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Background Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices. Methods We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017. Results Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis. Conclusions Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon’s skill. The appropriate indications must be established with more case registries because our experience is limited.

BackgroundImmune checkpoint inhibitors are widely used for treating malignant tumors, changed the framework of cancer treatment, but on the other hand, Immune-related adverse event occurs due to excessive immune response. Immune checkpoint inhibitor-related colitis shows symptoms similar to ulcerative colitis, and high-dose corticosteroids and anti-TNF-alpha antibodies are recommended, but surgical treatment has not yet been established for cases that are refractory to medical therapy.Case presentationThis case involved a 64-year-old male. PD-L1 expression in the recurrent lesion of lung adenocarcinoma was positive, and treatment with pembrolizumab was initiated. Hematochezia and diarrhea were observed 8 weeks after the start of the treatment and was diagnosed as irAE colitis. The patient was treated with corticosteroid, infliximab, mesalazine, and leukocytapheresis for irAE colitis, but was refractory. The patient's performance status was poor, and proctocolectomy and subtotal colectomy according to the treatment of refractory ulcerative colitis were not indicated, so a diverting loop ileostomy was performed to rest the colon. The abdominal symptoms resolved after the surgery, and chemotherapy was resumed 3 months after surgery. Stoma closure could not be performed because the mucosal lesions did not improve on colonoscopy; nevertheless, there were no symptoms of irAE colitis, and nivolumab could be administered from the eighteenth month after surgery. However, it was not effective, and the patient died of the primary disease two years after surgery.Discussion and ConclusionsWe encountered a case in which a diverting loop ileostomy was performed for irAE colitis refractory to medical treatment, and the symptoms were alleviated. However, surgical treatment of refractory irAE colitis and resumption of ICIs after irAE development need to be fully discussed.

Both peroxisomes and lipid droplets regulate cellular lipid homeostasis. Direct inter-organellar contacts as well as novel roles for proteins associated with peroxisome or lipid droplets occur when cells are induced to liberate fatty acids from lipid droplets. We have shown a non-canonical role for a subset of peroxisome-assembly [Peroxin (Pex)] proteins in this process in Drosophila. Transmembrane proteins Pex3, Pex13 and Pex14 were observed to surround newly formed lipid droplets. Trafficking of Pex14 to lipid droplets was enhanced by loss of Pex19, which directs insertion of transmembrane proteins like Pex14 into the peroxisome bilayer membrane. Accumulation of Pex14 around lipid droplets did not induce changes to peroxisome size or number, and co-recruitment of the remaining Peroxins was not needed to assemble peroxisomes observed. Increasing the relative level of Pex14 surrounding lipid droplets affected the recruitment of Hsl lipase. Fat body-specific reduction of these lipid droplet-associated Peroxins caused a unique effect on larval fat body development and affected their survival on lipid-enriched or minimal diets. This revealed a heretofore unknown function for a subset of Pex proteins in regulating lipid storage. This article has an associated First Person interview with Kazuki Ueda, joint first author of the paper.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

Thrombophilia increases the risk of venous thrombosis, but is rarely responsible for aortic thrombosis. Aortic mural thrombus (AMT) may be associated with a protein C deficiency. However, it is necessary to determine whether the protein C deficiency is congenital/hereditary or secondary/acquired (consumption of protein C during the process of thrombus formation). This study describes a 77-year-old Japanese woman with incidentally diagnosed AMT, who had a protein C deficiency (activity 54%, antigen 42%). Sequencing of the protein C gene revealed a heterozygous mutation of c.1268delG, p.Gly423Valfs＊82 in exon 9, indicating a congenital protein C deficiency. These findings indicate that very late onset AMT can occur in an adult with congenital protein C deficiency.

We performed two emergency microsurgical dura, skull, and scalp complex reconstructions. We used the rectus abdominis flap with free fascia lata and the anterolateral thigh flap with vascularized fascia lata. To achieve good postoperative result, reconstruction should be performed before meningitis or wound infection.

