A Rare Solitary Fibrous Tumor of the Mesorectum: A Case Report.

Solitary fibrous tumors (SFTs) are rare tumors that predominantly occur in the mesorectum. Few case reports have been published on mesorectal tumors, and this is the seventh case report. A 49-year-old female patient presented with a hypervascularized mesorectal tumor discovered incidentally during a routine medical examination. Using preoperative three-dimensional computed tomography (3D-CT), we identified vessels originating from the superior rectal and lateral sacral arteries, which are important sources of nutrients, and performed the procedure safely and without bleeding. Considering the lack of preoperative diagnosis and rectal blood flow, high anterior resection was performed. The histopathological diagnosis confirmed SFT, and the patient is currently doing well with no recurrence. Although SFT of the mesorectum occurs infrequently, it should be included in the differential diagnosis. In addition, the usefulness of preoperative 3D-CT, including the arterial phase, has been emphasized in such cases. This is the seventh reported case of a rare SFT in the mesorectum. Currently, there is no literature highlighting the usefulness of 3D-CT for SFTs of the mesorectum. However, it is a valuable preparatory tool for preoperative evaluation.

Stomal Prolapse Due to Sidedness of Transverse Loop Colostomy: A Retrospective Cohort Study.

Objectives: Stomal prolapse (SP) is one of the most common complications of loop colostomy and can impair a patient's quality of life. Herein, we evaluated the risk factors for SP to prevent its occurrence after a transverse loop colostomy. Methods: This retrospective study included 84 patients who underwent loop transverse colostomy between January 2016 and December 2020. We evaluated the incidence of SP and examined the relationship between perioperative factors and SP using univariate and multivariate logistic regressions. Results: SP occurred in 11 (13.0%) patients. Median time to SP was 99 postoperative days. In the univariate analysis, a right side abdominal wall stoma site, perioperative chemotherapy, and anti-VEGF antibody therapy were associated with a significantly higher incidence of SP. Multivariate analysis identified that construction of a temporary loop colostomy in the right transverse colon during rectal cancer surgery (odds ratio, 5.07; 95% confidence interval, 1.12-22.86) is an independent risk factor. Conclusions: In this study, multivariate analysis showed that the right side of the transverse colon was a risk factor for SP. Therefore, when constructing a transverse colon loop stoma, the stoma should be constructed in the left transverse colon to prevent SP.

Successful resection of rectal cancer and perirectal abscess following systemic chemotherapy and chemoradiotherapy: A case report.

INTRODUCTION AND IMPORTANCE: Perirectal abscesses are uncommon in colorectal cancer. Although abscess infection should be controlled before colorectal cancer treatment, abscess formation makes surgical resection and preoperative treatment difficult. There is currently no established treatment for colorectal cancer with perirectal abscesses. Here, we present a case of rectal cancer with a perirectal abscess that was resected after systemic chemotherapy followed by chemoradiotherapy. CASE PRESENTATION: A 73-year-old man presented to the outpatient clinic with complaints of weight loss and general malaise. Colonoscopy revealed a circumferential tumor 3 cm from the anal verge, and examination of the endoscopic biopsy specimen indicated a well-differentiated tubular adenocarcinoma. Pelvic magnetic resonance imaging revealed a perirectal abscess on the ventral aspect of the rectum. After sigmoid colostomy was performed to control the infection, 4 cycles of panitumumab and modified fluorouracil, leucovorin, and oxaliplatin were administered. After the perirectal abscess disappeared, chemoradiotherapy to the whole pelvis (radiotherapy 45Gy/25 fractions plus tegafur-gimeracil-oteracil) was administered. Total pelvic exenteration with an ileal conduit was performed via open surgery. The pathological diagnosis was well-differentiated tubular adenocarcinoma with complete resection and negative resection margins. No recurrence of cancer has been observed 26 months after surgery. CLINICAL DISCUSSION: Treatment of colorectal cancer with perirectal abscess is difficult to define the extent of resection due to the spread of inflammation. We believe that treatment should address high risk of local recurrence. CONCLUSION: After sigmoid colostomy, complete resection of colorectal cancer with perirectal abscess could be achieved by systemic chemotherapy followed by chemoradiotherapy.

