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To clarify the usefulness of identification of hepatic segmentation stained with an indocyanine green–photodynamic eye (ICG–PDE) system, we sequentially investigated the matching of visualization during hepatectomy in 40 patients at two institutions between 2009 and 2017. A low dose of ICG was administered into the portal flow to stain the estimated segments of the liver to be resected during hepatectomy, and segmentation images were observed using a PDE camera. Intraoperative ICG–PDE could be carried out for all patients without side effects. Complete segmental identification of the liver by blue dye stain and ICG–PDE was achieved in 30 (75%) and 35 (88%) patients, respectively, but the prevalence between them was not significantly different (p = 0.302). ICG–PDE segmentation in the estimated area was incomplete in three patients, and complete failure (no staining) was observed in two patients. The border between the posterior section and the caudate was identified in two patients. This preliminary study showed ICG–PDE to be a useful tool for clearly determining liver segmentation to estimate the area for resection.

Introduction: Tracheal adenoid cystic carcinoma (ACC) is rare and accounts for, International Journal of Surgery Case Reports, 48, pp.26-29; 2018

The VIO soft-coagulation system (VIO) with a monopolar electrode is a novel hemostatic device that provides hemostasis by superficial contact at the bleeding site without carbonization. Because heat injury remains a concern, surgical records and postoperative liver dysfunction were retrospectively evaluated in a cohort study.Between September 2010 and March 2016, 322 patients underwent hepatectomy in which hemostatic devices were used at two institutions. Surgical results with use of VIO at one institute (VIO group) were compared with those without use of VIO at a second institute (control group), and propensity analysis was performed.In limited resection and segmentectomy or sectionectomy performed in the VIO group, the prevalence of liver cirrhosis was significantly higher and the operation time was significantly longer in comparison with the control group (p 0.05). In all hepatectomies, postoperative levels of total bilirubin and aspartate or alanine transaminase tended to be increased and prothrombin activity tended to be lower in the VIO group in comparison with the control group (p 0.05). The prevalence of hepatic failure in the VIO group was significantly higher in comparison with that in the control group (p 0.05). In cases of segmentectomy or sectionectomy, blood loss was significantly increased in the VIO group in comparison with that in the control group (p 0.05) Propensity score matching showed that although the surgical records and outcomes were not significantly different between the groups, postoperative liver dysfunction was significant in the VIO group in comparison with the control group (p 0.05).Mild postoperative hepatic thermal injury with VIO was confirmed, and therefore, surgeons should take care when using the VIO system to make frequent wide resected cuts on the surface of the liver.

Highlights • The increased screening results in more pick up multiple primary tumors and that they are being reported more. • Diagnosis and treatment of multiple primary tumors is usually difficult. • A cancer board can be useful for this process., Introduction Multiple primary neoplasms are relatively rare, but their incidence has increased because of aging and improvements in diagnostic imaging. Presentation of case A 67-year-old man presented with epigastric pain. On upper gastrointestinal endoscopy, an ulcer was seen at the gastric angle, and biopsy showed moderately differentiated adenocarcinoma (AC). Colonoscopy demonstrated a 15-mm lesion in the sigmoid colon and a submucosal lesion in the lower rectum. The biopsy showed well differentiated AC and neuroendocrine tumor (NET). In addition, abdominal CT and MRI showed a 14-mm nodular lesion in the pancreatic body suggesting pancreatic duct cancer. Based on the above findings, four synchronous cancers, including the pancreas, stomach, sigmoid colon and rectum, were diagnosed, and surgery was performed. A midline incision was made in the upper abdomen, and a distal gastrectomy, pancreatic body and tail resection, and sigmoidectomy were performed. Trans-anal tumor resection was performed for the rectal lesion. Histopathology showed invasive pancreatic duct cancer, moderately differentiated AC of the stomach, moderately differentiated AC of the sigmoid colon, and NET G1 of the rectum. The patient had no postoperative complications, 4 years 3 months after resection, and he was disease-free from all of the cancers. Discussion The strategy of perioperative diagnosis and treatment for multiple primary tumors is usually difficult. This process was performed by consulting a cancer board, which could be useful as a practice guideline. Conclusion This patient in whom four tumors were completely resected at the same time and who has had a good clinical course was reported.