IntroductionMesenteric cysts are rare intra-abdominal masses. They do not show classic clinical findings and are detected incidentally during imaging because of their absent or nonspecific clinical presentation. We herein report 2 cases of mesenteric cysts that were successfully diagnosed and resected through a laparoscopic approach.Case presentationIn a 35-year-old man underwent a comprehensive medical checkup at another hospital, during which ultrasound incidentally revealed a cystic mass in his right retroperitoneum. The patient was referred to our hospital for surgical treatment. He was asymptomatic and his medical history was unremarkable. Physical examination revealed no palpable abdominal mass, and all laboratory test results were within normal ranges. Contrast-enhanced computed tomography showed a 7.2-cm-diameter smooth-surfaced, well-demarcated mass behind the right colon without a contrast effect (Fig. 1). We considered the cyst to be benign and localized in the mesentery of the ascending colon. In one patient, the cyst was located in the mesentery of the ascending colon and removed via a right hemicolectomy; in the other patient, the cyst was located in the sigmoid mesentery, which was completely resected through the operative wound under an open procedure after laparoscopic mobilization of the sigmoid mesentery. We chose the laparoscopic approach in both cases because the cysts were considered benign, noninfectious, and nonhemorrhagic. Histologic examination revealed cystic lymphangioma in both cases.ConclusionFor mesenteric cysts, laparoscopy could be a preferred approach in properly selected patients.

Anastomotic leakage is one of the most dreaded complications of colorectal surgery and is strongly associated with tissue perfusion. Indocyanine green fluorescence angiography (ICG-FA) using indocyanine green and near-infrared systems is an innovative technique that allows the visualization of anastomotic perfusion. Based on this information on tissue perfusion status, surgeons will be able to clearly identify colorectal segments with good blood flow for safer colorectal anastomosis. The results of several clinical trials indicate that ICG-FA may reduce the risk of AL in colorectal resection; however, the level of evidence is not high, as several other studies have failed to demonstrate a reduction in the risk of AL. Several large-scale RCTs are currently underway, and their results will determine whether ICG-FA is, indeed, useful. The major limitation of the current ICG-FA evaluation method, however, is that it is subjective and based on visual assessment by the surgeon. To complement this, the utility of objective evaluation methods for fluorescence using quantitative parameters is being investigated. Promising results have been reported from several clinical trials, but all trials are preliminary owing to their small sample size and lack of standardized protocols for quantitative evaluation. Therefore, appropriately standardized, high-quality, large-scale studies are warranted.

Adrenocortical carcinoma (ACC) is a rare tumor, and some histological variants (oncocytic, myxoid, and sarcomatoid ACCs) have been reported in addition to the conventional ACC. Among these subtypes, oncocytic ACC is histologically characterized by the presence of abundant eosinophilic granular cytoplasm in the carcinoma cells owing to the accumulation of mitochondria, which generally yields high 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET). Herein, we report the case of a 21-year-old woman with oncocytic ACC with low FDG uptake on PET scan. Her circulating levels of androgens were high, and androgen-synthesis enzymes were detected in carcinoma cells. The patient also had hypocholesterolemia. However, glucose transporter 1 (GLUT1) was not detected in the tumor, which was considered to account for the low FDG uptake by the tumor. To the best of our knowledge, this is the first case of low FDG uptake by oncocytic ACC without GLUT1 expression. Additionally, since hypocholesterolemia was reported in 3 previous reports of androgen-producing tumors, a possible correlation between androgenicity in adrenal tumors and the development of hypocholesterolemia could be postulated; however, further investigations are needed for clarification. This case highlights important information regarding the diversity of ACC and its impact on hypocholesterolemia.

Characterization of adrenocortical disorders is challenging because of varying origins, laterality, the presence or absence of hormone production, and unclarity about the benign or malignant nature of the lesion. Histopathological examination in conjunction with immunohistochemistry is generally considered mandatory in this characterization. We report a rare case of bilateral adrenocortical adenomas associated with unilateral adrenal endothelial cysts in a 65-year-old woman whose condition was not diagnosed before surgery. Detailed histological examination of the resected adrenal glands revealed hyperplasia in the zona glomerulosa. Despite hyperplasia, the patient had normal serum aldosterone levels and renin activity without clinical evidence of hypertension. The patient was treated with a sodium-glucose cotransporter protein 2 (SGLT2) inhibitor. This may have stimulated the renin-angiotensin-aldosterone system. To the best of our knowledge, this is the first case in which both relatively large bilateral adrenocortical adenomas and unilateral adrenal endothelial cysts were detected. This case also highlights the complexity and difficulty of preoperative diagnosis. Furthermore, this case reports the first detailed histopathological examination of adrenal lesions with SGLT2 treatment and the possibility of SGLT2 inhibitor treatment resulting in histological hyperplasia in the zona glomerulosa; however, it is difficult to prove a causative relationship between SGLT2 inhibitors and hyperplasia of the zona glomerulosa based on the data of this case. It can be confirmed only under limited conditions; therefore, further studies on adrenal gland histology employing SGLT2 inhibition are warranted.

