Intracystic gastrointestinal stromal tumor developed in the round ligament of the liver.

A 44-year-old woman was referred to our hospital for the examination and treatment of a presumed gallbladder tumor. Both ultrasound and computed tomography showed an intracystic tumor but failed to point out the discontinuity between the cystic lesion and the gallbladder. Magnetic resonance imaging, however, could clearly depict the presumed intracystic tumor and the discontinuity between the gallbladder and the target lesion. Both contents of the gallbladder and the cystic lesion showed hypo and hyper intense patterns, though both with slightly different intensities, on T1- and T2-weighted images, respectively. Under the preoperative diagnosis of early gallbladder cancer despite these image findings, laparoscopic cholecystectomy was attempted to the patient. Laparoscopic observation, however, revealed that the target lesion was not continuous with the gallbladder and was located in the round ligament of the liver. Intraoperative findings led us to do cholecystectomy and resection of the adjacent cystic tumor. The intracystic tumor was 3 cm in size and had minute solid component inside the cyst wall. Pathological study of the presumed gallbladder cancer showed epithelioid cells and spindle cells growing in sheet like and storiform fashions, respectively. Cystic walls mainly consisted of hypo cellular fibrous components. Immunohistochemical staining of the tumor was positive for CD117 and negative both for desmin and S100, leading to the diagnosis of gastrointestinal stromal tumor. MIB-1 labelling index of the gastrointestinal stromal tumor was 8%. The patient recovered uneventfully and has been well without any recurrences for 3 months.

Focal coagulative necrosis of the liver in a patient with sustained virologic response to anti-hepatitis C virus therapy.

A 69-year-old woman with chronic hepatitis C virus (HCV) infection was referred to our hospital due to liver enzyme abnormalities. Four years after anti-HCV therapy, the patient with sustained virologic response and no clinical symptoms developed an oval hepatic mass with mixed high and low internal echoes near the portal vein on ultrasound. Magnetic resonance imaging (MRI) of the liver lesion showed a slightly hypo intense pattern on T1-weighted images, a hyper intense pattern both on T2- and diffusion-weighted images, a slight rim enhancement pattern with no intra-lesional enhancement up to the late phase, and a very low intense pattern on hepatobiliary phase images. Positron emission tomography/computed tomography (PET / CT) showed no areas of avid radiotracer uptake in the liver. No tumor markers showed abnormally high values. All these images and laboratory findings led us to the assessment of the liver lesion as a non-neoplastic disorder. However, due to the patient's strong preference to get both definitive diagnosis and cure of the lesion, the patient underwent laparoscopic partial hepatectomy. Pathological study showed 2 necrotic areas surrounded by multiple lymph follicles, epithelioid cells, lymphocytes, collagen fibers, and plasma cells, leading to the diagnosis of focal coagulative necrosis of the liver (FCNL). Physicians should note that FCNL can occur without any symptoms and can be diagnosed at least as a non-neoplastic disorder with combined MRI and PET/CT analysis.

Well-Differentiated Adenocarcinoma Spreading Widely in the Gastric Submucosa.

A 56-year-old woman was referred to our hospital due to dry mouth. Diagnostic upper gastrointestinal endoscopy showed slightly elevated lesions both on the anterior wall and lesser curvature in the upper part of the stomach. Biopsy-proven tuble-forming atypical cells in the two lesions led us to treat the presumed early gastric cancers with endoscopic submucosal dissection (ESD). Pathological examination of the ESD specimen showed well-differentiated malignant cells spreading widely in the submucosa with positive lateral and deep margins. On retrospective image re-evaluation after ESD, we noticed the correlation between the presumed early gastric cancers and the multiple submucosal cyst-like lesions in the gastric wall on computed tomography. Under the tentative diagnosis of gastric cancers originating not from orthotopic gastric mucosa but from submucosal ectopic gastric gland, the patient underwent laparoscopic total gastrectomy and regional lymph node dissection, revealing the tumor infiltration to the serosa and regional lymph node swelling. Postoperative pathological evaluation showed lymph node metastases, multiple submucosal cyst-like lesions lined with a single layer of presumably benign epithelium, papillary adenocarcinoma cells in the submucosa, and tubular adenocarcinoma cells both in the mucosal and subserosal regions. The patient was discharged on the postoperative 7th day without any events and completed adjuvant chemotherapy on an outpatient basis. General surgeons should note that cyst-like lesion(s) in the gastric wall might be a predictor of extensive submucosal cancer cell spreading even in a case of well-differentiated gastric adenocarcinoma.

