Takatsugu Matsumoto

Laparoscopic surgery for small-bowel obstruction caused by Meckel's diverticulum.

A 26-year-old woman was referred to our hospital because of abdominal distention and vomiting. Contrast-enhanced computed tomography showed a blind loop of the bowel extending to near the uterus and a fibrotic band connecting the mesentery to the top of the bowel, suggestive of Meckels diverticulum (MD) and a mesodiverticular band (MDB). After intestinal decompression, elective laparoscopic surgery was carried out. Using three 5-mm ports, MD was dissected from the surrounding adhesion and MDB was divided intracorporeally. And subsequent Meckels diverticulectomy was performed. The presence of heterotopic gastric mucosa was confirmed histologically. The patient had an uneventful postoperative course and was discharged 5 d after the operation. She has remained healthy and symptom-free during 4 years of follow-up. This was considered to be an unusual case of preoperatively diagnosed and laparoscopically treated small-bowel obstruction due to MD in a young adult woman.

A Case of Gastric Heterotopic Pancreatitis Resected by Laparoscopic Surgery

Heterotopic pancreas (HP) is a rare entity which is defined as the presence of pancreatic tissue lacking anatomical and vascular continuity with the pancreas. It is most commonly found along foregut derivatives, such as the stomach, duodenum, and jejunum. It is frequently encountered incidentally in asymptomatic patients, and symptomatic patients are rare and do not exhibit any specific symptoms. Accordingly, HP is difficult to diagnose before surgery. Here we report an unusual case of gastric heterotopic pancreatitis causing gastric outlet obstruction diagnosed preoperatively using endoscopic ultrasonography guided fine needle aspiration cytology. A 21-year-old woman was referred to our hospital because of abdominal pain, nausea, and vomiting. Gastroduodenal endoscopic examination revealed an oval-shaped submucosal tumor in the gastric body. Contrast-enhanced computed tomography (CT) revealed that the tumor had a cystic component and marked perigastric inflammation. Endoscopic ultrasonography (EUS) demonstrated a hypoechoic mass arising from the third to fourth layer of the gastric wall. Pancreatic exocrine glands were detected by EUS-guided fine needle aspiration biopsy. The lesion was diagnosed as gastric heterotopic pancreas with inflammation of the pancreatic tissue. Laparoscopic partial gastrectomy was performed, and the diagnosis was also histologically confirmed. The patient was discharged 5 days after the operation. She has remained healthy and symptom-free during 10 months of follow-up. We experienced a first case of gastric heterotopic pancreatitis which was correctly diagnosed preoperatively and resected by laparoscopic surgery. Partial resection of the heterotopic pancreatic tissue could lead to a good outcome.

The preoperative globulin-to-albumin ratio, a novel inflammation-based prognostic system, predicts survival after potentially curative liver resection for patients with hepatocellular carcinoma

Although the globulin‐to‐albumin ratio (GAR) is useful for prognostication of patients with various cancers, its relationship with hepatocellular carcinoma (HCC) remains unclear. The study aims to investigate the relationship between GAR and postoperative survival among patients with HCC undergoing potentially curative liver resection (LR).

Successful Right Hemihepatectomy for a Patient with Right-Sided Round Ligament

Right-sided round ligament (RSRL) is a rare congenital anomaly that is strongly associated with a number of intrahepatic vascular anomalies. Here, we report a 77-year-old male case of hepatolithiasis associated with RSRL for which resection was performed using right hemi-hepatectomy (RHH). Intraoperative ultrasonography revealed that the portal branch of segment 4 ramified from the right anterior portal branch, and the patient was diagnosed as having RSRL. To decide the resection line, the portal branch of segment 4 was punctured and stained with indigo carmine under ultrasonographic guidance, clearly demonstrating the demarcation line between the right and left hemiliver. RHH was then carried out successfully without injuring the portal branch of segment 4.

Mini-Laparotomy for Superior Mesenteric Artery Aneurysm Due to Takayasu's Arteritis

Superior mesenteric artery aneurysm (SMAA) is reported to be the third-most common type of visceral aneurysm (VA), accounting for 5% of all VAs. The etiology of SMAA is commonly thought to be infection, and it usually exists in the proximal part of the superior mesenteric artery, which is suitable for endovascular treatment. We herein report an extremely rare case of the distal part of SMAA caused by Takayasus arteritis (TA), which was successfully resected using a mini-laparotomy method without impairing the intestinal blood supply. A 51-year-old woman was admitted to our hospital with sustained fever and lower back pain. Physical examination showed that she had a discrepancies in blood pressure between both arms. Contrast-enhanced whole-body computed tomography showed stenosis of the thoracic aorta and an aneurysm located in the distal part of the superior mesenteric artery. The diameter of the aneurysm was 4.5 cm. The aneurysm was resected via 4-cm mini-laparotomy, and the vascularity of the intestine was successfully preserved. The postoperative course was uneventful, and the patient was diagnosed as having TA based on both clinical and pathologic findings. Additional corticosteroid therapy was started to treat the arteritis, and at 3-month follow-up she was without critical incidents. Mini-laparotomy is a safe and less-invasive approach to treat SMAA, especially when the lesion is located in the distal part of the artery.

