Multiple large cell neuroendocrine carcinomas in the rectum and descending colon presented with liver metastasis: A case report.

Colorectal large cell neuroendocrine carcinoma (LCNEC) is rare and multiple LCNECs have not been previously reported. We encountered a case of multiple LCNECs in the rectum and the descending colon. A 66-year-old man presented with anal pain. Colonoscopy showed an ulcerated infiltrating tumor in the rectum, and 0.5 cm of erosion in the descending colon. A biopsy revealed LCNEC in both regions. Abdominal computed tomography revealed irregularly enhanced wall thickening at the rectum and hepatic metastases. Due to the diagnosis of LCNEC, laparoscopic abdominoperineal resection of the rectum was performed. Histopathological examination showed a poorly differentiated, LCNEC in both regions. Immunohistochemical examination demonstrated that the tumor cells were positive for chromogranin and synaptophysin. LCNEC was confirmed, and systemic chemotherapy with cisplatin/irinotecan was initiated. To our knowledge, this is the first case report that describes multiple LCNECs in the rectum and descending colon.

["Let's become the surgeon" the present status of the medical course beside teaching in Department of surgery, Daisan Hospital the Jikei University School of medicine: based on the experience OF clinical Clark ship for 5 years].

In Department of Surgery, Daisan Hospital, The Jikei University School of Medicine, Clinical Clark ship (C.C.) is positively taken in the bedside teaching of the medical course fifth and sixth grader from April, 2010. We think that the C.C. is a good opportunity to tell the charm of the surgeon to the students. We introduce a bedside teaching going in our Department, based on the experience of the C.C. for 5 years. In the bedside teaching of our department, there are many tasks not to advance before when students do not have discussion with preceptors, about participation in surgery, presentation of the preoperative conference, visiting of outpatient care and night practice. Moreover, students decide the theme about submitting report and research presentation. For our department which built a bedside teaching with on the job training as a concept from 2010, "students in the C.C." is welcome and beneficial for the doctors, the students itself and the patients. When C.C. will be introduced into all Department of our university in earnest from 2016, we have to examine the merits and demerits in future so that C.C. functions going well.

Large gastrointestinal stromal tumor and advanced adenocarcinoma in the rectum coexistent with an incidental prostate carcinoma: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the leading mesenchymal neoplasia in the gastrointestinal tract, but GIST arising from the rectum is rare. When a secondary neoplasia coexists in the vicinity of a rectal GIST, more aggressive treatment strategies may be needed to cure the diseases. PRESENTATION OF CASE: We herein describe a 76-year-old man with a large gastrointestinal stromal tumor along with an advanced adenocarcinoma in the rectum that coexisted with prostate carcinoma. Preoperative examination revealed an advanced adenocarcinoma of the upper rectum and a large pelvic mass suggestive of a GIST or a neuroendocrine tumor arising from the anterior wall of the lower rectum. To eradicate the tumor, total pelvic exenteration with ureterocutaneous fistula was carried out after obtaining written informed consent. Immuhistochemical studies revealed the concurrence of an advanced rectal cancer (T3, N1, M0) and a malignant GIST (c-kit-positive, CD34-positive, vimentin-positive, and CAM5.2-negative), and an incidental prostatic acinar adenocarcinoma. The patient was given adjuvant chemotherapy with imatinib and remains disease-free as of 12 months after surgery. DISCUSSION: A PubMed search for the case of coexistence of GIST with two other malignancies revealed only four cases, making this very rare condition. CONCLUSION: Radical surgery with perioperative adjuvant chemotherapy using tyrosine kinase inhibitors is the choice for treatment of large GISTs with a malignant potential. Our report suggests that aggressive surgical approach would be feasible, when a secondary tumor is present near the GIST.

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome, gastropleural fistula and pleural empyema: Report of a case.

INTRODUCTION: Bochdalek's diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD). PRESENTATION OF CASE: A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed. DISCUSSION: A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition. CONCLUSION: In dealing with adult BDH, possible post-repair ACS should be considered.

Parastomal hernias successfully repaired using a modified components separation method: two case reports.

INTRODUCTION: Parastomal hernia is a frequent complication after enterostomy formation. A repair using prosthetic mesh by way of a laparoscopic or open transabdominal approach is usually recommended, however, other procedures may be done if the repair is to be performed in a contaminated environment or when the abdominal cavity of the patient is difficult to enter due to postsurgical dense adhesion. The components separation method, which was introduced for non-transabdominal and non-prosthetic ventral hernia repair, solves such problems. CASE PRESENTATION: Case 1. A 79-year-old Japanese woman who underwent total cystectomy with ileal conduit for bladder cancer presented with a parastomal hernia, which was repaired using a keyhole technique. Simultaneously, an incisional hernia in the midline was repaired with a prosthetic mesh. One year after her hernia surgery, a recurrence occurred lateral to the stoma, but it was believed to be difficult to enter the peritoneal cavity because of the wide placement of mesh. Therefore, surgery using the components separation method was performed. CONCLUSION: The components separation method is a novel and effective technique for parastomal hernia repair, especially in cases following abdominal polysurgery or midline incisional hernia repairs using large pieces of mesh. To the best of our knowledge, this is the first report in English on the application of the components separation method for parastomal hernia repair.

