Purpose: This study was conducted to evaluate the effectiveness of the Endo GIA™ Reinforced Reload with Tri-Staple™ to prevent duodenal stump leakage after laparoscopic gastrectomy with Roux-en-Y reconstruction.

Methods: 74 cases who received laparoscopic gastrectomy with Roux-en-Y reconstruction during May 2013 to October 2015 were enrolled in this study. Duodenal stump was closured with the Reinforced Reload with Tri-Staple™ in 37 patients and it was also closed with the Endo GIA™ Reload with Tri-Staple™ in the remaining 37 patients. We compared postoperative complications.

Results: There were no differences between two groups in clinicopathological features. Postoperative duodenal stump leakages occurred in one patient (2.7％) in each of the two groups (p=1.00).

Conclusions: These results suggest that the Reinforced Reload with Tri-Staple™ is as safe as conventional linear staplers for duodenal stump closure.

We report our experience and outcomes of single-incision simultaneous laparoscopic surgery (SISLS) for two different abdominal diseases. During recent 5 years we performed SISLS in 5 patients. The mean age was 63.6 years, and 2 males and 3 females. Their preoperative diagnoses were cholecystolithasis and liver cyst in 2 cases, cholecystolithasis and chronic appendicitis, cholecystolithasis and gastric submucosal tumor and gastric submucosal tumor and right inguinal hernia in one, respectively. The operative approach used 3-ports glove method of 5-mm instruments from a transumbilical longitudinal incision 2.5 cm in diameter. There were no conversions to conventional or open method. They consisted of cholecystectomy and unroofing in 2 cases, cholecystectomy and appendectomy, cholecystectomy and local resection of stomach, and local resection of stomach and inguinal herniorrhaphy in one, respectively. The mean operation time, estimated blood loss and postoperative hospital stay were 120.8 min, 13.6 ml and 4.8 days. SISLS is a feasible and safe procedure without the elongation of operation time under the strict indication and an experienced surgeon of single-incision laparoscopic surgery.

【Object】Sacral neuromodulation (SNM), a minimally invasive surgical method, was introduced for patients with refractory fecal incontinence in 2014. Short-term outcomes were studied. 【Method】Seven patients showing poor results with conservative treatment were included in this study. Preoperative mano-volumetric data were compared in patients and healthy controls, and short-term outcomes were studied. 【Result】The vector volume (p=0.010) and maximum resting pressure (p=0.004) were significantly lower in patients than in healthy controls, but the high-pressure zone (p=0.256) and maximum squeeze pressure (p=0.682) were not significantly different between the two groups. The Cleveland Clinic Florida Fecal Incontinence Score (CCF-FI score) significantly improved from 14.6 to 9.3 after surgery. 【Conclusion】SNM is a minimally invasive method useful for treatment of refractory fecal incontinence, based on short-term outcomes. However, more cases and long-term follow-up need to be studied.

We designed a new method for laparoscopic ventral hernia operation. We put the first port on the top of the hernia orifice with a small incision, called “Hernia orifice precedent approach”. We can easily reach intraperitoneal free space through hernia orifice, because hernia site is usually the thinnest abdominal wall. We can also utilize the small incision to deal with laparoscopic surgical devices and to fix the mesh onto abdominal wall. Furthermore, we can perform trimmings of the surplus hernia-sac to prevent occurring seroma as we used to perform in open method ventral hernia operation. By our procedure, first of all, we can easily get reached to intraperitoneal free space. Moreover, we can fix the surgical mesh surely and give the preventive treatment for postoperative complications. Thus, this technique keeps not only the low invasiveness element of the laparoscopic surgery but has advantages of the open method surgery. These points are particularly useful for fatty patients with ventral hernia.

In the first case, a 92-year-old woman with Alzheimerʼs disease and cerebral infarction had swallowed a dental prosthesis. Chest radiography showed a dental prosthesis with a clasp in the upper esophagus. Emergency direct esophagoscopy was performed, but the prosthesis could not be removed. Therefore, esophagotomy was performed with right thoracotomy. Additionally, a gastrostomy was performed at the same time as the surgery. In the second case, an 82-year-old woman with dementia and cerebral infarction complained of odynophagia after swallowing a dental prosthesis 2 days previously. Chest radiography showed a dental prosthesis with a clasp in the esophagus. After an unsuccessful attempt to remove the prosthesis by esophagoscopy, an esophagotomy was performed with right thoracotomy. As in the first case, a gastrostomy was performed at the same time.

