Long-Term Outcomes of Conversion Hepatectomy for Initially Unresectable Colorectal Liver Metastases.

BACKGROUND: Chemotherapy, including molecular targeted agents, for metastatic colorectal cancer has greatly improved recently and offers an increased chance of conversion hepatectomy for patients with initially unresectable liver metastases. However, the long-term outcomes of conversion hepatectomy remain controversial. METHODS: We retrospectively assessed a consecutive series of 210 patients with colorectal liver metastases to evaluate the long-term outcomes of patients who underwent conversion hepatectomy and to clarify the predictive factors related to the conversion rate. RESULTS: Ninety-four cases were initially resectable and underwent primary hepatectomy. Of the 116 patients with initially unresectable liver metastases, 104 patients underwent chemotherapy (systemic or hepatic artery infusion). Twenty-four percent (11/46) of the initially unresectable liver-limited metastases that became resectable after chemotherapy were subsequently treated with conversion hepatectomy; however, there were no cases of conversion among the patients with extrahepatic metastases. The final resection rate of liver metastases was 50 % (105/210), including conversion hepatectomies. The predicted 5-year survival rate in the conversion hepatectomy group was 76 %. The conversion rate was significantly (P < 0.05) higher in patients with liver-limited metastases (24 %), patients with no LN involvement (27 %), the hepatic arterial infusion chemotherapy group (33 %), patients treated with anti-EGFR agents (21 %), and patients with a complete or partial response (33 %). CONCLUSIONS: Twenty-four percent of the patients with initially unresectable liver-limited metastases became resectable after chemotherapy, and the survival rate after conversion hepatectomy was not inferior to that of the primary hepatectomy cases. Chemotherapy regimens with high response rates are needed to achieve a higher conversion rate.

Three-step tumescent local anesthesia technique for inguinal hernia repair.

The optimal method of anesthesia for inguinal hernia repair is still controversial. We have developed "three-step tumescent local anesthesia (TLA) technique" for inguinal hernia repair, and recently showed that this technique is acceptable in view of short- and long-term clinical outcomes. Our study included 273 consecutive cases (290 sides) of elective inguinal hernia repair performed under the newly developed technique between September 2003 and May 2019, and overall clinical outcomes were considered to be safe and feasible. Herein, we report the surgical procedure of "three-step TLA technique." Briefly, we rapidly inject the diluted solution of local anesthetic and epinephrine step-by-step into the three following closed tissue space. Initially, 80 mL injection into the subcutaneous tissue before skin incision (Step 1). After the external oblique fascia is exposed, injection of 20 mL into the inguinal canal before the external oblique fascia is incised and opened (Step 2). The hernia sac and spermatic cord are then dissected, and the blunt dissection of the preperitoneal space is made by injecting 20 mL under the internal inguinal ring (Step 3), followed by placing a gauze into the preperitoneal space, creating the space for mesh placement. We consider that the most important point of this technique is achieved through the rapid injection of TLA solution into each closed tissue space, which makes for easier dissection, hemostasis, and good pain control.

Rapidly Growing Desmoid-Type Fibromatosis of the Mesentery of the Small Intestine after Distal Gastrectomy for Gastric Cancer.

We report the case of a 55-year-old man with a surgical history of distal gastrectomy with Roux-en-Y reconstruction performed 3 years prior to the present episode. During the follow-up, a newly developed, rapidly growing intraabdominal mass was detected in the mesentery of the small intestine. Although the patient had been asymptomatic, surgical resection was planned with the suspicion of malignancy, especially lymph node recurrence of the gastric cancer, owing to its rapid growth. Laparotomy showed that the tumor was located in the mesentery of the small intestine near the Roux-en-Y limb, and due to the involvement of the feeding vessels to the Roux-en-Y limb, the anastomotic site was resected en bloc with the tumor, and the whole Roux-en-Y limb was reconstructed. The histopathological finding was compatible with desmoid-type fibromatosis of the mesentery of the small intestine. Here we report our case and discuss the previously reported literature, especially related to gastric cancer.

