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Background Local duodenectomy and primary closure is a simple option for some nonampullary duodenal neoplasms. Minimizing the resection area while ensuring curability is necessary for safe primary duodenal closure. However, it is often difficult to determine the appropriate resection line from the serosal side. We developed clip-guided local duodenectomy to easily determine the resection range and perform local duodenectomy safely, then performed a retrospective observational study to confirm the safety of clip-guided local duodenectomy. Methods The procedure is as follows: placing endoscopic metal clips at four points on the margin around the tumor within 3 days before surgery, identifying the tumor extent with the clips under X-ray imaging during surgery, making an incision to the duodenum just outside of the clips visualized by X-ray imaging, full-thickness resection of the duodenum with the clips as guides of tumor demarcation, and transversely closure by Gambee suture. We evaluated clinicopathological data and surgical outcomes of patients who underwent clip-guided local duodenectomy at two surgical centers between January 2010 and May 2020. Results Eighteen patients were included. The pathological diagnosis was adenoma (11 cases), adenocarcinoma (6 cases), and GIST (1 case). The mean ± SD tumor size was 18 ± 6 mm, and the tumor was mainly located in the second portion of the duodenum (66%). In all cases, the duodenal defect was closed with primary sutures. The mean operation time and blood loss were 191 min and 79 mL, respectively. The morbidity was 22%, and all complications were Clavien–Dindo grade II. No anastomotic leakage or stenosis was observed. In the 6 adenocarcinoma patients, all were diagnosed with pT1a, and postoperative recurrence was not observed. The 1-year overall and recurrence free survival rate was 100%. Conclusions Clip-guided local duodenectomy is a safe and useful surgical option for minimally local resection of nonampullary duodenal neoplasms such as duodenal adenoma, GIST, and early adenocarcinoma.

With recent advances in the treatment of esophageal cancer and long-term survival after esophagectomy, the number of gastric tube cancer (GTC) has been increasing. Total gastric tube resection with lymph node dissection is considered to be a radical treatment, but it causes high post-operative morbidity and mortality. We report an elderly patient with co-morbidities who developed pyloric obstruction due to GTC after esophagectomy with retrosternal reconstruction. The patient was treated using distal partial gastric tube resection (PGTR) and Roux-en-Y reconstruction with preservation of the right gastroepiploic artery and right gastric artery. Intraoperative blood flow visualization using indocyanine green (ICG) fluorescence demonstrated an irregular demarcation line at the distal side of the preserved gastric tube, indicating a safe surgical margin to completely remove the ischemic area. PGTR with intraoperative ICG evaluation of blood supply in the preserved gastric tube is a safe and less-invasive surgical option in patients with poor physiological condition.

Anastomotic leakage (AL) is one of the major complications of gastro-esophageal anastomosis after esophagectomy, which causes short-term morbidity and mortality, as well as poor long-term survival. The aim of this study was to investigate factors which were associated with AL after esophagectomy in order to determine the optimal surgical technique to reduce AL. Methods A total of 128 patients with thoracic esophageal cancer underwent subtotal esophagectomy followed by retrosternal reconstruction with gastric conduit with cervical anastomosis using circular staple in our institute from January 2008 and January 2020. The relationship between AL and surgical procedures as well as clinicopathological characteristics of the patients were retrospectively investigated. In addition, we divided the patients into 65 cases in former period (December 2015) and 63 cases in later period (January 2016-) to compare the incidence of AL. Results AL was observed in 12 cases (9.4%) of the 128 patients. The incidence of AL decreased from 16.9% (11/65) in former period to 1.6% (1/63) in later period (p = 0.004). In comparison between the cases with and without AL (12 cases vs 116cases), statistically significant difference was seen in BMI (average ± SD, 24.2 ± 4.7 vs 21.6 ± 3.1; p = 0.02), anastomotic site (posterior wall/greater curvature, 11/1 vs 54/62; p = 0.004), and level of anastomosis (above/below superior border of manubrium of sternum, 12/0 vs 33/83; p Conclusion Surgical procedure which avoid excessive pressure on the gastric tube from the surrounding structures, such as sternum, may take an important role in reduction of AL after esophagectomy. However, multiple factors, such as nutritional status and obesity, also influence risk of anastomotic leakage.

The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.