Preoperative endoscopic tattoo marking improves lymph node retrieval in laparoscopic rectal resection: a retrospective cohort study.

PURPOSE: Harvesting at least 12 lymph nodes (LNs) is recommended for adequate tumor staging in colon surgery. Although preoperative endoscopic tattooing has been used for primary localization of tumors, its impact on LN retrieval in colorectal surgery remains controversial. We aimed to investigate the relationship between preoperative tattooing and LN retrieval after laparoscopic rectal resection. METHODS: We reviewed the records of 92 patients with rectal cancer who underwent laparoscopic resection from January 1, 2018 to December 31, 2019. Patients were categorized into 2 groups according to whether preoperative endoscopic tattooing was performed. The rate of adequate LN retrieval (≥12) was compared. RESULTS: The tattooed and non-tattooed groups comprised 49 and 43 patients, respectively. In the tattooed and non-tattooed groups, the rates of adequate LN retrieval were 75.5% and 55.8%, respectively (P=0.046). Univariate analysis revealed that female sex, tattooing, LN metastasis status, pathological pathological stage (p-stage), and LN dissection were predictive factors for adequate LN retrieval. In the multivariate analysis, female sex (odds ratio [OR], 3.34; 95% confidence interval [CI], 1.15-9.73; P=0.027), tattooing (OR, 2.87; 95% CI, 1.03-7.94; P=0.043), and p-stage (OR, 3.34; 95% CI, 1.04-10.75; P=0.043) were independent predictive factors for adequate LN retrieval after surgery. CONCLUSION: This study revealed that preoperative endoscopic tattooing was statistically significantly associated with adequate LN retrieval in patients with rectal cancer who underwent laparoscopic rectal resection. Preoperative endoscopic tattooing should be considered to improve disease assessment and avoid stage migration.

Proper use of appendiceal stump closure methods for surgical site infection in laparoscopic appendectomy.

INTRODUCTION: Although some studies have reported on the relationship between appendiceal stump closure methods and postoperative complications, there is no fixed method for this procedure. This study aimed to compare treatment outcomes of the existing procedures. METHODS: We retrospectively analyzed the records of 200 patients who underwent urgent laparoscopic surgeries and investigated whether the difference in the appendiceal stump closure method was a risk factor for surgical site infection. The patients were divided into the Endoloop and endostapler groups, and 45 propensity score-matched patients were included. The treatment outcomes of the two groups were compared. RESULTS: The patients with high body temperature showed significantly developed surgical site infection in multivariate analysis (P = .036). There was no significant difference in the appendix stump methods (Endoloop vs endostapler). Regarding postoperative complications, superficial and deep incisional surgical site infection, organ/space surgical site infection, ileus, and complications of Clavien-Dindo grade IIIa or higher; there was no significant difference between the endoloop and endostapler groups after propensity score matching (P = .725, 1.000, .645 and .557, respectively). CONCLUSION: By properly using the Endoloop and endostapler according to the severity of inflammation, the Endoloop can be safely performed in many cases. Inexpensive Endoloop as an option for stump closure methods should positively impact medical costs.

Single-incision laparoscopic ileocolectomy for solitary cecal colon diverticulitis with calcified fecalith: a case report.

The prevalence of colonic diverticular disease has been on the increase in Japan due to an increase in westernized diet and a rapidly aging population. However, solitary cecal diverticulum is rare and considered congenital in etiology. Solitary cecal diverticulitis with calcified fecaliths is even rarer. Herein, we report a case of cecal colon diverticulitis caused by a calcified fecalith in a 38-year-old woman treated with single-incision laparoscopic surgery. To the best of our knowledge, this report describes the first case of cecal colon diverticulitis caused by a calcified fecalith that was successfully treated with single-incision laparoscopic ileocolectomy.

Giant esophageal liposarcoma with squamous cell carcinoma resected via the cervical approach: a case report.

