A case of surgical treatment for bronchial foreign bodies with obstructive pneumonia

Children and older adults are prone to unintentional foreign body aspiration. A 69-year-old man with fever and anorexia presented with obstructive pneumonia resulting from foreign body aspiration. Attempts to remove the foreign body using a bronchoscope failed due to its adhesion to the periphery of the bronchus. Although antibiotic therapy did not improve the obstructive pneumonia caused by the bronchial foreign body, surgery enabled an improvement. The surgical specimen showed similar pathological findings as the fine brown granular material observed in root granulomas occurring as a complication following leakage of root canal filling used in the treatment of dental caries. Therefore, the bronchial foreign body may have been a dental filling. Case reports describing surgical improvement of difficult-to-remove bronchial foreign bodies with concurrent infection are rare.

[A Case of Transcatheter Arterial Chemoembolization and Surgical Resection of Left 7th Rib Metastasis after Surgery for Hepatocellular Carcinoma]

The patient was an 81-year-old man. After a liver posterior segmentectomy for hepatocellular carcinoma, a painful bulge was observed in the left anterior thoracic region during a routine outpatient visit. Elevated tumor markers and contrast- enhanced CT scan revealed a mass with contrast effect in the left 7th rib. Ultrasound-guided biopsy revealed hepatocellular carcinoma metastatic to the left 7th rib. There were no other obvious metastases, and the diagnosis of a single bone metastasis was made. The patient did not request chemotherapy and underwent transcatheter arterial chemoembolization 4 times. The patient did not show any improvement in tumor markers or shrinkage of the tumor, and his quality of life was deteriorated due to increased pain. The patient underwent left chest wall tumor resection and chest wall reconstruction. Postoperative tumor markers were normalized and pain improved markedly. We report a case of postoperative recurrence- free survival for 2 years.

PET Scanning May Not Distinguish Benign Schwannoma from Metastasis in a Patient with Lung Adenocarcinoma

A 69-year-old man was diagnosed with lung adenocarcinoma with metastasis because two masses in the right intercostal space and right back muscle showed high accumulation on positron emission tomography (PET). The 6-month treatment with osimertinib significantly reduced his lung lesion, but no changes were observed in the metastatic lesions. Needle biopsy revealed that the lesion in the right back muscle was a schwannoma. Surgical resection revealed that the right intercostal lesion was also a schwannoma; subsequently, a right upper lobectomy was performed. The patient was finally diagnosed with lung adenocarcinoma without metastasis. High accumulations of lesions observed on PET may indicate schwannomas.

LEARNING POINTS

Benign schwannomas could show high accumulations on positron emission tomography.Accurate diagnosis of schwannoma using only images is quite challenging.Histological examinations should be considered when asymptomatic lesions are suspected to be metastases.

Intrapleural Urokinase Injection after Medical Thoracoscopy for Empyema and Complicated Para-Pneumonic Effusion: A Case Series

Empyema and complicated para-pneumonic effusion (CPPE) often require surgical intervention because of insufficient antibiotic effect and chest tube drainage. From January 2017 to September 2021, we encountered seven patients who underwent intrapleural urokinase injection after medical thoracoscopy for the treatment of empyema or CPPE. None of the seven patients required further surgical interventions or showed any complications associated with the therapeutic procedures. The combined use of intrapleural urokinase injections and medical thoracoscopy may be an effective and safe therapeutic option for the management of empyema and CPPE.

Emergency laparoscopic trans-abdominal pre-peritoneal repair (TAPP) for irreducible inguinal hernia in Covid-19 patient: A case report and literature review

Introduction

With the global pandemic of COVID-19 for over two years, we might have to proceed surgical operation of patients with COVID-19 infection because of its emergency. Here we present a case who received an emergency operation for an irreducible inguinal hernia with COVID-19. We safely performed trans-abdominal pre-peritoneal repair (TAPP) in one surgery without any problems.

Presentation of case

52-year-old male with no specific past medical history came to the emergency department with complaints of right inguinal bulging and abdominal pain. On physical examination, a bulge in the right inguinal region was observed, so a right irreducible inguinal hernia was suspected. Since he had fever, we conducted a COVID-19 antigen test and it was positive. For we could not return with manually, and we decided to perform emergency surgery with appropriate infection control techniques. After laparoscopic return of the intestinal tract, a mesh was implanted using TAPP. The patient was discharged 2 days after surgery.

Discussion

Even in pandemic of COVID-19, cases of irreducible inguinal hernia could be occur. COVID-19 has systemic inflammation, so we worried about mesh infection. But this patient took TAPP safely in emergency surgery with COVID-19.

Conclusion

We experienced a case of TAPP proceeded patient with COVID-19. We considered that placement of a foreign material is acceptable when it is necessary in COVID-19 patient safely.

Axillary Lymph Node Swelling After COVID-19 Booster Vaccination: Japanese Case Report and Literature Review

BACKGROUND/AIM

COVID-19 has been a global pandemic for more than 2 years, and vaccination against COVID-19 using an mRNA vaccine is widespread. The COVID-19 vaccination can cause specific side-effects, such as axillary lymph node swelling; therefore, breast oncologists should pay attention to such occurrences. Initially, only two COVID-19 vaccinations were planned; however, in some countries third or fourth vaccines have been administered. Here, we present a female case who developed axillary lymph node swelling after her third vaccination. We have also reviewed the literature regarding this side-effect after a third or fourth COVID-19 vaccination.