We encountered two cases of elderly people with dementia who underwent removal of an esophageal foreign body (dental prosthesis with clasp) by right thoracotomy. Although right thoracotomy is a high-risk procedure for elderly patients, it is important to perform a gastrostomy at the same time to allow treatment after surgery.

A 66-year-old women admitted to our hospital because of left breast pain. She was performed core needle biopsy, and was diagnosed that her tumor was invasive lobular carcinoma of the breast, ER + / PgR- / HER2 1+ / Ki-67 30%. After complete evaluation, her tumor was deemed inoperable. Endocrine therapy was begun, but the effect was poor, thus, chemotherapy was initiated. She complained of severe coughing while drinking water and dysphagia 1 year later. Barium contrast esophagography showed a smooth, tapered narrowing at middle of the esophagus, and esophagoscopy revealed a circumferential stenosis without mucosal abnormality in the middle esophagus. Chest computed tomography scan showed esophageal wall thickness and stenosis of the middle thoracic esophagus, and she was diagnosed with esophageal metastasis. Dilatation by endoscopic balloon and metallic stent was performed, but stenosis was not relieved. After that, chest CT scan revealed esophagobronchial fistula. 6 months later, she had hematemesis, and an aortoesophageal fistula was identified by CT scan. She subsequently died of massive hematemesis and hemoptysis.

A 60-year-old man with anemia was referred to our hospital. Esophagogastroduodenoscopy revealed a type 1 gastric tumor with bleeding, and endoscopic mucosal resection was performed. Pathological examination revealed that the tumor was gastric cancer, and that the vertical margin of the specimen was positive for malignancy. Total gastrectomy was performed as additional surgical treatment. Intraoperatively, we discovered that the duodenum descended to the right, and that the small intestine was situated unilaterally in the right abdominal cavity. The cecum and ascending colon were not fixed to the retroperitoneum, and the entire colon was located in the middle to left abdominal cavity. We observed formation of Laddʼs Ligament, so we diagnosed this case as intestinal malrotation. After total gastrectomy, the Laddʼs ligament was dissected. The jejunum was lifted through the right side of the ascending colon, and Roux-en-Y reconstruction was performed. Appendectomy was also performed. In cases of surgery for gastric cancer with intestinal malrotation, we need to consider surgical procedures including treatment of intestinal malrotation and reconstruction of the digestive tract. However, as similar cases are rare, there are no standard operating procedures. Here, we report our case with a review of the relevant literature.

A 35-year-old female was referred to our hospital. Gastrointestinal endoscopy showed 50mm 0-Ⅱc lesion in the posterior wall of the upper gastric body and 25mm 0-Ⅱc lesion in the lesser curvature of the angle. On biopsy pathology, mucosa-associated lymphoid tissue (MALT) lymphoma was diagnosed in 50mm lesion and signet ring cell carcinoma was diagnosed in 25mm lesion. Chest and abdominal CT scans showed no lymph node swelling. Urea breath test showed positive, we diagnosed she was infected by Helicobacter pylori. Preoperatively, the MALT lymphoma diagnosed Lugano staging I, and the gastric cancer diagnosed L, Post, Less, Gre, 0-Ⅱc (25mm), T1aN0M0 Stage IA. The patient underwent a total gastrectomy. Finally, the MALT lymphoma diagnosed Lugano staging I, and the gastric cancer diagnosed L, Post, Less, Gre, 0-Ⅱc (17×13mm), T1aN0M0 Stage IA. We report a very rare case of simultaneous primary gastric MALT lymphoma and of early gastric cancer. It is important to determine method of treatment, considering effectiveness and quality of life after treatment.

The case pertains to an 85-year-old man that visited our hospital due to epigastric pain. An ulcer-like lesion was observed in the greater curvature of the lower stomach upon upper gastrointestinal endoscopy and concave reddened sites accompanied by atrophia continuing from the same site to the esophagogastric junction were observed in the posterior wall and lesser curvature. No malignant findings were observed from the reddened mucosal sites; however, well-differentiated adenocarcinoma was observed from the ulcerated lesion upon a biopsy. Upon close inspection, the patient was diagnosed with early Stage gastric cancer L 0Ⅱ-c (UL+) N0 M0. However, malignant findings of the reddened lesion could not be dismissed, so a total gastrectomy was carried out along with D1+lymph node dissection and Roux-en-Y reconstruction. A diffused submucosal heterotopic gastric gland corresponding to the reddened lesion was observed upon pathological diagnosis and intramucosal cancer in two sections was observed in addition to the cancer (M cancer) found prior to surgery.

