We have performed totally laparoscopic stomach-partitioning gastrojejunostomy for gastroduodenal outlet obstruction caused by advanced malignancies in 14 cases. We divided 14 patients into 2 groups according to age at surgery: those<80 years of age and thoseB80 years of age. We compared these 2 groups regarding preoperative status, operative findings, and postoperative course. We found that the stage of cancer in the older group was lower than in the younger group, the number of unresectable factors in the older group were fewer than in the younger group, and the postoperative stay in the older group was shorter than in the younger group. There were no serious postoperative complications in either group and all 14 patients were able to drink or eat the day after surgery. These results suggest that palliative, totally laparoscopic stomachpartitioning gastrojejunostomy may be the best option for elderly cancer patients with gastroduodenal outlet obstruction caused by advanced malignancies, even when their general conditions is poor. We should consider this surgical procedure as soon as possible when the patient decides on palliative treatment.
The aim of this study was to evaluate the long-term patency rate and complications associated with the use of the BBAVF in the early period.The records of all patients undergoing BBAVFs for hemodialysis access between June 2001 and June 2011 were retrospectively evaluated. We allowed the use of the BBAVF beginning two weeks after the fistula creation. The primary and secondary patencies were estimated using the Kaplan-Meier method.A total of 44 BBAVFs were created for 41 patients. Most (73.2%) of the patients had previously been on hemodialysis. A previous history of AVG creation was noted in 36.6% and previous insertion of a catheter was reported for 72.7% of the patients, respectively. The mean time to the first cannulation of the BBAVF was 18.8 days (13-42 days). In two cases, the BBAVFs were not used. Postoperative complications were noted in 2 cases, and included prolonged arm edema and thrombosis. There was no infection of the wound or steal syndrome. The primary and secondary patency rates were 68.1% and 84.2% at 1 year, 55.0% and 80.7% at 2 years, and 38.1% and 70.1% at 5 years, respectively.In this study, the patency rates following the early use of the BBAVFs were not inferior to the previously reported patency rates in the literature. In cases where the patients already have an inserted central catheter, the early use of the BBAVFs decreases the complications associated with catheters.
Familial adenomatous polyposis(FAP)is an autosomal dominantly inherited disorder, and the result of a germ line variant in the adenomatous poplyposis coli(APC)gene. FAP can be associated with various extracolonic lesions including thyroid cancer, which frequently occurs in women. We report the case of a 15-year-old woman diagnosed as FAP with multiple thyroid papillary carcinomas. Her mother had been treated for FAP with colorectal cancer and thyroid cancer in our department. Multiple tumors with a maximum diameter of 17 mm were detected in the right lobe of the thyroid gland during the preoperative examination. Papillary carcinoma was suspected based on fine-needle aspiration cytology. She was diagnosed with FAP because of multiple polyps on colonoscopy. We performed a subtotal thyroidectomy. Pathological findings revealed a cribriform-morular variant of papillary thyroid carcinoma. We report a rare case of papillary carcinoma of thyroid associated with FAP in a younger woman.
Endocytoscopy (EC) facilitates real-time histological diagnosis of esophageal lesions in vivo. We developed a deep-learning artificial intelligence (AI) system for analysis of EC images and compared its diagnostic ability with that of an expert pathologist and nonexpert endoscopists. Our new AI was based on a vision transformer model (DeiT) and trained using 7983 EC images of the esophagus (2368 malignant and 5615 nonmalignant). The AI evaluated 114 randomly arranged EC pictures (33 ESCC and 81 nonmalignant lesions) from 38 consecutive cases. An expert pathologist and two nonexpert endoscopists also analyzed the same image set according to the modified type classification (adding four EC features of nonmalignant lesions to our previous classification). The area under the curve calculated from the receiver-operating characteristic curve for the AI analysis was 0.92. In per-image analysis, the overall accuracy of the AI, pathologist, and two endoscopists was 91.2%, 91.2%, 85.9%, and 83.3%, respectively. The kappa value between the pathologist and the AI, and between the two endoscopists and the AI showed moderate concordance; that between the pathologist and the two endoscopists showed poor concordance. In per-patient analysis, the overall accuracy of the AI, pathologist, and two endoscopists was 94.7%, 92.1%, 86.8%, and 89.5%, respectively. The modified type classification aided high overall diagnostic accuracy by the pathologist and nonexpert endoscopists. The diagnostic ability of the AI was equal or superior to that of the experienced pathologist. AI is expected to support endoscopists in diagnosing esophageal lesions based on EC images.