CASE REPORT

A 64-year-old woman who came to our clinic regarding a mammography abnormality in her left breast. She had no palpable mass, but a left breast mass was shown by mammography, and ultrasonography and magnetic resonance imaging indicated a hamartoma. At 2 months after her second COVID-19 vaccination when she underwent these tests, she had no axillary lymph node swelling. We planned a follow-up after 6 months. At her next visit, by chance, she underwent ultrasonography 14 days after she received a third COVID-19 vaccination, and a swollen axillary lymph node was observed.

CONCLUSION

Axillary lymph node swelling can occur after a third COVID-19 vaccination. Therefore, breast oncologists will have to consider this side-effect of COVID-19 vaccination when diagnosing breast tumors.

Timing and Duration of Axillary Lymph Node Swelling After COVID-19 Vaccination: Japanese Case Report and Literature Review

BACKGROUND/AIM

COVID-19 vaccination is now performed in most of the world to limit the spread of the disease. The first mRNA vaccine was approved in clinical settings and has specific side effects including axillary lymph node swelling, which can be misdiagnosed as breast cancer metastasis. The timing of axillary lymph node swelling and its duration are unclear. Here, we present a Japanese case and review of the existing literature.

CASE REPORT

We report the case of a 67-year-old woman with breast calcification. She had regular follow ups in our hospital for this calcification and received ultrasonography of the breast and axilla at every visit. She visited 6 months before having her COVID-19 vaccination, and 7 days and 6 months after the first COVID-19 vaccination. She had a swollen axillary lymph node 7 days after the first vaccination, which although it was improved, remained for 6 months.

CONCLUSION

Axillary lymph node swelling occurred 7 days after vaccination and remained up to 6 months after it.

Axillary Lymph Node Swelling Mimicking Breast Cancer Metastasis After COVID-19 Vaccination: A Japanese Case Report and Literature Review

BACKGROUND/AIM

COVID-19 started to spread as a pandemic in December 2019 and COVID-19 vaccination has been initiated worldwide. The efficacy of vaccination has been scientifically proven, but it might cause axillary lymph node swelling. To diagnose patients with axillary lymph node swelling caused by COVID-19 vaccination, we herein reviewed existing literature on this symptom.

CASE REPORT

We report the case of a 70-year-old woman with a breast tumour. She had undergone cecum cancer surgery and regular computed tomography (CT). During breast tumour follow-up, she received scheduled CT that indicated severe axillary lymph node swelling mimicking breast cancer metastasis. We performed aspiration biopsy cytology of that lymph node, and determined this was not cancer metastasis but an effect of the COVID-19 vaccine. We confirmed this diagnosis at one month after computed tomography showed that the lymph node swelling had improved.

CONCLUSION

Axillary lymph node swelling can occur after COVID-19 vaccination. Therefore, it is important to consider the effect of the COVID-19 vaccination on axillary lymph node swelling when diagnosing breast tumours.

Extensive Organ Necrosis After Thoracic Endovascular Aortic Repair for Thoracic Aortic Aneurysm: A Report of the Usefulness of Laparoscopic Indocyanine Green Intraoperative Blood Flow Assessment

An 85-year-old man underwent thoracic endovascular aortic repair (TEVAR) for a thoracic aortic aneurysm (TAA). The day after TEVAR, the patient complained of abdominal pain. Blood tests showed lactic acidosis. Contrast-enhanced CT of the abdomen showed emphysema and poor contrast areas in the lower esophagus, total stomach, and duodenum. The left lobe of the liver also showed a poorly contrasted area. Indocyanine green (ICG) intraoperative blood flow evaluation was performed by laparoscopy to evaluate how organ ischemia is and whether resection of necrotic organs is possible. It was judged that resection of the poor perfusion area would not improve prognosis because of the extensive area of poor perfusion in the ICG intraoperative perfusion evaluation. In TEVAR for TAA, embolization of the celiac artery (CA) can be performed if collateral blood flow is demonstrated. However, in this case, extensive organ necrosis happened. We discuss the cause of this case and the usefulness of ICG intraoperative blood flow assessment when ischemia is suspected.

A case of intestinal obstruction caused by a mesodiverticular band in Meckel's diverticulum with ectopic pancreas treated by laparoscopic surgery

Introduction

We report a case of a patient who underwent laparoscopic surgery for intestinal obstruction caused by the mesodiverticular band of Meckel's diverticulum, with pathological specimens showing ectopic pancreas.

Presentation of case

A 56-year-old woman presented to our hospital with complaints of abdominal pain and vomiting. Upon close examination, we suspected strangulated intestinal obstruction, and performed an emergency surgery. An internal hernia with a band leading to a Meckel's diverticulum was noted. Focusing on the attachment of the band, leading to the Meckel's diverticulum, we suspected a mesodiverticular band and deemed it necessary to be resected. Surgery was completed with resection of the band to relieve the intestinal obstruction, with simultaneous resection of the Meckel's diverticulum. It was necessary to resect Meckel's diverticulum simultaneously for histopathological examination. Histopathological examination revealed a mesodiverticular band in the resected band and ectopic pancreas in the Meckel's diverticulum.

Discussion

We chose to perform a complete laparoscopic resection because of the presence of simple intestinal obstruction caused by mesodiverticular bands or diverticula. We believe that small laparotomy can be opted in less severe cases, regardless of laparoscopic completion.

