Yasuyuki Fukami

Efficacy of preoperative dexamethasone in patients with laparoscopic cholecystectomy: a prospective randomized double-blind study

BACKGROUND/PURPOSE Dexamethasone has been reported to reduce postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC). However, its effect on other surgical outcomes such as pain and fatigue have been unclear. The purpose of this clinical study was to evaluate the efficacy of preoperative dexamethasone in ameliorating postoperative symptoms after LC. METHODS In this prospective, double-blind, placebo-controlled study, 80 patients scheduled for LC were analyzed after randomization to intravenous dexamethasone (8 mg) or placebo. All patients underwent standardized procedures for general anesthesia and surgery, and were recommended to remain in hospital for 3 postoperative days. Episodes of PONV, and pain and fatigue scores on a visual analogue scale (VAS) were recorded. Analgesic and antiemetic requirements were also recorded. RESULTS There were no apparent side effects of the study drug. Seven patients (18%) in the dexamethasone group reported nausea, compared with 16 (40%) in the placebo group (p = 0.026). One patient (3%) in the dexamethasone group and 7 (18%) in the placebo group reported vomiting (p = 0.025). Dexamethasone significantly reduced the postoperative VAS pain score (p = 0.030) and VAS fatigue score (p = 0.023). The mean number of patients requiring diclofenac sodium 50 mg was 0.9 +/- 1.3 in the dexamethasone group and 2.2 +/- 2.5 in the placebo group (p = 0.002). CONCLUSIONS The regimen we employed is safe and without apparent side effects. These results suggest that preoperative dexamethasone (8 mg) significantly reduces the incidence of PONV, pain, and fatigue after LC.

Value of Laparoscopic Appendectomy in Perforated Appendicitis

BackgroundThe purpose of this clinical study was to evaluate the efficacy of laparoscopic appendectomy in patients with perforated appendicitis.MethodsThis study involved a total of 73 consecutive patients who had undergone appendectomy for perforated appendicitis between January 1999 and December 2004. While 39 patients underwent open appendectomy (OA) during the first 3 years, the remaining 34 patients underwent laparoscopic appendectomy (LA) during the last 3 years.ResultsThere was no case of LA converted to OA. No significant difference was found in the operating time between the two groups. Laparoscopic appendectomy was associated with less analgesic use, earlier oral intake restart (LA, 2.6 days; OA, 5.1 days), shorter median hospital stay (LA, 11.7 days; OA, 25.8 days), and lower rate of wound infections (LA, 8.8%; OA, 43.6%).ConclusionsThese results suggest that LA for perforated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): an analysis of tumor activity

A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure [1, 2]. The rapid regenerative response of the liver offers significant advantages. However, the acceleration of tumor growth after the first stage of the operation remains unknown. Herein, we report our experience using a tumor Ki-67 labeling index before and after ALPPS. A 49-year-old female presented at our hospital with severe constipation and epigastric pain. Dynamic computed tomography revealed a well-enhanced mass in the descending colon at the site of the splenic flexure, a remarkably dilated transverse colon and synchronous multiple liver metastases. An emergency colostomy at the transverse colon was performed. After five cycles of chemotherapy (FOLFOX/Bevacizumab), primary resection with synchronous segment III partial resection was performed. According to the TNM Classification of Malignant Tumor by the International Union Against Cancer, the tumor status was pT4 pN1 pM1. The patient’s liver did not show signs of sinusoidal obstruction syndrome. To achieve a curative resection of the multiple residual liver metastases, a right hepatic trisectionectomy was required. A liver function assessment using 99mTc-GSA scintigraphy and indocyanine green clearance was normal. However, the volumetric future liver remnant (FLR) was 19 % (317 ml), and we defined insufficient FLR. Therefore, we performed the ALPPS procedure. The first stage of the surgery involved surgical laparotomy. The right and left hemi-liver were mobilized. The right portal vein was ligated after a segment III partial resection for metachronous liver metastases. A transection of the liver parenchyma was performed along the right side of the falciform ligament with an ultrasound dissector. The identified middle hepatic vein was preserved. The right extended lobe was covered by a bioresorbable membrane to prevent adhesions. The abdomen was closed without placing a drain. The postoperative course was uneventful. On postoperative day 9, CT liver volumetry showed that the FLR volume increased from 317 to 475 ml. The FLR/ total liver volume ratio increased from 19 to 37 % before the second stage surgery (Fig. 1a, b). Twelve days after the first stage surgery, the second stage of the surgery was performed, and mild adhesions were found. The right hepatic artery was dissected and ligated. The right bile duct, right hepatic vein and middle hepatic vein were divided. The remaining parenchymal bridges of liver tissue were divided. An abdominal drain was placed at the resection surface, and the abdomen was closed. The postoperative course was uneventful (DindoClavien grade I), and the patient was discharged 11 days after the second stage surgery. The maximum standardized uptake value [SUV (max)] of fludeoxyglucose positron emission tomography (PET)/ CT at the segment VIII synchronous liver metastases was 4.3 before the first stage surgery. However, SUV (max) of PET/CT at the same tumor had increased to 6.3 on the day before the second stage surgery (Fig. 1c, d). We performed a tumor biopsy immediately after both the first and second laparotomy at the same segment VIII synchronous liver metastases. The Ki-67 labeling index of the tumor cells Y. Fukami (&) Y. Kurumiya S. Kobayashi Department of Surgery, Toyota Kosei Hospital, 500-1 Josui-cho, Toyota, Aichi 470-0396, Japan e-mail: yasuyuki490225@yahoo.co.jp

