Introduction: Despite the remarkable improvements in surgical techniques and technological advancements in the medical instruments used, anastomotic leakage (AL) still remains a serious complication after laparoscopic low anterior resection (Lap-LAR) of the rectum. The definitive mechanism underlying the occurrence of AL remains unclear, and the relationship between postoperative diarrhea and AL is still unknown.

Methods: This study was a retrospective study performed at a single institution in 65 consecutive patients with rectal cancer who underwent Lap-LAR by the double-stapling technique (DST) for anastomosis between January 2011 and April 2015. Various candidate factors associated with symptomatic AL were examined by univariate analyses. Furthermore, an additional analysis was also conducted to investigate the relation between diarrhea developing in the early phase after operation and the occurrence of AL.

Results: The rate of occurrence of symptomatic AL was 7.7% (5/65 cases). Univariate analysis only identified undoing of a diverting ileostomy creation as tending to be associated with the risk of development of AL (p = 0.07). Further analysis revealed a strong association between early postoperative diarrhea and the risk of AL in patients without a diverting stoma (p < 0.01).

Conclusions: Postoperative diarrhea occurring in the early phase after Lap-LAR may be a notable risk factor for symptomatic AL, especially in patients without a diverting stoma.

Purpose: We performed a prospective study to verify whether the safety or severity of postoperative pain could be affected by the number of trocars inserted for laparoscopic cholecystectomy (LC).

Methods: A total of 305 patients, after excluding subjects fitting the exclusion criteria, undergoing LC were randomly allocated to the 3-port LC group (n=153) or the 4-port LC group (n=152). The severity of postoperative wound pain was evaluated by the visual analogue scale (VAS) and by the number of postoperative analgesic doses required. The patient satisfaction was also estimated using VAS.

Results: There were no significant differences between the two groups in the VAS scores for wound pain, number of postoperative analgesic doses required, VAS scores for patient satisfaction, operation time, bleeding volume, or postoperative hospital stay. There was no case of conversion to laparotomy or intraoperative bile duct injury, although 3 cases of the 3-port LC group needed conversion to 4-port LC (2.0%).

Conclusion: Three-port LC was equivalent to 4-port LC in terms of the severity of postoperative pain and patient safety/satisfaction. Therefore, 3-port LC could potentially be established as the standard procedure for LC, with preparedness for additional trocar use in difficult cases.

Purpose: To use thermography as a blood flow evaluation method to determine the site of anastomosis during laparoscopic anterior rectal resection.

Methods: We enrolled 30 patients who underwent laparoscopic anterior rectal resection for rectal cancer. During the operation, the temperature around the planned site of anastomosis in the intestinal tract was measured by thermography, and the intestinal incision was made at the site where the temperature difference from a site 10 cm orad was under 2 degrees. We investigated various factors, including the incidence of postoperative suture failure.

Results: The characteristics of the 30 patients were as follows: mean age, 63.7 years; male/female ratio, 16:14. The tumor site was the RS in 16 cases, Ra in 9 cases, and Rb in 5 cases. Surgery was performed via the laparoscopic approach in all cases, with high anterior resection performed in 16 (53.3%) cases, low anterior resection in 9 (30.0%) cases, and super low anterior resection in 15 cases (16.7%). The intestinal incision site was determined by thermographic evaluation in all cases, and incision and anastomosis were performed. The maximum value of the measured temperature in each case was 32.5˚C, the minimum value was 28.8˚C, and the difference was 3.7˚C. Change of the incision site was required in 4 cases, and the final intestinal temperature (30.5˚C ± 2.02˚C) at the site of anastomosis was under 2 degrees in all cases as compared to the temperature at a site 10 cm orad (30.6˚C ± 0.97˚C). There were no cases of postoperative suture failure was observed.

Conclusion: Intestinal blood flow evaluation by thermography during laparoscopic anterior rectal resection for rectal cancer serves as an objective method that is minimally invasive and inexpensive. Further research is needed on the effect of such evaluation in preventing suture failure.