(+)-Epogymnolactam (1) was discovered as a novel autophagy inducer from a culture of Gymnopus sp. in our laboratory. To determine structure-activity relationships among (+)-epogymnolactam analogues comparing with cerulenin (2), we synthesized 5 analogues including (-)-epogymnolactam (3) having each different functional group, and 3 analogues with different side-chain lengths. Five analogues, 3, 4, 5, 6, and 7 did not significantly increase the ratio of LC3-II to LC3-I as an autophagy marker in NIH3T3 cells. These results suggest that presence and stereochemistry of (2R,3S)-epoxy group and cyclic syn-form (1b) of 1 are important for the activity as autophagy inducer. Hexyl analogue (8) as well as 1 having butyl side-chain dose-dependently increased the ratio of LC3-II to LC3-I, whereas octyl analogue (9) and 2 rather decreased the ratio. Decyl analogue (10) did not give a change in the ratio. Although 8 seemed to be an excellent autophagy inducer, it dose-dependently increased SQSTM1 (p62) as in the case of 2, whereas 1 showed a slight dose-dependent decrease of p62 as an index of autophagic protein degradation. These observations suggest that 8 is an autophagy modulator with different molecular target from 1 or 2.

To investigate the possible implications of autophagy, one of the degradation pathways induced by metabolic stress, in the dynamic reconstructive process of wound healing, the appearance and changes of punctate structures for microtubule-associated protein 1 light chain 3 (LC3), an autophagosome marker, were examined in a rat skin wound healing model. Although the ratio of LC3-II/LC3-I in Western blotting was not evidently changed during the wound healing process, LC3-positive dots were clearly observed in fibroblasts and myofibroblasts, and occasionally in macrophages, by immunohistofluorescence microscopy. Some of the LC3-positive dots were colocalized with Atg16L signal, an isolation membrane marker, and electron microscopy revealed the presence of typical autophagosomes in fibroblasts near the margin of the wound. The number of LC3-positive dots per fibroblast increased during the later period of the proliferation phase, and interestingly, it was higher in the margin than the center of the wound. It was also high in the periwound skin area. These results suggest that drastic functional changes in fibroblasts during wound healing process are accompanied by the alteration of the autophagy-lysosomal degradation system.

We performed nail fold reconstruction after digital mucous cyst (DMC) excision using an island-type lateral finger flap on seven patients (four males and three females). Our procedure is a simple and useful method to repair minor nail fold lesion defects after DMC excision.

BACKGROUND Microsurgical lower extremity reconstruction is challenging because of high incidence of vascular thrombosis compared to microsurgical head and neck reconstruction. The risk of vascular pedicle thrombosis increases, if patients have arterial sclerosis or intimal dissection at the recipient artery. We performed selective and continuous transarterial heparin infusion for postoperative anticoagulant therapy. METHODS Fifteen patients (10 men and 5 women; mean age of 55.1 years; range of 16–86 years) received lower leg reconstruction using free flap. Postoperatively, a catheter was inserted into the femoral artery during surgery. Heparin infusion was performed through the catheter as a postoperative therapy for patients who had a risk factor of vascular pedicle thrombosis. Until two days post-operation, heparin was started between 5,000 and 10,000 IU per day. In postoperative days 3 and 4, half of the initial dose of heparin was administered. In postoperative days 5 and 6, 25% of the initial dose of heparin was administered. RESULTS Recipient arteries were the posterior tibial (n=11), anterior tibial (n=2), lateral circumflex femoral (n=1), and medial sural (n=1) arteries. Thirteen of the 15 cases showed arterial sclerosis or intimal dissection at the recipient artery. There was no case of vascular thrombosis. Hematoma formation at flap recipient was observed in four cases. Their initial heparin dose was than 8.5±1.7 U/kg/h. CONCLUSION Continuous transarterial heparin infusion was an effective anticoagulant therapy for the patients who had received free tissue transfer to a lower extremity. The initial dose of heparin should not exceed 6.5 U/kg/h.