We encountered a rare case of the rupture of a left gastroepiploic artery aneurysm due to segmental arterial mediolysis. A 79-year-old man who had chest pain was transferred to our hospital due to the suspicion of angina pectoris. Based on angiocardiography, he had no severe coronary stenosis, and so we decided to admit him to the ICU without intravascular treatment. After hospitalization he was stable, but the next day he suddenly developed intense abdominal pain, and his blood pressure dropped. Computed tomography revealed the presence of ascites and the leakage of contrast medium outside of blood vessels at the central part of the gastric corpus. We diagnosed the patient with intra-abdominal hemorrhage and hemorrhagic shock caused by rupture of a gastric artery aneurysm, and decided to perform emergency surgery. During the operation, we found of the many hematomas in the abdominal cavity and active bleeding from the left gastroepiploic artery. We could stop the bleeding by partial resection of the greater omentum including the artery. Histopathologic findings indicated the presence of acute arterial dissection in the left gastroepiploic artery and marked segmental arterial mediolysis (SAM) as the background of lesions. His post-operative course was uneventful, and he was discharged on the 36th post-operative day.

A 76-year-old man suffering from continuous vomiting was referred to our hospital. Abdominal mass was palpable, and CT scan showed a huge abdominal cystiform tumor (20cm in diameter) and a whirl sign of the jejunum accompanied by a dilation of the oral side intestine. The tumor had papillary nodules inside of the cystic wall, while FDG-PET showed no FDG accumulation in the nodules. Meanwhile, FDG accumulated in the transverse colon liver flexure abnormally, suggesting coincidence of colon cancer. We diagnosed him as a case of volvulus of the small intestine induced by the small intestininal tumor, and performed an elective surgery. A huge cystiform tumor was located in the jejunum at about 10 cm from the ligament of Treitz, and the tumor had caused rotation of the jejunum at 180°, with the mesenteric vessels as the rotational axis. We underwent a partial resection of the jejunum including the tumor. Additionally, we performed colectomy with D3 lymph node dissection for the coexisted transverse colon cancer. Histopathologically, the cystiform tumor was diagnosed as GIST, which was positive for c-kit. Our case is the ninth reported in Japan as GIST of jejunum with small intestinal volvulus.

A 66-year-old female was transferred to our hospital with lower abdominal pain. Computed tomography revealed free-air spots on the peritoneum and in the uterus with an abnormal thickening of the sigmoid colon. Peritoneal and uterus perforations caused by sigmoid tumor were diagnosed. Therefore, an emergent surgery was planned. On performing laparotomy, it was observed that white infectious ascites leaked from the pelvis. Sigmoid colon tumor had adhered tightly to the uterus, and the uterus was perforated. Supravaginal amputation of the uterus, bilateral salpingo-oophorectomy, sigmoid colectomy, and D3 lymph node dissection were performed. Final diagnosis was acute disseminated peritonitis from uterine perforation in pyometra caused by sigmoid colon adenocarcinoma. No gynecological malignancy was found in the uterus. Pyometra generally occurs in elderly people and is caused by excretion disorder of the uterus cavity secretions. In our patient, the sigmoid colon adenocarcinoma had tightly adhered to the uterus and elicited excretion disorder; then, pyometra occurred in the uterus. The patient had left the pyometra; thereby argent peritonitis occurred due to uterus perforation in pyometra.

A 45-year-old woman was referred to a nearby clinic, complaining of left lower abdominal pain. Colonoscopy revealed stenosis of the rectosigmoid, although the biopsy only found inflammatory cells. On the other hand, abdominal contrast-enhanced computed tomography and pelvic magnetic resonance imaging showed tumor lesions in the anterior wall of the rectosigmoid behind the uterine cervix. In the diagnosis, we suspected intestinal endometriosis strongly because of the clinical course and examination results.