Highlights • SILS is one of the approaches to scarless surgery. • SILS technique is not easy because of the restricted movement and requires a long learning curve. • An organ retractor is effective for SILS not only to maintain a good operative view, but also to shorten the learning curve., Introduction Single-incision laparoscopic surgery has been reported to be a safe and feasible technique for colorectal cancer. However, the technique needs skill due to the limitations of the device. An organ retractor is a new grasp device that has the potential to overcome these limitations. Presentation of case A 63-year-old woman with a tumor palpated in the right lower quadrant of the abdomen presented to hospital. Colonoscopy showed a type 2 mass with nearly complete stenosis, and a biopsy specimen showed well-differentiated adenocarcinoma. Single-incision laparoscopic surgery ileocecal resection was performed using an organ retractor. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted. An organ retractor was used for hepatocolic ligament resection, resection of the ileocolic vessels, and resection of the insertion of the mesentery proper. For each resection, the trailer line’s tension was adjusted to provide a good operative view. The patient’s postoperative course was good, and she was discharged 7 days after surgery. Discussion An organ retractor was effective for single-incision laparoscopic surgery technique not only to maintain a good operative view, but also to change trailer line tension, which enabled safe dissection. Conclusion An organ retractor could facilitate single-incision laparoscopic surgery.

Introduction: The indocyanine green-photodynamic eye (ICG-PDE) system is useful to detect small hypervascular liver tumors, hepatocellular carcinoma (HCC), on the liver surface. This system may be also applied to improve determining the location of metastasis or tumor thrombus (TT). We herein report three case reports. ICG was administered preoperatively for functional testing and images of the tumor were observed during hepatectomy using a PDE camera. Case series: The patient in case 1 exhibited advanced HCC with TT in the portal trunk. The TT in the right portal vein was clearly fluorescent by ICG-PDE and the right portal vein was adequately transected to remove TT. The patient in case 2 exhibited a large HCC in the right liver and the right adrenal gland was simultaneously swollen with enhancement. By confirming the fluorescent spot in the right adrenal gland, the metastasized lesion was completely resected. The patient in case 3 previously underwent central bi-segmentectomy, and lymph node metastasis and TT in the vena cava was observed during one-year follow-up. Although it was difficult to detect the definite margin of these lesions by the outline appearance, both lesions could be clearly observed with strong fluorescence and were completely resected. Discussion and conclusion: ICG-PDE is a useful tool for detecting the precise tumor location even in extrahepatic tumor lesions, such as metastases or tumor thrombus, which is useful for deciding which parts to resect., International Journal of Surgery Case Reports, 46, pp.56-61; 2018

Pulmonary emphysema is a progressive disease with airspace destruction and an effective therapy is needed. Keratinocyte growth factor (KGF) promotes pulmonary epithelial proliferation and has the potential to induce lung regeneration. The aim of this study was to determine the possibility of using KGF gene therapy for treatment of a mouse emphysema model induced by porcine pancreatic elastase (PPE). Eight-week-old BALB/c male mice treated with intra-tracheal PPE administration were transfected with 80 μg of a recombinant human KGF (rhKGF)-expressing FLAG-CMV14 plasmid (pKGF-FLAG gene), or with the pFLAG gene expressing plasmid as a control, into the quadriceps muscle by electroporation. In the lung, the expression of proliferating cell nuclear antigen (PCNA) was augmented, and surfactant protein A (SP-A) and KGF receptor (KGFR) were co-expressed in PCNA-positive cells. Moreover, endogenous KGF and KGFR gene expression increased significantly by pKGF-FLAG gene transfection. Arterial blood gas analysis revealed that the PaO2 level was not significantly reduced on day 14 after PPE instillation with pKGF-FLAG gene transfection compared to that of normal mice. These results indicated that KGF gene therapy with electroporation stimulated lung epithelial proliferation and protected depression of pulmonary function in a mouse emphysema model, suggesting a possible method of treating pulmonary emphysema., Acta Histochemica et Cytochemica, 48(3), pp.83-94; 2015