Internal hernia through a peritoneal defect in the pouch of Douglas: Report of a case.

INTRODUCTION: Internal hernia is a rare entity which can cause intestinal obstruction. The most common type of internal hernia is the paraduodenal hernia which accounts for 53% of cases, and the internal hernia within the pelvis account for 7%. Perineal hernia, which is classified as pelvic hernia, usually occurs due to weakening of the pelvic floor musculature and thus, should be distinguished from the internal hernia caused by peritoneal defects in the pelvic cavity. PRESENTATION OF CASE: We present a case of 28-year-old female who presented intestinal obstruction. Conservative therapies failed and she required emergency laparotomy. The operative findings revealed a peritoneal defect of 2cm in diameter in the pouch of Douglas, through which the ileum was incarcerated and strangulated. The incarcerated bowel was reduced, and the intestinal color quickly returned to normal. Therefore a primary closure of the peritoneal defect was performed and the postoperative course was uneventful. DISCUSSION: A PubMed search for the case of internal hernia through a defect in the pouch of Douglas revealed only three, making this an extremely rare condition. CONCLUSION: Because of rarity of this hernia, the etiology is unknown. However, our patient is a young female with no history of pregnancy, abdominal surgery, or trauma, therefore the cause of the peritoneal defect is considered congenital.

Clinicopathological features of perforated colorectal cancer.

UNLABELLED: The aim of this retrospective study was to determine clinicopathological factors pertinent to the prognosis of perforated colorectal cancer (PCRC). PATIENTS AND METHODS: A retrospective review of clinical records of 17 cases of emergency primary resection for PCRC (stage IIIa in 2, stage IIIb in 6 and stage IV in 9) was performed. RESULT: The 5-year survival rate was 31% (31% for stage III and 12% for stage IV). When compared with non-PCRC (533 cases) in stage III (78.8%) or stage IV (14.8%), the 5-year survival rate of stage III perforated colorectal cancer was clearly worse (p<0.01) than the non-perforated counterpart. For stage IV, however, the two groups had a similar prognosis. MST of the PCRC was 31 months for stage III and 12 months for stage IV. Approximately half of the recurrence pattern of stage III (75%), or stage IV (44%) PCRC was peritoneal carcinomatosis. As for the type of operations performed, Hartmann's procedure was the preferred technique (71%), for which mortality and morbidity rate were both low. CONCLUSION: Because of the high incidence of peritoneal carcinomatosis and low 5-year survival rate, stage III PCRC should be regarded as a stage IV disease, for which postoperative chemotherapy seems essential.

Preoperative Diagnosis of Adult Intussusception Caused by Small Bowel Lipoma.

Adult intussusception is rare, accounting for only 5% of all intussusceptions, for which preoperative diagnosis is difficult. We herein report a preoperatively diagnosed case of adult intussusception caused by a small bowel lipoma. A 33-year-old man was admitted to our hospital with three weeks history of colicky epigastric pain. Computed tomography revealed thickening of the ileal wall suggestive of intussusception. Colonoscopy revealed an ileocolic intussusception. Barium enema for reduction of ileocolic intussusception demonstrated a small bowel tumor in the ileum 15 cm proximal to the ileocecal valve. The intussusception was reduced, and the patient underwent partial resection of the ileum encompassing the small bowel tumor. Histological findings confirmed the diagnosis of lipoma of the small bowel. The patient made a satisfactory recovery and remains well.

Immunogene therapy by adenovirus vector expressing CD40 ligand for metastatic liver cancer in rats.

BACKGROUND: We have explored a gene-therapeutic approach to stimulate antitumor immunity by adenoviral-mediated transfer of CD40 ligand (CD40L) to treat metastatic liver cancer in a rat model. MATERIALS AND METHODS: Rat metastatic liver cancer cells were implanted into the back of rats bilaterally. When the larger tumor reached 8.0 mm in diameter, adenovirus vector-expressing mouse CD40L was injected intratumorally as treatment group (n=5), while LacZ was injected in the control group (n=5). RESULTS: In the control group, the tumor gradually grew to be 20.7+/-1.6 (mean+/-SD) mm in intratumorally injected tumors and 21.8+/-3.7 mm in opposite tumors seven weeks after injection, respectively. In contrast, in the treatment group, the tumor was reduced to 3.6+/-8.2 mm and 3.7+/-8.2 mm. The tumor growth and survival rate were significantly different (p<0.001). CONCLUSION: Adenovirus vector-mediated CD40L gene therapy is an effective therapeutic method for metastatic liver cancer.