A Japanese Prospective, Multicenter Study of Colonic Stenting for Palliation Using a High Axial Force Self-Expandable Metal Stent for Malignant Large Bowel Obstruction in 200 Patients.

Evidence of the efficacy and safety of colorectal stent placement for palliation remains insufficient. This single-arm, prospective, multicenter study with a WallFlex enteral colonic stent included 200 consecutive patients with malignant large bowl obstruction in the palliation cohort. The technical and clinical success, as well as stent patency and complications as short-term (≤7 days) and long-term (>7 days) outcomes, of high axial force self-expandable metal stent (SEMS) placement was evaluated. The technical and clinical success rates were 98.5% and 94.5%, respectively. Non-recurrent colorectal obstruction at 1 year was 63.9%, and 71.2% of the patients remained free of recurrent colorectal obstruction until death or the last follow-up. Fifty-six patients (28.0%) received chemotherapy, and five patients were administered bevacizumab after stent placement. The overall complication rate was 47%, including four (2.0%) early-onset and ten (5.0%) late-onset perforations, mostly due to stent-edge injury. Only the use of a long SEMS was a risk factor for perforation. In conclusion, endoscopic colorectal stenting using high axial force SEMS is an effective and safe procedure for palliation in patients with malignant colorectal obstruction. However, care should be taken to avoid perforation at the stent edge when using a long SEMS.

Anti-nucleocapsid antibodies enhance the production of IL-6 induced by SARS-CoV-2 N protein.

A cytokine storm induces acute respiratory distress syndrome, the main cause of death in coronavirus disease 2019 (COVID-19) patients. However, the detailed mechanisms of cytokine induction due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain unclear. To examine the cytokine production in COVID-19, we mimicked the disease in SARS-CoV-2-infected alveoli by adding the lysate of SARS-CoV-2-infected cells to cultured macrophages or induced pluripotent stem cell-derived myeloid cells. The cells secreted interleukin (IL)-6 after the addition of SARS-CoV-2-infected cell lysate. Screening of 25 SARS-CoV-2 protein-expressing plasmids revealed that the N protein-coding plasmid alone induced IL-6 production. The addition of anti-N antibody further enhanced IL-6 production, but the F(ab')2 fragment did not. Sera from COVID-19 patients also enhanced IL-6 production, and sera from patients with severer disease induced higher levels of IL-6. These results suggest that anti-N antibody promotes IL-6 production in SARS-CoV-2-infected alveoli, leading to the cytokine storm of COVID-19.

Long-term outcomes of standardized colonic stenting using WallFlex as a bridge to surgery: Multicenter prospective cohort study.

OBJECTIVES: The oncological outcomes, especially high recurrence rate, of bridge-to-surgery (BTS) self-expandable metallic stent (SEMS) placement remain concerning, emphasizing the necessity of standardized SEMS placement. However, its impact on long-term BTS outcomes is unknown. We investigated the long-term outcomes of BTS colonic stenting using standardized SEMS placement. METHODS: This prospective, multicenter cohort study conducted at 46 hospitals in Japan (March 2012 to October 2013) included consecutive patients with stage II and III obstructive colorectal cancer managed with BTS SEMS placement. The SEMS placement technique was standardized by information dissemination among the participating hospitals. The primary outcome was overall survival (OS) after SEMS placement, and the secondary outcomes were relapse-free survival (RFS), recurrence, and short-term outcomes of SEMS placement and surgery. RESULTS: The 1-, 3-, and 5-year OS rates were 94.1%, 77.4%, and 67.4% (Kaplan-Meier), respectively, with high technical success (99.0%, 206/208) and low perforation (1.9%, 4/208) rates. The 1-, 3-, and 5-year RFS rates were 81.6%, 65.6%, and 57.9% (Kaplan-Meier), respectively, and the overall recurrence rate was 31.0% (62/200). The RFS rate was significantly poorer in patients with perforation (n = 4) than in those without perforation (n = 196) (log-rank P = 0.017); moreover, perforation was identified as an independent factor affecting RFS (hazard ratio 3.31; 95% confidence interval 1.03-10.71, multivariate Cox regression). CONCLUSION: This large, prospective, multicenter study revealed satisfactory long-term outcomes of BTS colonic stenting using a standardized SEMS insertion method, which might be specifically due to the reduced perforation rate. (UMIN000007953).