[A Case of Long-Term Remission with Surgical Therapy and Chemoradiotherapy for a Rapidly Increasing Large Cell Neuroendocrine Carcinoma(LCNEC)].

BACKGROUND: Large cell neuroendocrine carcinoma(LCNEC)is a relatively rare disease classified as a subtype of neuroendocrine tumor. LCNEC has clinical and histological similarities to small cell lung cancer, both of which have a similarly poor prognosis. There are also unclear points regarding treatment. CASE: 43-years-old, male. He had repeated intermittent fever from 1 month before the consultation. Cough appeared 4 days before the consultation, and the family doctor pointed out an abnormal shadow in the right lung field, and the patient was referred. Blood test showed increased CRP 1.34 mg/dL and mild inflammatory response. Chest CT showed an increased tumor with a major axis of 16 cm in the right thoracic cavity compared to 6 months ago. FDG-PET showed accumulation of SUVmax 11.83 in the same area. A CT-guided needle biopsy was performed, and although tumor cell hyperplasia of like a plasma cells was suspected, but most of them were coagulative necrotic images and could not be diagnosed. After hospitalization, fever continued and the general condition became poor, so surgery was performed for the purpose of diagnostic treatment. Preoperatively, Interventional Radiology was used to embolize the tumor-feeding blood vessels. Intrathoracic tumor resection and partial upper and lower lobe resection were performed under thoracotomy. Postoperative histopathological examination revealed that large round to polyhedron tumor cells proliferated in sheet-like or intercellular binding sparsely, and synaptophysin was positive, which was a diagnosis of large cell neuroendocrine cell carcinoma. The general condition improved promptly after the operation, and the patient was discharged 14 days after the operation without any complications. After discharge, 4 courses of adjuvant chemotherapy (CDDP plus CPT-11)were performed. Six months after the operation, the disseminated nodule recurred in the right thoracic cavity. Chemotherapy(CBDCA plus PTX plus BEV)and radiation therapy were performed and the patient was in remission. It has been 5 years since the operation and has not recurred. SUMMARY: We report a case of rapidly increasing LCNEC with long-term remission by surgical treatment and chemoradiotherapy, with some review of the literature.

Evaluation of additional gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer.

BACKGROUND: Performing additional surgery after noncurative endoscopic submucosal dissection (ESD) for early gastric cancer is controversial. Our aims are to clarify the risk factors for lymph node metastasis (LNM) and local residual cancer (RC) after noncurative ESD and to determine recommendations for additional treatment. METHODS: Of the 1483 patients who underwent ESD for early gastric cancer between January 2012 and April 2020, we retrospectively analyzed 151 patients diagnosed as having a lesion not meeting the curative criteria after ESD. Of these patients, 100 underwent additional gastrectomy, and 51 were observed without surgery. RESULTS: Surgical specimens showed LNM in 14 patients (14.0%) and local RC in 7 (7.0%). However, 81 patients (81.0%) had neither of these malignancies. Multivariate analysis revealed that a positive lymphatic invasion (P = 0.035) and an undifferentiated type (P = 0.047) were independent risk factors for LNM, whereas a positive horizontal margin (P = 0.010) was an independent risk factor for local RC. Furthermore, the prevalence of LNM was significantly higher in patients with both positive lymphatic and vascular invasions. In the additional gastrectomy group, 3 patients (3.0%) had recurrences, and 2 patients (2.0%) who had distant recurrences died of gastric cancer. In the observation group, recurrence was observed in 3 patients (5.9%). One patient (2.0%) who had liver metastasis died of gastric cancer. Of the 2 patients (3.9%) who had local recurrences, one underwent additional ESD, and the other without additional ESD died of other disease. The 5-year overall survival rates in the additional gastrectomy and observation groups were 87.4% and 73.8%, respectively (log-rank test, P = 0.008). CONCLUSION: Following noncurative ESD for early gastric cancer, we recommend an additional gastrectomy with lymph node dissection for patients with lymphovascular invasion and/or undifferentiated type. Careful follow-ups without additional surgery may be acceptable for patients with advanced age, severe comorbidity, or no lymphovascular invasion.