Introduction and importance Mediastinal cystic lesions, such as paratracheal air cyst (PTAC) and bronchogenic cyst (BC), are rare anomaly usually found incidentally in thoracic imaging. Special attention is needed in the case of thoracic surgery. Case presentation All three patients were male, 71, 73, and 76 years old. Preoperative CT showed each had a lobular cystic lesion at the right posterolateral side of trachea in the thoracic outlet 11, 14, and 19 mm in size, respectively, with air density and tracheal communication, leading to a diagnosis of PTACs. An oval cystic lesion, 7 mm in size, was found in one patient at the right lateral side of the upper esophagus with low density and without tracheal communication, leading to a diagnosis of paraesophageal BC. Intraoperative findings of the three PTACs demonstrated a soft bulge from the membranous portion of trachea that was left intact. The BC had an oval elastic structure, mimicking a metastatic lymph node, and was removed with the mediastinal lymph nodes. Histological examination showed ciliated columnar epithelium, confirming a diagnosis of BC. Clinical discussion PTACs are associated with increased intraluminal pressure due to chronic lung disease. BCs are congenital anomalies that originate from abnormal budding of the embryonic foregut. Conclusion PTACs and BCs need to be considered in preoperative image diagnosis in patients with esophageal cancer. PTACs should be left intact to avoid tracheal injury, while removal of isolated BCs is recommended as a diagnostic and therapeutic measure., Highlights • Paratracheal air cyst (PTAC) and bronchogenic cyst (BC) are rare anomaly. • Three PTACs and a BC were found in patients who received thoracoscopic esophagectomy for esophageal cancer. • PTACs were carefully left intact to avoid tracheal injury. • BC was removed for diagnostic and therapeutic measure. • PTACs and BCs need to be considered in preoperative image diagnosis in patients with esophageal cancer.

Postoperative early ambulation contributes to the improvement of postoperative outcomes; however, the definition of “early” ambulation is unclear. In this study, we aimed to define desirable “early” ambulation after digestive surgery in terms of short-term outcomes and to identify the risk factors for delayed ambulation. We retrospectively analyzed 718 patients who underwent major digestive surgery between January 2016 and May 2019 in our hospital. The timing of first ambulation after surgery was reviewed and correlated with short-term postoperative outcomes and perioperative patient characteristics. Of 718 patients, 55% underwent first ambulation at postoperative day (POD) 1, 31% at POD 2, and the remaining patients at POD 3 or later. Whereas short-term outcomes were equivalent among patients with first ambulation at POD 1 and those at POD 2, patients who delayed ambulation until POD 3 or after had an increased incidence of infectious complications (P = 0.004), longer hospitalization (P

Highlights • Mesenteric hematoma is a rare condition without specific symptoms. • Rivaroxaban is not affect to the value of PT or APTT. • It is difficult to diagnose mesenteric hematoma., Introduction Mesenteric hematoma is a rare condition caused by bleeding localized in the mesenteric vascular tree. This is a first report of spontaneous mesenteric hematoma caused by rivaroxaban. Presentation of case The patient was a 71-year-old man who had taken rivaroxaban for paroxysmal atrial fibrillation. He had experienced abdominal pain and diarrhea for the prior 3 days. He had little melena and was referred to our institute. He presented with hypotension on arrival. Computed tomography (CT) revealed a 10 cm mass in the mesentery of the sigmoid colon with extravasation. Active bleeding from the sigmoid colic arteries was embolized with angiography on the day of admission. On the second day, we operated on the patient. We detected 200 mL of bloody ascites accumulated in the abdomen. The serosa of the sigmoid colon was ruptured along the tenia due to the compression of the hematoma in the mesentery. The sigmoid colon was resected and a descending colostomy was reconstructed. Operative and pathological findings did not reveal the cause of bleeding. We finally diagnosed the patient with spontaneous mesenteric hematoma associated with rivaroxaban. Discussion Previous reports of mesenteric hematoma with anticoagulant were associated with warfarin. Since rivaroxaban is not affect to the value of prothrombin time (PT) and activated partial thromboplastin time (APTT) and mesenteric hematoma presents non-specific symptoms, it is difficult to diagnose mesenteric hematoma in the patients taking rivaroxaban. Conclusion It is important to keep in mind that mesenteric hematoma is one of the critical complications in patients taking rivaroxaban.

