Laparoscopic subtotal cholecystectomy (LSC) has been recognized as a safe and feasible alternative surgical procedure for a difficult laparoscopic cholecystectomy (LC) with severe inflammation in Calot’s triangle. We compared the surgical outcomes of cholecystectomy for acute cholecystitis between standard LC and LSC using laparoscopic linear stapler. 172 patients were diagnosed as acute cholecystitis, among them, 16 patients who underwent LSC and other 156 patients who underwent standard LC were enrolled in this study. The severity grading of acute cholecystitis in LSC group was significantly higher than LC group. Operation time was longer in the LSC group than LC group. LSC had significantly more intraoperative blood loss compared to LC. However, there was no significant difference in the postoperative complications between two groups. LSC using laparoscopic linear stapler contributes surgeons avoid common bile duct injury in difficult LC.

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Introduction: Lactate level and clearance were hypothesized to be potential prognostic factors for mortality in patients with refractory cardiogenic shock who underwent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). This study aimed to determine the prognosis of VA-ECMO patients and whether the lactate level at intensive care unit (ICU) admission (La) and at 24 h after VA-ECMO induction (L24), minimum (L24min) or maximum (L24max) lactate level within 24 h after VAECMO induction, and/or maximum lactate level after ICU admission (Lmax) could predict ICU mortality in VA-ECMO patients. Materials and Methods: This retrospective observational study included consecutive patients who underwent VA-ECMO for severe cardiogenic shock and admitted to the ICU in a hospital from April 2009 to March 2017. Risk factors for ICU mortality with respect to lactate levels after VA-ECMO induction were determined through multiple logistic regression analysis. Results: VA-ECMO induction was performed in 67 adult patients, of whom 23 (34.3%) survived to ICU discharge. La, L24min, L24max, and Lmax were risk factors for ICU mortality in VA-ECMO patients after adjustment for the Acute Physiology and Chronic Health Evaluation II score and use of continuous renal replacement therapy and refractory ventricular arrhythmia after VA-ECMO induction, which were confounding factors in univariate analysis (La: odds ratio [OR], 1.44; 95% confidence interval [CI], 1.13-2.05; L24min: OR, 1.20; 95% CI, 1.01-2.56; L24max: OR, 1.44; 95% CI, 1.11-2.02; Lmax: OR, 1.52; 95% CI, 1.14-2.21). Conclusion: Lactate levels can be a therapeutic target and indicator of the need for improved patient management after VAECMO induction.

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Background: Lenvatinib is one of the few therapeutic options available for radioiodine-refractory thyroid cancer. However, the factors that determine the therapeutic outcomes remain unknown. Methods: Patients with thyroid carcinoma treated with lenvatinib who had been dead or who had survived for longer than a halfyear were retrospectively compared. We evaluated the clinical parameters when lenvatinib was started, and also studied the tumor volume reduction ratio, the duration until re-growth of the largest metastatic lesion, the thyroglobulin (Tg) reduction rate, and the duration until re-elevation of Tg after lenvatinib between survivors and dead patients. Results: We identified 16 patients, with an average age of 73.1±7.6 yrs and a male-to-female ratio of 5 to 11, who had advanced differentiated thyroid cancer that was treated with lenvatinib. Nine patients had died after 8.9±6.1 months, whereas 7 survived for 13.0±2.0 months after starting lenvatinib. The patients who died were older than the survivors (76.7±6.5 vs. 68.6±6.6 yrs, p=0.03). Malignant pleural effusion (p=0.017) and symptomatic metastatic disease (SMD) (p=0.039) were associated with death in a Kaplan-Meier survival analysis. Age (p=0.012, HR 1.150, CI 1.030-1.320) and SMD (p=0.014, HR 8.069, CI 1.503-61.34) were associated with poor outcome in a multivariate Cox proportional hazard model. The duration until the re-elevation of Tg was longer in survivors than in patients who died (6.43±4.55 vs. 2.17±1.39 months, p=0.025). Conclusions: We identified multiple factors, including SMD, that were related to poor outcomes after lenvatinib treatment. This study suggests that lenvatinib might be started before patients develop SMD.