Liver Abscess and Prolonged Postoperative Intra-Abdominal Free Air without Anastomotic Leakage after Laparoscopic Gastrectomy.

An 84-year-old thin, i.e., body mass index of 17.8, woman with gastric cancer underwent laparoscopic distal gastrectomy and lymph node dissection followed by Roux-en-Y reconstruction. During the operation, Nathanson liver retractor (NLR) was used to press the left lobe of the liver. The patient recovered uneventfully and was discharged on the 9th postoperative day. The patient, however, developed abdominal pain just on the day of discharge. Sudden onset of the abdominal pain and massive free air on computed tomography made us do diagnostic laparoscopy. Detailed laparoscopic observation showed slight liver swelling at the pressure site of the NLR, superficial band-shaped color change on the left lobe of the liver, and no anastomotic leakage, suggesting the massive free air caused by prolonged retention of postoperative intra-abdominal air. Two days later, persistent fever, inflammatory findings, and presumed liver abscess showing no healing tendency made us do ultrasound-guided aspiration to the liver focus. Bacterial culture test showed the bacterium Escherichia coli, being sensitive to meropenem. Despite the failure of abscess drainage, antibiotic therapy using meropenem gradually alleviated her symptoms and the patient was discharged from the hospital in 15 days after the abscess aspiration. Surgeons should note possible prolonged postoperative intra-abdominal free air and liver abscess without anastomotic leakage after laparoscopic gastrectomy especially in thin patients to avoid inappropriate postoperative management.

[A Case of Preoperative Diagnosis of Intraductal Papillary Tumor with Good Course after Surgical Resection].

BACKGROUND: Intraductal papillary neoplasm of bile duct(IPNB)is a papillary tumor that develops in the bile duct inside and outside the liver, and is a relatively new disease concept recognized as a precancerous/early cancer lesion of bile duct cancer. CASE: A 74-year-old woman. A nearby doctor pointed out liver dysfunction in a medical examination, and he was introduced for the purpose of detailed examination. No subjective symptoms were observed. The blood sampling test showed no increase in tumor markers. Abdominal CT/MRI examination and abdominal echo examination showed multiple nodules from the origin of the left intrahepatic bile duct and intrahepatic bile duct dilation predominantly on the left side. No other findings indicating metastasis were found, including the PET-CT test. Endoscopic retrograde cholangiography revealed a poorly contrast-enhanced area in the B3 region, and intraluminal ultrasonography confirmed a mass that coincided with the poorly contrast-enhanced area and grew papillary. No tumor growth was observed in the other branches or common bile ducts, but all ducts were filled with suspended matter, which was thought to be mucus. Histopathological examination of the tumor biopsy revealed atypical epithelium with papillary structure and moderate nuclear atypia. A diagnosis of intraductal papillary tumor was made, and left hepatic lobectomy was performed. Postoperative histopathological examination revealed a complex papillary growth of highly dysplastic mucus-producing epithelium similar to the pancreatic duct/bile duct epithelium, and no obvious infiltrative growth. The postoperative course was uneventful, and the patient was discharged 16 days after the operation. Currently, 6 months after the operation, he is outpatient without recurrence. We report a case of intraductal papillary tumor that had a favorable course after surgical resection in the preoperative diagnosis, with some review of the literature.