Successful Surgical Intervention of Strangulated Ileus with a Simple Cut of the External Iliac Vein without Vein Reconstruction.

A 67-year-old woman with epigastralgia was referred to our hospital. The patient had undergone hysterectomy, bilateral oophorectomy, omentectomy, and radical pelvic and para-aortic lymph node dissection for her ovarian cancer 6 years before. Despite the gastrointestinal decompression therapy under the presumed diagnosis of adhesive ileus, computed tomography scans taken 3 days after the onset of epigastralgia showed marked dilatation of the small intestine and an oval high-density mass, that is, thrombi, in the right femoral vein. Aggravation of ileus with the thrombi in the femoral vein made us to treat the patient with surgery. Intraoperative findings showed that the terminal ileum was strangulated by a gap between the exposed right external iliac vein and artery presumably formed by pelvic lymph node dissection. Distal ileum strangulated by the gap, however, showed no ischemic change with no surgically available peritoneum left around the external iliac vein. To prevent the pulmonary embolism and the recurrence of this type of ileus due to both the thrombi and the persistent gap, we released the strangulated ileum with a simple cut of the external iliac vein without vein reconstruction. The patient recovered uneventfully and was discharged on the 13th day after operation. The patient has been well with nominal right leg edema. In this situation, that is, internal hernia caused by external iliac vessels with thrombi in the femoral vein and no leg edema, a simple cut of the external iliac vein without vein reconstruction is a feasible treatment option.

Short-Term Outcomes of Colorectal Stenting Using a Low Axial Force Self-Expandable Metal Stent for Malignant Colorectal Obstruction: A Japanese Multicenter Prospective Study.

(1) Background: Endoscopic colorectal stenting with high technical success and safety is essential in discussing the oncological outcomes for the management of malignant colorectal obstruction. Mechanical properties of self-expandable metal stents are usually considered to affect clinical outcomes. (2) Methods: A multicenter, prospective study was conducted in Japan. A self-expandable metal stent with low axial force was inserted endoscopically. The primary endpoint was clinical success, defined as the resolution of symptoms and radiological findings within 24 h. Secondary endpoints were technical success and adverse events. Short-term outcomes of 7 days were evaluated in this study. (3) Results: Two hundred and five consecutive patients were enrolled. Three patients were excluded, and the remaining 202 patients were evaluated. The technical and clinical success rates were 97.5% and 96.0%, respectively. Major stent-related adverse events included stent migration (1.0%), insufficient stent expansion (0.5%), and stent occlusion (0.5%). No colonic perforation was observed. There were two fatal cases (1%) which were not related to stent placement. (4) Conclusions: The placement of self-expandable metal stents with low axial force is safe with no perforation and showed high technical and clinical success rates in short-term outcomes for the management of malignant colorectal obstruction.

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.

A case of bilateral methotrexate-associated diffuse large B-cell lymphomas of the breasts with unique clinical presentation and outcome.

A 54-year-old woman on methotrexate (MTX) treatment developed reddish skin change in her right breast. Mammography and ultrasound showed no masses in the breasts but bilateral mammary glands presented diffuse lower-level echoes. Only 19 days later, the patient developed bilateral breast masses. Histological examination showed that diffuse large B-cell lymphoma cells spread widely and sparsely in the bilateral breasts in addition to the tumor cell conglomerate, leading to the diagnosis of MTX-associated lympho-proliferative disorders (MTX-LPDs). Withdrawal of MTX resulted in complete disappearance of the left MTX-LPD in 2 months but no regression of the right MTX-LPD. Chemotherapy led to a partial response followed by re-growth of the right MTX-LPD. Re-biopsy of the right MTX-LPD revealed double/triple hit lymphoma. Second-line and later-line chemotherapies caused no regression of the right MTX-LPD. The patient died in a year after the diagnosis of MTX-LPDs. Breast oncologists should note the presence, biology, and diagnostic images of MTX-LPD.

A Case of Locally Advanced Breast Cancer Successfully Treated with Multidisciplinary Therapy.

