Predictors of 1-year mortality after gastrectomy for gastric cancer.

PURPOSE: One-year mortality is important for referrals to specialist palliative care or advance care planning (ACP). This helps optimize comfort for those who cannot be cured or have a lower life expectancy. Few studies have investigated the risk factors for 1-year mortality after gastrectomy for gastric cancer (GC). METHODS: A total of 1415 patients with gastric cancer (stages I-IV) who underwent gastrectomy between 2005 and 2020 were included. The patients were randomly assigned to the investigation group (n = 850) and validation group (n = 565) in a 3:2 ratio. In the investigation group, significant independent prognostic factors for predicting 1-year survival were identified. A scoring system for predicting 1-year mortality was developed which was validated in the validation group. RESULTS: Multivariate analysis revealed that the following seven variables were significant independent factors for 1-year survival: age ≧78, preoperative comorbidity, total gastrectomy, postoperative complication (Clavien-Dindo classification CD â‰§ 3a), stage III and IV, and R2 resection. While developing a 1-year mortality score (OMS), an age ≧78 was scored 2, preoperative comorbidity, total gastrectomy, and postoperative complication (CD â‰§ 3a) were scored 1, and stage III, IV, and R2-resection were scored 2, 3, and 3, respectively. OMS 3 had a sensitivity of 91% and a specificity of 66% for predicting death within 1 year. In the validation group, OMS 5 had a sensitivity of 55% and a specificity of 93% for predicting death within 1 year. CONCLUSIONS: OMS may provide important information and help surgeons select the timing of ACP in patients with GC.

Clinical features and risk factors for appendiceal diverticulitis: a comparative study with acute appendicitis.

PURPOSE: Despite their similar clinical characteristics, appendiceal diverticulitis (AD) and acute appendicitis (AA) are pathologically distinct. This study compared the clinical features of AD and AA and identified relevant risk factors. METHODS: Patients who underwent appendectomy with a preoperative diagnosis of either AD or AA were categorized based on histopathological findings. The two groups were compared in terms of various clinical factors. RESULTS: Among the 854 patients included in the study, a histopathological evaluation revealed 49 and 805 cases of AD and AA, respectively. A univariate analysis demonstrated that AD was more prevalent than AA among older, taller, and heavier males. A multivariate analysis revealed that male sex, a white blood cell (WBC) count < 13.5 × 103/µL, an eosinophil count ≥ 0.4%, and a mean corpuscular volume (MCV) ≥ 91.6 fL were significant factors differentiating AD from AA. In addition, pathological AD emerged as an independent risk factor for abscess and/or perforation. CONCLUSIONS: AD was associated with an older age, robust physique, and significant risk of abscess and/or perforation despite a low WBC count. In addition to imaging modalities, the preoperative factors of male sex, a WBC count < 13.5 × 103/µL, an eosinophil count ≥ 0.4%, and a MCV ≥ 91.6 fL may be useful for distinguishing AD from AA.

Isolation, Diversity and Characterization of Ulvan-Degrading Bacteria Isolated from Marine Environments.

In this study, we aimed to isolate bacteria capable of degrading the polysaccharide ulvan from the green algae Ulva sp. (Chlorophyta, Ulvales, Ulvaceae) in marine environments. We isolated 13 ulvan-degrading bacteria and observed high diversity at the genus level. Further, the genera Paraglaciecola, Vibrio, Echinicola, and Algibacter, which can degrade ulvan, were successfully isolated for the first time from marine environments. Among the 13 isolates, only one isolate (Echinicola sp.) showed the ability not only to produce externally expressed ulvan lyase, but also to be periplasmic or on the cell surface. From the results of the full-genome analysis, lyase was presumed to be a member of the PL25 (BNR4) family of ulvan lyases, and the bacterium also contained the sequence for glycoside hydrolase (GH43, GH78 and GH88), which is characteristic of other ulvan-degrading bacteria. Notably, this bacterium has a unique ulvan lyase gene not previously reported.

Production of 4-Deoxy-L-erythro-5-Hexoseulose Uronic Acid Using Two Free and Immobilized Alginate Lyases from Falsirhodobacter sp. Alg1.