A case of laparoscopic resection of leiomyosarcoma arising in the mesentery of descending colon: a case report and review of the literature.

Leiomyosarcoma of mesenteric origin is rare and may be managed by laparoscopic surgery as a less invasive procedure, on the condition that the tumor can be resected with a safe margin.

Metachronous Pancreatic and Thyroid Metastases from Primary Soft-Tissue Myoepithelioma in the Clavicular Region: A Case Report of a Long-Term Survivor.

BACKGROUND Myoepithelioma is a rare neoplasm that differentiates toward myoepithelial cells. This condition mainly occurs in the salivary gland and rarely in the  soft tissue or internal organs. Long-term survival with repeated multiple rounds of resection for recurrence is rarely reported. CASE REPORT A 69-year-old man was diagnosed with metachronous pancreatic and thyroid metastases from myoepithelioma, which initially originated from a resected soft-tissue lesion in the left clavicular region in 2007. In addition, a locally recurrent lesion was resected and the patient received brachytherapy in 2015. Moreover, a metachronous metastatic lesion in the right lung was resected in 2017. Histopathological examination confirmed that all lesions were myoepithelioma. In the present case, pancreatoduodenectomy and right hemithyroidectomy for both metastatic lesions were successfully performed. Histopathology revealed small round-to-spindle-shaped tumor cells with atypia, proliferating in reticular formation, accompanied by myxoid stroma with chondromyxoid and hyalinized stroma, and the histology was similar to that observed in the previous specimen. Immunohistochemistry revealed positivity for cytokeratin (AE1/AE3), glial fibrillary acidic protein, vimentin, and S-100, and confirmed the diagnosis of myoepithelioma. To the best of our knowledge, this is the first study presenting a long-term survivor of soft-tissue myoepithelioma who underwent repeated multiple rounds of resection for recurrence in various organs. CONCLUSIONS We reported the case of a long-term survivor of soft-tissue myoepithelioma requiring multiple rounds of surgical resection for local recurrence and metachronous metastases in the lung, pancreas, and thyroid. When managed appropriately, some patients might benefit in terms of survival from repeated resection of recurrent lesions.

Oncological outcomes of repeat metastasectomy for recurrence after hepatectomy for colorectal liver metastases. A case series.

BACKGROUND: Although hepatectomy is the standard and only curative treatment for colorectal liver metastases, recurrence occurs in various organs, including the remnant liver, lung, peritoneum, and others. The outcomes and predictive factors of repeat metastasectomy for recurrence after initial hepatectomy remains controversial. METHODS: We retrospectively assessed a consecutive series of 132 patients who underwent hepatectomy for colorectal liver metastases in a single institute. RESULTS: There were 99 recurrence cases after initial hepatectomy, and 42 patients underwent metastasectomy (first repeat metastasectomy) to achieve R0 (17 liver cases, 16 lung cases, and 9 multiple or other cases), while 19 patients underwent subsequent second repeat metastasectomy (4 liver cases, 7 lung cases, and 8 multiple or other cases). Among the 99 recurrent cases after initial hepatectomy, the 5-year overall survival rate of the patients who underwent first repeat metastasectomy was significantly higher than that of chemotherapy/BSC (best supportive care) patients (60% vs. 14%, P < 0.0001). Furthermore, among the 26 recurrent cases after first repeat metastasectomy, the 5-year overall survival rate of the patients who underwent second repeat metastasectomy was significantly higher than that of chemotherapy/BSC patients (P = 0.024). A multivariate analysis revealed that lack of adjuvant chemotherapy, a short (<12 months) disease-free interval, and right-side colon primary were the independent poor prognostic factors for the overall survival after first repeat metastasectomy. CONCLUSION: The current study indicated that repeat metastasectomy for recurrence after initial hepatectomy for colorectal liver metastases could achieve a longer survival time, especially for patients with favorable predictive factors.