A 42-year-old woman with locally advanced luminal breast cancer was referred to our hospital. Ultrasonography showed marked skin thickening with obscured breast mass. Positron emission tomography showed bilateral swelling in the axillar, parasternal, and supraclavicular lymph nodes in addition to the primary breast cancer. Following the patient's request, we treated her with primary bevacizumab-containing chemotherapy followed by radiotherapy to the breast due to the histologically proven widely spreading cancer remnants in the skin after chemotherapy. Thereafter, the patient underwent mastectomy and axillary dissection with a vertical rectus abdominis musculo-cutaneous flap to cover the skin defect. Pathological examination showed no viable cancer cells both in the breast and lymph nodes but imperceptible cytokeratin AE1 + 3-positive cells in the skin. Although wound healing needed 3 months due to the influence of preoperative radiotherapy, the patient has been well on endocrine therapy without any recurrence for more than 7 years.

A Case of Diffuse Large B Cell Lymphoma of the Breast with Predominantly High-Level Internal Echoes.

A 70-year-old woman had a large mass in her right breast. Mammography displayed focal asymmetrical density in the scattered areas of fibroglandular density. Ultrasonography showed the tumor to have predominantly high-level internal echoes. Histological examination showed that the tumor was composed of CD20-positive atypical cells with a large nucleus, scant cytoplasm, and abundant mitoses accompanied by a lot of fat cell interspersion and the diagnosis of diffuse large B cell lymphoma was made. We considered that the massive back scattering generated by the heterogeneity of acoustic impedance between fat cells and tumor cells brought about the high-level internal echoes. The patient had undergone chemotherapy followed by radiotherapy to the breast and regional nodes and has been well without lymphoma recurrence for more than 6 years. Although breast malignant lymphoma generally shows very low-level internal echoes, it could have high-level internal echoes especially in case of a non-dense breast.

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.

Determining the difference in the efficacy and safety of self-expandable metallic stents as a bridge to surgery for obstructive colon cancer among patients in the CROSS 0 group and those in the CROSS 1 or 2 group: a pooled analysis of data from two Japanese prospective multicenter trials.

PURPOSE: This study compared the feasibility and safety of endoscopic placement of self-expandable metallic stents (SEMSs) as a bridge to surgery (BTS) between patients with obstructive colorectal cancer (CRC) classified as ColoRectal Obstruction Scoring System (CROSS) 0 and those with CROSS 1 or 2. METHODS: We conducted a post hoc analysis of two prospective, observational, single-arm multicenter clinical trials and performed a pooled analysis of the data. In total, 336 consecutive patients with malignant colorectal obstruction underwent SEMS placement. The primary endpoint was clinical success, defined as resolution of symptoms and radiological findings within 24 h. Secondary endpoints were technical success and adverse events. RESULTS: High clinical (98.0% vs. 98.4%) and technical (96.7% vs. 97.8%) success rates were observed in both groups (CROSS 0 vs. CROSS 1 or 2). The adverse event rate was low. The mean stricture length was lower (3.8 ± 1.2 cm vs. 4.4 ± 1.8 cm) and laparoscopic surgery more common (56.7% vs 52.2%) in the CROSS 0 group than in the CROSS 1 and 2 group. CONCLUSION: This study was the first to compare the degree of stricture in different CROSS groups and demonstrated comparable results with respect to the short-term efficacy and safety of SEMS placement as a BTS for obstructive CRC in CROSS 0, 1, and 2 patients.

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.

Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction: pooled analysis of 426 patients from two prospective multicenter series.