Introduction Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. Presentation of case A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein. Discussion There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely. Conclusion Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis., Highlights • Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment because of high postoperative morbidity and mortality. • No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. • Hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with liver cirrhosis. • Hybrid surgery using laparoscopy and Lichtenstein’s technique is effective for patients with incarcerated inguinal hernia with severe abdominal varicosis.

Introduction and importance Chylous ascites (CA) is an infrequent, intractable complication that may arise after abdominal surgery. Although various attempts at treatment have been adopted, to date, none of them have been consistently effective. We describe the successful treatment of CA using lymphangiography and embolization with lipiodol. Case presentation A 79-year-old woman underwent laparoscopic surgery for rectum cancer at another hospital. She was discharged on postoperative day (POD) 9; however, she had to be treated and hospitalized for CA three times until POD 76. She visited our hospital to undergo treatment for CA on POD 90 because the previous conservative treatment had not improved her condition. The computed tomography (CT) scans revealed ascites effusion. We performed lymphangiography and embolization with lipiodol two times. Repeated CT on POD 134 showed that the ascites had not increased. Clinical discussion Lymphangiography and embolization with lipiodol effectively resolved chylous leakage that occurred after abdominal surgery. Additionally, we compare the features of two groups of cases of CA: one group in which patients were treated by lymphatic intervention and the second in which patients were treated through surgical procedures. Conclusion We were thus able to demonstrate the clinical effectiveness of lipiodol lymphangiography in treating CA.

Highlights • Diaphragmatic hernia is a rare late-onset complication associated with RFA for HCC. • The tumor location is closely related to the risk of diaphragmatic hernia caused by RFA. • Patients with HCC often have severe liver dysfunction and cirrhosis. • Laparoscopic approach is safe and minimally invasive for severe cirrhosis patient. • The hernia gate was closed by suture, and vulnerable area was reinforced using mesh., Introduction and importance We describe the case of a patients with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was treated by laparoscopic repair. Case presentation An 82-years-old man with history of HCC with hepatitis C virus-related liver cirrhosis (Child-Pugh B). The patient was treated RFA to HCC for segment 4, 5, 6, 8. After 16 months from latest RFA for segment 8, the patient was admitted to our hospital because of mild dyspnea. Computed tomography revealed a diaphragmatic herniation of bowel loops into the right thoracic cavity. The patients electively underwent laparoscopic repair of the diaphragmatic hernia. The patient was discharged from hospital without any post-operative complications. Clinical discussion The only treatment to diaphragmatic hernia is surgery, but liver cirrhosis patients limits this possibility. For the surgical treatment of patients with severe cirrhosis, the operation should be carefully assessed. We believe that a laparoscopic approach should be used for repairing diaphragmatic hernia. In the present case, we considered that a laparoscopic approach was safer and more feasible than open laparotomy. Conclusion Diaphragmatic hernia is a rare late-onset complication associated with RFA for HCC. And patients with HCC often have severe liver dysfunction and cirrhosis. A laparoscopic approach is safe and minimally invasive for sever cirrhosis patients.

Dioecy is a plant mating system in which individuals of a species are either male or female. Although many flowering plants evolved independently from hermaphroditism to dioecy, the molecular mechanism underlying this transition remains largely unknown. Sex determination in the dioecious plant Asparagus officinalis is controlled by X and Y chromosomes; the male and female karyotypes are XY and XX, respectively. Transcriptome analysis of A. officinalis buds showed that a MYB-like gene, Male Specific Expression 1 (MSE1), is specifically expressed in males. MSE1 exhibits tight linkage with the Y chromosome, specific expression in early anther development and loss of function on the X chromosome. Knockout of the MSE1 orthologue in Arabidopsis induces male sterility. Thus, MSE1 acts in sex determination in A. officinalis.

We have treated two patients who had an Achilles tendon and overlying tissue defect using an anterolateral thigh flap with fascia lata. Postoperatively, skeletal suspension of the affected leg and intra-arterial heparin infusion were performed for seven days. Six weeks postoperatively, the patients could walk again.