Background Epithelial cell adhesion molecule (EpCAM) is a marker for circulating tumor cells (CTCs) in various types of cancer. Cell surface antigens, such as CD90 and CD44, have been reported to be cancer stem cell (CSC) markers in esophageal squamous cell carcinoma (ESCC). The aim of this study was to assess the use of CD90 and CD44 as markers to identify clinically significant CTC subpopulations in ESCC. Methods We collected 3 mL of peripheral blood from 10 ESCC patients and 10 healthy volunteers to detect combined expression of EpCAM, CD90, and CD40 using flow cytometry. Results The number of EpCAM-positive cell counts (average ± SD) in the patients was significantly higher than healthy volunteers (29.1 ± 35.9 and 2.3 ± 2.5, P = 0.001). The proportions (average ±SD) of CD90- and CD44-positive cells in EpCAM-positive cells were 45.7% ± 42.4% and 98.7% ± 2.7%, respectively. EpCAM-positive/CD44-positive CTC counts, which was equivalent to EpCAM-positive CTC counts, correlated with pathologic V factors in the resected primary tumors (P > 0.01). EpCAM-positive/CD90-positive CTC counts, but not EpCAM-positive/CD90-negative CTC counts, correlated with pathologic V factors in the resected primary tumors (P = 0.01). Our results suggested that combined expression of EpCAM and CD90 may useful to detect CTC subsets, which have highly metastatic features in ESCC. CD44, on the other hand, is equivalent to EpCAM as a marker to detect CTCs in ESCC.

Background Multiple pancreaticoduodenal artery aneurysms in association with median arcuate ligament syndrome (MALS) are relatively rare. A treatment option, such as a median arcuate ligament (MAL) release or embolization of the aneurysms, should be considered in such cases, but the treatment criteria remain unclear. Case report A 75-year-old man was transferred to our hospital because of a ruptured pancreaticoduodenal aneurysm. Emergency angiography showed stenosis of the root of the celiac axis (CA), a ruptured aneurysm of the posterior inferior pancreaticoduodenal artery (PIPDA), and an unruptured aneurysm of the anterior inferior pancreaticoduodenal artery (AIPDA). Coil embolization of the PIPDA was performed. Five days after embolization, the gallbladder became necrotic due to decreased blood flow in the CA region, and an emergency operation was performed. We performed a cholecystectomy and released the MAL to normalize the blood flow of the CA region. However, the patient died on postoperative day 8 because of rupture of the untreated aneurysm of the AIPDA. Conclusions This is the first report of metachronous ruptures of multiple pancreaticoduodenal aneurysms due to MALS, even after a MAL release. Although rare, a residual aneurysm in the pancreatic head region may need to be embolized quickly.

Pneumonia is the second-most common complication in postoperative patients and is associated with significant morbidity and high costs of care. We aimed to determine the risk factors for pneumonia after general and digestive surgery. The medical records of 1,016 patients who underwent general and digestive surgery between January 2016 and March 2019 in our hospital were reviewed. Of the 1,016 patients, 67 (6.6%) developed postoperative pneumonia. The multivariate analysis showed that significant predictors of postoperative pneumonia were a poor Eastern Cooperative Oncology Group performance status (ECOG-PS), low forced vital capacity and low forced expiratory volume in one second in the spirometry test, malnutrition (low serum albumin levels and low controlling nutritional status scores and prognostic nutritional index [PNI] values), esophagectomy, upper gastrointestinal surgery, and nonlaparoscopic surgery. Of these factors, the combination of PNI and ECOG-PS clearly stratified patients into low-, intermediate-, and high-risk groups with respect to developing postoperative pneumonia (area under the curve: 0.709). Although postoperative pneumonia is associated with many clinical variables, active medical intervention for the prevention of pneumonia in patients with multiple risk factors can improve the postoperative course. In particular, perioperative nutritional care may prevent postoperative pneumonia in patients with malnutrition and a poor PS.

658 Background: Early studies raised concerns over whether preoperative treatment led to postoperative complications or even death. In contrast, recent studies have reported that initial treatment (IT) prior to resection of pancreatic ductal adenocarcinoma (PDAC) is safe, with no significant increase in overall morbidity or mortality, despite evidence for more advanced disease. In this study, we analyzed the clinical impact of chemotherapy or chemoradiotherapy as IT, focusing on treatment duration, on morbidity and mortality in patients with resected PDAC. Methods: We enrolled 509 consecutive patients, with 417 in the upfront surgery group and 92 in the IT group. The IT group was subdivided into 72 patients treated for < 8 months and 20 treated ≥8 months. We compared rates of postoperative Clavien–Dindo grade ≥III complications between the groups. Multivariate logistic regression analysis was used to find independent predictors of complications. Results: The upfront surgery and IT groups did not significantly differ in overall postsurgical complications. The rate of postoperative pancreatic fistula was significantly less in the IT group. Rates of other complications did not significantly differ, except for severe infection and delayed gastric emptying. Initiation of adjuvant chemotherapy was later in the IT group than in the upfront surgery group (43.2 vs 57.8 days, P < 0.001). In contrast, rates of overall complications significantly differed between the < 8 months and ≥8 months IT groups, although their background clinical factors did not differ. In multivariate analysis, operative procedure (distal pancreatectomy and distal pancreatectomy with celiac axis resection) (odds ratio [OR] 6.950, P = 0.0416) and IT ≥8 months (OR: 4.508, 95%, P = 0.0156) were independent predictive factors for postoperative complications. Conclusions: The incidence of postoperative complication was similar between the upfront surgery group and the IT group, however, it was significantly higher in the ≥8 months IT group in patients who underwent PDAC resection.