The patient was a 53-year old woman who had noticed a right breast mass three weeks earlier and presented herself at a clinic for examination. She was diagnosed as having right breast angiosarcoma, breast cancer, cecal cancer and uterine cancer. Eleven years earlier, she had been diagnosed as having right breast cancer and received chemotherapy and radiotherapy without surgery. She gave a family history of juvenile rectal cancer. She was treated by hysterectomy and ileocecal resection, and underwent right mastectomy, axillary dissection and skin grafting a month later. The final pathological diagnosis of the breast tumor was a collision cancer between angiosarcoma and invasive ductal carcinoma. She was diagnosed as having Li-Fraumeni syndrome (LFS) and underwent genetic counselling. She received adjuvant chemotherapy (weekly paclitaxel) for 6 months after the surgeries, but the angiosarcoma showed local recurrence and she received pazopanib therapy. We report a case of radiation-induced collision cancer between breast angiosarcoma and invasive ductal carcinoma in a patient with LFS.

A 73-year-old man was referred to our hospital for the evaluation of dysphagia. He was diagnosed as having esophageal cancer, and histological examination of biopsy specimens revealed mixed neuroendocrine carcinoma and squamous cell carcinoma. As the tumor was resectable by surgery, we performed esophagectomy with two-field lymphadenectomy. Currently, there is no consensus on the treatment of mixed-type neuroendocrine carcinoma and squamous cell carcinoma. Therefore, herein, we discuss the methods that could be used to treat this kind of complicated tumor with some review of the literature.

A 67-year-old female patient was diagnosed as having a gastrointestinal stromal tumor (GIST) during a medical checkup. Esophagogastroduodenoscopy revealed a submucosal tumor with an ulcer in the fundus of the stomach. Abdominal CT showed a mass measuring 67 mm in diameter, that invaded the diaphragm and the left adrenal gland. Because the patient refused consent for resection, we administered imatinib mesylate for 3 months. Since the tumor shrank to a diameter of 32 mm from 67 mm, the patient was referred again for resection and underwent robotic-assisted laparoscopic proximal gastrectomy with double-flap reconstruction. Histopathologically, the tumor was replaced by tissue showing hyaloid changes. Immunohistochemically, the tumor cells were negative for all of the GIST-related markers, and pathological complete response was achieved. During the 14 months of monitoring, no evidence of recurrence was detected. We report a case of gastric GIST, which became resectable by minimally invasive surgery after neoadjuvant chemotherapy with imatinib mesylate, and pathological complete response was obtained.

Gastric volvulus is a rare disease, but is sometimes recurrent. Therefore, it should be treated by surgery. We report the case of an adult patient with gastric volvulus and hiatal hernia who was treated by laparoscopic surgery. An 84-year-old woman with a history of vomiting was referred to our hospital. She gave a history of having been diagnosed as having gastric volvulus thrice in the previous 6 months. Abdominal computed tomography showed mesentero-axial gastric volvulus with a hiatal hernia. We performed esophagogastroduodenoscopy, which revealed no areas of necrosis. Therefore, we retained a stomach tube, released the hernia, and discharged the patient. Three days later, however, the patient returned with recurrent gastric volvulus, and we performed laparoscopic surgery. First, we performed reefing of the esophageal hiatus and reconstructed the cardia by the Toupet method. Then, we performed gastropexy between the greater curvature and the left diaphragm. The postoperative course was uneventful. Until now, 7 months after the surgery, there has been no recurrence. Laparoscopic gastropexy for gastric volvulus is considered to be a minimally invasive and safe method, even if there is hiatal hernia.