Falsirhodobacter sp. alg1 expresses two alginate lyases, AlyFRA and AlyFRB, to produce the linear monosaccharide 4-deoxy-L-erythro-5-hexoseulose uronic acid (DEH) from alginate, metabolizing it to pyruvate. In this study, we prepared recombinant AlyFRA and AlyFRB and their immobilized enzymes and investigated DEH production. Purified AlyFRA and AlyFRB reacted with sodium alginate and yielded approximately 96.8% DEH. Immobilized AlyFRA and AlyFRB were prepared using each crude enzyme solution and κ-carrageenan, and immobilized enzyme reuse in batch reactions and DEH yield were examined. Thus, DEH was produced in a relatively high yield of 79.6%, even after the immobilized enzyme was reused seven times. This method can produce DEH efficiently and at a low cost and can be used to mass produce the next generation of biofuels using brown algae.

Optimal cutoff value of preoperative CEA and CA19-9 for prognostic significance in patients with stage II/III colon cancer.

PURPOSE: This unicentric, retrospective cohort study aimed to identify the optimal cutoff values of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) for the prognosis in patients with stage II/III colon cancer. METHODS: After excluding 43 patients with CA19-9 levels < 0.2 U/mL, 588 were included. Receiver operating characteristic curves were constructed to determine the optimal cutoff values of CEA and CA 19-9 for disease relapse. RESULTS: The median CEA and CA19-9 values were 3.6 (interquartile range: 2.1-7.2 ng/mL) and 14.3 (interquartile range: 8.1-30.0) U/mL, respectively. The optimal cutoff values of CEA and CA19-9 were 5.4 ng/mL and 22.4 U/mL, respectively. A multivariate analysis of relapse-free survival (RFS) showed that cancer stage, CEA, and CA19-9 were significant independent factors. The RFS of patients with stages II and III colon cancer was significantly stratified by CEA (< 5.4/ ≥ 5.4 ng/mL) and CA19-9 (< 22.4/ ≥ 22.4 U/mL). Prognostication based on the reference values (< 5.0 ng/mL for CEA and < 37.0 U/mL for CA19-9) was less significant than that based on the optimal cutoff values. Both elevated CEA and CA19-9 had no value dependency on RFS: RFS curves were similar between extremely elevated CEA (≥ 54.0 ng/ml) and intermediate CEA (5.4-54.0 ng/ml) and between extremely elevated CA19-9 (≥ 224.0 U/ml) and intermediate CA19-9 (22.4-224.0 U/ml). CONCLUSION: The optimal cutoff values of preoperative CEA and CA19-9 for RFS were 5.4 ng/ml and 22.4 U/mL, respectively, in patients with stages II and III colon cancer. Further relapse risk stratification is possible using these values.

Late complications associated with totally implantable venous access port implantation via the internal jugular vein.

PURPOSE: Several studies have analyzed late complications associated with totally implantable venous access ports (TIVAP) implantation via the internal jugular vein (IJV); however, the reported results are inconclusive. The aim of the study is to elucidate the characteristics and risk factors of late complications associated with TIVAP implantation via the IJV. METHODS: The study included 482 patients who underwent TIVAP implantation for long-term chemotherapy and/or nutritional support between April 2012 and December 2017. Most patients (95.2%) had malignant diseases. Events requiring TIVAP removal were defined as TIVAP-related complications. RESULTS: The median TIVAP and global follow-ups were 319 days (IQR 152-661) and 218,971 catheter days, respectively. The 3-year cumulative TIVAP availability rate was 70%. There were 44 complications (incidence of 9.1%; 0.201 complications/1000 catheter days). Infectious, catheter-related, and port-related complications occurred in 21, 14, and 9 patients, respectively with infectious complications occurring earlier and more frequently than catheter- and port-related complications. Multivariate analysis revealed that age < 65 years and presence of non-gastrointestinal diseases were significant unfavorable factors for TIVAP-related complications. Patients with 1 and 2 of these factors had an elevated risk (2.2 and 5.4 times, respectively) compared with those without. CONCLUSIONS: Among the late complications associated with TIVAP implantation via the IJV, infectious complications occur earlier and more frequently than catheter- and port-related complications. Patients with an age < 65 years and having non-gastrointestinal diseases have a significantly high risk of TIVAP-related complications.

Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis.