Clinical effect of hyperbaric oxygen therapy in adhesive postoperative small bowel obstruction

Hyperbaric oxygen (HBO) therapy is a controversial treatment for adhesive postoperative small bowel obstruction, with only a few small studies reported. The aim of this study was to assess the clinical value of HBO therapy in the treatment of adhesive postoperative small bowel obstruction.

Side-to-end anastomosis in a colostomy for acute malignant large-bowel obstruction: Side-to-end anastomosis with a colostomy (STEC procedure)

This report describes the use of side-to-end anastomosis in a colostomy for an acute malignant large-bowel obstruction. A 59-year-old man presented with a colonic obstruction due to advanced descending colon cancer. The preoperative imaging studies revealed a complete obstruction of the descending colon at the site of the splenic flexure, a remarkably dilated transverse colon, and no other metastatic lesions. Side-to-end anastomosis was performed with the colostomy because of the high comorbidity associated with such cases. When the patient’s general condition improved, a stoma closure was performed under local anesthesia. In conclusion, a side-to-end anastomosis with a colostomy (STEC procedure) was found to be a simple, useful, and cost-effective technique for an acute malignant large-bowel obstruction, particularly in a high-risk patient.

A case of anaplastic carcinoma of the pancreas producing granulocyte-colony stimulating factor

We report a case of anaplastic carcinoma of the pancreas with production of granulocyte-colony stimulating factor (G-CSF) in a 59-year-old male. He was referred to our hospital with a chief complaint of epigastralgia and suffered from leukocytosis. Differential diagnosis included pancreatic tumors and submucosal tumor of the stomach, but definite preoperative diagnosis could not be made. He underwent distal pancreactomy, total gastrectomy with Roux-en-Y reconstruction and splenectomy. He recovered uneventfully postoperatively and was discharged from hospital on the 14th postoperative day. Histological examination showed anaplastic carcinoma of the pancreas. Since the peripheral leukocyte count was sharply decreased after the operation, we suspected the tumor would be producing G-CSF. Then immunohistochemistry showed a positive stain in the tumor. Therefore, we diagnosed the tumor as anaplastic carcinoma of the pancreas producing G-CSF. Three months after the resection, local recurrence was detected by abdominal computed tomography. The patient died of hemorrhagic shock due to tumor invasion of the intestine 8 months after the operation.