BACKGROUND: Liposarcoma is one of the most common soft tissue sarcomas, but is extremely rarely found in the esophagus. There have been no reports of esophageal liposarcoma together with superficial carcinoma of the esophagus. Here, we report a patient who underwent complete resection of esophageal liposarcoma with carcinoma via a cervical approach. CASE PRESENTATION: A 66-year-old man was diagnosed with an esophageal tumor 11 years ago, but he left it untreated. He presented to our hospital with progressive dysphagia and appetite loss since the previous year. Esophagogastroduodenoscopy (EGD) showed a large pedunculated submucosal tumor (SMT) originating at the esophageal entrance, extending to the gastroesophageal junction. Additionally, there was a superficial carcinoma on the surface of the SMT, 30 cm from the incisor teeth. Three-dimensional computed tomography (3D-CT) showed a giant elongated intraluminal tumor extending downwards from the cervical esophagus. We diagnosed a giant esophageal polyp accompanied by a superficial carcinoma and performed tumor resection via a cervical approach. The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass. The final diagnosis by histopathological and immunohistochemical examination was well-differentiated liposarcoma and esophageal squamous cell carcinoma. He was discharged on postoperative day 14 with drastic improvement in his swallowing ability. CONCLUSION: We reported an extremely rare case of esophageal liposarcoma together with esophageal squamous cell carcinoma that was successfully resected through a small cervical incision.

[Clinical Outcome of Robot-Assisted Distal Pancreatectomy in Our Institutional Introduction].

We evaluated the clinical outcome and assessed the safety of robot-assisted distal pancreatectomy(RADP)of early 5 cases in our institutional introduction. We followed the guidelines for introduction of robot-assisted pancreatectomy proposed by Japanese Society of Endoscopic Surgery. Patients' characteristics were 2 men and 3 women, 45-79(median 52) years old, and 3 patients with neuroendocrine neoplasm, 1 with intraductal papillary neoplasm and 1 with mucinous cystic neoplasm. Spleen-preserving RADP was performed in 2 cases. Clinical outcomes of 5 cases underwent RADP were, operation time was 308-437(median 330)minutes, blood loss was 5-270(median 100)mL and none received transfusion. Postoperative pancreatic fistula and postoperative complication more than Grade Ⅲa(Clavien-Dindo classification)were none. Postoperative hospital stay was 7-11(median 8)days. RADP in our institution was safely introduced by following the proposal of guidelines.

Cutaneous metastasis of cecum cancer with MSI-high and BRAFV600E mutation: a case report.

BACKGROUND: Cutaneous metastases of colorectal cancer (CRC) are rare, occurring in 0.7% to 5% of cancer patients. Furthermore, the molecular subtypes of cutaneous metastasis of CRC are unclear. Here, we present a rare case of cutaneous metastasis of high-frequency microsatellite instability (MSI-high)/BRAFV600E-mutant cecum cancer. CASE PRESENTATION: A 77-year-old woman presented at the outpatient clinic with a subcutaneous mass on her left back. An excisional biopsy was performed and metastatic cutaneous adenocarcinoma was diagnosed. A computed tomography scan of the thorax and abdomen showed thickening of the cecum wall, the presence of pericolic lymph nodes, multiple masses in the liver, and a single nodule in the right lung. Right colectomy with D2 lymphadenectomy and functional end-to-end anastomosis was performed because of the almost-complete intestinal obstruction. The expression of KRAS wild type, BRAFV600E mutation, and MSI-high was detected in the cecum cancer using molecular pathological examination. She received chemotherapy with XELOX + BEV regimen (capecitabine + oxaliplatin + bevacizumab). After four administrations, a computed tomography scan showed reduction of distant metastases, which suggested partial response. CONCLUSIONS: We encountered a rare case of cutaneous metastasis of MSI-high and BRAFV600E-mutant cecum cancer. In the future, it will be necessary to accumulate more cases to identify clinical features and more effective treatments for CRCs with cutaneous metastasis.

Rare Contents of an Internal Hernia through a Defect of the Broad Ligament of the Uterus.