Conclusion

We suspected adherent bowel obstruction and detected a band. We focused on band attachment and determined that the band should be resected if it was attached to Meckel's diverticulum. The resection method should be carefully selected, and the specimen should be histopathalogically examined.

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We report a case of intestinal obstruction due to a mesodiverticular band.

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The resection method for Meckel's diverticulum should be carefully selected.

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Histopathological examination of the specimen should be performed.

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Small laparotomy can be opted for less severe cases.

COVID-19 Screening of Breast Cancer Patients During Treatment: A Single Center Experience in Japan

BACKGROUND/AIM

Breast cancer treatment mainly involves interventional methods such as surgical resection and chemotherapy. How to best perform these treatments during the COVID-19 pandemic remains to be established.

PATIENTS AND METHODS

Patients with breast cancer who received SARS-CoV-2 PCR screening before cancer treatment from December 2020 to April 2021 were included. PCR screening was performed within 72 hours of the scheduled admission time and treatment.

RESULTS

A total of 19 tests in 15 patients were analysed. Fourteen cases displayed no symptoms, and five cases had some symptoms. COVID PCR tests were negative in all cases.

CONCLUSION

COVID-19 screening can ensure that breast cancer patients do not miss scheduled treatments as a result of the pandemic. Diagnosis of patients with symptoms that are shared by COVID-19 infection, chemotherapy, and breast cancer recurrence must be performed carefully.

Anticoagulant Use as an Independent Risk Factor and Higher In-Hospital Mortality in Patients Showing Alveolar Hemorrhage in Diffuse Lung Disease

Background and objectives: Bronchoalveolar lavage (BAL) is commonly performed to evaluate diffuse lung disease and occasionally to identify alveolar hemorrhage. However, the clinical impact of alveolar hemorrhage and its risk factors in patients with diffuse lung disease have not been clarified. Materials and Methods: We retrospectively analyzed the medical records of all patients who underwent BAL to evaluate diffuse lung disease from January 2017 to December 2020. Alveolar hemorrhage was defined as progressive hemorrhagic BAL fluid or the presence of ≥20% hemosiderin-laden macrophages in the BAL fluid. Logistic regression analysis was performed to assess the association between alveolar hemorrhage and other factors. Results: Sixty subjects were enrolled in this study. Alveolar hemorrhage was observed in 19 subjects (31.7%) with idiopathic interstitial pneumonia, acute respiratory distress syndrome, interstitial pneumonia with autoimmune features, drug-induced lung injury, eosinophilic pneumonia, adenocarcinoma, and systemic lupus erythematosus. The use of anticoagulants was a significant risk factor for alveolar hemorrhage (odds ratio 7.57, p = 0.049). Patients with alveolar hemorrhage required intubated mechanical ventilation more frequently (63.2% vs. 24.4%, p = 0.005) and had higher in-hospital mortality rates (26.3% vs. 4.9%, p = 0.028) than those without alveolar hemorrhage. Conclusions: Alveolar hemorrhage was observed in various etiologies. The use of anticoagulants was a significant risk factor for alveolar hemorrhage. Patients with alveolar hemorrhage showed more severe respiratory failure and had higher in-hospital mortality than those without alveolar hemorrhage.

Transcatheter arterial embolization for hemorrhagic rupture of a simple hepatic cyst: A case report

Hemorrhagic rupture is a very rare and life-threatening hepatic cyst complication. Several treatment methods have been used for hepatic cyst hemorrhage and/or rupture; however, transcatheter arterial embolization for hepatic cyst hemorrhage has been poorly documented. An 80-year-old man receiving dual antiplatelet therapy was diagnosed with hemorrhagic rupture of a hepatic cyst. Transcatheter arterial embolization using a coil was performed for A6 branch confirmed active extravasation. His condition improved promptly after treatment, and the hepatic cyst gradually became smaller as compared to the size before hemorrhage. Transcatheter arterial embolization is suitable for hepatic cyst hemorrhage and might be a minimally invasive treatment option for a symptomatic hepatic cyst.

Lumbar artery aneurysm complicated by a fistula between the aneurysm and the duodenum in a patient with Leriche syndrome: A case report

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The arterio-enteric fistula between lumbar artery and duodenum is rare pathology.

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Aneurysm may occur in the collateral circulation in patients with Leriche syndrome.

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Endovascular embolization can control hemorrhage immediately.

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Fistula closure and debridement is recommended for control of local infection.

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Endovascular embolization can serve as a landmark for the debridement of aneurysm.

Introduction

Various collateral pathways maintain blood flow to the lower extremities in patients with Leriche syndrome. The occurrence of true aneurysms in the lumbar artery—a component of an extensive collateral circulation network in patients with Leriche syndrome—is extremely rare.

Presentation of case

A 73-year-old man with Leriche syndrome was diagnosed with lumbar artery aneurysm complicated by a duodenal fistula. The patient underwent endovascular repair, surgical duodenal fistula closure, and debridement of the aneurysm wall until coil exposure.

Discussion

With the same mechanism, patients with aortic occlusive disease may develop an aneurysm and arterio-enteric fistula in the collateral circulation. Combination of treatments may be important for hemostasis, control of infection, and maintaining adequate distal perfusion.