Intrapancreatic bile duct metastasis from colon cancer after resection of liver metastasis with intrabiliary growth: a case report

An extremely rare case of intrapancreatic bile duct metastasis from sigmoid colon adenocarcinoma is herein presented. Sigmoid colon cancer (T3, N0, M0, stage IIA) had been diagnosed and treated by sigmoidectomy in October 1993. In December 2002, a liver metastasis with intrabiliary growth was found, and this was treated by extended right hepatic lobectomy and caudate lobectomy with extrahepatic bile duct resection. In February 2014, intrapancreatic bile duct metastasis was found, and this was treated by subtotal stomach-preserving pancreatoduodenectomy. The intrapancreatic metastasis was judged to have arisen from cancer cell implantation, either by spontaneous shedding of cancer cells or as a complication of percutaneous transhepatic biliary drainage. Twelve months have passed since the last surgical intervention, and there has been no sign of local recurrence or distant metastasis. Differential diagnosis between intrahepatic cholangiocarcinoma and intrabiliary growth of a liver metastasis originating from colorectal adenocarcinoma is difficult but very important for determining the therapeutic strategy. Careful examination is needed to diagnose intrahepatic biliary dilatation, especially for patients with a history of carcinoma in the digestive tract and even if years have passed since curative resection of the digestive tract cancer. Aggressive surgical management for localized recurrence of a hepatic metastasis from colorectal adenocarcinoma may improve patient survival.

Determination of therapeutic strategy for adhesive small bowel obstruction using water-soluble contrast agents: An audit of 776 cases in a single center

Background. Several studies have investigated the diagnostic and therapeutic role of water‐soluble contrast agents in adhesive small bowel obstruction, but there is no clear diagnostic classification for the determination of therapeutic strategy. The aim of this study was to clarify the clinical value of classification using water‐soluble contrast agents in patients with adhesive small bowel obstruction. Methods. Between January 2009 and December 2015, 776 consecutive patients with adhesive small bowel obstruction were managed initially with water‐soluble contrast agents and were included in the study. Abdominal x‐rays were taken 5 hours after administration of 100 mL water‐soluble contrast agents and classified into 4 types. The medical records of the patients with adhesive small bowel obstruction were analyzed retrospectively and divided into 2 groups of patients with complete obstruction (ie, the absence of contrast agent in the colon) with (type I) or without (type II) a detectable point of obstruction and a group with an incomplete obstruction (ie, the presence of contrast agent in the colon) with (type IIIA) or without (type IIIB) dilated small intestine. Results. Types I, II, IIIA, and IIIB were identified in 27, 90, 358, and 301 patients, respectively. The overall operative rate was 16.6%. In the patients treated conservatively (types IIIA and IIIB), 647 patients (98.2%) were treated successfully without operative intervention. The operative rate was 3.4% (n = 12/358) in type IIIA vs 0% (n = 0/301) in the type IIIB group (P = .001). Compared with type IIIA, type IIIB was associated with earlier initiation of oral intake (2.1 vs 2.6 days, P < .001) and a lesser hospital stays (9 vs 11 days, P < .001). Conclusion. This new classification using water‐soluble contrast agents is a simple and useful diagnostic method for the determination of therapeutic strategy for adhesive small bowel obstruction.

Bilobar versus unilobar multiple colorectal liver metastases: a propensity score analysis of surgical outcomes and recurrence patterns

Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long‐term outcomes and recurrence patterns after one‐stage resection in patients with bilobar versus unilobar MCLM.

A 12-mm Carcinoid Tumor of the Minor Duodenal Papilla with Lymph Node Metastases

Carcinoid tumors located in the minor duodenal papilla are extremely rare, with only a few cases reported in the literature. Herein, we report the case of a 71-year-old man with a 12-mm carcinoid tumor at the minor duodenal papilla with lymph node metastases. Multidetector-row computed tomography with contrast enhancement revealed a 12-mm well-enhanced tumor in the duodenum. Upper gastrointestinal endoscopy showed a 12-mm submucosal tumor at the minor papilla of the duodenum. Biopsy specimens revealed a carcinoid tumor, and a subtotal stomach-preserving pancreatoduodenectomy was performed. Carcinoid tumors at the minor duodenal papilla have a high prevalence of nodal disease, even for tumors <2 cm in diameter. Therefore, we believe that radical resection with tumor-free margins (i.e. pancreatoduodenectomy) is the treatment of choice.