Herniation through a defect of the uterine broad ligament is a rare internal hernia that is difficult to diagnose definitively. Common hernia contents contain ileal loops. Herein, we report a rare case of internal herniation of both the ileum and fallopian tube through a defect of the broad ligament. A 52-year-old woman presented to our hospital with suprapubic pain and vomiting. She had a history of bowel obstruction following cesarean section. On abdominopelvic computed tomography, we suspected a closed-loop obstruction associated with bowel herniation in the right broad ligament. However, we could not identify an area of poor enhancement adjacent to distended small intestines. Emergency laparoscopic exploration revealed a viable ileal loop and incarcerated organ. Therefore, we switched to laparotomy that revealed the right fallopian tube as the ischemic organ. We reduced the hernia, resected necrotic right fallopian tube, and closed the defect of the broad ligament. The patient had an uneventful postoperative course. Rare hernia contents might complicate preoperative clinical diagnosis. Laparoscopy is useful for establishing a definitive diagnosis and treating broad ligament hernias.

Simultaneous laparoscopic hiatal hernia repair and pyloroplasty for a type 3 hiatal hernia with post-ESD pyloric stenosis for early gastric cancer.

We present a case of early gastric cancer in the pylorus with a type 3 hiatal hernia, which was treated by endoscopic submucosal dissection (ESD). A 70-year-old man was referred to our hospital with a hiatal hernia. Endoscopy revealed early gastric cancer, and we performed an ESD adaptation at the pylorus. The ESD was successful, but post-ESD pyloric stenosis occurred. Symptoms of hiatal hernia worsened because of the pyloric stenosis. Laparoscopic hiatal hernia repair with Toupet fundoplication and Heineke-Mikulicz pyloroplasty was simultaneously performed. The postoperative course was good, and follow-up after discharge was uneventful. To our knowledge, there have been no reports in which laparoscopic hiatal hernia repair, fundoplication, and pyloroplasty were simultaneously performed for a substantial hiatal hernia with post-ESD pyloric stenosis.

Reduced-port surgery for right paraduodenal hernia in an adult patient: A case report and review of the literature.

Paraduodenal hernia (PDH) is a congenital internal hernia caused by an abnormal rotation of the midgut during embryotic life; it is characterized as right- or left-sided according to the hernial sac location. Herein, we describe a case of a 30-year-old male patient who was preoperatively diagnosed with right PDH and underwent successful laparoscopic repair using reduced-port surgery (RPS). The patient presented with postprandial nausea, vomiting, and upper abdominal pain. Contrast-enhanced CT and an upper gastric series led to the preoperative diagnosis of right PDH associated with intestinal malrotation. Thereafter, laparoscopic repair using RPS was performed. After the small bowels were reduced from the hernial sac, the hernial orifice was opened widely and laterally. The postoperative course was uneventful. This is the first report of a successful laparoscopic surgery on right PDH using RPS.

Acute cholecystitis caused by gallbladder metastasis from non-small cell lung cancer: a case report.

Although non-small cell lung cancer can metastasize to any part of the body, metastasis to the gallbladder is extremely rare. We present a case of acute cholecystitis caused by gallbladder metastasis from non-small cell lung cancer. A 66-year-old man diagnosed with primary stage IV T4N3M1b non-small cell lung cancer was admitted to our hospital to receive chemotherapy, during which he presented with right upper abdominal pain. Abdominal contrast-enhanced computed tomography showed an enhanced mass at the neck of the gallbladder and gallbladder distension with obvious wall thickening. Acute cholecystitis caused by obstruction of the gallbladder neck by malignancy was suspected. Open cholecystectomy, extrahepatic bile duct resection, and Roux-en-Y choledochojejunostomy were performed. Pathological and immunohistochemical examinations revealed gallbladder metastasis originating from non-small cell lung cancer. In conclusion, when a patient with lung cancer presents with acute cholecystitis, the rare possibility of gallbladder metastasis should be considered.

[Two Cases of Stevens-Johnson Syndrome after Nivolumab Therapy for Gastric Cancer].