Confirmed complete response to nivolumab for advanced gastric cancer with peritoneal dissemination: a case report.

BACKGROUND: Recent advances in cancer immunotherapy have been remarkable, with many reports on the clinical effects of immune checkpoint inhibitors. Nivolumab has been covered by the national health insurance in Japan as a third-line agent for advanced and recurrent gastric cancer since September 2017. The objective response rate for nivolumab for gastric cancer is 11.2%. However, patients' quality of life during this treatment has not been examined. Here, we report a case in which multidisciplinary treatment, including with nivolumab, resulted in long-term survival and improved quality of life. CASE PRESENTATION: A 70-year-old Asian woman was referred for surgery for gastric cancer. Postoperative pathological examination revealed peritoneal dissemination, and the patient was diagnosed with stage IV gastric cancer. Therefore, she was treated with S-1 and cisplatin based on negative immunohistochemical staining of resected specimens for human epidermal growth factor receptor 2. However, owing to instability and adverse events, treatment was subsequently changed to S-1 monotherapy. Two years after changing to S-1 monotherapy, she developed recurrence of peritoneal dissemination and was treated with docetaxel. Radiation therapy was also used because the recurrent lesions were local. However, 6 months later, new peritoneal dissemination and lymph node metastasis were observed and nivolumab was started. Subsequent abdominal computed tomography revealed a marked reduction in the disseminated nodules and lymphadenopathy. After 54 cycles of nivolumab, the lesions had disappeared completely. The patient has not developed side effects, including immune-responsive adverse events, has improved quality of life, and is returning to work. She is currently taking nivolumab, and there is no evidence of recurrence approximately 3 years after starting nivolumab. CONCLUSIONS: Nivolumab may have beneficial effects in some patients with advanced or recurrent gastric cancer. Although the prognosis for gastric cancer and peritoneal dissemination is poor, multidisciplinary treatment that includes nivolumab may lead to long-term survival.

A Case of Lung Adenocarcinoma with Pulmonary Hypertrophic Osteoarthropathy Showing Pathological Complete Response to a Pembrolizumab-Containing Chemoimmunotherapy.

A 65-year-old woman with prolonged cough and presumed pulmonary hypertrophic osteoarthropathy was referred to our hospital. Computed tomography showed 2 tumors larger than 3 cm in size and massive hilar lymph node enlargement in the right lung. Pathological examination of the transbronchial lung biopsy specimen showed atypical malignant cells, presumed adenocarcinoma, with 1% positivity of programmed cell death 1 ligand (PD-L1). Three courses of chemoimmunotherapy with pembrolizumab (400 mg q3w), carboplatin (AUC 5 mg/mL · min q3w), and pemetrexed (500 mg/m2 q3w) were well tolerated and brought about a quasi-complete response both of the lung tumors and lymph nodes and complete symptom relief of the pulmonary hypertrophic osteoarthropathy, finally leading to the surgical intervention, that is, lobectomy and lymph node dissection. Postoperative pathological examination showed no viable cancer foci both in the lung tumors and lymph nodes. The patient recovered uneventfully. Physicians should note the combination chemoimmunotherapy including pembrolizumab, with curative intent, to optimally treat patients with locally advanced non-small cell lung cancer (NSCLC) even if the NSCLC bears a small amount of PD-L1.

Subdiaphragmatic abscess due to penetration of a duodenal ulcer successfully treated with endoscopic transgastric drainage: a case report.