Conclusion

Endovascular embolization can control bleeding as well as serve as a landmark for the debridement of contaminated aneurysm. Surgical fistula closure and aneurysm-wall debridement are useful for control of local infection.

A Case of Alveolar Haemorrhage Induced by Iodinated Contrast Medium Use

An 81-year-old man complaining of exertional dyspnoea underwent coronary angiography using an iodinated contrast medium. After angiography, the patient required systemic corticosteroid therapy because of respiratory failure due to alveolar haemorrhage. Percutaneous coronary intervention was performed 29 days after angiography using the same contrast medium. After the intervention, the patient required intubated mechanical ventilation and renal replacement therapy. Bronchoalveolar lavage was bloody with many haemosiderin-filled macrophages. Systemic corticosteroid therapy again improved his clinical condition. Iodinated contrast media may cause alveolar haemorrhage and re-exposure to contrast media may induce a more severe adverse reaction.

LEARNING POINTS

Iodinated contrast media may cause alveolar haemorrhage.Re-exposure to iodinated contrast media may induce a more severe adverse reaction.

Multidisciplinary Lung Cancer Tumor Board Connecting Eight General Hospitals in Japan via a High-Security Communication Line

PURPOSE

The complexity of lung cancer treatment is rapidly increasing, necessitating the use of multidisciplinary approaches for improving outcomes. Although it is common for institutions to have their own tumor boards, tumor boards connecting several general hospitals, and therefore allowing for more diverse opinions, are not prevalent.

MATERIALS AND METHODS

A tumor board connecting eight hospitals was formed to discuss patients for whom formulating a treatment strategy was difficult. Physicians and hospital staff accessed a high-security communication line via LiveOn ( Japan Media Systems Corporation, Tokyo, Japan), which is completely isolated from the Internet and password protected, that enables each hospital to share the electronic medical records and images of relevant patients at other hospitals on desktop computers in real time. The lung cancer tumor board began in April 2017 and has since been held every Tuesday evening for 1 hour. Preparatory records containing the age, sex, histology, TNM classification, background, and discussion points for each patient are created before each tumor board meeting. After the tumor board discussion, all conclusions and related articles used in the board are added to the minutes, which are finalized as Microsoft Word files, consolidated, and archived. These files can be retrieved later using key words.

RESULTS

From April 2017 to June 2018, 202 patients were discussed. Although TNM classification was not changed for any patient, diverse opinions led to a change in the proposed strategy for 49 of 202 patients.

CONCLUSION

The multidisciplinary tumor board was useful in obtaining various opinions from the perspectives of different experts. This should be evaluated in a prospective study.

A Case of Spontaneous Regression of Pulmonary Small Cell Carcinoma

An 82-year-old man was examined using chest computed tomography after treatment for pneumonia. Imaging showed a nodular shadow in the left lower lobe with associated enlarged lymph nodes. A polypoid tumour was observed on bronchoscopic examination, and the histological findings showed pulmonary small cell carcinoma with infiltration of CD3-positive and CD8-positive lymphocytes. The patient declined any antitumoural therapy and experienced an exacerbation of heart failure treated with atrial natriuretic peptide. Eighteen months after the diagnosis, the polypoid tumour had disappeared. T lymphocyte-mediated immunity and the antitumoural effects of atrial natriuretic peptide may have influenced the observed spontaneous regression.

Isolated internal iliac artery aneurysm causing rectal necrosis due to compression early after endovascular repair: A case report

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Many advantages of endovascular repair for aneurysms have been reported.

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The compression by aneurysms was not resolved early after endovascular repair.

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Rectal necrosis caused by residual aneurysms early after endovascular repair is rare.

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Aneurysm reduction and intestinal resection after embolization was a useful method.

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Embolization performed earlier assisted surgical decompression of aneurysms.

Introduction

Recently, endovascular repair has become the first-line treatment for internal iliac artery aneurysm (IIAA). However, rectal necrosis due to the compression of the residual IIAA early after endovascular repair is rare.

Presentation of case

We present a rare case of a huge, isolated left IIAA that severely compressed the rectum and ureter. The patient underwent emergency endovascular repair; however, rectal necrosis occurred 10 days later because the repair failed to shrink the size of the aneurismal sac.

Discussion

We hypothesize that the compression of the residual IIAA caused rectal necrosis. During open surgery, endovascular repair disrupted blood flow within the IIAA, which probably allowed for aneurysm dissection and residual hematoma removal.

Conclusion

Endovascular repair alone could not immediately release compression on the surrounding organs; however, open surgical removal of aneurysms after successful endovascular repair may be a useful option for IIAAs with compression of surrounding organs.

Transarterial Embolization With Complementary Surgical Ligation of Gastroduodenal Artery for Ruptured Pancreaticoduodenal Artery Aneurysm

