Transhiatal lower mediastinal lymph node dissection for esophagogastric junction carcinoma by interconnecting four body cavities

BackgroundDue to the limited number of landmark structures, it is difficult to standardize the surgical procedures for advanced esophagogastric junction cancer such as Ivor Lewis esophagectomy that require transhiatal lower mediastinal lymph node dissection (TH-LMND). We demonstrate an easily reproducible procedure for TH-LMND, wherein four body cavities, namely, the abdominal cavity, infracardiac bursa (ICB), and left and right thoracic cavities are interconnected.MethodsFirst, the dissection between the right crus and the esophagus was used to connect the abdominal cavity to the ICB — a lower mediastinal cavity separated from the omental bursa during embryonic development [1,2]. Second, the right thoracic cavity was opened with the shortest distance by dissecting the cranial side of the ICB. The right pulmonary ligament was dissected from the right lung. Third, the dissection to the contralateral side while exposing the aorta and the pericardium connected the left and right thoracic cavities. Then, the left pulmonary ligament was dissected from the left lung. The dissected tissues, including the lymph nodes, were subsequently peeled from the esophagus.ResultsBetween April 2018 and August 2021, 14 patients underwent laparoscopic or robotic TH-LMND via the procedure above. The median time required to complete the dissection was 75 min. None of the procedures were converted to open surgery, and none of the patients experienced intraoperative complications such as pericardial injury, lung injury, or massive bleeding.ConclusionThe surgical concept of interconnecting four body cavities made the procedure more accessible and reproducible while achieving en bloc TH-LMND.     

Richter's hernia

Richter's hernia is associated with rapid onset of gangrene and a high mortality. We report a case of a strangulated inguinal Richter's hernia of the cecum requiring a laparotomy and bowel resection. Due to the misleading clinical presentation, a high index of suspicion, particularly in patients with a history of laparoscopic surgery, will minimize delay in diagnosis.     

Clinical and dermoscopic features of extramammary Paget's disease: A retrospective analysis of 49 cases

BackgroundExtramammary Paget's disease (EMPD) is a rare cutaneous malignancy that can be easily confused with other diseases due to its diverse clinical manifestations, delaying the timing of treatment. Therefore, early diagnosis is extremely important. It has been reported that dermoscopy can be used to evaluate superficial skin tumors.ObjectiveTo investigate the dermoscopic characteristics of EMPD diagnosed by histopathology and to develop a decision tree model that can provide clinicians with a reference to facilitate early diagnosis.MethodsAll patients were evaluated by dermoscopic and histopathologic examinations. Dermoscopic images were assessed, and a decision tree model was constructed using SPSS (version 25.0).ResultsA total of 49 patients were included in this study. We found that EMPD was most likely to be misdiagnosed when the disease duration was less than 2.5 years. Porcelain-white patches were the only key clinical feature other varying dermoscopic features could not be differentiated from those of EMPD-mimicking diseases. Polymorphic vessels were considered to be significant when the duration of the disease ranged from 0.1 year to 2.5 years. However, when the duration was >2.5 years, present (or absent) glomerular vessels were all considered EMPD.ConclusionsDermoscopy can be used as an auxiliary diagnostic tool for the diagnosis and management of EMPD. The decision tree can guide clinical diagnosis further validation studies are necessary due to the limited number of cases.     

Hepatic ischemia-reperfusion increases circulating bone marrow-derived progenitor cells and tumor growth in a mouse model of colorectal liver metastases

BackgroundHepatic pedicle clamping is often required to reduce blood loss and transfusion during liver resection. However, the question remains whether use of hepatic pedicle clamping promotes tumor growth. Endothelial progenitor cells (EPCs) are mobilized from bone marrow in response to tissue ischemia, which allows neovascularization of ischemic tissue. It has been suggested that EPCs are involved in tumor progression. We hypothesized that hepatic ischemia reperfusion (I/R)-induced mobilization of EPCs could enhance growth of microscopic tumor, therefore promoting liver metastasis in a mouse model of colorectal cancer.Materials and methodsWe used mouse models of hepatic I/R and hind limb ischemia. For comparison, we studied mice that underwent limb ischemia as positive controls of EPC mobilization. At day 0, we divided 40 mice into four groups: hepatic I/R, hind limb ischemia, combined hepatic I/R and hind limb ischemia, and control (sham midline incision laparotomy). At day 2, we induced liver metastasis in all mice by injecting CT-26 cells into the spleen. Time-dependent circulating EPCs were determined by flow cytometry. We evaluated liver metastasis and microvascular density on day 21.ResultsThe number of circulating progenitor cells increased rapidly in the ischemic groups compared with the control group. Hepatic I/R significantly increased tumor outgrowth compared with the control group. Increased tumor growth was associated with enhanced CD31-positive microvascular density in liver tissue.ConclusionsHepatic I/R leads to mobilization of bone marrow–derived EPCs and enhanced intra-hepatic angiogenesis, which is associated with increased tumor burden in an animal model of colorectal liver metastasis.     

Complications in paediatric liver transplant from Kuwait when transplanted abroad

Background and study aimsSince the introduction of liver transplantation (LTx) in children suffering from liver failure in 1963, many centres around the world have offered this service to children that have no other alternative. The aim of this retrospective study is to analyse the results of paediatric liver transplant in Kuwait over the last decade.Patients and methodsA retrospective chart review was done involving paediatric patients during the time period of 1995–2004. The information collected included patient demographics, indications for liver transplantation, survival of both patient and allograft, and complications.ResultsA total of 16 cases were found and analysed. The mean age was 3.6 years (ranged 5 months–17 years). There were nine boys and seven girls. The most common indications for LTx were biliary atresia and metabolic liver disease. All the liver transplants were done abroad. There were totally nine deceased donor and seven living related cases. The complications were acute cellular rejection in five, hypertension in two, biliary complications in four, cytomegalovirus (CMV) infection in three and post lymphoproliferative disease in two cases. All but one patient are presently alive.ConclusionThe above information demonstrates that LTx in Kuwati children is safe and improves the quality of life for those that would otherwise have no other alternative.     

Malignant liver tumours

The liver is commonly affected by both primary and metastatic malignancy. The surgical management of liver tumours must be carefully considered to ensure good oncological outcomes and to avoid serious complications of liver surgery. Primary tumours of the liver include hepatocellular carcinoma and cholangiocarcinoma. The resectability of primary liver tumours is dependent on thorough preoperative staging. Primary liver tumours pose a major global health burden, particularly in Asia and in countries affected by epidemic viral hepatitis. Metastatic disease commonly affects the liver and often hepatic resection in such circumstances provides the best chance of prolonging life and disease free survival. This review discusses recent advances, in addition to the epidemiology, diagnosis and management of both primary and secondary liver tumours.