Case 1: A 51-year-old man with advanced gastric cancer and peritoneal metastasis was referred to our hospital. He received fourth-line chemotherapy with nivolumab, but it became PD. Next, he received S-1 plus docetaxel therapy as fifth- line therapy. After 2 courses of S-1 plus docetaxel, erythema and blisters appeared on his limbs, with erosions of the oral mucosa and penis. We diagnosed Stevens-Johnson syndrome(SJS)based on the clinical and pathological findings. He received steroid treatment, but the cutaneous symptoms persisted; therefore, it was impossible to continue the chemotherapy because of the SJS. Case 2: A 75-year-old woman with recurrence of peritoneally disseminated gastric cancer received third-line chemotherapy with nivolumab. After 1 course of nivolumab, erythema appeared on her body and limbs, with erosion of the lips and oral mucosa. We diagnosed SJS based on the clinical findings. She received steroid treatment, but the cutaneous symptoms persisted; therefore, it was impossible to continue chemotherapy because of the SJS. It should be noted that the onset of serious irAEs, such as SJS, might make continuous chemotherapy difficult.

[Laparoscopic Left Hemicolectomy-It Is Confirmed That the Accessory Middle Colonic Artery Branched from the Splenic Artery Showed by Preoperative 3D-CT].

There is a wide variety of vessel types in the transverse colon region. Among them, it is very rare that the accessory middle colonic artery(A-MCA)is branched from the splenic artery. We found a transverse colon cancer. The dominant vessel of the cancer was the A-MCA branched from the splenic artery. This vessel type was confirmed by preoperative 3D-CT. We performed a laparoscopic left hemicolectomy for the cancer. In this study, we report a case of safe laparoscopic surgery in which we separate the A-MCA branched from the splenic artery using the preoperative 3D-CT image.

Successful Use of Negative Pressure Wound Therapy for Abdominal Wall Necrosis Caused by a Perforated Ascending Colon Using the ABThera System.

BACKGROUND: The practice of leaving the abdomen open after an emergency laparotomy has gained increasing popularity recently. Negative pressure wound therapy (NPWT) is known as an effective technique in the management of an open abdomen (OA). A new device, the ABThera™ Open Abdomen Negative Pressure Therapy System (KCI USA, San Antonio, TX, USA), was specifically designed to achieve a temporary abdominal closure (TAC) in the management of an OA. This study was aimed at presenting a successful experience of treating a case of abdominal wall necrosis caused by a perforated ascending colon using the ABThera System. Case Presentation. A 66-year-old man was admitted to our hospital with complaints of severe pain in the abdomen. On admission, abdominal contrast-enhanced computed tomography (CT) showed fluid collection, an air pocket in the subcutaneous fat layer of the abdominal wall, and edematous changes in the adipose tissue in the peritoneum and abdominal wall. Based on a diagnosis of peritonitis resulting from a perforated ascending colon, emergency surgery was performed. A right hemicolectomy, ileostomy construction, and debridement of the necrotic tissues were performed. However, necrotizing fasciitis rapidly spread; therefore, more necrotic tissue was debrided in a second operation. The abdominal wall defect was left open, and the ABThera System was used in the management of the OA; this device promoted wound healing. A reduction was observed in the size of the open wound with visible granulation tissue. The defect was finally covered with a mesh split-thickness skin graft and anterolateral thigh flap. CONCLUSIONS: In the management of a case of a massive wound with infection, it can be of great benefit to treat the wound with NPWT initially to decrease its size. The ABThera System could facilitate early and safe management of an OA by surgeons.

[Outcome of Repeated Surgical Resections of Hepatic and Pulmonary Metastases from Colorectal Cancer].