The association between pancreaticoduodenal artery aneurysm (PDAA) and local hemodynamic changes in pancreaticoduodenal arcades is well established. However, there are few case reports of PDAA associated with acute aortic dissection. In this article, we outline and discuss the case of a 61-year-old man diagnosed with a type A acute aortic dissection who underwent emergency surgery and developed sudden-onset severe abdominal pain and shock 10 days later. Contrast-enhanced computed tomography showed a ruptured PDAA with feeding vessels from the gastroduodenal and superior mesenteric arteries, with evidence that the celiac artery was diverged from a false lumen. Transarterial embolization via the superior mesenteric artery alone was not expected to achieve hemostasis, so we performed a hybrid procedure involving transarterial embolization cannulated from superior mesenteric artery with complementary surgical ligation of the gastroduodenal artery. The postoperative course was uneventful, and follow-up contrast-enhanced computed tomography showed no persistence of the aneurysm 8 days after the second operation. This case proposed that visceral arterial malperfusion due to acute aortic dissection can cause PDAA in the early postoperative period. Although previous reports suggest that endovascular treatment is preferable, it may not always be feasible. Since ruptured PDAAs are often not detected during surgery, surgical treatment can be overly invasive. Whereas, transarterial embolization with complementary clamping or ligation of the gastroduodenal artery for ruptured PDAA is less invasive and can control hemorrhage, especially when cannulation to the celiac artery is impossible. Notably, the technique did not cause organ ischemia, presumably because the small collateral vessels of the pancreaticoduodenal arcades permitted sufficient blood flow. If endovascular treatment is unable to achieve rapid hemostasis, this technique may be a useful option for ruptured PDAA.

Iatrogenic esophageal perforation that could be treated indirectly by cervical esophagostomy and laparoscopic surgery

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It is very rare case that each esophageal stump become connected and patent spontaneously.

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Two-stage surgery is useful for esophageal perforation if radical operation is difficult.

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Esophageal perforation can be resolved without direct closure if appropriate drainage is performed.

Introduction

Successful nonoperative management has been reported for esophageal perforation; however, some cases require surgery.

Case presentation

We presented the case of an 85-year-old woman with iatrogenic thoracic esophageal perforation in whom primary repair or resection of the perforated esophagus was difficult because she was elderly and had severe aortic valve stenosis. Therefore, we selected a two-stage surgery; laparoscopic gastrostomy, jejunostomy, posterior mediastinal drainage, and cervical esophagostomy were performed. We planned reconstruction after the perforation was closed, but endoscopic examination revealed spontaneous patency of each esophageal stump. Endoscopic balloon dilation was necessary because of esophageal stenosis; however, anastomotic surgery was unnecessary.

Conclusion

This case report suggests that esophageal perforation is resolved without direct closure if appropriate drainage is performed.

A case of synchronous advanced gastric cancer and locally advanced prostate cancer with combined laparoscopic and robotic surgery: A case report

INTRODUCTION

The optimal management strategy for synchronous gastric cancer (GC) and prostate cancer (PCa) remains unclear, particularly in cases in which two cancers are progressive.

PRESENTATION OF CASE

A 68-year-old man diagnosed with synchronous advanced GC and locally advanced PCa was referred to our institution. Laparoscopic total gastrectomy (LTG) and robotic-assisted radical prostatectomy were simultaneously performed. The postoperative course was similar to the standard postoperative course of LTG alone. Pathological diagnoses were T3N3aM0 gastric adenocarcinoma and T3N0M0 prostatic adenocarcinoma. Adjuvant chemotherapy and adjuvant androgen deprivation therapy (ADT) for GC and PCa were initiated on postoperative days 15 and 27, respectively. Six months subsequent to surgery, the patient received adjuvant chemotherapy and ADT, and no evidence of cancer recurrence was observed.

DISCUSSION

In terms of survival, curative resection with adjuvant therapy is advantageous for patients with advanced GC or locally advanced PCa. At present, treatment for synchronous cancer should be combined with optimal management for individual cancers. Minimally invasive surgery may play an important role in the multidisciplinary treatment of synchronous advanced cancer.

CONCLUSION

Combined laparoscopic and robotic surgery for synchronous GC and PCa allows for minimally invasive radical resection and appropriate adjuvant therapy.

A rare case of for synchronous advanced cancer of ascending colon and urinary bladder with simultaneous laparoscopic resection: A case report

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The case of synchronous primary colorectal cancer and bladder cancer remains rare.

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Multidisciplinary treatment is required for synchronous advanced colorectal cancer and bladder cancer.

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Simultaneous laparoscopic resection may be proposed for postoperative multidisciplinary treatment.

Introduction

Advances in diagnostic techniques have resulted in an increase in the diagnosis of numerous patients with multiple primary cancers. However, the diagnosis of synchronous primary colorectal cancer and bladder cancer remains rare.

Presentation of case

A 69-year-old man diagnosed with synchronous advanced cancer of the ascending colon and urinary bladder underwent simultaneous laparoscopic resection. His postoperative course was similar to that of routine colorectal cancer. The patient refused adjuvant therapy. The patient was diagnosed as having recurrence of bladder cancer 3 months after surgery; he died 9 months after surgery.

Discussion

For multiple primary malignant tumors, simultaneous tumor resection is preferred. Simultaneous laparoscopic resection may be proposed for postoperative multidisciplinary treatment. If an established regimen is determined in the future, neoadjuvant chemotherapy may be an option for the treatment of synchronous advanced cancer.

Conclusion

Simultaneous laparoscopic surgery is a greatly beneficial approach for synchronous cancer requiring multidisciplinary treatment. Additionally, an appropriate support system for patients is indispensable for completing multidisciplinary treatment.