Background/aims Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been used to diagnose gastrointestinal submucosal tumors (SMTs). Although rapid on-site evaluation (ROSE) has been reported to improve the diagnostic accuracy of EUS-FNA for pancreatic lesions, on-site cytopathologists are not routinely available. Given this background, the usefulness of ROSE by endosonographers themselves for pancreatic tumors has also been reported. However, ROSE by endosonographers for diagnosis of SMT has not been reported. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA with ROSE by endosonographers for SMT, focusing on diagnosis of gastrointestinal stromal tumor (GIST), compared with that of EUS-FNA alone. Methods Twenty-two consecutive patients who underwent EUS-FNA with ROSE by endosonographers for SMT followed by surgical resection were identified. Ten historical control subjects who underwent EUS-FNA without ROSE were used for comparison. Results The overall diagnostic accuracy for SMT was significantly higher in cases with than without ROSE (100% vs. 80%, p=0.03). The number of needle passes by FNA with ROSE by endosonographers tended to be fewer, although accuracy was increased (3.3±1.3 vs. 5.9±3.8, p=0.06). Conclusions ROSE by endosonographers during EUS-FNA for SMT is useful for definitive diagnosis, particularly for GIST.

The purpose of the present study is to demonstrate a useful approach (isotope-IV method) for analyzing drug-drug interactions (DDIs) following the oral administration of drugs using stable isotope-labeled compounds. Verapamil hydrochloride (VER) was used as a drug model. Deuterium-labeled VER (VER-d6, 0.005 mg/kg) was intravenously administered to rats with or without a pre-treatment with 1-aminobenzotriazole (ABT, 100 mg/kg), a potent CYP inhibitor, 1.5 h after the oral administration of VER (1 mg/kg). PK parameters such as AUCpo, AUCiv, and CLtot were evaluated after the oral and intravenous administration of VER from the plasma concentration-time profiles of VER and VER-d6 in each rat. The oral bioavailability (F) of VER in rats was calculated as 0.02 ± 0.01 and was significantly increased to 0.45 ± 0.24 by the pre-treatment with ABT. Further PK analyses revealed that CYP-mediated metabolism was more strongly inhibited by ABT in the intestine (Fg) than in the liver (Fh). These results were consistent with those obtained using the conventional method in which oral and intravenous administration studies were performed using different rat groups. Therefore, the isotope-IV method is effective for performing PK analyses including DDIs after the oral administration of drugs.

Key Clinical Message Pseudolymphomatous folliculitis (PLF) is a rare lesion. Sometimes, the clinical appearance is characterized by multiple large, firm violaceous nodules. In cases with multiple lesions, such biopsy should be performed on one lesion, and once PLF is determined, monitoring for the remained tumor is considered to be the best treatment.

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

We treated nine patients with skin defect produced by digital mucous cyst (DMC) excision on the finger and toe using lateral finger flap (LFF). The postoperative scars were esthetically acceptable and no recurrence of mucous cysts was observed. Our LFF is a simple method to repair minor distal dorsal finger defects.

Highlights • Pancreaticoduodenectomy is a difficult and challenging operation, and a gastric tube is frequently used for reconstruction after subtotal esophagectomy for esophageal cancer. • The right gastro-omental artery is important for supplying blood flow to the gastric tube. • Surgeries for pancreatic head tumors become incredibly difficult in patients who have undergone esophageal reconstruction with a gastric tube. • We describe successful arterial reconstruction using the middle colic artery in a patient who had undergone esophageal reconstruction with a gastric tube and whose right gastro-omental artery had been resected., Introduction There are no reports on vessel reconstruction of right gastro-omental artery deficits due to pancreatic tumor resection. Here, we describe successful arterial reconstruction using the middle colic artery in a patient who had undergone esophageal reconstruction with a gastric tube and whose right gastro-omental artery had been resected. Presentation of case A 70-year-old man underwent subtotal esophagectomy and reconstructive surgery with a retrosternal gastric tube for esophageal cancer. A follow-up computed tomography (CT) scan revealed a tumor on the pancreatic head that was adjacent to the right gastro-omental artery. Pancreaticoduodenectomy (PD) was subsequently performed. The gastro-omental artery was resected along with the tumor, creating a 7-cm deficit. The anastomosis was performed between the right branch of the middle colic artery and the distal end of the right gastro-omental artery. No complications that involved blood flow to the reconstructed esophagus were postoperatively observed. Four months after surgery, the blood flow to the gastric tube was confirmed by a contrast CT scan. Discussion We reconstructed the right gastro-omental artery using the middle colic artery, and not a vein graft, as that would have required vessel anastomosis at two locations. The middle colic artery branches on the posterior surface of the pancreas, which is located close to the right gastro-omental artery. Conclusion The middle colic artery provides sufficient blood supply to the pulled-up gastric tube. PD can be performed even in patients who have undergone esophageal reconstruction.