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Graves’ disease is an autoimmune disorder that induces increase in thyroid hormone production and release. Although euthyroid should be desirable to ensure a safe operation, some patients still undergo thyroidectomy with hyperthyroidism. The aim of this study was to evaluate our preoperative strategies in patients with Graves’ disease. A total of 186 patients underwent thyroidectomy for Graves’ disease between 2003 and 2017. We gave all of these patients potassium iodide (KI) in order to decrease their thyroid hormone levels. We compared the clinical factors among three groups defined by the value of serum free triiodothyronine (FT3) after the administration of KI: (1) the good control group (n=126) with ≤ 6.0 pg/mL, (2) the fair control group (n=35) with > 6.0 but ≤ 10.0 pg/mL, and (3) the poor control group (n=25) with > 10.0 pg/mL. KI decreased the serum levels of thyroid hormone. However, some patients still had hyperthyroidism, and the subsequent administration of corticosteroid reduced FT3 but not thyroxine. Regarding the intraoperative course, the heart rate at 1 h after beginning general anesthesia was higher in the poor control group than in the good control group (p < 0.05), and the proportion of patients given adrenergic beta-blocker was higher in the poor control group than in the other groups (p < 0.01 each). One patient in the fair control group experienced suspected thyroid storm after total thyroidectomy. The occurrence rate of other deteriorations was identical among the three groups. With preparative KI and corticosteroid administration, almost all patients with Graves’ disease were able to undergo thyroidectomy safely.

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Ciliated hepatic foregut cysts (CHFC) are extremely rare, and most are benign cysts of the liver arising from remnants of the embryonic foregut. CHFC is usually found incidentally and as mostly asymptomatic cysts. We report squamous cell carcinoma (SCC) arising in a CHFC in a 50-year-old Japanese woman. She consulted our hospital for upper abdominal pain. A computed tomography and an ultrasound showed a cystic region including calcification and a solid mass in segment 4 of the liver. Left hepatectomy, B6 bile duct resection, and biliary-jejunal anastomosis were performed. Microscopic examination revealed that part of the cyst was lined by a characteristic ciliated pseudostratified columnar epithelium surrounding a connective tissue, a slightly thick fibrotic smooth muscle stromal layer, and an outer fibrous capsule. The cyst wall contained a low-papillary mural nodule showing atypical squamous hyperplasia with high-grade dysplasia. Stromal invasion was identified at the base of the nodule, leading to the diagnosis of well-differentiated SCC arising from a CHFC. We recommend careful clinical follow-up for patients with relatively large CHFCs as potentially malignant lesions and excision if they show any clinical manifestation.

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Simultaneous occurrence of non-Hodgkin’s lymphoma (NHL) and solid carcinomas, such as colon, lung, and breast cancers, is relatively rare. We report a case of coincidental detection of diffuse large B-cell lymphoma (DLBCL) in the inner inguinal lymph node of a patient with uterine endometrial cancer FIGO stage IA. The patient was a 69-year-old woman and she visited a primary care doctor presenting with increased vaginal discharge. She was diagnosed as having uterine endometrial carcinoma. Laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection were performed. The final pathologic examination revealed uterine endometrial carcinoma (endometrioid carcinoma grade 1) and DLBCL was detected in the inner inguinal lymph node. No other malignant lymphoma legions were detected by positron emission tomography-computed tomography (PET-CT). She was diagnosed as having uterine endometrial carcinoma FIGO stage IA (pT1apN0pM0) and malignant lymphoma stage I according to the Ann Arbor clinical staging system. She was treated with six cycles of chemotherapy comprising rituximab, cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP) for the malignant lymphoma. The patient remains in complete remission 8 months after completing chemotherapy.

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