A case of invasive pulmonary aspergillosis during treatment for acute exacerbation of interstitial lung disease

Prolonged immunosuppressive therapy is a risk factor for invasive pulmonary aspergillosis. We report a case of a 79-yearold man who underwent immunosuppressive therapy with methylprednisolone and cyclosporine for an acute exacerbation of interstitial lung disease. Ten days after initiation of immunosuppressive therapy, the patient reported night sweats and purulent sputum, and chest computed tomography scan revealed consolidation. He was diagnosed with invasive pulmonary aspergillosis, and required vasopressor support with oxygen therapy. After the administration of voriconazole and the modulation of immunosuppressive therapy, his condition improved. Short-term immunosuppressive therapy can also induce invasive pulmonary aspergillosis.

Combined laparoscopic and robotic surgery for synchronous colorectal and genitourinary cancer: A case series

INTRODUCTION

Advances in diagnostic techniques and treatment have resulted in an increase in patients with synchronous cancer. Surgical reports of combined laparoscopic and robotic resection for synchronous colorectal and genitourinary cancer are rare.

MATERIALS AND METHODS

Between August 2015 and November 2017, three patients underwent combined laparoscopic and robotic surgery for synchronous colorectal and genitourinary cancer in our hospital.

RESULTS

Case 1 was a 59-year-old man with synchronous rectal and prostate cancer treated by combined laparoscopic anterior resection and robotic-assisted prostatectomy. Case 2 was a 77-year-old man with synchronous cancer of transverse colon and left kidney treated by combined laparoscopic transverse colectomy and robotic-assisted partial nephrectomy. Case 3 was a 74-year-old man with synchronous adenocarcinoma of descending colon and prostate treated by combined laparoscopic left hemicolectomy and robotic-assisted prostatectomy.

DISCUSSION

In simultaneous endoscopic surgery, it is necessary to consider sequence of resection, intraoperative position of patient and port arrangement. Simultaneous surgery allows promptly for postoperative adjuvant chemotherapy.

CONCLUSION

Combined laparoscopic and robotic surgery for synchronous colorectal and genitourinary cancer is suitable for advanced cancer cases requiring multidisciplinary treatment.

Adverse events of stapling in thoracic surgery: relations between an incidence of adverse events and a stapling volume

PURPOSE

The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, sometimes adverse events (AEs) of stapling are experienced. The aim of the present study was to retrospectively analyze AEs of stapling in thoracic surgery.

METHODS

A retrospective multi-institutional review was conducted by the 27 institutions of the Central Japan Lung Cancer Surgery Study Group. Between January 2009 and December 2010, 4495 patients underwent thoracic surgery using mechanical stapling.

RESULTS

Stapling of various tissues was performed 16403 times. Total number of AEs related to stapling was 126 (0.77%). One hundred and nine events occurred intraoperative and 17 events occurred postoperative. The AE rates ranged from 0% to 1.8%. No relationship was seen between the incidence of AE and a stapling volume of thoracic surgery.

CONCLUSION

We have investigated intraoperative and postoperative AEs of stapling. Generally, stapling in thoracic surgery was safe. An AE rate of stapling in thoracic surgery is not influenced by the numbers of stapling in institutions.

Virtual CT colectomy by three-dimensional imaging using multidetector-row CT for laparoscopic colorectal surgery

Laparoscopic colorectal surgery has been attracting attention for its capacity to improve the quality of life (QOL) of patients. However, there are disadvantages to this approach, namely, it is difficult to obtain an image of the entire view of the operative field, and organs and lesions cannot be manipulated directly by the surgeon during surgery. For this reason, it takes a relatively large amount of time to ligate vessel, which can vary between patients. Furthermore, vessels and organs can be damaged during lymph nodes dissection under laparoscopic guidance, leading to heavy bleeding that prevents the surgeon from having access to a good view of the operative field. Then, to assess preoperatively the vascular anatomy, we carried out multiphase, contrast-enhanced examinations using multidetector-row CT (MDCT) on patients with colorectal cancer, and prepared the fused image of 3D images of arteries, veins, the colorectum, organs, and tumor. We called the utilization of 3D imaging virtual CT colectomy, which contributed to rapid and safe manipulation of the origins of the arteries and the veins, as well as lymph nodes dissection, without incurring injury to the involved arteries and veins.

Effect of saline pushing after contrast material injection in abdominal multidetector computed tomography with the use of different iodine concentrations

PURPOSE

To investigate whether saline pushing after contrast material improves hepatic vascular and parenchymal enhancement, and to determine whether this technique permits decreased contrast material concentration.

MATERIAL AND METHODS

120 patients who underwent hepatic multidetector computed tomography were divided randomly into four groups (Groups A-D): receiving 100 ml of contrast material (300 mgI/ml) only (A) or with 50 ml of saline solution (B); or 100 ml of contrast material (350 mgI/ml) only (C) or with 50 ml of saline solution (D). Computed tomography (CT) values of the aorta in the arterial phase, the portal vein in the portal venous inflow phase, and the liver in the hepatic phase were measured. Visualization of the hepatic artery and the portal vein by 3D CT angiography was evaluated as well.

RESULTS

Although the enhancement values of the aorta were not improved significantly with saline pushing, they continued at a high level to the latter slices with saline pushing. The enhancement value of the portal vein increased significantly and CT portography was improved with saline pushing. The enhancement value of the liver was not improved significantly using saline pushing. In a comparison between groups B and C, the enhancement values of the aorta and portal vein and the visualization of CT arteriography and portography were not statistically different.

CONCLUSION

The saline pushing technique can contribute to a decrease in contrast material concentration for 3D CT arteriography and portography.