Laparoscopic high anterior resection was performed. Histopathologocal findings confirmed the diagnosis of endometriosis of the rectosigmoid. The postoperative course was uneventful and she was discharged from our hospital in the 9^th postoperative day.

An 81-year-old man was admitted with general malaise and constipation. Colonoscopy showed a type 2 circular tumor 5cm from the anal verge. CT and MRI showed signs of invasion in the prostate and the sacrum (cT4b). Because he had bowel obstruction symptoms, we firstly constructed a colostomy. After that, six cycles of mFOLFOX6 systemic chemotherapy was administered. CT and MRI after chemotherapy showed reduction in tumor size and disappearance of tumor invasion. Seven weeks after chemotherapy, he underwent abdominoperineal resection without any other organ resection. Histological examination revealed negative margin. Tumor regression grading of chemotherapy was Grade 2. At the follow-up 20 months after surgery, he was alive without recurrence. With our present experience, we consider that mFOLFOX6 preoperative chemotherapy regimen could have a local effect comparable with chemo radiation for locally advanced rectal cancer.

Case 1: A 66-year-old man was transported to the emergency room with malaise and anorexia. Emphysematous cholecystitis was suspected based on abdominal CT, and emergency percutaneous transhepatic gallbladder drainage (PTGBD) was thus performed. The patient was discharged on hospital day 11 with the PTGBD tube clamped. However, the clamp had to be released because of relapse of cholecystitis, and open cholecystectomy was performed on day 37. Acute cholecystitis was confirmed by pathological findings.

Case 2: A 60-year-old man was referred to our clinic with upper abdominal pain. Emergency PTGBD was performed for emphysematous cholecystitis identified by abdominal CT. The PTGBD tube was clamped on hospital day 11, but cholecystitis relapsed. Thus, the patient underwent laparoscopic cholecystectomy on day 19. Acute necrotic cholecystitis was identified based on pathological findings.

The bile culture detected Clostridium perfringens in these two cases. Both patients had a good postoperative course and were discharged 15 days and 8 days, respectively, after the cholecystectomy.

Emphysematous cholecystitis, which is a variant of acute cholecystitis according to the guidelines, frequently leads to a serious condition. PTGBD may also be useful in high-risk patients with this form of cholecystitis, which is classified as a severe complication.

A 57-year-old woman who had a diagnosis of asymptomatic primary biliary cirrhosis (PBC) at 40 years old, was admitted to another hospital because of jaundice. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) revealed an obstruction site in the distal bile duct. She was placed an endoscopic retrograde biliary drainage (ERBD) tube in the common bile duct for obstructive jaundice. She was referred to our hospital for the purpose of surgical treatment. We made the diagnosis of the distal bile duct carcinoma associated with PBC and performed pancreaticoduodenectomy with a modified Childʼs method and liver biopsy. The resected specimen of the distal bile duct showed a 2.5cm nodular-infiltrating tumor. Histopathological examination revealed distal bile duct carcinoma associated with Scheuerʼs classification Ⅱ-Ⅲ PBC. The postoperative course was uneventful and she was discharged on the 37th postoperative day. However, liver metastases were observed 12 months after surgery, and she died of liver metastases 28 months after surgery. Although PBC complicated by malignant tumors is common, the bile duct carcinoma associated with PBC is rare. We herein report a surgical case of distal bile duct carcinoma associated with PBC and provide a review of the literature.

Pancreatic arteriovenous malformation is very rare disease. We report a case of pancreatic arteriovenous malformation associated with duodenal ulcer. A 48-year-old man complaining of black stool was admitted to hospital. A gastrointestinal fiberscopic examination revealed a ulcer on oral side of the papilla of Vater. Abdominal contrast-enhanced CT showed hypervascular lesion in pancreatic head. Celiac and superior mesenteric arteriogram showed racemose vascular network in the head of pancreas and filling of portal vein in the early arterial phase. With a diagnosis of pancreatic arteriovenous malformation or hypervascular tumor, we underwent pylorus- preserving pancreaticoduodenectmy. Arteriovenous-malformation was diagnosed in pathology.