Feasibility and Safety of Early Oral Feeding in Patients with Gastric Cancer After Radical Gastrectomy.

An enhanced recovery after surgery (ERAS) protocol is useful in patients undergoing colorectal surgery. However, its feasibility for gastric surgery remains unclear. This study aimed to evaluate the feasibility and safety of early oral feeding (EOF) for patients with gastric cancer after radical gastrectomy. The EOF protocol was implemented in 397 patients who underwent radical gastrectomy between 2005 and 2014 at our hospital. The protocol was common in 277 patients after distal gastrectomy (DG) and 120 patients after total gastrectomy (TG). The patients were scheduled to start drinking water in the morning of the first postoperative day and to start thin rice gruel with a liquid nutrition supplement on the second postoperative day. We analyzed the incidence of postoperative complications and surgical outcomes in these patients. Furthermore, we analyzed risk factors for dropout from the EOF protocol. All patients started drinking water, while 26 patients were unable to start eating. The EOF protocol was implemented in 371 patients (93%), and 48 patients stopped eating. Specifically, 227 patients (87%) after DG and 96 patients (88%) after TG followed the EOF protocol perfectly. The incidence of postoperative complications, including anastomotic leakage (n = 0), ileus (n = 22), and pneumonia (n = 11), was 15% and that of clinically significant events (≥ grade 3) was 4.3%. Multivariate analysis showed that the male gender, comorbidities, and intra-operative bleeding are independent risk factors for dropout from the EOF protocol. EOF can be safely implemented in patients after radical gastrectomy.

Recurrence of Noninvasive Perianal Extramammary Paget's Disease in the Lymph Nodes without Local Recurrence after Complete Excision.

Primary extramammary Paget's disease (EMPD) is a rare intraepithelial adenocarcinoma. Lymph node metastasis from noninvasive EMPD originating in the anorectal region is extremely rare, and the recurrence of noninvasive EMPD is commonly associated with local recurrence mainly due to an insufficient resection margin. We herein report a case of inguinal and para-aortic lymph node recurrence without local recurrence after complete margin-free surgical resection of noninvasive perianal EMPD. The patient was a man in his 40s who presented with an erythematous plaque of 7 × 5 cm in the perianal region, which had been present for 1 year. Biopsy from the perianal skin suggested EMPD; it was positive for cytokeratin (CK)7 and negative for CK20. Underlying malignancy was ruled out based on whole-body enhanced computed tomography (CT) and total colonoscopy. Surgery including complete wide resection of the lesion with preservation of the rectum was performed, and VY-advancement flap reconstruction and flap-rectum anastomosis were performed. A histological examination of the whole specimen with 5-mm slices confirmed noninvasive EMPD resected with all-negative surgical margins. At 2 years and 6 months after surgery, however, enlargement of the inguinal and para-aortic lymph nodes was detected by follow-up enhanced CT, and the recurrence of EMPD was diagnosed based on left inguinal lymph node biopsy. The patient underwent chemotherapy without a remarkable response. He died of the disease 53 months after the first surgery. This is the first case report of lymph node metastasis without local recurrence after complete margin-free resection of noninvasive perianal EMPD.

A retrospective analysis of emergency surgery for cases of acute abdomen during cancer chemotherapy. Case series.