[Three-dimensional CT angiography of the hepatic artery with multislice CT: differences in image quality according to scanning pitch]

Three-dimensional CT angiography was reconstructed from the hepatic artery using multislice CT, and the effect of pitch during scanning on the quality of obtained images was examined. We randomly divided patients into two groups, with images of one group scanned at helical pitch 3 and images of the other at helical pitch 5.5. CT angiography was reconstructed by a volume-rendering technique. Evaluation was done visually, taking the sharpness of images of branches of the hepatic artery as a measure. Three-dimensional imaging scanned at pitch 3 tended to be better than that scanned at pitch 5.5.

Assessment of extensive surgery for locally advanced lung cancer. Safety and efficacy of induction therapy

OBJECTIVE

Locally advanced lung cancer has a poor prognosis, despite extensive surgery conducted in an effort to improve survival. We evaluated the safety and efficacy of induction therapy prior to extensive surgery for locally advanced lung cancer.

METHODS

Primary resection for lung cancer was done in 549 consecutive patients divided into three groups; 446 undergoing standard pulmonary resection (no extensive surgery), 87 undergoing extensive surgery without induction therapy, and 16 undergoing surgery after induction therapy.

RESULTS

Morbidity was 23.5%, 28.6%, and 43.8%, respectively. The rate was significantly higher in the induction group compared with the no extensive surgery group (P < 0.05). Surgical mortality was 0.67%, 3.4%, and 6.3%, respectively. The difference was statistically significant between the no extensive surgery and extensive surgery groups (P < 0.02), and between the no extensive surgery and induction groups (P < 0.02). Hospital mortality was 2.2%, 9.2%, and 6.3%, respectively. The rates were significantly higher in the extensive surgery (P < 0.01) and induction (P < 0.05) groups compared to the no extensive surgery group. Five-year survival was 50.3% for the patients who received induction therapy, and 14.7% for the patients who did not receive induction therapy.

CONCLUSIONS

Survival differences between the induction and non induction groups were not significant, but some patients with T3 or T4 disease may benefit from induction therapy. The high morbidity of induction treatment should be recognized, and strict candidate selection and careful postoperative care used to help prevent increased mortality.

[Intrapulmonary laceration revealed by computed tomography in a patient with pneumomediastinum]

An 18-year-old man had bronchial asthma and a pneumomediastinum. A computed tomographic scan of the chest revealed the pneumomediastinum, intrapulmonary laceration of the S1b, and a small amount of air in the perivascular space from V1a to V1. Increased pressure in intrapulmonary airways may have resulted in ruptured S1b alveoli and air leakage into the interstitium between the surrounding secondary lobules. The air may have moved along the perivascular space (pulmonary vein) toward the hilum, and eventually into the mediastinum. We know of no previous report of pneumomediastinum in which images of intrapulmonary lesions are presented. In this case computed tomography revealed the mechanism by which the pneumomediastinum probably developed.

[Clinical considerations from sixteen cases with mediastinal malignant lymphoma]

Sixteen cases with mediastinal malignant lymphoma were treated in our department and a correlation made between the prognosis and other factors: first symptom, maximum diameter of the tumor, type of operation, pathological subtype, clinical stage. First symptom and compressed or invasive symptom with mediastinal mass were not related to prognosis. The cases with bulky tumor over 10 cm in diameter showed a tendency toward poorer prognosis. Complete or incomplete resection did not have significant effect. The cases of Hodgkin's disease had relatively good prognosis. Classification of clinical stage (Ann Arbor classification) did not show significant correlation with prognosis and may be inadequate for staging of mediastinal malignant lymphoma. Surgical treatment may be adapted for mediastinal Hodgkin's disease and early stages of thymic malignant lymphoma.

[A case of hamartoma originated from the chest wall]

Hamartoma originated from the chest wall is rare. All reported cases are infant's ones. A 16-year-old man was admitted to our hospital because of chest pain and abnormal shadow in routine chest X-ray film. Thoracotomy was performed under the diagnosis of pulmonary sequestration in the left apical region. However, the operation revealed a tumor originated from the chest wall, which was diagnosed hamartoma by histological examination. Re-operation was required because of hemothorax caused by residual tumor. Second and third ribs were resected with residual tumor. There is no evidence of recurrence one year after the second operation.

[A high concentration of itraconazole in an aspergilloma]

A 66-year-old woman was given 100 mg/day of itraconazole for eight months to treat pulmonary aspergillosis with an aspergilloma. The amount of purulent sputum decreased, but open drainage was done because the fever continued and because no improvement was seen on the chest X-ray film. No aspergillus was cultured from the surgical specimen, but fungi were observed microscopically. The concentration of itraconazole in plasma was 249 ng/ml. The concentrations in specimens of the lung and of the aspergilloma obtained by thoracotomy were 81 ng/g and 837 ng/g, respectively. The high concentration in the aspergilloma had made the fungus inactive. The itraconazole concentration may have been very high for three reasons: (1) the concentration increased in purulent fluid, (2) itraconazole easily entered the aspergilloma through the root at the cavity wall, and (3) itraconazole dissolved in lipid derived from destroyed fungus.

