Surgical management of primary undifferentiated pleomorphic sarcoma of the rectum: a case report and review of the literature.

BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that has been reclassified from malignant fibrous histiocytoma with the development of the pathological diagnosis. It principally occurs in the extremities but rarely occurs in the rectum. We herein report a rare case of UPS arising in the rectum. CASE PRESENTATION: A 85-year-old woman was referred to our hospital with a complaint of anal pain, which had persisted for several months. Computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. Colonoscopy revealed a submucosal elevation in the rectum without any exposure of the tumor to the surface. Contrast-enhanced CT and magnetic resonance imaging revealed an 80-mm mass that originated in the rectal muscular propria, and we suspected a gastrointestinal stromal tumor. No lymph node metastasis or distant metastasis was observed. We performed a laparoscopic Hartmann's operation. Intraoperatively, severe adhesion around the tumor caused tumor injury and right ureteral dissection. Thus, laparoscopic right ureteral anastomosis and ureteral stenting were additionally performed. The operation time was 6 h and 3 min, and the estimated blood loss was small. The patient was discharged without complications 25 days after surgery. A pathological examination showed that the tumor was composed of highly heterogeneous cells with no specific differentiation traits, leading to a diagnosis of UPS. Contrast-enhanced CT performed 2 months after surgery showed bilateral pelvic lymph node enlargement, which indicated recurrence. Considering the patient's age, we performed radiotherapy (50 Gy/25 Fr targeting the pelvic region). At present, 16 months have passed since the completion of radiotherapy. Contrast-enhanced CT shows that the recurrent lymph nodes have disappeared, and no new distant metastasis has been observed. CONCLUSIONS: We reported a case of UPS arising in the rectum. The surgical procedure and indication of preoperative therapy should be carefully selected because complete removal of the tumor is desirable in UPS.

Laparoscopy-Assisted Repair for Intersigmoid Hernia.

Intersigmoid hernia is a rare clinical entity. Only 6 cases of laparoscopic repair for intersigmoid hernia have been reported since 1977. We herein report such a case, which was successfully diagnosed preoperatively and treated with laparoscopic repair. A 50-year-old man with a chief complaint of abdominal pain and vomiting was admitted for the treatment of small bowel obstruction. The patient had no history of abdominal surgery. Computed tomography showed a dilated small bowel and a closed loop of small bowel dorsal to the sigmoid colon and the sigmoid mesocolon. With a diagnosis of an incarcerated internal hernia, the patient underwent emergency laparoscopy-assisted surgery. Laparoscopy showed that the ileum had herniated into the intersigmoid fossa, and therefore the patient was diagnosed with an intersigmoid hernia. Because bowel ischemia was not observed, we reduced the incarcerated small bowel, and the hernial defect was widely opened. After operation, the patient developed ileus and was treated with transnasal ileus tube. Thereafter, the patient made a satisfactory recovery and was discharged on postoperative day 21. The patient is in good general condition without ileus 42 months postoperatively.

CA19-9 Concentration After First-line Chemotherapy Is Prognostic Predictor of Metastatic Colon Cancer.

BACKGROUND/AIM: To evaluate whether the serum levels of CEA or CA19-9 concentration is a useful predictor of survival in patients with metastatic colon cancer (mCC). PATIENTS AND METHODS: Between 2012 and 2015, 113 patients with mCC who underwent chemotherapy according to the Japanese Colorectal Cancer Treatment Guidelines at four Jikei University Hospitals were enrolled in this study. The two serum tumor makers, CEA and CA19-9 were measured before first-line chemotherapy and at four months thereafter. RESULTS: Serum CA19-9 concentration at four months after first-line chemotherapy (p=0.003, HR=3.761) and first-line chemotherapy including oxaliplatin (p=0.038, HR=0.312) were independent predictors of survival in patients with mCC. By excluding the transverse colon, only serum CA19-9 concentration at four months after first-line chemotherapy (p=0.005, HR=3.660) was identified as the predictor of survival. CONCLUSION: Serum CA19-9 concentration after first-line chemotherapy seems to be a useful predictor of survival in patients with mCC.

Sentinel Node Navigation Surgery for Early Gastric Cancer: Analysis of Factors Which Affect Direction of Lymphatic Drainage.

