Shinichiro Koketsu

Surgical resections of ulcerative colitis associated with dysplasia or carcinoma

BackgroundUlcerative colitis (UC) patients have an increased risk of colorectal dysplasia and carcinoma. The purpose of this study was to analyze the clinical features and surgical treatment of ulcerative colitis associated with dysplasia or carcinoma.MethodsWe operated on 41 UC patients since April 2000. Twelve of the cases were associated with dysplasia or carcinoma. Ten patients were male and two were female; the median age was 58.0 years, and the average duration of disease was 19.2 years. Nine cases were pancolitis type and three were left-sided type. Six cases were remission-relapsing type and six were chronic inflammation type. In 10 of 12 cases, dysplasia or carcinoma was diagnosed before the operations. Nine cases were primary operations and two were second-time operations.ResultsAmong ten patients who underwent primary operations, four patients had open surgery and six patients had hand-assisted laparoscopic surgery (HALS). Seven patients received anus/anal sphincter-preserving operations with reconstruction by the ileal pouch technique. Ileal pouch anal-canal anastomosis (IPACA) was performed in five cases and ileal pouch anal anastomosis (IPAA) in two cases. Abdomino-peritoneal resection was performed in two cases, proctcolectomy with permanent ileostomy in one case, and right hemicolectomy in one case. A 39-year-old patient was unresectable due to dissemination of the carcinoma. A 55-year-old patient who underwent IPACA showed night soiling postoperatively. Other patients who received IPAA and IPACA showed favorable anal function postoperatively. Histological examination showed low-grade dysplasia in two cases, high-grade dysplasia in three cases, and adenocarcinoma in seven cases. In the seven cases of adenocarcinoma, four, two, and one cases were stage 1, 3, and 4 according to TNM classification. Three of five cases with dysplasia were detected by surveillance colonoscopy. All patients with carcinoma were symptomatic and did not undergo surveillance colonoscopy.ConclusionsIPACA by HALS was safely performed as an anal-preserving operation in UC patients with dysplasia or carcinoma. Non-anal-preserving operations for aged patients showed a preferable postoperative course. Surveillance colonoscopy is essential for detecting dysplasia before the development of carcinoma.

Fluorescence Cholangiography in Laparoscopic Cholecystectomy: Experience in Japan

We describe a new modality for intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) and its evaluation in 15 patients diagnosed as having gallbladder stones who were scheduled to undergo laparoscopic cholecystectomy. The patients included 6 males and 9 females with a mean age of 54 years and a mean BMI of 22.3. Standard four-port laparoscopic cholecystectomy was performed in 11 patients and single-incision laparoscopic cholecystectomy in the other 4. ICG was infused 1 h before surgery. We observed the biliary tract under real-time fluorescence imaging guidance, and confirmed the positions of the gallbladder, cystic duct, and common bile and hepatic duct on the monitor. The cystic artery was also observed after reinjection of ICG. The procedure was completed successfully in all cases, and no additional ports or conversion to open cholecystectomy were necessary. The mean operation time was 88 min. We obtained a clear view of the biliary tract in all patients, and the cystic artery was confirmed 10 s after reinjection of ICG. There were no specific perioperative complications related to the intravenous injection of ICG. The median postoperative hospital stay was 3 days. Intraoperative exploration of the biliary tract using ICG is a useful approach for identification of the biliary anatomy without cannulation into the cystic duct, X-ray equipment or use of radioactive materials. We expect that this modality will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.

Intramucosal adenocarcinoma of the ileum originated 40 years after ileosigmoidostomy

BackgroundSmall bowel adenocarcinomas (SBAs) are rare carcinomas. They are asymptomatic and usually neither endoscopy nor contrast studies are performed for screeningCase presentationA 72-year-old Japanese male had a positive fecal occult blood test at a regular check-up in 2006. He suffered appendicitis and received an ileosigmoidostomy in 1966. A colonoscopy revealed an irregular mucosal lesion with an unclear margin at the ileum side of the anastomosis. A mucosal biopsy specimen showed adenocarcinoma histopathologically. Excision of the anastomosis was performed for this patient. The resected specimen showed a flat mucosal lesion with a slight depression at the ileum adjacent to the anastomosis. Histological examination revealed a well differentiated intramucosal adenocarcinoma (adenocarcinoma in situ). Immunohistological staining demonstrated the overexpression of p53 protein in the adenocarcinoma.ConclusionAdenocarcinoma of the ileum at such an early stage is a very rare event. In this case, there is a possibility that the ileosigmoidostomy resulted in a back flow of colonic stool to the ileum that caused the carcinogenesis of the small intestine.

A Case of Poorly Differentiated Adenocarcinoma with Signet Ring Cell Carcinoma of the Duodenal Bulb: A Case Report

Duodenal cancers are rare. Histopathologically, most duodenal cancers are adenocarcinoma. Signet ring cell carcinoma (SRCC) is a rare tumor more commonly found in the stomach than at other sites in the digestive tract. SRCC is extremely uncommon in the duodenum, with most of these tumors occurring in the ampulla. Until now, there are few case reports of duodenal cancers with SRCC. To accumulate case reports, we report a rare case of nonampullary duodenal bulb SRCC. A 74-year-old man was admitted to our hospital with melena. Esophagogastroduodenoscopy (EGD) showed a duodenal bulb ulcer. He was treated with a proton pump inhibitor. However, 1 month later, he was readmitted to our hospital with epigastric pain and nausea. A second EGD examination showed an ulcer at the duodenal bulb. Biopsies taken from the ulcer showed SRCC. Distal gastrectomy and duodenal bulb resection were performed. Histologic examination of the specimen showed a type 4 lesion located from the duodenal bulb to the pyloric antrum. The tu...

An effective new method for the placement of an anti-adhesion barrier film using an introducer in laparoscopic surgery

Postoperative small bowel obstruction (SBO) is one of theserious complications of abdominopelvic surgery. One ofthe major causes of SBO is the formation of intra-ab-dominal adhesions. The rate of SBO is reportedly 2–6 % inlaparoscopic surgery, although it is lower than in laparo-tomy [1, 2]. Furthermore, peritoneal and bare pelvic floordefects after resection of the rectum are observed afterabdominoperineal resection for rectal cancer, and theycause postoperative wide adhesions of the small intestine tothe pelvic floor. An anti-adhesion barrier film (Sepra-film