BACKGROUND: Treatment for acute abdomen during chemotherapy is frequently difficult because of the complicated status of the patients, and there have been only a few case series summarizing the outcomes of emergent surgery during chemotherapy. The aim of this study was to clarify the clinical outcomes of emergency surgery for acute abdomen during chemotherapy and identify predictive factors associated with mortality. METHODS: We retrospectively analyzed the records of patients who underwent emergency surgery for acute abdomen within 30-days after anti-cancer drugs administration between 2009 and 2020. RESULTS: Thirty patients were identified. The primary malignancies were hematological (n = 7), colorectal (n = 4), lung (n = 4), stomach (n = 2), breast (n = 2), prostate (n = 2) and others (n = 5). Fifteen patients were treated with the regimen, including molecular-targeted anti-cancer drugs (Bevacizumab: 8 cases, Rituximab: 4, Ramucirumab: 2, and Gefitinib: 1). Indications for emergency surgery were perforation of the gastrointestinal tract (n = 24), appendicitis (n = 3), bowel obstruction (n = 2), and gallbladder perforation (n = 1). Severe morbidity (Clavien-Dindo IIIa or more) occurred in 8 cases (27%), and there were 6 in-hospital deaths (20%). Significant factors related to in-hospital death were age >70 years old (P = 0.029), poor performance status (ECOG score 1 or 2) (P = 0.0088), and serum albumin level <2.6 g/dl (P = 0.026). The incidence of acute abdomen (odds ratio 5.31, P = 0.00017) was significantly higher in the patients receiving anti-VEGF drugs than in those without anti-VEGF drugs. CONCLUSION: This study identified three predictive factors associated with in-hospital death after emergency surgery during chemotherapy: an older age, poor performance status, and low serum albumin level.

Preoperative chemotherapy in colorectal cancer patients with synchronous liver metastasis.

The response to preoperative chemotherapy is useful for predicting prognosis in unresectable and resectable disease. However, the prognostic benefit of chemotherapy prior to hepatectomy in patients with colorectal carcinoma and resectable or marginally resectable liver metastases remains unclear. The present study investigated the effect of preoperative chemotherapy on the prognosis of patients with colorectal cancer and resectable or marginally resectable synchronous liver metastasis. A total of 106 patients were retrospectively reviewed, who underwent hepatectomy for colorectal metastasis. The prognosis of 64 patients who received neoadjuvant chemotherapy (NAC) were compared with the 42 patients who did not (non-NAC). Furthermore, a total of 43 patients who responded to chemotherapy were compared with the 21 who did not. Preoperative chemotherapy was administered for 5.7 months, wherein 50 patients (78%) received a single regimen, and 54 (84%) received oxaliplatin. There were more patients with <3 metastases and maximum diameters <5 cm in the non-NAC group. The median survival time was 86.0 and 71.6 months in the NAC and non-NAC groups, respectively (P=0.33). Subgroup analysis on the basis of tumor size and number showed no prognostic differences between the two groups. The median survival time was longer in responders than in non-responders (85 vs. 56 months; P=0.01). However, the median relapse-free survival was equivalent in both groups (16.4 and 10.7 months). Preoperative chemotherapy did not prolong survival. Furthermore, it did not prevent recurrence, even in clinical responders. Therefore, it should not be routinely offered to patients with resectable liver metastasis before their hepatectomy.

Metastases of soft tissue sarcoma to the liver: A Historical Cohort Study from a Hospital-based Cancer Registry.

BACKGROUND: Hepatic metastasis of soft tissue sarcoma is rare compared to lung metastasis, and the literature is scarce. We examined the risk of hepatic metastasis according to the site of occurrence and histological type. METHODS: From a Hospital-based Cancer Registry, 658 patients registered between 2007 and 2017 with soft tissue sarcomas were evaluated. The exclusion criteria were gastrointestinal stromal tumors, tumors of unknown origin, and follow-up periods of less than 1 month. SPSS 25 was used for statistical analysis. RESULTS: The risk of hepatic metastasis was significantly higher in the retroperitoneum (HR, 5.981; 95% CI, 2.793-12.808) and leiomyosarcoma (HR, 4.303; 95% CI, 1.782-10.390). Multivariate analysis showed that the risk of hepatic metastasis as first distant metastasis was high in leiomyosarcoma (HR, 4.546; 95% CI, 2.275-9.086) and retroperitoneal onset (HR, 4.588; 95% CI, 2.280-9.231). The 2-year survival rate after hepatic metastasis was 21.7%. CONCLUSIONS: The onset of hepatic metastasis indicates a poor prognosis. However, hepatic metastasis from retroperitoneal sarcoma and leiomyosarcoma may be the first distant metastasis in some cases. For retroperitoneal sarcoma and leiomyosarcoma, additional screening for hepatic metastasis such as contrast CT should be considered during staging and follow-up after treatment.

