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We used modified and dynamic intraoperative cholangiography (IOC) navigation during laparoscopic subtotal cholecystectomy for difficult gallbladders. We have defined an IOC that does not open the cystic duct as a modified IOC. Modified IOC methods include the percutaneous transhepatic gallbladder drainage (PTGBD) tube method, the infundibulum puncture method, and the infundibulum cannulation method. Case 1 was chronic cholecystitis after PTGBD for acute cholecystitis with pericholecystic abscess. In this case, modified IOC was performed via PTGBD, and biliary anatomy and incarcerated stone were confirmed. Case 2 was chronic cholecystitis after endoscopic sphincterotomy for cholecystocholedocholithiasis. In this case, modified IOC was performed via gallbladder puncture needle, and biliary anatomy and incision line were confirmed. The target point on the laparoscopic image was determined by moving the tip of the grasping forceps under modified IOC, which we call modified and dynamic IOC. We conclude that the navigation by the modified and dynamic IOC via PTGBD tube or puncture needle is useful to identify biliary anatomy, incarcerated gallbladder stone, and safe incision line during laparoscopic subtotal cholecystectomy .

A 71-year-old woman was referred to our department for abdominal pain. She was diagnosed with acute obstructive cholangitis due to cystic duct and bile duct stones after cholecystectomy and Roux-en-Y gastrojejunostomy. Two years ago, the patient underwent endoscopic and laparoscopic treatment for cystic duct and bile duct stones, however, the stones remained. This time, she was treated with stone removal using percutaneous papillary balloon dilatation (PPBD). Large stones in the common hepatic and bile ducts were crushed by electrohydraulic lithotripsy and then pushed out into the duodenum through the dilated papilla of Vater using a balloon catheter covered with the sheath and cholangioscopy. Stone in the cystic duct was pulled to the common bile duct and pushed to the duodenum. Stone removal using PPBD is an excellent alternative for patients with cystic duct and bile duct stones unable to be treated with endoscopic or laparoscopic stone removal.

Aberrant right posterior hepatic duct (ARPHD) is one of the anatomical anomalies of the bile duct. It is a risk factor for bile duct injury during laparoscopic cholecystectomy (LC). ARPHD can be diagnosed before surgery by magnetic resonance cholangiopancreatography or drip infusion cholangiographic-computed tomography. However, it is not easy to identify ARPHD during LC. Classic intraoperative cholangiography (IOC) procedure that does not lead to bile duct injury avoidance needs to be modified. In modified IOC, cannulation is performed from the infundibulum or neck of the gallbladder. We reported a modified and dynamic IOC procedure that can identify ARPHD safely and precisely during LC. The modified IOC provided direct evidence of no injury to ARPHD in 2 cases.

Sarcoidosis-lymphoma syndrome associated with portal hypertension is very rare. A 68-year-old female presented with a 5 kg weight loss in 6 months. Soluble interleukin-2 receptor activity was increased and total platelet count was decreased. Contrast-enhanced computed tomography showed the presence of hepatosplenomegaly and a 3 cm-sized tumor in segment 3 of the liver. The hepatic venous catheterization showed mild portal hypertension. On fluorodeoxyglucose-positron emission tomography/computed tomography, progressive malignant lymphoma was suspected. However, bone marrow biopsy showed multiple noncaseating granulomas. A laparoscopic liver biopsy revealed that the liver tumor had features of Hodgkin lymphoma. There were multiple noncaseating epithelioid granulomas in the portal tracts of the liver. Splenectomy for splenomegaly and partial hepatectomy for the liver tumor were performed. Pathological examination of the resected specimens revealed multiple noncaseating epithelioid granulomas in the liver and spleen. Histopathology of the liver tumor confirmed classic Hodgkin lymphoma with mixed cellularity. We conclude that hepatic venous catheterization, positron emission tomography/computed tomography, and pathological examinations of bone marrow, liver, and spleen are crucial for the diagnosis of sarcoidosis-lymphoma syndrome associated with portal hypertension.

