Usefulness of Detailed Analysis with Operative Procedure of Total Laparoscopic Hysterectomy (TLH) Done a Single Surgeon, to Master the Surgical Technique of TLH and Gain Higher Proficiency

Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysis of women who underwent TLH for benign diseases between April, 2014 and March, 2016 was conducted by a single surgeon in a single hospital (Showa University of Fujigaoka Hospital). We divided the main procedures of the TLH operation into five sections, and measured the time required for each section. These cases were divided into three groups, group 1, 2, and 3. Results: There were 54 cases of TLH over two years for a single surgeon, and 21 cases that included essential operative procedures were divided into three groups of seven cases each. The average duration of the surgery (min.) was 178.3 ± 48.2 in the group 1, 128.3 ± 15.6 in the group 2, and 111.3 ± 15.9 in the group 3. A significant reduction in the required time was observed between group 1, 2, and 3 groups. As the number of cases increased, the operation time became statistically significantly shorter for every section except B and D. The skill growth rate was different at each section. Conclusion: For a single surgeon, as the number of surgical cases increased, we recognized the increased skill with the procedure in every section and the rate of skill growth differed for different sections. The difference of growth rate for each section implied that the number of operative cases required for a surgeon in each section was different.

A Case of Low-Grade Appendiceal Mucinous Neoplasm of Its Difficultly to Distinguish from a Right Ovarian Tumor Due to Postmenopause

We here present a rare case of appendiceal tumor mimicking ovarian tumor in menopause woman. The patient was a 56-year-old woman, G1P1, who presented to our hospital with a right adnexal cyst diagnosed at another hospital. Transvaginal echocardiography showed a cyst in the right adnexal region, and pelvic contrast-enhanced MRI revealed a small cyst in the same region. The left ovary was atrophic and identifiable. It was unclear whether the cyst was contiguous with the gastrointestinal tract. Blood tests showed no elevation of tumor markers. We considered its possibility of a gastrointestinal origin, but since right normal ovary was not found, we thought the tumor was of ovarian origin and decided on a laparoscopic resection of the right adnexa. Intraoperatively, we observed atrophied bilateral normal ovaries, and the pelvic tumor was contiguous to the appendix. Surgeons performed a laparoscopic appendectomy after consultation with us. After resection we searched the abdominal and pelvic cavities, but found no obvious disseminated lesions. The histological diagnosis was low-grade appendiceal mucinous neoplasm (LAMN), a rare benign tumor of the appendix. Appendiceal tumors can be difficult to differentiate from right ovarian tumors due to their close anatomic location in the pelvis. It is possible to determine whether the tumor is of ovarian or appendiceal origin by identifying normal ovaries and the location of the feeding vessels into the tumors. In our case, there were no lesions other than the appendix, but LAMN can metastasize to the ovary, cause pseudomyoxoma peritonei, or be an overlapping tumor with an ovarian tumor. If an appendiceal tumor is diagnosed after surgery for ovarian tumor, the intra-abdominal cavity should be searched for metastasis or dissemination, and a thorough search for ovarian lesions should be performed with the possibility of an overlapping tumor in mind.

Treatment outcomes of chemotherapy between unresectable and recurrent biliary tract cancer

AIM:To evaluate the differences in the treatment outcomes between the unresectable and recurrent biliary tract cancer patients who received chemotherapy.METHODS:Patients who were treated with gemcitabine and S-1 combination therapy in the previous prospective studies were divided into groups of unresectable and recurrent cases.The tumor response,time-toprogression,overall survival,toxicity,and dose intensity were compared between these two groups.RESULTS:Response rate of the recurrent group was higher than that of the unresectable group(40.0%vs25.5%;P=0.34).Median time-to-progression of the recurrent and unresectable groups were 8.7 mo(95%CI),1.2 mo,not reached)and 5.7 mo(95%CI:4.0-7.0 mo),respectively(P=0.14).Median overall survival of the recurrent and the unresectable groups were 16.1 mo(95%CI:2.0 mo-not reached)and 9.6 mo(95%CI:7.1-11.7 mo),respectively(P=0.10).Dose intensities were significantly lower in the recurrent groups(gemcitabine:recurrent group 83.5%vs unresectable group 96.8%;P<0.01,S-1:Recurrent group 75.9%vs unresectable group 91.8%;P<0.01).Neutropenia occurred more frequently in recurrent group(recurrent group 90%vs unresectable group 55%;P=0.04).CONCLUSION:Not only the efficacy but also the toxicity and dose intensity were significantly different between unresectable and recurrent biliary tract cancer.

伴有自主神经受累的慢性炎症性脱髓鞘性多发神经根性神经病

We report a case of chronic acquired neuropathy predominantly affecting senso ry and autonomic nerves. Investigations showed a demyelinating polyradiculoneuro pathy with axonal degeneration and depletion of postganglionic noradrenergic fib ers in the rectal mucosa. Intravenous immunoglobulin and corticosteroid administ ration were effective in alleviating symptoms and improving electrophysiological abnormalities. This neuropathy may be a novel variant of chronic inflammatory d emyelinating polyradiculoneuropathy (CIDP), in which autoimmunoreactivity is directed not only against myelin but also against axon-or ganglion-compos ing protein. Autonomic nerve involvement does not exclude a diagnosis of CIDP.