BACKGROUND: Subdiaphragmatic abscesses are sometimes caused by intraabdominal infections. We report a case of endoscopic ultrasound-guided transgastric drainage. CASE PRESENTATION: A 75-year-old Asian man was referred to our hospital for treatment for upper gastrointestinal bleeding. On admission, blood tests showed a marked inflammatory response, and abdominal computed tomography showed free air in the abdominal cavity and a left subdiaphragmatic abscess. Therefore, the patient was diagnosed with an intraabdominal abscess associated with a perforated duodenal ulcer. Because he did not have generalized peritonitis, fasting and antibiotic treatment were the first therapies. However, because of the strong pressure on the stomach associated with the abscess and difficulty eating, we performed endoscopic ultrasound-guided transgastric drainage. After treatment, the inflammatory response resolved, and food intake was possible. The patient's condition remains stable. CONCLUSIONS: Drainage is the basic treatment for subdiaphragmatic abscesses; however, percutaneous drainage is often anatomically difficult, and surgical drainage is common. We suggest that our success with endoscopic ultrasound-guided transgastric drainage in this patient indicates that this approach can be considered in similar cases and that it can be selected as a minimally invasive treatment method.

Regressed Seminoma with Metastases to the Jejunum and Retroperitoneum.

A 66-year-old man with vomiting and weight loss was referred to our hospital. Abdominal computed tomography showed small bowel obstruction caused by a presumed small intestinal tumor. Single-balloon endoscopy showed an ulcerated tumor and marked stenosis of the jejunum. Immunohistochemical staining suggested the tumor to be poorly differentiated or undifferentiated carcinoma. The patient underwent open surgical resection of the jejunal tumor and regional lymph nodes both to improve the quality of life of the patient and to possibly get a cure of the presumed jejunal carcinoma. Pathological examination of the excised tumor and lymph nodes including para-aortic lymph nodes showed large-sized tumor cells and massive lymphocyte infiltrates. Immunostaining showed the tumor cells to be OCT3/4, AE1/AE3, CD117, and D2-40 positive, leading to the diagnosis of metastatic seminoma. With the preoperative diagnosis of a presumed burned-out tumor of the testis, the patient underwent left high orchiectomy. Pathological examination of the left testis showed marked scar tissue, no teratoma elements, and no residual tumor cells. Under the final diagnosis of regressed seminoma, the patient has received combination chemotherapy using bleomycin, etoposide, and cisplatin as adjuvant chemotherapy. Surgical oncologists should take regressed seminoma into their differential diagnosis when the biopsy specimens of the presumed intestinal malignancy show poorly differentiated or undifferentiated atypical cells with massive lymphocyte infiltrates, especially in postpubertal men. Confirmation of a malignant noninvasive component should be another important clue to the appropriate differential diagnosis when choosing between metastatic seminoma and poorly differentiated or undifferentiated intestinal primary malignancies.

[A Case of Lung Adenocarcinoma with Pulmonary Hypertrophic Osteoarthropathy].

BACKGROUND: Hypertrophic osteoarthropathy(HOA)is a syndrome that has three signs, the digital finger, periosteal neoplasia of the iliac bone, and arthritis. Among them, the secondary 1 associated with lung disease is called pulmonary hypertrophic osteoarthropathy(PHO). It is reported that many of the underlying diseases are associated with primary lung cancer, but in Japan, this is a rare condition with about 0.2 to 5.0%. CASE: A 68-year-old man. The patient was complaining of an arthralgia, and treated by the department of rheumatology. The thoracic CT scan for a screening pointed out a tumor in the right lower lobe, and referred to the department of surgery. Blood test showed CEA 21.8 ng/mL and LH 10.2 mIU/mL, FSH 23.1 mIU/mL. Chest CT showed a lung mass measuring 6.5×3.5 cm in the right lower lobe, and tracheobronchial lymph- node swelling. Bone scintigraphy showed abnormal accumulations in the long bones. We performed right lower lobectomy by thoracoscope. The pathological results were adenocarcinoma, G2, pT3, pN1, pm0, pl1, Ly1, V1, stage ⅢA. The arthralgia was relieved early after surgery. The patient recovered uneventfully and was discharged after the operation. Adjuvant chemotherapy was started, he was been well without recurrence.