Objectives. To investigate the usefulness of contrast-enhanced endoscopic ultrasonography (CE-EUS) for histological differentiation of pancreatic tumors.Methods. CE-EUS was performed for consecutive patients having a pancreatic solid lesion, and tumors were classified into three vascular patterns (hypervascular, isovascular, and hypovascular) at two time phases (early-phase and late-phase). Correlation between vascular patterns and histopathology of resected pancreatic cancer (PC) tissues was ascertained.Results. The final diagnoses of 147 examined tumors were PC(n=109), inflammatory mass(n=11), autoimmune pancreatitis(n=9), neuroendocrine tumor(n=8), and others(n=10). In late-phase images, 104 of 109 PCs had the hypovascular pattern, for a diagnostic sensitivity and specificity of 94% and 71%, respectively. Of 28 resected PCs, 10 had isovascular, and 18 hypovascular, patterns on the early-phase image. Early-phase isovascular PCs were more likely to be differentiated than were early-phase hypovascular PCs (6 well and 4 moderately differentiated versus 3 well, 14 moderately, and 1 poorly differentiated,P=0.028). Immunostaining revealed that hypovascular areas of early-phase images reflected heterogeneous tumor cells with fibrous tissue, necrosis, and few vessels.Conclusion. CE-EUS could be useful for distinguishing PC from other solid pancreatic lesions and for histological differentiation of PCs.

Summary:. We performed a new procedure for reconstruction of donor site of a deltopectoral (DP) flap. A 58-year-old man presented with a wide subcutaneous abscess, which was caused by acute mandibular osteomyelitis due to dental caries. On admission, the patient received a neck incision for drainage. However, necrosis of the neck skin was observed after drainage. The patient had an 8 × 10 cm skin and soft-tissue defect, which we covered with a DP flap (15 × 7 cm). The DP flap donor site was reconstructed using a 16 × 8 cm pedicled thoracodorsal artery perforator (TDAP) flap. There was no flap necrosis, abscess formation, or scar contracture of the DP region. Debulking of the TDAP flap was not required. The pedicled TDAP flap is useful for the reconstruction of the donor site of DP flap. In this report, we describe our operative procedure.

Background We report a rare case of a juxta-adrenal schwannoma that could not be discriminated from an adrenal tumor before surgical resection and was complicated by bilateral hyperaldosteronism. To the best of our knowledge, this is first case in which both a juxta-adrenal schwannoma and hyperaldosteronism co-existed. Case presentation A 69-year-old male treated for hypertension was found to have a left supra-renal mass (5.8 × 5.2 cm) by abdominal computed tomography. His laboratory data showed that his plasma aldosterone concentration (PAC) was within the normal range, but his plasma renin activity (PRA) was reduced, resulting in an increased aldosterone/renin ratio (ARR). Load tests of captopril or furosemide in the standing position demonstrated autonomous aldosterone secretion and renin suppression. Adrenal venous sampling (AVS) with ACTH stimulation indicated bilateral hypersecretion of aldosterone. A left supra-renal tumor was resected because of the possibility of malignancy and was found to be a benign schwannoma arising from the juxta-adrenal region together with an adrenal gland. The dissected left adrenal gland was morphologically hyperplastic in the zona glomerulosa, but was immunohistochemically negative for CYP11B2 (aldosterone synthase). Multiple CYP11B2-positive adrenocortical micronodules were detected in the adrenal gland, indicating micronodular hyperplasia. Although bilateral aldosteronism was indicated by AVS before the operation, the PRA, PAC and ARR values were within their respective reference ranges after resection of the unilateral tumor, suggesting that the slight increase in hormone secretion from the remaining right-sided lesion could not be detected after resection. Conclusion A clinical and morphologic diagnosis of juxta-adrenal schwannoma is difficult, particularly in a case of hyperaldosteronism, as shown in this case. These data suggest the complexity and difficulty diagnosing adrenal incidentaloma.