BACKGROUND: Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA. METHODS: Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017). RESULTS: The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8 years vs. 44.0 ± 20.3 years, p = 0.0002), and the ratio of patients with AA aged ≧ 75 years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001). CONCLUSIONS: During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.

Clinical and prognostic differences between surgically resected right-sided and left-sided colorectal cancer.

PURPOSE: A growing body of evidence suggests that right-sided colorectal cancer (RCRC) differs from left-sided colorectal cancer (LCRC) in certain clinicopathological features. Therefore, we investigated the difference between RCRC and LCRC in a series of 899 patients. METHODS: We reviewed data retrospectively, from 899 patients who underwent R0-resection for stage II and III CRC and compared the clinicopathological factors between patients with RCRC and LCRC. RESULTS: The patients with RCRC tended to be older, more likely female, with a larger tumor, higher pathological T stage, and a greater proportion of their tumors were poorly differentiated adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma than the patients with LCRC,. Recurrence-free survival (RFS) of the patients with RCRC tended to be higher than that of the patients with LCRC and was significantly better among patients with stage II cancer. The overall survival (OS) was similar for patients with RCRC and LCRC, irrespective of cancer stage. CONCLUSION: Compared with the patients with LCRC, those with RCRC had several oncologically unfavorable factors, with better RFS in stage II and similar OS in stages II and III. These results suggest that the biological aggressiveness of RCRC is lower than that of LCRC in stage II; however, it can increase after relapse.

Overweight or Obesity is an Unfavorable Long-Term Prognostic Factor for Patients who Underwent Gastrectomy for Stage II/III Gastric Cancer.

BACKGROUND: Obesity has been reported to be a prognostic factor for many diseases in epidemiological studies; however, the results of studies examining the relationship between obesity and gastric cancer (GC) prognosis are inconsistent. METHODS: A total of 460 patients with Stage II and III GC who underwent open R0 gastrectomy were included. Age, sex, body mass index (BMI classified into < 18.5, 18.5-25, and ≥ 25 kg/m2), stage, and postoperative adjuvant chemotherapy were analyzed to investigate the correlation with relapse-free survival (RFS). RESULTS: Five-year RFS was 51% for the study patients. Five-year RFS values were 47.6%, 54.3%, and 40.1% for patients with BMI < 18.5, 18.5-25, and ≥ 25 kg/m2, respectively. The forest plot for relapse risk according to BMI showed a U shape. Multivariate analysis for RFS showed significant differences in stage and BMI; the hazard ratio for recurrence in patients with BMI ≥ 25 kg/m2 was 1.42 (95% confidence interval: 1.01-2.02, p = 0.0423) with reference to patients with BMI < 25 kg/m2. BMI ≥ 25.0 was associated with longer operation times, more blood loss, fewer lymph nodes dissected, more frequent postoperative surgical site infection, and intra-abdominal abscesses. CONCLUSIONS: BMI ≥ 25 kg/m2 is an unfavorable prognostic factor for patients who underwent gastrectomy for Stage II and III GC.

Culture-based bacterial evaluation of the appendix lumen in patients with and without acute appendicitis.

PURPOSE: Controversy exists over whether bacterial flora within the appendix differs between patients with and without appendicitis. To examine these potential differences, we cultured the appendiceal luminal microbiota of patients with and without acute appendicitis, and identified the bacterial species therein. METHODS: Fifty-seven patients with acute appendicitis and 37 patients without acute appendicitis who underwent curative resection of colorectal cancer and prophylactic appendectomies (control group) were included. Appendicitis patients were classified into the phlegmonous group or the gangrenous appendicitis group histopathologically. There was no patient with perforated appendicitis. Aerobic isolates were identified using standard identification schemata, and anaerobic isolates were identified according to the Japanese guidelines. RESULTS: There were no significant differences among the three groups in the median number aerobe species present per patient. However, the median number anaerobe species in the gangrenous appendicitis group was significantly higher than that of the control group and the phlegmonous appendicitis group. In addition, the incidence of patients with Bacillus species, Fusobacterium nucleatum, and Bilophila wadsworthia increased as the disease progressed from phlegmonous to gangrenous appendicitis. CONCLUSION: The present results suggest that increased diversity of anaerobes and the translocation of Bacillus species, F. nucleatum, and B. wadsworthia are associated with the progression of acute appendicitis.