Combined dose ratios of dopamine and dobutamine and right ventricular performance after cardiac surgery

The effect of combined administration of different dose ratios of dobutamine (DB) and dopamine (DA) (DB/DA ratio of 1:1; 1.5:0.5; 2:0; 0.5:1.5; and 0:2), with the added dose kept constant (10 micrograms/kg/min-20 micrograms/kg/min), on right ventricular function (measured by the thermal washout method with the aid of a rapid-response thermistor) was determined in ten patients after cardiac surgery (between 12 and 24 h after surgery). The following values represent the mean +/- SD of DB only and of the DB/DA-equal combination vs DA only. The DB/DA-equal or DB-dominant combination increased the right ventricular ejection fraction vs DA only (0.39 +/- 0.12 [p less than 0.01] and 0.37 +/- 0.11 [p less than 0.05], respectively, vs 0.32 +/- 0.12) and the stroke volume index (43 +/- 12 ml/m2 [p less than 0.01] and 41 +/- 15 ml/m2, respectively, vs 38 +/- 14 ml/m2) and decreased right ventricular end-diastolic pressure (RVEDP) (10 +/- 4 mm Hg [p less than 0.01] and 11 +/- 4 mm Hg [p less than 0.05], respectively, vs 13 +/- 5 mm Hg) and pulmonary capillary wedge pressure (10 +/- 4 mm Hg [p less than 0.01] and 12 +/- 5 mm Hg [p less than 0.05], respectively, vs 14 +/- 6 mm Hg) to the same degree as DB alone. The DB/DA-equal or DB-dominant combination did not induce tachycardia (heart rate, 105 +/- 11 [p less than 0.05] and 95 +/- 14 beats per minute, respectively, vs 90 +/- 17 beats per minute) or have any effect on the right ventricular end-diastolic volume index (RVEDVI) (115 +/- 30 ml/m2 and 117 +/- 33 ml/m2, respectively, vs 127 +/- 42 ml/m2). Moreover, the diastolic parameters of the right ventricle (the ratio of RVEDVI/RVEDP: 15 +/- 8 [p less than 0.05] and 13 +/- 7, ml/mm Hg/m2, respectively, 11 +/- 5 ml/mm Hg/m2) decreased as the ratio of DA increased. This change in the diastolic properties of the right ventricle might have been caused by release of norepinephrine in the myocardium by DA or by improved coronary perfusion with DB. The DB/DA-equal and DB-dominant combinations were superior to DB or DA alone and to the DA-dominant combination in obtaining enhanced right ventricular performance.

Effects of injection site on the accuracy of thermal washout right ventricular ejection fraction measurements in clinical and model investigations

The purpose of this investigation was to improve the accuracy of measurement of thermal right ventricular ejection fraction (RVEF) using the modified Swan-Ganz catheter. Three serial ejection fractions (EFs) (EF1, 2, 3) and the mean were calculated, based on Holt's theory. RVEFs were compared between right ventricular (RV) and atrial (RA) injection in ten intensive care unit (ICU) patients using a modified catheter having RV and RA orifices (15 cm and 30 cm from the distal end, respectively), and paired duplicate (two patients) or triplicate (eight patients) measurements were performed. To determine what factors interfere with RVEF, a model heart (with diastolic volume of 150 ml) was constructed, in which model injection of cold water to the direct inflow tract (RA), to the direct mixing chamber (RV), or through the catheter running in the inflow tract were compared. When EFs were compared between RV and RA injection, those for the former were greater (RV vs RA in EF1 and EFmean: 0.46 +/- 0.15 vs 0.23 +/- 0.11 in EF1, and 0.45 +/- 0.13 vs 0.28 +/- 0.11 in EFmean, mean +/- SD, p less than 0.01). When the serial EFs were compared in each injection type, in the RV injection EF3 was the smallest as was EF1 in the RA injection. The same phenomenon was observed in the model as in the patients, and moreover when cold water was injected in RA through a catheter running through the circuit, EFs were greatly underestimated (EF1 = 0.29 +/- 0.02 at preset EF = 0.4). We conclude that these phenomena were caused by sluggish movement of the cold indicator from RA to RV when injected into RA, and by interference with the cooled cardiac chamber and catheter. Consequently, the first or second EFs obtained from RV injection might be closest to the actual values because of the least interference with those factors.

[Analysis of factors influencing the accuracy of ejection fraction measurement based on the thermal washout technic--investigation in a model heart]

Evaluation of ejection fraction and ventricular volume is more difficult in the right side of the heart than in the left side. Thermal washout method in the right ventricle with the aid of a rapid response thermistor made it possible in the clinical practice, but its accuracy is uncertain. We attempted to elucidate what factors could influence the accuracy of the measurement of the right ventricular ejection fractions in a model circuit and artificial heart equipped with two one-way valves. Findings are as follow: 1) By ventricular injection of the cold water it is possible to evaluate the ejection fractions more accurately than by atrial injection. The latter technique measured the ejection fraction 8.4% lower than the actual values. 2) The first ejection fraction measured will be the most accurate among the serially obtained ejection fractions using a thermal washout curve. 3) When the ejection fraction is high, the ejection fractions calculated from the later part of a thermal washout curve will be falsely low. 4) When the cold water is injected through the catheter running in the circuit, the effect of the catheter cooling could not be neglected and ejection fraction will be measured falsely low. The temperature change is so small in the later part of the descending limb of the thermal washout curve, that the effect of catheter cooling and ventricular cooling will be exaggerated and the calculation of the temperature change will be measured falsely high. This seems to be the cause of our findings in this research.(ABSTRACT TRUNCATED AT 250 WORDS)