Xanthogranulomatous cholecystitis: a review of 31 patients.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory gallbladder disease which is difficult to diagnose and treat; XGC may be confused with gallbladder cancer. The present study aimed to evaluate the clinical and radiological features and surgical outcomes, with the aim to determine the appropriate treatment approaches for XGC. METHODS: This retrospective study analyzed the clinical characteristics, intraoperative findings, and postoperative outcomes of 31 patients (2.0%) who were diagnosed with XGC based on histopathological findings among 1513 patients who underwent cholecystectomy at our hospital between January 2010 and July 2019. RESULTS: Preoperative ultrasonography and computed tomography findings indicated acute cholecystitis, chronic cholecystitis, and suspicious XGC in 26 (83.9%) patients with thickening of the gallbladder wall and suspicious gallbladder cancer in 5 (16.1%) patients. Abdominal pain and jaundice were observed in 18 (58.1%) patients and 5 (16.1%) patients, respectively. Biliary drainage before surgery was performed in 21 (67.7%) patients. Laparoscopic cholecystectomy, which was performed in 23 (74.2%) patients, was converted to open cholecystectomy in 12 (52.2%) of these 23 patients. Among the patients with other diseases treated during the study period, laparoscopic cholecystectomy was performed in 1377 patients and converted to open surgery in 71 (5.2%) patients. Five patients with suspicious gallbladder cancer underwent open surgery. In these patients, intraoperative frozen section analysis was useful in distinguishing between XGC and gallbladder cancer and was important in avoiding unnecessarily extended surgery. CONCLUSION: Laparoscopic cholecystectomy for XGC is possible, but often difficult due to severe inflammation. The frequency of conversion to open surgery is higher in patients with XGC than those with other forms of cholecystitis. XGC may resemble gallbladder cancer based on the diagnostic imaging findings, and intraoperative frozen section analysis is essential to avoid unnecessarily extended surgery.

Sigmoid Volvulus with Widespread Bowel Ischemia after Endoscopic Reduction Successfully Treated with Elective Laparoscopic Surgery.

An 87-year-old man complaining of abdominal distention was referred to our hospital. Plain radiograph and enhanced computed tomography (CT) showed a dilated sigmoid colon with a coffee bean sign, leading to the diagnosis of sigmoid volvulus. Based on symptoms and the CT and laboratory test findings, we initially treated the patient with endoscopic reduction, resulting in successful reduction of the sigmoid volvulus with widespread presumed mucosal ischemia. Due both to the lack of emerging symptoms suggesting colon perforation and to the laboratory test findings after endoscopic reduction, we treated the patient without further urgent surgical intervention. Two months later, the patient underwent successful elective laparoscopic surgery with a redundant sigmoid colon resection and a functional end-to-end anastomosis. He has been well without any events for 20 months. Conservative treatment with careful observation should be taken into consideration in the treatment of sigmoid volvulus with mild to moderate ischemia after endoscopic reduction.

Cases of two patients with aortoduodenal fistula who underwent emergency operation.

INTRODUCTION: Aortoduodenal fistula (ADF) is a rare but life-threating condition, and it is an important cause of massive gastrointestinal bleeding. Primary ADF often occurs as a result of aortic aneurysm, and secondary ADF develops after the placement of aortic prosthetic graft. PRESENTATION OF CASES: Case 1: A 64-year-old man with hematemesis was transferred to our hospital. The patient was diagnosed with primary ADF. Thus, we performed prosthetic graft replacement for an aortic aneurysm, and suturing of the duodenal fistula and duodenojejunal side-to-side anastomosis were performed. He was then discharged on the 35th postoperative day. After 2 years and 10 months, he died of other diseases. Case 2: A 76-year-old man with a history of abdominal aortic aneurysm repair with a prosthetic graft 5 years back who presented with hematemesis and melena was transferred to our hospital. The patient was diagnosed with secondary ADF, and an emergency endovascular aneurysm repair (EVAR) and suturing of the duodenal fistula were perfomed. He was transferred for rehabilitation purposes on the 108th postoperative day but eventually died of pneumonia 6 months after surgery. DISCUSSION: ADF is associated with high mortality. Initial bleeding is usually minor and often intermittent. However, it leads to severe bleeding and hemorrhagic shock. EVAR is preferred over open surgery because it can be performed faster and is less invasive. Recently, in case of hemorrhagic shock, EVAR is used as first-line treatment. CONCLUSION: Accurate diagnosis and immediate treatment are important for the survival of patients with ADF.

