoracotomy and laparotomy. Of these, 214 underwent feeding jejunostomy (FJ group) and 206 patients underwent feeding via gastric tube with round ligament of the liver (FG group). Catheter-related complications, other postoperative complications, and mortality were compared between the two groups. The incidence of catheter site infection during catheterization in the FG group was significantly lower (n = 1/206, 0.5%) compared to the FJ group (n = 11/214, 5.1%) (P < 0.01). The postoperative bowel obstruction did not occur in the FG group, while it occurred in eight patients (3.7%) in the FJ group (P < 0.01). The incidences of other catheter-related and postoperative complications were similar between the two groups. Feeding catheter gastrostomy with the round ligament of the liver can be a useful enteral feeding access after esophagectomy, because the incidence rate of severe catheter-related complications, such as surgical site infection and mechanical obstruction tend to be lower with this technique compare to jejunostomy.