Backgrounds/Aims Preoperative nutritional status has been reported to influence patient outcomes after pancreatectomy. The Prognostic Nutritional Index (PNI) is a useful parameter to reflect the outcomes of patients undergoing gastrointestinal surgery. Therefore, the relationship between the PNI and clinicopathological factors, surgical data, and postoperative morbidity were retrospectively evaluated at two academic institutes in a cohort study. Methods Curative pancreatectomy was performed on 222 patients at the University of Nagasaki between 1995 and March 2015, and 101 at the University of Miyazaki between April 2015and March 2018. The PNI was calculated using preoperative albumin and total cholesterol levels. Results The mean PNI in our series was 39.2±5.4 and the prevalence of PNIs less than 40 was observed in 134 patients (44%). The PNI was not significantly different between normal, hard, and fatty architecture of the pancreatic parenchyma. The PNIs were significantly negatively correlated with higher age (p

Keratinocyte growth factor (KGF) is considered to be one of the most important mitogens for lung epithelial cells. The objectives of this study were to confirm the effectiveness of intratracheal injection of recombinant human KGF (rhKGF) during compensatory lung growth and to optimize the instillation protocol. Here, trilobectomy in adult rat was performed, followed by intratracheal rhKGF instillation with low (0.4 mg/kg) and high (4 mg/kg) doses at various time-points. The proliferation of alveolar cells was assessed by the immunostaining for proliferating cell nuclear antigen (PCNA) in the residual lung. We also investigated other immunohistochemical parameters such as KGF, KGF receptor and surfactant protein A as well as terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling. Consequently, intratracheal single injection of rhKGF in high dose group significantly increased PCNA labeling index (LI) of alveolar cells in the remaining lung. Surprisingly, there was no difference in PCNA LI between low and high doses of rhKGF with daily injection, and PCNA LI reached a plateau level with 2 days-consecutive administration (about 60%). Our results indicate that even at low dose, daily intratracheal injection is effective to maintain high proliferative states during the early phase of compensatory lung growth., ACTA HISTOCHEMICA ET CYTOCHEMICA, 46(6), pp.179-185; 2013

Introduction Meckel's diverticulum (MD) is a congenital true diverticulum that is residual yolk duct tissue, and some cases with complications require surgery. It has been reported that laparoscopic surgery is effective for patients with an MD. Presentation of case A 79-year-old man with melena visited our hospital. Upper gastrointestinal series and colonoscopy showed no bleeding lesion. Double-balloon endoscopy was then performed to examine the small intestine. The examination showed a large diverticulum 80 cm proximal to the ileocecal valve and a circular ulcer. MD resection was performed using single-incision laparoscopic surgery (SILS) technique through a 3-cm zig-zag incision in the umbilicus. Three ports were inserted for the scope and forceps devices. The MD was located 80 cm proximal to the ileocecal valve. There were no other intestinal lesions. From the wound, the lesion could be easily moved outside the body. The MD including the ulcer lesion was then resected. The patient's postoperative course was good, and he rarely felt wound pain. He started dietary intake three days after surgery and was discharged from hospital eight days after surgery. Discussion SILS technique has attracted attention in the field of laparoscopic surgery. Using a single port with multiple working channels, SILS can reduce the number of incisions and the rates of incisional hernia port site-related complications, as well as improve cosmesis. Conclusion A definite diagnosis of an MD was made by double-balloon endoscopy preoperatively. The SILS approach was effective for cosmesis, postoperative pain, and a shortened hospital stay., International Journal of Surgery Case Reports, 33, pp.67-70; 2017

症例は84歳，男性．心窩部痛を主訴に受診．腹部CT検査では膵全体に多発する嚢胞が指摘され，また膵体部に3cm大の嚢胞に隣接した3cm大の低濃度腫瘍を認めた．内視鏡的逆行性膵管造影検査では膵体部での主膵管の著明な狭窄と尾側膵管の数珠状の拡張を呈していた．超音波内視鏡検査では嚢胞内の結節から膵実質の不整な腫瘍への連続性を認め，膵管内乳頭粘液性腫瘍（IPMN）に由来した膵癌が疑われた．膵体尾部切除術を施行し病理組織学的検査で膵IPMNに由来した膵腺扁平上皮癌の診断を得た．術後経過は良好で術後23カ月無再発生存中である．膵IPMNに由来した膵腺扁平上皮癌の報告はまれであり若干の文献的考察を加えて報告する．