The patient was a 66-year-old male. Distal gastrectomy (D2 dissection) was performed for lower-body type 3 gastric cancer. Histopathology revealed L, Post, Type3, 70×60 mm, por2, pT4a, int, INFc, ly3, v1, pN3a (8/20), pPM0 (25 mm), pDM (50 mm), CY0, StageⅢC. Postoperative adjuvant chemotherapy (Tegafur/Gimeracil/Oteracil; TS-1^®) was administered for one year. There was no apparent recurrence until one year eight months after the surgery, when the patient presented with headaches, dizziness, vomiting, nausea, blacking out in the right eye, and double vision. Although a head CT/MRI revealed no obvious abnormalities, the findings of cerebrospinal fluid examination led to the diagnosis of meningeal carcinoma secondary to gastric cancer. A ventriculo-peritoneal shunt (hereinafter, VP shunt) was placed and administration of methotrexate (hereinafter, MTX) into the medullary cavity through the shunt was initiated. The patient’s symptoms improved and it became possible for him to return to work. Meningeal carcinoma from gastric cancer is rare and the prognosis is said to be very poor. Herein, we report a patient, along with a review of the pertinent literature, who showed a relatively prolonged survival of 11 months from the onset of intracranial hypertension among patients with meningeal carcinomatosis.

An 80-year-old woman was admitted to our hospital complaining of abdominal pain. She was diagnosed as having enteritis, prescribed medications, and discharged home. Subsequently, she returned to our hospital again complaining of vomiting and bloating. Abdominal computed tomography performed a second time at admission showed ascites on the liver surface and intestinal edema, which had not been observed in the first CT performed at the previous admission. The patient had a history of having undergone surgery for appendicitis, so suspecting the possibility of strangulated bowel obstruction caused by adhesions, we performed emergency laparotomy. A hard substance was detected in the intestinal tract about 10 cm proximal to the terminal ileum, and we diagnosed the patient as having food-induced bowel obstruction. The hard substance could not be negotiated through the Bauhin valve, so that we had to cut the intestinal tract open to remove it appeared to be a fibrous bolus. Food residue in the oral intestinal tract was drained as much as possible, and the incision was closed with sutures. A postoperative questionnaire confirmed that the patient had eaten dried apples. Cases of food-induced bowel obstruction caused by dried fruits are extremely rare, with only three previous reports, in addition to our own case. Dried fruits should be considered as a possible cause in the differential diagnosis of food-induced bowel obstruction.

The patient was a 63-year-old female patient who had undergone endovascular aneurysm repair with placement of a graft for dissecting aortic aneurysm thrice. Furthermore, she had also undergone aortic replacement for endoleak after stent-graft failure. CE-CT after the surgery revealed superior mesenteric artery dissection, ascending colon contrast failure, and cholecystitis, and emergency laparotomy was performed on the same day. Intraoperatively, the small intestine was found to be not necrotic. Therefore, we performed indocyanine green (ICG) fluorography, which provided a contrast-enhancing effect, and we performed only cholecystectomy. While the patient required intensive care postoperatively, she was discharged from our hospital 71 days after the surgery.

ICG fluorography is a simple and objective blood flow evaluation method that can be used during operation, and is useful to accurately identify areas of necrosis during emergency surgery for ischemic bowel disease.

We report a case of primary jejunal cancer located near the Treitz ligament that was treated by laparoscopic-assisted surgery, along with a review of the pertinent literature. An 80-year old woman visited our hospital with the complaints of melena and anemia. Although we could not detect the cause of the anemia by upper and lower gastrointestinal endoscopy, capsule endoscopy revealed a lesion with slight bleeding in the jejunum. Enteroscopy revealed a tumor measuring about 20 mm in diameter at a site approximately 5 cm anal to the Treitz ligament. Under a preoperative diagnosis of primary jejunal adenocarcinoma, we performed laparoscopic-assisted surgery. After mobilization of the duodenum by a laparoscopic-assisted procedure, tumor resection with lymph node dissection and duodenojejunostomy were performed via a mini-laparotomy. The histopathological diagnosis of the tumor was well-differentiated jejunal adenocarcinoma (StageⅠ). At present, 3 months since the surgery, the patient survives, without any evidence of recurrence.

