Novel technique of abdominal wall nerve block for laparoscopic colostomy: Rectus sheath block with transperitoneal approach

A 62-year-old man who had acute rectal obstruction due to a large rectal cancer is presented. He underwent emergency laparoscopic colostomy. We used the laparoscopic puncture needle to inject analgesia with the novel transperitoneal approach. In this procedure, both ultrasound and laparoscopic images assisted with the accurate injection of analgesic to the correct layer. The combination of laparoscopic visualization and ultrasound imaging ensured infiltration of analgesic into the correct layer without causing damage to the bowel. Twentyfour hours postoperatively, the patient's pain intensity as assessed by the numeric rating scale was 0-1 during coughing, and a continuous intravenous analgesic was not needed. Colostomy is often necessary in colon obstruction. Epidural anesthesia for postoperative pain cannot be used in patients with a coagulation disorder. We report the use of a novel laparoscopic rectus sheath block for colostomy. There has been no literature described about the nerve block with transperitoneal approach. The laparoscopic rectus sheath block was performed safely and had enough analgesic efficacy for postoperative pain. This technique could be considered as an optional anesthetic regimen in acute situations.

Recent evolution of living donor liver transplantation at Kyoto University:How to achieve a one-year overall survival rate of 99%?

Previously,living donor liver transplantation was considered as a“high-risk,high-return”medical treatment due to the relatively high short-term mortality.It is our task to change“high-risk,high-return”into a“low-risk,high-return”situation.In this review article,the recent evolutions in living donor liver transplantation for both donors and recipients at Kyoto University such as portal vein pressure modulation,hybrid donor operation,and perioperative management considering sarcopenia,focusing on improvement of short-term outcomes are described.Under a paradigm of“marketing and innovation”,various innovations and efforts have been made over the last decade aiming at improving the short-term outcomes of both donors and recipients.By doing so,excellent short-term results after living donor liver transplantation have been achieved,along with a potentially epoch-making discoveries.

Postoperative functional evaluation of gastrectomy for gastric cancer

To improve the quality of surgical procedures for gastric cancer,it is essential to consider many components comprehensively,including gastric motility,small intestinal absorption,hormones that affect gastric motility and appetite,presence or absence of vagus nerve preservation,esophageal regurgitation on endoscopic findings,in addition to whether or not there is a physiological route for food passage through the duodenum.Furthermore,proper functional evaluation cannot be performed without considering the form and amount of energy in the nutritional supplement to be loaded,and the posture at the time of investigation.The results of functional evaluation vary according to the method selected from many available options,but we believe that use of the most physiologically accurate,appropriate and selectable option will enable us to arrive at the best resection/reconstruction technique.We have reported that it is important to consider the preservation of three elements when performing gastrectomy:1)reduction of the extent of gastrectomy,2)preservation of the pylorus,and 3)preservation of the vagus nerve;among which preservation of the remnant stomach is the most important.Furthermore,the selection of a reconstruction method that maintains secretion of hormones beneficial to gastric motility preserves the energy balance inherent in the human body,and also provides better quality of life.

Proposal of definition and diagnostic criteria for sarcopenic obesity by ESPEN and EASO

In the last decade,many investigators including us have reported the negative impact of preoperative sarcopenia or low skeletal muscle mass on outcomes after surgery including hepato-biliary-pancreatic(HBP)surgery such as liver transplantation,liver surgery,biliary surgery,and pancreatic surgery(1-5).In addition to low skeletal muscle mass,the abnormality of body compositions,decreased muscle quality and visceral obesity,has been clarified to be also negatively associated with poor outcomes after HBP surgery(2-5).Consequently,it was easily supposed that co-existence of sarcopenia and obesity,called sarcopenic obesity(SO),had more strong negative impact on outcomes.Actually,not a few studies have demonstrated negative clinical impact of SO on outcomes after HBP surgery using various definitions for SO(6-10).We reported that patients with SO,defined by low skeletal muscle mass with high visceral fat to subcutaneous fat ratio evaluated by preoperative computed tomography(CT)image,had significant worse survival than non-sarcopenia patients and patients with sarcopenia only after liver transplantation,hepatic resection,and pancreatic resection(6-9).

Need for pancreatic stenting after sphincterotomy in patients with difficult cannulation