Highlights • A case showed perforation of gastric intramural metastasis from esophageal cancer. • Rapid tumor regression by preoperative chemotherapy may cause the perforation. • Minimally invasive curative resection was achieved by a two-step operation., Introduction Perforation of intramural metastasis to the stomach (IMS) from esophageal cancer during chemotherapy has not been reported. Presentation of case A 68-year-old male consulted our hospital due to appetite loss. He was diagnosed with advanced esophageal squamous cell carcinoma in the lower thoracic esophagus along with a large IMS in the upper stomach. The patient received preoperative chemotherapy of docetaxel, cisplatin, and 5-fluorouracil (DCF). During the second cycle of DCF, he had upper abdominal pain and was diagnosed with gastric perforation. Omental implantation repair for the perforation, peritoneal drainage, tube-gastrostomy, and tube-jejunostomy were performed. At 24 days after emergency surgery, he underwent thoracoscopic radical esophagectomy with total gastrectomy and reconstruction with colonic interposition. Pathological findings in the esophagus demonstrated complete replacement of the tumor by fibrosis. The gastric tumor was replaced by scar tissue with multinucleated giant cells along with a small amount of viable cancer cells. The patient was alive and healthy at 14 months after the radical operation, without tumor recurrence. Discussion The gastric perforation occurred due to rapid regression of the IMS which had involved the whole gastric wall before chemotherapy. Close monitoring to detect rapid tumor shrinkage during chemotherapy in patients with IMS may be warranted. A two-step operation was proposed to achieve safe curative treatment in patients with perforation of IMS during preoperative chemotherapy. Conclusion We describe the first reported case of a patient with esophageal squamous cell carcinoma who showed perforation of IMS during preoperative chemotherapy.

Our previous experimental study of perforated peritonitis in rats proved that peritoneal lavage with strong acid electrolyzed water (SAEW) has no adverse effects, reduces the bacteria count in the ascitic fluid more effectively than saline, and increases the survival rate significantly. Thus, we conducted a randomized controlled study, applying SAEW in the treatment of perforated appendicitis in children. Forty-four patients, aged 3–14 years, were randomly divided into two groups: Group S (n = 20), in which the peritoneal cavity was lavaged with 100 ml/kg saline and the wound was washed out with 200 ml saline; and Group E (n = 24), in which the peritoneal cavity was lavaged with 100 ml/kg SAEW and the wound was washed out with 200 ml SAEW. No adverse effect of SAEW was observed in Group E. There was no difference in the bacterial evanescence ratio of ascitic fluid after lavage between Groups S and E (11.1 and 15.8 %, respectively). A residual abscess developed in one patient from each group (5.0 and 4.2 %, respectively). The incidence of surgical site infection (SSI) was significantly lower in Group E than in Group S (0 and 20 %, respectively; P

Background Mediastinoscopic esophagectomy is a minimally invasive surgery for thoracic esophageal cancer avoiding one-lung ventilation or transthoracic procedure. Methods We performed for the first time in the literature, salvage esophagectomy with combination of mediastinoscopic cervical approach and laparoscopic/mediastinoscopic transhiatal approach for recurrent thoracic esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy (dCRT) in a patient who had previously undergone a left pneumonectomy for primary lung cancer. Results A 66-year-old man was diagnosed as local recurrence of lower ESCC (cT3N0M0 cStage II) at 9 years after dCRT. His medical history included left-sided pneumonectomy for lung adenocarcinoma 9 years previously. Then the patient was diagnosed as lower thoracic ESCC (cT3N1M0 cStage III) at 2 months after pneumonectomy. He received dCRT consisting of CDDP/5-FU infusion and irradiation (60 Gy) and achieved complete response. No evidence of tumor recurrence was observed at endoscopic surveillance up until 6 years after dCRT. For this present surgery, a cervical wound was made and the intramediastinal procedure was performed under pneumomediastinum. After mobilization of upper/middle thoracic esophagus, the esophageal wall was safely separated from the remaining part and the stump of the left main bronchus. Dense adhesions between the esophagus and fibrotic tissue at the site of previous left mediastinal pleural resection was divided using a sealing device. In the abdomen, 5 ports were inserted to perform abdominal and transhiatal procedures under CO2 insufflation. After mobilization of the stomach, fibrotic scar tissue around the lower esophagus was divided using a sealing device and the peri-esophageal space dissected from cervical and transhiatal approach were connected to completely mobilize the thoracic esophagus. The esophagectomy was uneventfully carried out followed by reconstruction with gastric conduit via retrosternal rout. Pathological findings demonstrated a moderately differentiated ESCC (pT3-AD pN1 M0 pStage III), indicating that R0 resection was successfully performed. The patient has been closely observed as an outpatient and was alive and healthy at 3 months after the operation without tumor recurrence. Conclusion Mediastinoscopic esophagectomy is a safe and curative treatment strategy for esophageal cancer patients who had a previous pneumonectomy, even in salvage surgery for recurrent cancer after dCRT. Disclosure All authors have declared no conflicts of interest.