Previous reports have demonstrated that repeated surgical resections of resectable hepatic and pulmonary metastases from colorectal cancer contribute to a better prognosis. We retrospectively assessed the outcomes of 19 patients with colorectal cancer who underwent repeated resections of hepatic and pulmonary metastases between February 2007 and February 2017. The median observation period was 69.9 months, and 26 liver and 27 lung resections were performed. The cumulative 5-year survival rates after resection of the last metastasis was 75.1% and the median disease-free survival after resection of the last metastasis was 34.7 months. Although 7 patients showed recurrence and 4 patients died, 7 patients exhibited long-term survival. Univariate analysis revealed that simultaneous liver and lung metastases were significantly predictor of poor prognosis(p=0.039). Progress of the patients in the present study were comparable to those in previous reports. Therefore, we propose that repeated surgical resection of hepatic and pulmonary metastasis from colorectal cancer could improve patient prognosis. Further studies should examine to identify more accurate prognostic factor with large series.

A rare case of enlarged gastric heterotopic pancreas with retention cysts: A case report and literature review.

INTRODUCTION: Gastric heterotopic pancreas (HP) is usually asymptomatic and benign; however, it may become evident when it is complicated by pathological changes such as inflammation, bleeding, and malignant transformation. PRESENTATION OF CASE: A 43-year old man was diagnosed with gastric HP 18 years prior suffered a haemorrhage from the enlarged gastric HP with multiple cystic lesions. Although endoscopic ultrasonography-guided fine needle aspiration showed no malignancy, he underwent a partial gastrectomy for diagnosis and treatment. Postoperative histological findings revealed ectopic pancreatic tissue with retained cysts that consisted of dilated pancreatic ducts without malignancy. DISCUSSION: This is a first report of enlarged gastric HP due to the expansion of retained cysts. Gastric HP is rarely enlarged by pathological changes including inflammation, retention cysts, or malignant neoplasms. CONCLUSION: Symptomatic enlarged gastric HP should be respected and further examined histologically to ensure diagnostic accuracy.

[Simultaneous Distal Gastrectomy, Distal Pancreatectomy, and Splenectomy Based on Remnant Gastric Blood-Flow Evaluation with Intraoperative ICG Fluorescence].

The splenic artery and vein are important to the remnant stomach after distal gastrectomy(DG). Hence, total gastrectomy is recommended when performing gastrectomy and distal pancreatectomy(DP)with splenectomy(S). In the present case, a man in his 70s was diagnosed with early gastric cancer. Abdominal CT detected a dilated main pancreatic duct. Chronic pancreatitis was suspected, but malignancy could not be completely ruled out. Thus, DG with Roux-en-Y reconstruction and DP with S were performed simultaneously. The remnant gastric blood flow was evaluated with intraoperative indocyanine green(ICG)fluorography and the blood flow was confirmed. Finally, the remnant stomach was preserved. The postoperative course was uneventful, except for the occurrence of anastomosis edema. This result suggests that ICG fluorescence is useful to evaluate remnant gastric blood flow and that it may be possible to perform DG and DP with S simultaneously depending on the case.

[Effect on Prognosis of Immune-Related Adverse Events after Nivolumab Treatment in Gastric Cancer].

BACKGROUND: The clinical efficacy of nivolumab has been shown as a third-line treatment for advanced gastric cancer; however, nivolumab sometimes causes immune-related adverse events(irAEs). We retrospectively examined the clinical features and influence on treatment in cases of irAEs after nivolumab treatment. METHOD: We retrospectively examined 43 patients who received nivolumab treatment at our institution between October 2017 and December 2019. RESULT: The incidence of irAEs was 23.2%(10/43), and Grade 3 or higher irAEs included interstitial pneumonia, hypoadrenalism, Stevens- Johnson syndrome(SJS), and type 1 diabetes. Three patients showed long-term disease control after irAE onset. Meanwhile, SJS prevented patients from continuing treatment for gastric cancer. DISCUSSION: Nivolumab is effective in some patients with gastric cancer, while irAEs made subsequent treatment difficult. Trifluridine/tipiracil or irinotecan are also known to be effective as therapeutic drugs after third-line treatment for gastric cancer in addition to nivolumab; therefore, the choice of the third-line drug and management of irAEs owing to individual cases are considered desirable. CONCLUSION: Long-term efficacy is expected with nivolumab, but it may be necessary to recognize that the onset of serious irAEs might make subsequent treatment difficult.