The mean corpuscular volume as a prognostic factor for colorectal cancer.

PURPOSE: The aim of the present study was to identify the factors investigated during routine blood examinations which can predict the disease outcome independent of the tumor stage. METHODS: Data from 1174 patients with stage I, II, and III CRC who underwent R0 resection were included. We investigated the correlations between the preoperative routine blood examination data, and clinicopathological factors, and disease-free survival (DFS) using univariate and multivariate analyses. RESULTS: The univariate analysis showed that tumor location, tumor stage, CRP, serum albumin, creatine kinase, neutrophil-to-lymphocyte ratio, red blood cell count, mean corpuscular volume (MCV), and the administration of postoperative adjuvant chemotherapy were significantly correlated with the DFS. The multivariate analysis of the factors associated with the DFS showed that stage and MCV were significant factors; an MCV of <80 fL was associated with a superior DFS in comparison to an MCV of 80-100 fL (hazard ratio: 0.31, 95% confidence interval: 0.13-0.61, p = 0.0003). The DFS in patients with an MCV of <80 fL was superior to that in patients with an MCV of ≥80 fL, irrespective of whether the patients underwent postoperative adjuvant chemotherapy. CONCLUSION: MCV was a prognostic factor for the DFS, independent of the tumor stage, in CRC patients who underwent R0 resection.

Construction of bioengineered yeast platform for direct bioethanol production from alginate and mannitol.

Brown macroalgae are a sustainable and promising source for bioethanol production because they are abundant in ocean ecosystems and contain negligible quantities of lignin. Brown macroalgae contain cellulose, hemicellulose, mannitol, laminarin, and alginate as major carbohydrates. Among these carbohydrates, brown macroalgae are characterized by high levels of alginate and mannitol. The direct bioconversion of alginate and mannitol into ethanol requires extensive bioengineering of assimilation processes in the standard industrial microbe Saccharomyces cerevisiae. Here, we constructed an alginate-assimilating S. cerevisiae recombinant strain by genome integration and overexpression of the genes encoding endo- and exo-type alginate lyases, DEH (4-deoxy-L-erythro-5-hexoseulose uronic acid) transporter, and components of the DEH metabolic pathway. Furthermore, the mannitol-metabolizing capacity of S. cerevisiae was enhanced by prolonged culture in a medium containing mannitol as the sole carbon source. When the constructed strain AM1 was anaerobically cultivated in a fermentation medium containing 6% (w/v) total sugars (approximately 1:2 ratio of alginate/mannitol), it directly produced ethanol from alginate and mannitol, giving 8.8 g/L ethanol and yields of up to 32% of the maximum theoretical yield from consumed sugars. These results indicate that all major carbohydrates of brown macroalgae can be directly converted into bioethanol by S. cerevisiae. This strain and system could provide a platform for the complete utilization of brown macroalgae.

[Secondary Dementia Due to Leptomeningeal Metastasis of Breast Cancer Improved by Whole Brain Radiation].

A 62-year-old woman received chemotherapy for breast cancer with bone metastasis and malignant pleural and pericardial effusion. She was examined by imaging for progressive cognitive impairment and headache. Enhanced MRI findings showed multiple solid tumors on brain surface, and brain perfusion scintigraphy showed blood flow decrease in both parietal lobes. She was diagnosed with secondary dementia due to leptomeningeal metastases of breast cancer, and whole brain external irradiation was performed(30 Gy/15 Fr). After treatment, multiple tumors were decreased in size and her cognitive impair- ment was improved.

Diagnostic value of procalcitonin for acute complicated appendicitis.