Abstract Background and Aim Objective measurements are not available for determining bowel sounds. The present study sought to evaluate the efficacy of a novel bowel sound monitoring system for perioperative use in patients undergoing gastric surgery. Methods The study enrolled 14 patients who underwent surgery for gastric cancer at Kochi Medical School from 2017 to 2018. Preoperative and postoperative bowel sounds were recorded using a newly developed real‐time analysis system in the operating theater and recovery room. Clinical information and bowel sound count data were obtained to compare preoperative and postoperative measures. Results The median preoperative and postoperative bowel sound counts across all patients were 1.4 and 2.5 counts per minute (cpm), respectively. In patients who underwent laparoscopic gastrectomy, the postoperative bowel sound count was significantly higher than that recorded preoperatively (2.3 vs. 1.6 cpm, P = 0.005). The findings also revealed a significant negative correlation between postoperative bowel sound count and operation time (r = −0.714, P = 0.003). Conclusions The real‐time bowel sound analysis system tested herein presents a promising diagnostic tool to quantitatively evaluate bowel movements associated with surgery. Our results suggested a need for shorter operation times for gastric procedures with respect to peristalsis recovery and supported the use of minimally invasive surgery.

Abstract Background and Aim Disorders in bone metabolism have long been recognized as typical sequelae of gastrectomy; however, the pathogenesis has not been fully elucidated, resulting in a variation of reported incidence. This study aimed to evaluate current bone health by measuring bone mineral density (BMD) in patients treated by gastrectomy for gastric cancer, with a focus on incidence and risk factors of osteoporosis. Methods The study enrolled 81 patients who underwent gastrectomy for gastric cancer at Kochi Medical School. BMD of the lumbar spine was measured by dual‐energy X‐ray mineral absorptiometry, with the results expressed as a percentage of the young adult mean (YAM). Clinical data were also obtained to investigate associations with BMD. Results Of the 81 study patients, 12 (14.8%) were deemed to have osteoporosis, defined by a percentage of YAM

Abstract Background Spontaneous mesenteric hematoma (SMH) is a rare condition characterized by intraperitoneal hemorrhage of unknown etiology. SMH without worsening of general status allows conservative management; however, patients showing chronological changes on imaging require surgical intervention to rule out possible malignancy. Case presentation A 69-year-old man was referred to our hospital to evaluate an abdominal mass with no associated clinical symptoms. He had a history of chronic hepatitis C and diabetes mellitus. Six months earlier, computed tomography (CT) revealed a 75-mm tumor arising from the jejunum, suspected to be a gastrointestinal stromal tumor (GIST) of the small intestine. Following a further 6 months of observation, the patient was referred to our hospital. Abdominal contrast-enhanced CT revealed a well-defined heterogeneous round tumor with a maximum diameter of 75 mm adjacent to the upper jejunum. The tumor was accompanied by calcification at the periphery, with no evidence of augmentation over the prior 6 months. Diffuse lymphadenopathy was observed around the aorta and splenic artery. Under the diagnosis of GIST arising from small intestine, the patient underwent elective surgery. The resection revealed an elastic soft tumor at the mesentery adjacent to the upper jejunum with severe adhesion between the tumor and jejunum. The tumor origin was unclear; thus, we performed mesenteric excision and partial enterectomy without lymph node dissection. The tumor was surrounded by fibrous capsular tissue containing massive hemosiderin deposits and cholesterol crystals showing partial calcification, resulting in a diagnosis of spontaneous hematoma of the mesentery. Conclusions We report a case of SMH mimicking small intestinal GIST. It is difficult to diagnose long-established SMH because its radiological features change with time, and more case reports are needed to improve the accuracy of diagnosis.

Abstract Background Our aim was to clarify the incidence of bowel obstruction associated with a feeding jejunostomy (BOFJ) after thoracoscopic esophagectomy and its association to characteristics and postoperative change in body weight. Methods We reviewed 100 consecutive patients who underwent thoracoscopic esophagectomy with gastric tube reconstruction and placement of a jejunostomy feeding catheter for esophageal cancer. The incidence of BOFJ was evaluated and the change in body weight after surgery was compared between patients with and without BOFJ. Results BOFJ developed in 17 patients. Compared to patients without BOFJ, those with BOFJ had a higher preoperative body mass index (23.3 kg/m2 versus 20.9 kg/m2, P = 0.022), and greater postoperative body weight loss rate: 3 month, decrease to 84.2% of initial body weight versus 89.3% (P = 0.002). Patients with BOFJ had shorter distance between the jejunostomy and midline (40 mm versus 48 mm, P = 0.011) compared to patients without BOFJ. On multivariate analysis, higher preoperative body mass index (odds ratio (OR) = 9.248; 95% confidence interval (CI) = 1.344–63.609; p = 0.024), higher postoperative weight loss at 3 months (OR = 8.490; 95% CI = 1.765–40.837, p = 0.008), and shorter distance between the jejunostomy and midline (OR = 8.160; 95% CI = 1.675–39.747, p = 0.009) were independently associated with BOFJ. Conclusion Patients of BOFJ had greater preoperative body mass, shorter distance between jejunostomy and midline, and greater postoperative weight loss.