A Novel Approach for Hepatic Arterial Reconstruction after Total Pancreatectomy with Common Hepatic Artery Resection Using Inferior Phrenic Artery

Background/Aims: Because of the anatomical characteristics, pancreatic cancers (PC) can easily invade to visceral vessels such as celiac artery, superior mesenteric artery, common hepatic artery (CHA) and portal vein, which makes curative resection difficult. In this study, we report an R0 resection for locally advanced PC by total pancreatectomy, combined resection of CHA, and reconstruction of hepatic artery using autologous left inferior phrenic artery (IPA). Methods: A 47-year-old woman with complaints of low back pain was referred to our department. Contrast-enhanced computed tomography revealed a hypo-attenuation tumor of the pancreatic body measuring 70 mm, which completely encased the CHA. When unresectable locally advanced PC was diagnosed, systematic chemotherapy was administrated. After downstaging, she underwent surgery with curative intent. The tumor completely infiltrated the peripheral part of the CHA and gastroduodenal artery. As the tumor also extended to the head of the pancreas, total pancreatectomy and combined resection of CHA were performed. Then the exposed left IPA and proper hepatic artery were anastomosed with a microvascular technique. Results: R0 resection was performed for restoring hepatic arterial flow and the postoperative course was uneventful without any postoperative morbidity. Conclusion: Hepatic artery reconstruction using IPA is a simple and safe procedure in selected patients.

Living donor liver transplantation in a highly allo-sensitized recipient: confusing influence of rituximab on the lymphocytotoxicity crossmatch test; a case report

Objective: We report a successful living donor liver transplantation (LDLT) from donor (husband) to highly allo-sensitized recipient (wife) against donor-adopting sufficient preoperative preparatio...

A Case of Intracystic Papillary Neoplasm With an Associated Invasive Adenocarcinoma

Intracystic papillary neoplasm (ICPN) is a preinvasive neoplasm of the gallbladder. Preoperative discrimination between ICPN and gallbladder cancer (GC) is difficult. The standard surgical strategy for ICPN has not yet been established. Herein, we report a case of ICPN with an associated invasive adenocarcinoma. A gallbladder tumor was detected by abdominal ultrasonography in an asymptomatic 69-year-old man, and he was referred to our hospital. Although computed tomography (CT), endoscopic ultrasonography, and magnetic resonance imaging findings in the present case were similar to those for GC, positron emission tomography-CT revealed that fluorodeoxyglucose (FDG) did not accumulate within the tumor. These imaging features suggested that patient was suspected to have GC with serosal invasion, and he underwent extended cholecystectomy and D2 lymph node dissection. He did not develop any postoperative complications, and he was discharged on postoperative day 7. There was no evidence of recurrence for 20 mon...

Preoperative neutrophil-to-lymphocyte ratio for prognostication of patients with distal bile duct carcinomas undergoing surgery.

BACKGROUND Surgical resection continues to be the current standard treatment for distal bile duct carcinoma (DBC), as no effective alternative treatment exists. However, even after resection, the long-term prognosis is poor. Simple biomarkers that can predict response or toxicity, and which are applicable to all community oncology settings worldwide, have not been identified. Differential white-cell counts, such as the neutrophil-to-lymphocyte ratio (NLR), as markers of inflammation, may be simple and readily available biomarkers. This study aimed to determine whether the NLR can be used as a predictor of surgical outcome in patients with DBC. MATERIALS AND METHODS We enrolled 91 DBC patients who had undergone pancreatoduodenectomy (PD) at a single institution between April 2000 and December 2013. Blood was sampled on admission for determination of NLR. An NLR of ≥5 was selected as the cut-off value for validation. RESULTS Seventeen patients had an NLR of ≥5 (Group 1; 18.7%), while 74 had an NLR of <5 (Group 2; 81.3%). The 1-, 3- and 5-year survival rates for Group 1 patients were 75.9, 34.5 and 34.5%, respectively, while those for Group 2 patients were 94.8, 55.2 and 46.6%, respectively (p = 0.02). There were no significant inter-group differences in clinicolaboratory background factors such as the mean operation time, bleeding volume, tumor size, CRP, neutrophil count and lactate dehydrogenase (LDH) level. On the other hand, there were significant inter-group differences for albumin level (p = 0.011), lymphocyte count (p = 0.001) and NLR (p < 0.001). Multivariate analyses were performed for factors such as gender, age, maximum tumor diameter, drainage method, operation time, bleeding volume, pathology, albumin, CRP, neutrophil count, lymphocyte count, LDH and NLR. The results revealed that NLR (odds ratio, 2.032; 95% CI, 0.999-4.134; p = 0.040) was associated with postoperative overall survival. CONCLUSIONS An NLR of ≥5 predicts a poor outcome in patients undergoing PD for DBC. NLR is an independent indicator of overall survival for such patients.