A rapid and reliable test for detection of complicated appendicitis would be useful when deciding whether emergency surgery is required. We investigated the clinical usefulness of procalcitonin for identifying acute complicated appendicitis. We retrospectively analyzed 63 patients aged ≥15 years who underwent appendectomy without receiving antibiotics before admission and had preoperative data on the plasma procalcitonin level (PCT), body temperature (BT), white blood cell count (WBC), neutrophil / lymphocyte ratio (N/L ratio), and C-reactive protein level (CRP). Patients were classified into 3 groups: group A (inflammatory cell infiltration of the appendix with intact mural architecture), group B (inflammatory cell infiltration with destruction of mural architecture, but without abscess or perforation), and group C (macroscopic abscess and/or perforation). For identifying destruction of mural architecture, the diagnostic accuracy of PCT was similar to that of BT or CRP. However, the diagnostic accuracy of PCT was highest among the five inflammatory indices for identifying abscess and/or perforation, with the positive predictive value of PCT for abscess and/or perforation being higher than that of CRP (73% vs. 48%). Univariate analysis of the predictors of abscess and/or perforation revealed that a plasma PCT level ≥0.46 ng/mL had the highest odds ratio (30.3 [95% confidence interval: 6.5-140.5] versus PCT <0.46 ng/mL). These findings indicate that procalcitonin is a useful marker of acute appendicitis with abscess and/or perforation.

Formosa haliotis sp. nov., a brown-alga-degrading bacterium isolated from the gut of the abalone Haliotis gigantea.

Four brown-alga-degrading, Gram-stain-negative, aerobic, non-flagellated, gliding and rod-shaped bacteria, designated LMG 28520T, LMG 28521, LMG 28522 and LMG 28523, were isolated from the gut of the abalone Haliotis gigantea obtained in Japan. The four isolates had identical random amplified polymorphic DNA patterns and grew optimally at 25 °C, at pH 6.0-9.0 and in the presence of 1.0-4.0 % (w/v) NaCl. Phylogenetic trees based on 16S rRNA gene sequences placed the isolates in the genus Formosa with Formosa algae and Formosa arctica as closest neighbours. LMG 28520T and LMG 28522 showed 100 % DNA-DNA relatedness to each other, 16-17 % towards F. algae LMG 28216T and 17-20 % towards F. arctica LMG 28318T; they could be differentiated phenotypically from these established species. The predominant fatty acids of isolates LMG 28520T and LMG 28522 were summed feature 3 (iso-C15 : 0 2-OH and/or C16 : 1ω7c), iso-C15 : 1 G and iso-C15 : 0. Isolate LMG 28520T contained menaquinone-6 (MK-6) as the major respiratory quinone and phosphatidylethanolamine, two unknown aminolipids and an unknown lipid as the major polar lipids. The DNA G+C content was 34.4 mol% for LMG 28520T and 35.5 mol% for LMG 28522. On the basis of their phylogenetic and genetic distinctiveness, and differential phenotypic properties, the four isolates are considered to represent a novel species of the genus Formosa, for which the name Formosa haliotis sp. nov. is proposed. The type strain is LMG 28520T ( = NBRC 111189T).

A case of undifferentiated carcinoma of the pancreas mimicking main-duct intraductal papillary mucinous neoplasm (IPMN).

We report here a rare case of undifferentiated carcinoma of the pancreas mimicking main-duct intraductal papillary mucinous neoplasm. In an 80-year-old woman, an approximately 8-mm papillary mass was incidentally detected at the downstream edge of a dilatated main pancreatic duct lumen on CT and MRI. Main pancreatic duct dilatation in the pancreatic body and tail and parenchymal atrophy were observed in the upstream of the mass. Histopathologically, the tumor protruded into the downstream edge of the dilatated main pancreatic duct lumen in the pancreatic body. The tumor cells had highly atypical nuclei and abundant polymorphic structures, and showed positive staining for granulocyte colony-stimulating factor, which led to the diagnosis of undifferentiated carcinoma. A total of 13 cases of undifferentiated carcinoma with intraductal tumor growth have been reported to date. The case report by Bergmann et al. has been the smallest in histopathological specimen, and the present case is the smallest in size detected by radiological images. Since early undifferentiated carcinoma of the pancreas can resemble those of main-duct intraductal papillary mucinous neoplasm in cross-sectional images, we have to consider undifferentiated carcinoma in the differential diagnosis of the solitary and papillary mass with low contrast enhancement in early phase in the main pancreatic duct.

Short- and long-term outcomes of open inguinal hernia repair: comparison of the Prolene Hernia System and the Mesh Plug method.

