Yosuke Kano

Internal hernia after laparoscopic-assisted proximal gastrectomy with jejunal interposition for gastric cancer: a case report

Internal hernia after gastrectomy is a rare complication. It can progress rapidly to vascular disturbance, necrosis, and perforation, therefore early diagnosis and surgical treatment is essential. We present a case of internal hernia following laparoscopic-assisted proximal gastrectomy with jejunal interposition reconstruction in a 68-year-old man, who presented with acute abdominal pain and vomiting. Computed tomography showed a whirl sign, ascites, and a closed-loop formation of the small intestine. We diagnosed an internal hernia and performed emergency surgery. Laparotomy revealed chyle-like ascites and extensive small intestine with poor color. We recognized that about 20 cm of jejunum from the ligament of Treitz was strangulated behind the pedicle of the jejunum lifted during laparoscopic-assisted proximal gastrectomy. We relieved the strangulation, whereupon the color of the strangulated intestine was restored. Therefore, we did not perform intestinal resection and reconstruction. Finally, we fixed the jejunal pedicle and mesentery of the transverse colon. We report this case as there are few reported cases of internal hernia after laparoscopic-assisted proximal gastrectomy.

Pathogenic Germline BRCA1/2 Mutations and Familial Predisposition to Gastric Cancer

Most gastric cancers (GCs) are considered sporadic, however familial aggregation occurs in 10% of cases1, 2. Approximately 5% of GCs are caused by an autosomal dominant inherited trait, with carriers having a strongly increased risk of GC and other cancers3. Clinical criteria for this entity were defined by the International Gastric Cancer Linkage Consortium (IGCLC)4. Among these, hereditary diffuse gastric cancer (HDGC) is a well-known type of familial GC (FGC). About 40% of families fulfilling the clinical criteria for HDGC have germline CDH1 mutations5. A subset of the remaining families of HDGC, and ones fulfilling the criteria of other familial GC, harbor pathogenic germline mutation in other genes which associated with hereditary cancer predisposition syndromes4. Hereditary breast and ovarian cancer (HBOC) is one of the best-described inherited cancer predisposition syndromes, caused by pathogenic germline BRCA1 or BRCA2 (BRCA1/2) mutations6–9. The increased risks of cancers other than breast and ovarian cancers were observed in the carriers10. The association between germline BRCA1/2 mutation and increased risk of GC were demonstrated in previous studies for HBOC families11–14. Regarding FGC, a recent large-scale study demonstrated that germline BRCA2 mutations were identified in patients who had a family history which fulfilled the criteria of HDGC, but lacking CDH1 mutations15. Therefore, it is possible that germline BRCA1/2 mutations may cause familial predisposition to GC. Recent advances of comprehensive genomic analysis enable us to identify the genomic alterations in GC16. BRCA1/2 mutations were shown in the subset of GC tumor tissues, however the association between germline BRCA1/2 mutations and familial predisposition to GC were not fully understood. Previously we performed genomic sequencing of 207 Japanese GCs using 435-gene panel, and identified BRCA1/2 mutations in tumor17. In this study, we conducted BRCA1/2 genetic testing in seven Japanese GC patients whose tumor had BRCA1/2 mutations. We identified pathogenic germline BRCA1/2 mutations in three patients, who have a familial component of GC.

Severe cellulitis and abdominal wall emphysema following laparoscopic colonic surgery: A case report

Abdominal wall emphysema is a common complication of laparoscopic surgery. This condition is usually harmless; however, if an infection occurs, it can develop into a serious condition such as necrotizing fasciitis. We report a case of a 51‐year‐old woman suffering from severe cellulitis that spread from an area of abdominal wall emphysema after laparoscopic surgery for sigmoid colon cancer. Recognizing this complication, early diagnosis, and prompt treatment are cornerstones for successful management of this potentially fatal disease.

Intrathoracic esophagojejunostomy using OrVil™ for gastric adenocarcinoma involving the esophagus.

AIM To demonstrate a new surgical technique of lower mediastinal lymphadenectomy and intrathoracic anastomosis of esophagojejunostomy using OrVil™. METHODS After a total median phrenotomy, the supradiaphragmatic and lower thoracic paraesophageal lymph nodes were transhiatally dissected. The esophagus was cut off using a liner stapler and OrVil™was inserted. Finally, end-to-side esophagojejunostomy was created by using a circular stapler. From July 2009, we adopted this surgical technique for five patients with gastric cancer involving the lower esophagus. RESULTS The median operation time was 314 min (range; 210-367 min), and median blood loss was 210 mL (range; 100-838 mL). The median numbers of dissected lower mediastinal nodes were 3 (range; 1-10). None of the patients had postoperative complications including anastomotic leakage and stenosis. The median hospital stay was 16 d (range: 15-20 d). The median length of esophageal involvement was 14 mm (range: 6-48 mm) and that of the resected esophagus was 40 mm (range: 35-55 mm); all resected specimens had tumor-free margins. CONCLUSION This surgical technique is easy and safe intrathoracic anastomosis for the patients with gastric adenocarcinoma involving the lower esophagus.

Two-Step Laparoscopic Surgery for a Patient with Synchronous Double Cancer of the Colon and Stomach Accompanied by Severe Chronic Obstructive Pulmonary Disease

Laparoscopic treatment strategies for synchronous intra-abdominal malignancies have not yet been standardized. We report a successful case of two-step laparoscopic surgery for synchronous double cancer of the colon and stomach accompanied by severe chronic obstructive pulmonary disease (COPD). A 66-year-old man with COPD was diagnosed as having advanced colon cancer and early gastric cancer. On admission, he could not go upstairs (Grade III according to the Hugh-Jones classification) and his forced expiratory volume in 1 second was 600 mL (35.9%). The patient initially underwent laparoscopy-assisted sigmoidectomy with D3 lymphadenectomy, followed by laparoscopy-assisted distal gastrectomy with D1 lymphadenectomy 68 days later. The patients each postoperative course was uneventful with no pulmonary complications, and the patient was discharged 9 and 11 days after the first and second operations, respectively. The present case demonstrates that two-step laparoscopic surgery may be a safe and feasible surgical procedure for high-risk patients with synchronous intra-abdominal malignancies.