Abstract Background Granulomatosis with polyangiitis (GPA) induces respiratory tract and kidney granulomatous inflammation due to small-vessel vasculitis. However, gastrointestinal involvement, and especially colon perforation, is rare. Case presentation A 40-year-old man diagnosed with GPA was admitted to our hospital for GPA management. He was started on anti-cluster of differentiation 20 antibody (rituximab) therapy after admission and suffered severe abdominal pain 2 weeks later. A clinical diagnosis of sigmoid colon perforation was made, and we performed sigmoid colon resection with colostomy. Histopathological examination revealed loss of vascular wall and neutrophil infiltration. He was discharged from the hospital after intravenous immune globulin therapy. Conclusions Although gastrointestinal involvement is rare in GPA, severe complications require surgical intervention. Bowel perforation should be considered an important complication of GPA.

Abstract Background The demand for breast reconstruction after mastectomy is rising. The use of deep inferior epigastric perforator (DIEP) flap in autologous reconstruction is a popular approach. There were some reports about abdominal complications after breast reconstruction. However, there was no report about spontaneous rupture of abdominal wall. Case presentation A 46-year-old female patient was diagnosed with left breast cancer. Left mastectomy with sentinel lymph node biopsy was performed, and the breast was reconstructed using DIEP flap simultaneously. She suffered heavy abdominal pain and vomiting at postoperative day 4. Computed tomography showed bowel herniation into the subcutaneous tissue caused by left abdominal wall rupture. The abdominal wall was sutured and repaired using mesh by emergency surgery. Conclusions To the best of our knowledge, this is the first case about spontaneous rupture of abdominal wall after breast reconstruction using DIEP flap to be reported in the English literature. DIEP flap on breast reconstructive surgery may cause spontaneous rupture of abdominal wall.

Abstract Background Although a recent randomized clinical trial has demonstrated that the objective response rate to nivolumab for metastatic gastric cancer was 11.2%, there was no patients confirmed complete response. Herein, we report on a case of liver metastasis arising from early gastric cancer in which a complete clinical response was achieved to nivolumab as third-line therapy. Case presentation A 77-year-old man was referred to Kochi Medical School Hospital for the treatment of liver metastases from gastric cancer. The patient had undergone laparoscopic total gastrectomy with regional lymph node dissection 30 months prior for early gastric cancer, with a final diagnosis of T1N0M0, stage IA. The patient developed solitary splenic metastasis measuring 42 mm 28 months later and underwent splenectomy because there was no evidence of further metastatic lesions in any other organ. The patient was treated with S-1 plus oxaliplatin based on negative immunohistochemical staining of the resected specimens for human epidermal growth factor receptor 2 (HER2). Four months after the splenectomy, the patient developed multiple liver metastases and was treated with ramucirumab plus paclitaxel. Because of disease progression, the patient was administered 3 mg/kg, i.v., nivolumab every 2 weeks. After 4 cycles of systemic treatment using nivolumab, abdominal computed tomography revealed marked shrinkage of the liver metastases. After 12 cycles of nivolumab, the liver metastases had disappeared completely. The patient did not develop any adverse reactions, including immune-reactive adverse events, during treatment. The patient continues to receive nivolumab, and there is no evidence of disease recurrence in the 8-month period since starting nivolumab. Conclusions To the best of our knowledge, this is the first case report in the English literature of a gastric cancer patient achieving a complete clinical response to nivolumab, and highlights the potential for successful treatment of metastatic gastric cancer using nivolumab.

Background: Situs inversus totalis (SIT) is a rare congenital condition in which the thoracic and abdominal organs are inverted like a mirror image. Case Report: We present a case of synchronous gastric cancer and gastrointestinal stromal tumor (GIST) associated with SIT in a 74-year-old man who was admitted to our department to treat gastric cancer. Esophagogastroduodenoscopy revealed a depressed lesion and a submucosal tumor (SMT) in the middle-third of the stomach. Abdominal contrast-enhanced computed tomography revealed complete inversion of the internal organs, and the common hepatic artery branched from the superior mesenteric artery. The patient underwent laparoscopic distal gastrectomy with regional lymph node dissection and Billroth I reconstruction. The macroscopic observation of the resected specimen revealed a depressed lesion measuring 2.0×1.5 cm in diameter and an SMT measuring 2.2×1.8 cm. Conclusion: Careful preoperative anatomic evaluation is important in SIT because the situs anomalies may be accompanied by major vascular anomalies. [ABSTRACT FROM AUTHOR]