PURPOSE: Tension-free mesh repair of adult inguinal hernias has become a standard procedure, but there have been few comparisons of the postoperative outcome after hernia repair using the Prolene Hernia System (PHS) vs. the Mesh Plug (MP) method in a large number of patients from a single institution. METHODS: We reviewed the medical records of patients to investigate the short- and long-term outcomes of the different types of hernia repair. Late symptoms were evaluated by questionnaire. A total of 1,141 repairs performed from 1999 to 2008 (PHS in 957 and MP in 184 repairs) were evaluated. RESULTS: There were 93 early postoperative complications (8.2%). A subcutaneous hematoma was found more frequently after MP repair compared with after PHS repair (3.8 vs. 1.3%, P = 0.013). Seven hundred and ten patients (62.2%) could be followed up for more than 2 years. Recurrence was detected in 14 patients with PHS repair and two patients with MP repair (1.5 vs. 1.1%, P = 0.956). Wound infections occurred in three patients (0.3%) with PHS repair vs. none with MP repair (P > 0.999). Patients with PHS and MP repair showed no significant differences in the long-term wound pain. CONCLUSIONS: The recurrence and wound infection rates were similar after hernia repair using the PHS and MP methods. Patients undergoing PHS repair developed fewer subcutaneous hematomas. An older age (≥65 years) was a significant independent risk factor for recurrence.

Genome sequence of Vibrio sp. strain 10N, an ulvan-degrading bacterium isolated from coastal seawater collected at Ise Bay, Japan.

Genome sequence of an ulvan-degrading bacterium, Vibrio sp. strain 10N, is presented. The genome is 5,358,550 bp with a G + C content of 46.5%. A total of 4,712 coding sequences, including two novel ulvan lyase genes encoding a BNR4 and a glycoside hydrolase (GH88) motif, are known to be involved in the degradation of green algae.

Appendiceal adenocarcinoma associated with Amyand's hernia: a case report.

We encountered a rare case of appendiceal carcinoma associated with Amyand's hernia, which was difficult to diagnose preoperatively. A 74-year-old man presented to our hospital with right lower abdominal pain. A hard mass was palpable in the right lower abdomen, and blood tests showed a slightly elevated inflammatory response. Computed tomography revealed a 7 × 5 cm mass with indistinct borders and heterogeneous internal density extending from the cecum to the right lower abdominal wall. We diagnosed appendiceal abscess, however, percutaneous biopsy which was performed for differential diagnosis with appendiceal carcinoma showed no malignancy. Thereafter, the patient was followed up. Two months later, a blood test showed insignificant changes in the inflammatory response and a high serum carcinoembryonic antigen level (48.6 ng/mL). An ultrasound showed a mass contiguous to the appendix, extending to the abdominal wall, with abundant blood flow signals. Fluorodeoxyglucose-positron emission tomography showed a high accumulation of fluorodeoxyglucose in the mass. Four months after the initial visit, the patient had an open ileocecal resection combined with an abdominal wall resection based on the preoperative diagnosis of appendiceal carcinoma invading the abdominal wall. During laparotomy, an enlarged appendix tip extended from the internal inguinal ring outside the inferior epigastric artery to the abdominal wall. Histopathological examination of the appendiceal tumor revealed well-differentiated adenocarcinoma, T4b (abdominal wall), N0, Ly0, and V0. When a right lower abdominal mass extends from the cecum to the abdominal wall, appendiceal tumors associated with Amyand's hernia should be considered.

Impalement injury to the left buttock with massive bleeding: a case report.

A 67-year-old man fell from the second floor of his home and was impaled on an iron pipe used for a garden stake. The pipe was 2 cm in diameter and had entered his left buttock to his anus. A plain abdominal X-ray film showed that the tip of the pipe was located in front of the 4th lumbar vertebra, so the penetration distance was 30 cm. An emergency operation was performed for hemorrhagic shock. Laparotomy revealed massive intra-abdominal bleeding, injuries of the sigmoid and transverse mesocolon, superior rectal artery, and the first part of the duodenum. Because of suspected lower rectal injury, division of the upper rectum, closure of the rectal stump, and sigmoidostomy were performed. Gauze packing into the pelvic cavity was performed for uncontrollable bleeding. All the gauze was postoperatively removed from the drain wound without laparotomy. Six months after the operation, he underwent a second operation including anastomosis of the descending colon and lower rectum, which allowed him to live a normal daily life.