Robot–assisted Laparoscopic Prostatectomy (RALP) is one of the newest modality for treatment of prostate cancer, and has great advantages including good stereoscopic visualization and good manoeuvrability. Thus, the number of RALPs performed in Japan is rapidly increasing. We started performing RALPs in June, 2014. Within the first twenty-eight candidates for this surgery, there were three cases in which RALP were avoided. The first case had a 60mL volume prostate protruding into the bladder. The second case had history of transurethral resection of the prostate, and was under observation for unruptured cerebral aneurysm. The third case had thrombi in the subclavian and common carotid arteries. The patient also had history of repeated laparoscopic inguinal hernia repair (LIHR), thus adhesion in the pelvis was expected. The first two cases underwent minimum incision endoscopic surgery. The third case underwent high-dose radiation therapy. Possible influence of LIHR on prostatectomy should be known widely. Even after sufficient experience with the procedure, in such cases where complications due to the Trendelenburg position is a concern, other modalities should be considered.

A 84-year-old man was reffered to our hospital because of a growing mass in his left inguinal area. Abdominal enhanced CT showed a large tumor, 19cm in a diameter which occupied left lower abdomen and grow into the inguinal canal. FDG-PET CT revealed a FDG accumulation in the tumor. The tumor showed a low signal intensity on a T1-weighted image, a high signal intensity on a T2-weighted image and a heterogenous contrast effect on contrast-enhanced MRI. Although it was suspected malignant stromal tumor or sarcoma, we did not do biopsy of the tumor because the risk of dissemination. For the purpose of diagnosis and total removal of the tumor, operation was underwent. Histopathological examination revealed growth of spindle cells, and immunohistopathological staining was positive for CDK4, MDM2 and p16, finally it was diagnosed retroperitoneal dedifferentiated liposarcoma. Whereas, the MIB-I positive rate was 30%. The patient is doing well one year and half after surgery, with no signs of reccurrence.

A woman in her 70s was admitted to our hospital suffering from abdominal pain. She had slight abdominal fullness and tenderness in the left lower abdomen. Abdominal computed tomography (CT) showed mild dilatation of the small intestine. A second abdominal CT scan was performed due to the patientʼs complaints of increased pain. The small intestine was more dilatated, and the sigmoid mesocolon was herniated from the inside to the outside. Given these findings, we diagnosed the patient with mesosigmoid hernia and performed emergency surgery. The intraoperative findings revealed that the small intestine was located in the left abdomen, through the hiatus in the mesosigmoid. We pull out the incarcerated small intestine and closed the hiatus. Mesosigmoid hernia is a rare disease, and only 15 cases have been reported in Japan. A preoperative diagnosis is very difficult, and to our knowledge, our case is the first to be diagnosed before operation.

An 80s man was examined by a local physician for the chief complaints of abdominal pain, distended abdomen, and vomiting. Abdominal x-ray revealed dilatation of the small bowel, leading to a diagnosis of intestinal obstruction. The patient was then referred to our hospital. Abdominal computed tomography revealed marked dilatation of the small bowel; hence, the patient was directly admitted to the hospital. His only remarkable medical history was hypertension, and he had never undergone laparotomy. Following admission to the hospital, an ileus tube was inserted for conservative treatment. As the intestinal obstruction showed no improvement, laparoscopic surgery was performed on the ninth day of hospitalization. Observation of the abdominal cavity revealed that the small bowel was strangulated in an abnormal depression in the left sigmoid mesocolon, leading to a diagnosis of intersigmoid hernia. The strangulated portion of small bowel was then laparoscopically released. As the previously strangulated portion of small bowel showed good coloring and no signs of necrosis, the intestinal tract was not resected and the surgery was completed after expanding the hernia orifice. Postoperative progress was satisfactory, and the patient was discharged from hospital on the seventh postoperative day. Together with a brief discussion of the literature, this study reports a case in which an intersigmoid hernia, a relatively rare disorder, was laparoscopically repositioned.

A 64-year-old woman was admitted to our hospital for a 15-cm retroperitoneal cystic tumor, which, on testing, showed abnormally high FDG-PET uptake (maximal standardized uptake: 6.09). The tumor was suspected of malignant potential, and was resected with a combined laparoscopic and perineal approach. She was discharged from the hospital on postoperative day 18 without any post-operative complications. The tumor was histologically diagnosed as a presacral epidermoid cyst, and was benign, despite CT and FDG-PET results suggestive of malignancy. Because presacral epidermoid cysts are difficult to diagnose as benign or malignant preoperatively, complete resection is necessary. The combined laparoscopic and perineal approach can be useful for tumors that invade other organs or organs that are very large.