Calcification and abscess formation around the catheter tip of a central venous access port: a case report.

BACKGROUND: Thrombosis of the internal jugular vein occasionally occurs in association with long-term placement of a central venous catheter; however, such complications rarely involve calcification within the blood vessels. We report a case of calcification and abscess formation around a central venous catheter tip. CASE PRESENTATION: Our patient was an 84-year-old Asian woman who developed a fever that had started approximately 5 months after the placement of a central venous catheter. At the time of presentation, blood tests showed a marked inflammatory response, and chest computed tomography showed a high absorption area and air density around the catheter tip. Therefore, the patient was diagnosed with abnormal intravascular calcification and a deep neck abscess associated with long-term central venous catheter placement. The initial plan was to administer antibiotics and remove the central venous catheter. However, central venous catheter removal was deemed difficult due to the calcification and therefore required an incision. Because of the patient's advanced age and dementia, her family requested antibiotic treatment only. Following antibiotic treatment, the patient's inflammatory response normalized, and her fever resolved. The treatment was discontinued, and the patient's condition gradually stabilized. CONCLUSIONS: Catheter-related complications of central venous catheter placement include vascular occlusion, extravasation of the infusion, and infection. However, abnormal calcification in the blood vessels is extremely rare, and there has been only one case report of a neonate with central venous catheter-related vascular calcification in Japan. The etiology of intravascular calcification is considered to be related to the infusion content and the infusion rate of high caloric infusions and blood products. The incidence of complications associated with long-term central venous catheter placement is expected to increase with the increasing aging of the population and advances in chemotherapy. The report of the clinical course of this rare case adds to the body of knowledge in this area.

A clinical comparison of laparoscopic versus open appendectomy for the treatment of complicated appendicitis: historical cohort study.

BACKGROUND: Appendectomy is one of the most common operations. Laparoscopic appendectomy (LA) is considered first-line treatment, but the use of LA for treatment of complicated appendicitis remains controversial. Here, we performed a retrospective analysis to compare clinical outcomes between patients treated with LA and those who underwent open appendectomy (OA). METHODS: Data for 179 patients who underwent an operation for the treatment of complicated appendicitis at our hospital between 2011 and 2017 were retrospectively analyzed. The selection included 89 patients who underwent a conventional appendectomy and 90 patients who were treated laparoscopically. Outcome measures such as mean operative time, blood loss, time until oral intake duration of hospital stay, and postoperative complications were analyzed. Logistic regression analysis was performed to determine the concurrent effects of the examined factors on the rate of postoperative complications. RESULTS: The mean ages of patients in the OA and LA groups were 50.17 ± 22.77 and 50.13 ± 25.84 year. Mean operative times were longer in the LA group than OA (10.2.56 ± 44.4 versus 85.4 ± 43.11 min; p = 0.009). The duration of hospital stay was shorter for the LA group (9.61 ± 5.57 versus 12.19 ± 8.4; p = 0.016). There were no significant differences in return to consumption of oral intake between the LA and OA groups (2.03 ± 1.66 versus 2.48 ± 2.17; p = 0.123). Multivariable analysis found that the rate of postoperative complications was significantly reduced for the LA group, in comparison with the postoperative-complication rate of the OA group (16.7% versus 27%; odds ratio 0.376; 95% CI 0.153-0.923; p = 0.0327). CONCLUSIONS: These results suggest that LA is a safe and efficient operative procedure that provides clinically beneficial advantages in comparison with OA. Thus, when possible, appendectomy for complicated appendicitis should be attempted using a laparoscopic approach. TRIAL REGISTRATION: Retrospectively registered.