AIM:To investigate the need for pancreatic stenting after endoscopic sphincterotomy(EST)in patients with difficult biliary cannulation.METHODS:Between April 2008 and August 2013,2136 patients underwent endoscopic retrograde cholangiopancreatography(ERCP)-related procedures.Among them,55 patients with difficult biliary cannulation who underwent EST after bile duct cannulation using the pancreatic duct guidewire placement method(P-GW)were divided into two groups:a stent group(n=24;pancreatic stent placed)and a no-stent group(n=31;no pancreatic stenting).We retrospectively compared the two groups to examine the need for pancreatic stenting to prevent post-ERCP pancreatitis(PEP)in patients undergoing EST after biliary cannulation by P-GW.RESULTS:No differences in patient characteristics or endoscopic procedures were observed between the two groups.The incidence of PEP was 4.2%(1/24)and29.0%(9/31)in the Stent and no-stent groups,respectively,with the no-stent group having a significantly higher incidence(P=0.031).The PEP severity was mild for all the patients in the stent group.In contrast,8 had mild PEP and 1 had moderate PEP in the no-stent group.The mean serum amylase levels(means±SD)3 h after ERCP(183.1±136.7 vs 463.6±510.4 IU/L,P=0.006)and on the day after ERCP(209.5±208.7vs 684.4±759.3 IU/L,P=0.002)were significantly higher in the no-stent group.A multivariate analysis identified the absence of pancreatic stenting(P=0.045;odds ratio,9.7;95%CI:1.1-90)as a significant risk factor for PEP.CONCLUSION:In patients with difficult cannulation in whom the bile duct is cannulated using P-GW,a pancreatic stent should be placed even if EST has been performed.

Colon cancer arising from colonic diverticulum:A case report

BACKGROUND Colonic diverticulosis is a common disease, and the coexistence of colonic diverticulosis and colorectal cancer is often seen clinically. It is very rare that colon cancer arises from the mucosa of a colonic diverticulum. When colon cancer arises in a diverticulum and then tends to develop outside the wall, without developing within the lumen, the differential diagnosis from complicating lesions due to colonic diverticulitis is difficult. CASE SUMMARY A 76-year-old man was admitted to a nearby clinic with a chief complaint of discomfort and urinary frequency. Since a vesicosigmoidal fistula was seen on abdominal computed tomography, he was referred to our hospital. Laparoscopic sigmoidectomy was performed because the various diagnostic findings were diagnosed as a vesicosigmoidal fistula with diverticulitis of the sigmoid colon. However, on histopathological examination, it was diagnosed as a vesicosigmoidal fistula due to colon cancer arising in the diverticulum. Laparoscopic partial resection of the bladder was performed because local recurrence was observed in the bladder wall one and a half years after surgery. It is currently one year after reoperation, but there has been no recurrence or metastasis. CONCLUSION Colon cancer arising in a diverticulum of the colon should be considered when diverticulitis with complications is observed.

Neoadjuvant chemoradiotherapy for locally advanced gastric cancer with bulky lymph node metastasis:Five case reports

BACKGROUND Neoadjuvant chemoradiotherapy(NACRT)has not been accepted as a general therapy for gastric cancer because of its localized effect and toxicity for radiosensitive organs.However,if radiation therapy could compensate for the limited or inadequate treatment choices available for elderly patients and/or those at high risk,the available therapeutic options for advanced gastric cancer might increase.From this perspective,we present our experiences of five patients with advanced gastric cancer in whom we used NACRT therapy with interesting results.CASE SUMMARY We admitted five patients with clinical Stage III gastric cancer and bulky lymph node metastasis or adjacent organ invasion at the time of diagnosis.A total of 50 Gy of preoperative intensity modulated radiation therapy was delivered to the patients in doses of 2.0 Gy/d,together with a regimen of concomitant chemotherapy comprising two courses of oral tegafur/gimeracil/oteracil(S-1;65 mg/m2 per day)for three consecutive weeks followed by two weeks of rest,starting at the same time as radiotherapy.All patients underwent no residual tumor resection and a pathological complete response of the primary tumors was achieved in two patients.The incidence of hematological toxicity was low,although the digestive toxicities of anorexia and diarrhea developed in three of the five patients,necessitating termination of radiation therapy at 30 Gy and S-1 at three weeks.However,even 30 Gy of irradiation and half the dose of S-1 resulted in sufficient downstaging,indicating that even a reduced amount of NACRT could confer considerable effects.CONCLUSION Slightly reduced NACRT might be useful and safe for patients with locally advanced gastric cancer.

An international expert consensus of management of recurrent hepatocellular carcinoma: a viewpoint

We read with great interest the article titled "Multidisciplinary management of recurrent and metastatic hepatocellular carcinoma after resection: an international expert consensus" (1) published in Hepato Biliary Surgery and Nutrition.

Short postoperative hospital stay after pancreaticoduodenectomy:what is real minimally invasive surgery?

Pancreaticoduodenectomy(PD)is performed for patients with tumors located in the region of the head of the pancreas,including cancer of the head of the pancreas,periampullary cancer,and distal bile duct cancer.PD is considered one of the most difficult and invasive surgeries in hepato-biliary-pancreatic surgeries because it requires meticulous techniques both in resection and reconstruction.Moreover,postoperative complications such as postoperative pancreatic fistula(POPF)and delayed gastric emptying(DGE)sometimes occur after PD,which leads to relatively higher mortality and longer postoperative hospital stay compared with other digestive surgeries.In PD,laparoscopic and robotic surgeries,called minimally invasive surgery(MIS),have recently been introduced.However,the incidence of postoperative complications and the length of the postoperative hospital stay have not decreased significantly after the introduction of such MIS(1-3).