Aim: To determine whether markers of systemic inflammatory response and nutrition are a predictor of treatment response in patients with trastuzumab-treated unresectable advanced gastric cancer. Patients and Methods: Twenty-one patients who received chemotherapy for unresectable advanced gastric cancer at Kochi Medical School from 2013 to 2020 were enrolled. Clinicopathological information and systemic inflammatory response data were obtained retrospectively to investigate associations between baseline cancer-related prognostic variables and survival outcomes. Results: The median overall survival (OS) and progression-free survival (PFS) for the whole cohort were 24.5 (range=1.9-88.4) months and 7.0 (range=2.0-23.4) months, respectively. The objective response rate and disease control rate were 52.4% and 81.0%, respectively. The median PFS for patients with a neutrophil to lymphocyte ratio (NLR) <2.8 was significantly longer than that for those with NLR ≥2.8 (8.9 vs. 6.0 months; p=0.048). Although the median OS also tended to be longer for patients with NLR <2.8, the difference was not statistically significant. No significant differences in median OS and PFS were observed between patients with a prognostic nutrition index (PNI) <41.6 and those with PNI ≥41.6. Conclusion: An NLR ≥2.8 is a predictor of poorer prognosis in patients receiving systemic treatment with trastuzumab and chemotherapy for unresectable advanced or recurrent gastric cancer. [ABSTRACT FROM AUTHOR]

Recurrent laryngeal nerve paralysis (RLNP) after esophagectomy is a common complication and associated with aspiration pneumonia. In this study, we assessed the risk of RLNP and the usefulness of immediate reconstruction of recurrent laryngeal nerve (RLN) to prevent respiratory complications after esophagectomy. Seven hundred and eighty-two consecutive patients underwent an esophagectomy with three-field lymph node dissection, simultaneous gastric conduit reconstruction, and cervical anastomosis. Vocal cord function was observed using a flexible laryngoscope. Reconstruction between RLN and ipsilateral vagus nerve was performed during esophagectomy. RLNP was observed in 229 (29.3%) of the patients after esophagectomy: 198 unilateral and 31 bilateral cases. Of the 198 unilateral RLNP, vocal cord paralysis was observed predominantly on the left side (82.7%). RLNP was significantly associated with postoperative respiratory complications (P < 0.001) requiring a tracheotomy (P < 0.001) and mechanical ventilation (P < 0.001) and was also associated with esophagogastric anastomotic leakage (P = 0.015); consequently, the postoperative hospital stay was longer for patients with RLNP (P < 0.001). A longer operation time (P < 0.001) and advanced age (P = 0.038) were identified as significant independent predictors of RLNP. Resection of the RLN together with metastatic nodes was performed in 29 cases. The patients underwent RLN reconstruction (n = 11) had a significantly shorter postoperative hospital stay than those without RLN reconstruction (n = 18) (P = 0.019). In conclusion, RLNP was related to a poorer postoperative course among patients undergoing an esophagectomy. New surgical technologies are recommended for prevention of RLNP. [ABSTRACT FROM AUTHOR]

Splenic hamartoma is a rare benign tumor, and although minimally invasive surgery may be suitable for this condition, there have only been 2 previous reports of laparoscopic surgery. Here we report the third case of splenic hamartoma managed by laparoscopic splenectomy. A 37-year-old male was incidentally diagnosed by abdominal ultrasonography with a hypoechoic mass measuring 2.5 cm × 2.4 cm in the spleen. Color Doppler sonography showed multiple flow signals within the mass and contrast-enhanced computed tomography revealed strong enhancement of the lesion. On T1- and T2-weighted magnetic resonance images, the splenic mass was demonstrated as isointense and hyperintense respectively. Although a malignant tumor could not be ruled out, a hand-assisted laparoscopic splenectomy was performed because the splenic mass was limited in size and had not invaded adjacent organs. The pathological diagnosis was splenic hamartoma. The postoperative course was uneventful and the patient was discharged by the seventh postoperative day. Although splenic hamartomas have some specific imaging features, more reports and analyses of these cases are required to increase the reliability of the diagnosis and management. Hand-assisted laparoscopic splenectomy may play a pivotal role in the postoperative diagnosis and management of this condition.