We report the case of a patient with ruptured pseudoaneurysm of the hepatic artery following laparoscopic cholecystectomy for acute cholecystitis. The patient was a 75-year-old man who presented to his neighborhood clinic with fever and right upper abdominal pain. He was diagnosed as having acute cholecystitis with cholelithiasis, and transferred to our hospital for further examination and treatment. After initial conservative therapy, we performed laparoscopic cholecystectomy on day 6 after admission. On postoperative day 2, the patient developed hypotension, anemia and liver dysfunction. Abdominal CT revealed a liver hematoma and emergency TAE was performed. Pseudoaneurysms in peripheral branches of the right hepatic artery and left hepatic artery replaced from the left gastric artery were detected and embolized. Because our case showed evidence of fluid collection on the surface of the liver, we considered that the perihepatic abscess could have caused the rupture of the hepatic artery pseudoaneurysm.

A 79-year-old man with Huntington’s disease (HD) was referred to Ageo Central General Hospital for acute abdominal pain. Abdominal CT showed an enlarged gallbladder, with thickening of the gallbladder wall. Due to his comorbidities and for further study for jaundice, we selected PTGBD instead of emergent surgical intervention. The patient was discharged with a drain in place, but due to uncontrolled involuntary movements, his drain became dislodged. Then, we performed elective laparoscopic cholecystectomy, without complications. Herein, we report a case of acute cholecystitis in a patient with HD who was successfully treated by laparoscopic cholecystectomy, suggesting that such patients could also be treated according to the usual guidelines.

The patient was a 77-year-old female patient who had undergone nephrectomy for right renal cell carcinoma 13 years ago. She presented to us with nausea, and CT showed two hypervascular tumors in the pancreas measuring 40 mm and 9 mm in diameter. The tumor measuring 40 mm in diameter showed a heterogeneous area within it, which was assumed to represent an area of necrosis. On MRI, the tumors were visualized as low-intensity areas on T1WI and as high-intensity areas on T2WI, and had capsule-like structures. There was no evidence of any other metastatic lesions. Based on the history and imaging findings, we suspected the tumors as being pancreatic metastases from renal cell carcinoma. Distal pancreatectomy with splenectomy was performed, considering her age and QOL. After the surgery, the patient developed a pancreatic fistula, ISGPF grade A, and remnant pancreatitis, but she could be discharged from the hospital after 30 days. We finally diagnosed the patient as a case of pancreatic metastasis from renal cell carcinoma, because the histopathological findings showed that the tumor was composed clear cells. In addition to the lesions detected in the preoperative images, histopathological examination revealed another micro metastasis measuring 2 mm in diameter. Pancreatic metastasis from renal cell carcinoma is rare. We encountered a case of renal cell carcinoma who presented with pancreatic metastatic tumors 13 years after nephrectomy, and report our case herein, along with the relevant literature.

The patient was an 83-year-old woman who presented with a history of dysphagia for two years. Examination revealed an abnormal opacity on the chest X-ray, and she was referred to our hospital. CT imaging revealed dislocation of the stomach into the mediastinum through the esophageal hiatus and a defect in the abdominal wall at the lateral edge of the left rectus abdominis muscle with prolapse of fatty tissue through the defect.

We diagnosed the patient as having both esophageal hiatal hernia and a Spigelian hernia, and performed laparoscopic hernia repair for both. The hiatal hernia defect was closed by primary suture of the diaphragmatic crus and reinforced by mesh placement, followed by Toupet fundoplication. At the same time, the Spigelian hernia was repaired using a mesh.

To the best of my knowledge, this is the first case report of esophageal hiatal hernia and Spigelian hernia repaired by laparoscopic surgery at the same time in the Japanese literature.