The purpose of this study was to determine reliable predictors of outcome of biliary atresia (BA) after Kasai's operation.Fifty-four BA cases that underwent Kasai's operation at our institution over two decades were reviewed. The cases were divided into two groups: Group I: cases that required liver transplantation or died (n=30) and Group II: cases alive with the native liver. Serum levels of total bilirubin (TB), direct bilirubin (DB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured sequentially after surgery. For cut-off determination, receiver operating characteristic (ROC) analysis was employed.Serum TB, DB, AST, and ALT in Group I were significantly higher than those in Group II at 1, 2, and 3 months after surgery (p.05). The most reliable cut-offs determined by ROC analysis were DB of 0.7 mg/dl at 2 months (sensitivity; 93%, specificity; 75%) and AST of 94 IU/L at 2 months (sensitivity; 87%, specificity; 71%). The 54 cases were re-divided into three groups according to the cut-off values: group G (good) with DB and ASTcut-offs (n=16; Group I:II=1:15), group M (moderate) with DB or ASTcut-offs (n=9; Group I:II=4:5), and group P (poor) with DB and AST ≥ cut-offs (n=29; Group I:II=25:4). The 15-year survival rate in groups G, M, and P was 94%, 44%, and 22%, respectively (p.001).The combination of serum DB and AST at 2 months after Kasai's operation is a reliable predictor of long-term BA outcome.

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a “0-IIb+IIa” lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage.

To investigate the impact of cow's milk allergy (CMA) on infants with Hirschsprung's disease (HD).Twenty-four patients, who developed gastrointestinal symptoms before the age of 60 days and underwent surgery for HD in the period between January 2003 and December 2012, were enrolled in this study. They were divided into two groups based on CMA-related findings: stimulation index of lymphocyte stimulation test300 % and the presence of eosinophilic infiltration in the resected colon. Ten patients were determined specimen as not having CMA (Group A), because they did not satisfy any of the criteria. The remaining 14 were determined as having possible CMA (Group B), because they satisfied either or both findings. Patient background characteristics, pre- and postoperative clinical history, and laboratory data were compared between Groups A and B.Pre- and postoperative enterocolitis did not occur in Group A patients. Postoperative enterocolitis was more frequent in Group B than in Group A (p = 0.04). Other clinical and laboratory data did not show significant difference between the two groups.CMA is a possible risk factor for postoperative enterocolitis in patients with HD.

Background: The p75 neurotrophin receptor (p75NTR) is a cancer stem cell (CSC) marker in esophageal squamous cell carcinoma (ESCC). This study aimed to assess the use of p75NTR in detecting circulating tumor cells (CTCs) in ESCC. Methods: Peripheral blood mononuclear cell expression of epithelial cell adhesion molecule (EpCAM) and p75NTR was detected in 23 ESCC patients (13 received chemo or chemoradiotherapy and 10 received curative surgery) and 10 healthy controls by flow cytometry. Results: EpCAM + p75NTR+ cell counts (average ± SD) were significantly higher in patients (n = 23, 16.0 ± 18.3) compared to controls (n = 10, 0.4 ± 0.9, p = 0.013). The sensitivity and specificity to differentiate ESCC patients from controls were 78.3 and 100 % (cut-off value 4.0), respectively. EpCAM + p75NTR+, but not EpCAM + p75NTR- cell counts, correlated with clinically diagnosed distant metastasis (n = 13, p = 0.006) and pathological venous invasion in resected primary tumors (n = 10, p = 0.016). Malignant cytology was microscopically confirmed in isolated EpCAM + p75NTR+ cells with immunocytochemical double staining. Conclusions: p75NTR is suggested to be a useful marker for clinically significant CTCs, which exhibit highly metastatic features in ESCC.