Additional surgery after endoscopic submucosal dissection for colorectal cancer: a review of 53 cases.

BACKGROUND: Endoscopic submucosal dissection (ESD) allows the en bloc resection of tumors and is particularly indicated for T1 colorectal cancer. The number of patients undergoing additional surgery after colorectal ESD is increasing. This study aimed to retrospectively evaluate the efficacy and long-term outcomes in patients with additional surgery. METHODS: Of 1018 patients who underwent colorectal ESD in our hospital between February 2010 and July 2018, 53 patients who underwent additional surgery in our hospital were retrospectively analyzed and investigated for their clinicopathological characteristics. The need for additional surgery was determined by a pathological examination according to the guideline [1]. RESULTS: In total, 53 patients (24 men, 29 women; mean age, 68.2 years; mean tumor diameter, 30.5 mm) were included. Laparoscopic surgery was performed in 47 (88.7%) patients. Liver metastases were preoperatively observed in one patient, for whom hepatectomy was simultaneously performed. All procedures included pathological R0 resection. Postoperative complications occurred in 9 (17.0%) patients. There were no complications requiring reoperation. Fifteen (28.3%) patients had a positive vertical margin; of these patients, residual tumor was observed in the resected specimens of two (13.3%) patients. Eight patients (15.1%) had lymph node metastasis (LNM): four (25.0%) and four (10.8%) of 16 and 37 patients with and without vascular invasion, respectively. Eleven patients (20.8%) had grade 2 or 3 tumor budding, and four (36.4%) of these had LNM. Postoperative recurrence was observed in two (3.8%) patients. CONCLUSION: Additional surgery after ESD for T1 colorectal cancer was effective and had good long-term outcomes.

[Two Cases of Advanced Gastric Cancer with Simultaneous Liver Metastasis with Long-Term Recurrence-Free Survival].

We report 2 cases of postoperative long-term survival of gastric cancer with synchronous liver metastasis. Case 1 was a 65- year-old man. Examination for anemia revealed advanced type 5 cancer in the antrum and suspected invasion of the transverse colon. A nodule 15mm in diameter suspected to be metastasis was also found in the liver S2. As no unresectable factors were present, partial hepatectomy, partial transverse colon resection, and distal gastrectomy were performed. Postoperatively, S-1 chemotherapy was administered for 14 months. Seven years after surgery, the patient is alive without recurrence. Case 2 was a 67-year-old woman. Examination for anemia revealed advanced type 2 cancer in the lower gastric body and a nodule 12mm in diameter suspected to be liver metastasis in the liver S8. Partial resection of the liver, total gastrectomy, cholecystectomy, and splenectomy were performed because no unresectable factors were observed. Postoperatively, chemotherapy with S-1 was administered for 38 months. Six years after surgery, she is alive without recurrence. Although there is no clear evidence for radical surgery for gastric cancer with simultaneous liver metastases, these results indicate that resection may be considered in cases with small numbers of metastases.

[A Case of Gastrointestinal Stromal Tumor in the Rectum with Preservation of Anal Function after Neoadjuvant Chemotherapy UsingImatinib].

A n 81-year-old woman was admitted to our institution. Computed tomography performed before transcatheter aortic valve implantation(TAVI)for aortic stenosis revealed a tumor in the rectum. Lower endoscopy revealed that the tumor was a 60mm submucosal tumor and located 2 cm from the anal verge. Abiopsy revealed the diagnosis to be gastrointestinal stromal tumor(GIST). Although the tumor was located near the anal verge and might have invaded the surrounding organs, neoadjuvant chemotherapy(NAC) with 400mg/day of imatinib was initiated to preserve anal function as requested by the patient and her family. After 3 months, the tumor size decreased by 36.6% and there was a decrease in rate of tumor shrinkage. We performed transanal tumor resection and temporary colostomy. After 6 months, we performed colostomy closure, and the patient has remained recurrence-free and is continuing chemotherapy.