The case was a 75-year-old man. The patient had back pain and an abdominal CT scan was performed. The scan revealed an 8 cm mass in the left lower abdomen, containing both fatty and solid components. An abdominal MRI showed the mass had shifted position, with the solid component exhibiting high signal intensity on diffusion-weighted imaging, suggesting a liposarcoma originating from the small bowel mesentery. For diagnosis and treatment, laparoscopic-assisted surgery was performed. Laparoscopic observation revealed a mobile mass within the jejunal mesentery, and a small laparotomy was conducted to remove it. Histologically, the tumor was identified as a liposarcoma with both well-differentiated and dedifferentiated components. There was no recurrence for 6 years after the surgery.
We experienced a case of low-grade appendiceal mucinous neoplasm complicated by pseudomyxoma peritonei that was successfully treated with cytoreductive surgery and early postoperative intraperitoneal chemotherapy. The patient was a 26- year-old man with massive ascites and a swollen appendix on the computed tomography(CT). The appendix was a cystic mass of 5 cm in size. The entire parietal peritoneum, omentum, stomach, spleen, gall bladder, and entire colon were covered with numerous mucous nodules. Total colectomy, total gastrectomy, splenectomy, cholecystectomy, total omentectomy, parietal peritonectomy, ileostomy, and intraperitoneal irrigation were performed. The pathological diagnosis was low-grade appendiceal mucinous neoplasm. Postoperative intraperitoneal chemotherapy with cisplatin and mitomycin C was performed. A residual tumor was found on the dorsal side of the hepatoduodenal ligament 3 months postoperation on the CT. The residual tumor was successfully excised via a concomitant resection of the hepatic caudate lobe. Postoperative intraperitoneal chemotherapy was then performed. No recurrence was found at 8 months postoperation. The addition of early postoperative intraperitoneal chemotherapy improved the patient's quality of life in a short period. This could be one of the treatment options.
A 54-year-old woman underwent high anterior resection with D3 lymphadenectomy for rectal cancer at another hospital. She was diagnosed with well-differentiated adenocarcinoma of rectal cancer, pT3, N1, H0, P0, M0, fStage III a. She did not receive adjuvant chemotherapy. Eighteen months after surgery, abdominal CT at our hospital showed a 19mm-sized mass in S7 of the liver. EOB-MRI also showed a mass in the same location. The mass was a ring contrast-enhanced lesion on dynamic phase, had a low signal pattern on liver cell phase, and had high signal pattern on diffusion-weighted imaging. As such, it was diagnosed as liver metastasis of rectal cancer, and surgery was performed. During surgery, the tumor was found to be located between the liver and diaphragm. Thus, we performed partial resection of the liver diaphragm. Histopathologically, the tumor was the same well-differentiated adenocarcinoma as the primary tumor. In addition, the tumor existed only in the diaphragm and was pumping out the liver. Therefore, we diagnosed the tumor as a diaphragm metastasis of rectal cancer. On literature review, only 8 reports of colorectal metastatic tumors involving the diaphragm were found.
A 72 year-old man was admitted to the hospital to receive treatment for resting pain and an ulcer, which had developed on an amputation stump, 4 months after he had undergone a thrombectomy, below-the-knee popliteal-dorsal pedis artery bypass of his left leg, and digital amputation of his 2nd toe. Angiography demonstrated diffuse arterial and bypass occlusion in his left leg that did not include a sural artery, which was the main collateral. Therefore, the patient underwent reversed saphenous vein bypass from the common femoral artery to the medial sural artery. His leg pain disappeared, and the ulcer healed promptly.