BACKGROUND: Self-expandable metallic stenting (SEMS) for malignant colorectal obstruction (MCO) as a bridge to elective surgery (BTS) is a widely used procedure. The aim of this study was to assess short-term outcomes of SEMS for MCO as BTS. METHODS: This study analyzed pooled data from BTS patients who were enrolled in two multicenter prospective single-arm observational clinical studies that used different stent types. Both studies were conducted by the Japan Colonic Stent Safe Procedure Research Group (JCSSPRG). The first study evaluated the WallFlex™ colonic stent for BTS or palliative treatment (PAL) from May 2012 to October 2013 and the second evaluated the Niti-S™ colonic stent from October 2013 to May 2014. Fifty-three facilities in Japan participated in the studies. Before each study started, the procedure had been shared with the participating institutions by posting details of the standard methods of SEMS placement on the JCSSPRG website. Patients were followed until discharged after surgery. RESULTS: A total of 723 consecutive patients were enrolled in the two studies. After excluding nine patients, the remaining 714 patients were evaluated as a per-protocol cohort. SEMS placement was performed in 426 patients (312 WallFlex and 114 Niti-S) as BTS and in 288 as PAL. In the 426 BTS patients, the technical success rate was 98.1% (418/426). The clinical success rate was 93.8% (392/418). SEMS-related preoperative complications occurred in 8.5% of patients (36/426), perforations in 1.9% (8/426), and stent migration in 1.2% (5/426). Primary anastomosis was possible in 91.8% of patients (391/426), 3.8% of whom (15/393) had anastomosis leakage. The overall stoma creation rate was 10.6% (45/426). The postoperative complication rate was 16.9% (72/426) and mortality rate was 0.5% (2/426). CONCLUSIONS: SEMS placement for MCO as BTS is safe and effective with respect to peri-procedural outcomes. Further investigations are needed to confirm long-term oncological 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.

[A Case of Advanced Gastric Cancer with Liver Metastases Treated with Curative Conversion Therapy after S-1 plus Oxaliplatin].

An 81-year-old man was referred to our hospital. Upper gastrointestinal endoscopy revealed a type 2 tumor in the antrum of the stomach. The histopathological findings showed a moderately differentiated HER2-negative adenocarcinoma. Two low-density areas of 17mm and 26mm in diameter were observed in the liver S6 and S8respectively at the CT scan. Nine courses of S-1 plus oxaliplatin(SOX)therapy were administered to this patient with gastric cancer and liver metastases. Since both the primary tumor and the liver metastases were significantly reduced by the chemotherapy, distal gastrectomy(D2 dissection)and partial liver resection(liver S6, S8)were performed. The histopathological findings revealed no tumor cells in the primary tumor, lymph nodes, and liver metastases, with a histologic effect of Grade 3. The patient underwent adjuvant therapy with S-1. He has been alive without recurrence for 11 months post-surgery.

A case report of primary pancreatic leiomyosarcoma requiring six additional resections for recurrences.

INTRODUCTION: Primary pancreatic leiomyosarcoma is extremely rare. We report a case in which six additional resections were required to treat recurrent tumors in a 5-year period following the primary operation. PRESENTATION OF CASE: A 69-year-old man presented with a pancreatic tumor. Abdominal computed tomography scan showed a large heterogeneous mass with a necrotic area arising from the pancreatic body. We performed distal pancreatectomy, splenectomy, and wide resection of the transverse mesocolon. Histopathological examination confirmed the diagnosis of a pancreatic leiomyosarcoma. We repeatedly performed surgery on recurrent tumors. DISCUSSION: Primary pancreatic leiomyosarcoma is considered to be a highly aggressive malignancy. The most effective treatment is complete surgical resection with tumor-free margins. Even when tumors recur, it is possible to improve the prognosis by further resection. CONCLUSION: Long-term survival is achievable by repeated resection of recurrent tumors.

Perforation associated with endoscopic submucosal dissection for duodenal neoplasm without a papillary portion.

AIM: To investigate predictors of perforation after endoscopic resection (ER) for duodenal neoplasms without a papillary portion. METHODS: This was a single-center, retrospective, cohort study conducted between April 2003 and September 2014. A total of 54 patients (59 lesions) underwent endoscopic mucosal resection (EMR) (n = 36) and endoscopic submucosal dissection (ESD) (n = 23). Clinical features, outcomes, and predictors of perforation were investigated. RESULTS: Cases of perforation occurred in eight (13%) patients (95%CI: 4.7%-22.6%). Three ESD cases required surgical management because they could not be repaired by clipping. Delayed perforation occurred in two ESD cases, which required surgical management, although both patients underwent prophylactic clipping. All patients with perforation who required surgery had no postoperative complications and were discharged at an average of 13.2 d after ER. Perforation after ER showed a significant association with a tumor size greater than 20 mm (P = 0.014) and ESD (P = 0.047). CONCLUSION: ESD for duodenal neoplasms exceeding 20 mm may be associated with perforation. ESD alone is not recommended for tumor treatment, and LECS should be considered as an alternative.