症例は77歳，男性．14年前に気管腺様嚢胞癌に対し気管管状切除術を施行，術後局所再発予防目的に計60Gyの放射線治療が行われた．術後6年目，8年目に転移性肺腫瘍を認め肺部分切除術が施行された．初回手術より14年後に多発する転移性肝腫瘍が指摘され，肝拡大後区域切除術+ラジオ波焼灼術を施行，4年の無再発生存期間が得られた．現在新たに右腎転移を認めており切除を最優先として治療方針を検討中である．気管腺様嚢胞癌の遠隔転移に対する切除例の報告は少なく，なかでも肝転移切除症例の報告は1例のみときわめてまれである．気管腺様嚢胞癌は長い経過で遠隔転移をきたす特徴があるが，再発巣に対する積極的外科的切除により長期生存も可能であると思われ，今回報告した．

We evaluated the efficacy and safety of the administration of low-dose unfractionated heparin(LDUH)for the prevention of pulmonary thromboembolism after lung cancer surgery. We operated on 206 patients with primary lung cancer for 8 years;128 males and 78 females, mean age:69.9±8.8 years. All patients were administrated LDUH 5,000 units every 12 hours from the operation day until the day when the patient could walk around the floor. No patients suffered from clinical pulmonary thromboembolism in this period. The duration of treatment was 4.6±2.6 days and the chest tube duration was 5.4±3.0 days. We experienced post-operative intra-thoracic bleeding in 2 patients during the previous 4 years. Based on this experience, we introduced new eligibility criteria;we discontinued LDUH administration on the operation day if diffuse adhesion in the thoracic cavity was observed at operation or intraoperative blood loss was over 500 ml. The dose of LDUH was decreased to 2,500 unit every 12 hours if the postoperative bleeding was over 400 ml on the operation day or the patient's body weight was less than 40 kg. After introduction of the new criteria, no severe bleeding complications occurred during the latter 4 years.

Hepatectomy is accepted as the standard therapy in patients with resectable liver metastases. In recent years, the techniques such as microwave coagulation therapy (MCT) and radiofrequency ablation therapy (RFA) have been developed, so we have many options to treat. We evaluated nineteen subjects with cases of liver metastases who underwent thermoablative procedures with or without hepatectomy. RFA and MCT were used in 6 cases and 2 cases, respectively. In other 11 cases, they received a combined therapy: RFA+hepatectomy in 5 cases, and MCT+hepatectomy in 6 cases. Thermoablative therapy was used for 39 metastatic tumors. The mean tumor size was 13.7 mm, and a local recurrence was observed in 8 nodules (21%). No significant differences were observed in DFS and OS between thermoablative therapy and hepatectomy. Many patients with liver metastases received a repeated treatment, so we have to care about the remnant liver function. We conclude that thermoablative therapy with hepatectomy seems to be a less invasive procedure and effective therapy.

OBJECTIVE: In rats pulmonary resection is followed by lung compensatory growth. However, the molecular mechanism underlying lung compensatory growth remains unclear. Keratinocyte growth factor is expressed in lung tissue and is considered a possible mitogen for lung epithelial cells. The objectives of this study were to define the role of keratinocyte growth factor and its receptor in rat lung compensatory growth after trilobectomy and the effect of exogenous keratinocyte growth factor gene transfection. METHODS: Adult Lewis rats were used. Right trilobectomy was performed in the operation group and sham thoracotomy in the sham group. In the operation group, keratinocyte growth factor-FLAG or FLAG expression vector was transfected directly into the lung by means of electroporation. Expression of keratinocyte growth factor and its receptor and alveolar cell proliferation index based on proliferating cell nuclear antigen levels were measured in the right lung at day 14 after the operation. RESULTS: Proliferating cell nuclear antigen, keratinocyte growth factor, and keratinocyte growth factor receptor expression in lung epithelial cells was significantly increased at day 4 after trilobectomy. Transfection of keratinocyte growth factor-FLAG expression vector resulted in further significant enhancement of proliferating cell nuclear antigen at day 4 after trilobectomy; however, the transfection of FLAG expression vector did not alter the enhancement of proliferating cell nuclear antigen. Exogenous expression of keratinocyte growth factor in the remaining lung by means of electroporation significantly augmented epithelial proliferation and decreased the average airspace distance (mean linear intercept). CONCLUSION: Our results implicate keratinocyte growth factor in the induction of alveolar epithelial cell proliferation for compensatory lung growth and indicate that overexpression of keratinocyte growth factor in the remaining lung by means of electroporation significantly augmented lung epithelial proliferation., The Journal of thoracic and cardiovascular surgery, 137(6), pp.1499-1507; 2009