BACKGROUND AND PURPOSE: We started performing sentinel node navigation surgery (SNNS) for patients with early gastric cancer (EGC) using infrared ray electronic endoscopy (IREE) with indocyanine green injection from year 2000. The EGCs usually have complex lymphatic drainage, unidirectional or multidirectional lymphatic flow. In this study, we investigated and clarified factors that affect the direction of gastric lymphatic drainage. PATIENTS AND METHOD: Consecutive 60 patients with EGC who underwent SNNS by IREE from year 2006 to 2014 were enrolled to this study. Patients' age, gender, location of tumors, operative method, previous treatment by endoscopic submucosal dissection (ESD), presence of pathological ulcerative scar and maximum tumor diameter were enrolled as parameters which may affect direction of lymphatic drainage and analyzed. RESULT: Bivariate analysis demonstrated that the presence of pathological ulcerative scar (P = 0.01), tumor location (g.c vs. a.w vs. p.w vs. l.c, P = 0.01), and maxim tumor diameter (P = 0.0003) were relevant to direction of gastric lymphatic drainage. Multivariate analysis showed that tumor location (g.c/a.w/p.w vs. l.c, odds ratio 8.227, P = 0.011) and the maximum tumor diameter (odds ratio 1.057, P = 0.037) are independent factors that affect direction of gastric lymphatic flow. Of tumors, 78% located at lesser curvature had unidirectional lymphatic drainage, and 93% of tumors whose diameter was 40 mm and more had multidirectional lymphatic drainage. CONCLUSION: Our investigation revealed that the tumor location and tumor diameter were the key factors which affect the direction of lymphatic drainage, which is useful fact to understand the complexity of gastric lymphatic drainage.

Comparison of Postoperative Outcomes Between Laparoscopic and Open Surgery for Colorectal Cancer.

BACKGROUND/AIM: To determine the superiority of the laparoscopic vs. open technique for colorectal cancer surgery. PATIENTS AND METHODS: We performed a retrospective analysis of consecutive patients who underwent curative surgery by laparoscopic colectomy (LC) or open colectomy (OC) for colon cancer. The patients were classified into two groups: as LC group and OC group. We retrospectively assessed clinical characteristics, intraoperative and postoperative outcomes and long-term outcomes between the two groups by univariate analysis. RESULTS: The LC group had significantly less intraoperative blood loss, complications, and shorter post-operative hospital stay than the OC group. The overall survival of Stage II in the LC group is significantly longer than the OC group. DFS of Stage III in the LC group was significantly longer than the OC group. CONCLUSION: LC showed more favorable results in both short-term and long-term outcomes than OC.

Which Is the Safer Anastomotic Method for Colon Surgery? - Ten-year Results.

BACKGROUND/AIM: In colon surgery, the anastomotic method is generally selected by surgeon's preferences or by local conditions. In this study, we retrospectively analyzed anastomotic complications to assess safe methods of anastomosis in colonic resection. PATIENTS AND METHODS: We retrospectively analyzed a total of 684 cases, performed between July 2003 and June 2013 in our Hospital. Anastomosis complications, such as leakage, stricture and bleeding, were analyzed in relation to the three methods of anastomosis, hand-sewn (HS), functional end-to-end (FEEA) and triangulating anastomosis (TRI). RESULTS: Univariate analysis indicated that the incidence of leakage was significantly lower in laparoscopic surgeries (p=0.034) and TRI (p=0.047). The results of the multivariable analysis indicated that anastomotic leakage was significantly less with TRI (p=0.029). CONCLUSION: In colon surgery, TRI seems to be associated with a low risk of anastomotic leakage compared to HS and FEEA.

Enhanced Recovery After Surgery Programs for Laparoscopic Colorectal Resection May Not Need Thoracic Epidural Analgesia.

BACKGROUND/AIM: The aim of this study was to evaluate the necessity of thoracic epidural analgesia (TEA) as enhanced recovery after surgery (ERAS) programs for laparoscopic colorectal surgery (LC). PATIENTS AND METHODS: We retrospectively compared between perioperative outcomes of patients who underwent LC with TEA (n=31) and with multimodal analgesia (MMA) (n=31). Furthermore, we also evaluated the patients' satisfaction by a questionnaire survey to the nurses. RESULTS: The only numeric rating scale (NRS) score on post-operative day (POD) 1 of the MMA group was significantly higher than that in the TEA group (p=0.002). In multivariate analysis, the factors that demonstrated significant correlation with hospital stay did not include analgesia. The 74% of the nurses felt equal or higher analgesic effect in the MMA group and interestingly, 84% of them answered that they would choose MMA if they were to undergo LC. CONCLUSION: TEA may not be necessary for ERAS in LC.