A hepatic sclerosing hemangioma emerged in the postoperative course of multiple gastric carcinoid tumors masquerading as metachronous liver metastasis.

INTRODUCTION: Hepatic sclerosing hemangiomas are rare tumors whose appearance on imaging is similar to that of malignant tumors. The resulting difficulties in preoperative diagnosis frequently lead to surgical resection in order to accurately identify the tumor. CASE PRESENTATION: A 68-year-old man was diagnosed with multiple gastric carcinoid tumors (T1N1M0, pStage IIIB) after total gastrectomy with D2 lymph node dissection. Enhanced computed tomography of the abdomen 2 years after the initial surgery revealed a novel solid lesion with ring enhancement measuring 22 × 15 mm at S5 of the liver. Metachronous liver metastasis from multiple gastric carcinoid tumors was suspected, and partial hepatectomy of S5 was successfully performed. Histopathological diagnosis was sclerosing hemangioma with no malignant findings. DISCUSSION: Ours is the first reported case of a newly appearing sclerosing hemangioma excised and diagnosed histopathologically. Hepatic sclerosing hemangiomas are rarely observed, but they are often resected under a preoperative diagnosis of malignant lesion due to the similarity on imaging studies. CONCLUSION: Surgeons must consider that a hepatic tumor may be a sclerosing hemangioma, particularly when the lesion appears to be ring enhanced.

Laparoscopic Resection of an Abdominal Wall Metastasis 5 Years after Primary Colorectal Cancer Resection.

We report the case of a 65-year-old male with a metachronous abdominal wall metastasis secondary to colorectal cancer. The patient had presented 5 years ago to another facility with a perforated sigmoid colon cancer (pT4a[SE], N0, M0, pStage II), rectal cancer (T2[MP], N0, M0, pStage I), and Fournier gangrene. He had then undergone sigmoidectomy and rectal resection along with S-1 adjuvant chemotherapy. No relapse was observed thereafter. However, currently, 5 years after initial surgery, the patient noticed a palpable mass in the left lower abdomen and was referred to our hospital for further assessment and treatment. Percutaneous echo-guided needle biopsy of the tumor revealed an adenocarcinoma tissue. Following 6 courses of FOLFOX plus cetuximab chemotherapy, laparoscopic resection for abdominal wall metastasis was successfully performed. The resected tissue was pathologically characterized as adenocarcinoma, which was compatible with the recurrence of the primary colorectal carcinoma resected 5 years ago. The abdominal wall metastasis was attributed to the cancer cell implantation secondary to the perforated sigmoid colon cancer treated 5 years ago.

Late Cutaneous Metastasis Originating from Gastric Cancer with Synchronous Metastasis.

An 89-year-old man was diagnosed with late cutaneous metastasis in the right axilla 6 years after undergoing a surgery for gastric cancer with synchronous cutaneous metastasis in the same site. The patient became aware of small reddish nodules in the right axilla, and computed tomography imaging showed an irregular thickening of the right axillary skin. No other sign of recurrence was observed. By en-bloc resection, the nodules were diagnosed as late cutaneous metastasis from gastric cancer. The patient received no additional postoperative chemo- or radiotherapy and was only carefully observed. Cutaneous metastases from gastric cancer have a high recurrence rate even if total resection with no residual cancer is achieved. Therefore, meticulous follow-up, including routine visual inspection, is required for the early detection of late cutaneous metastases.

Laparoscopic Resection of a Primary Retroperitoneal Mucinous Cystadenoma.

Primary retroperitoneal mucinous cystadenoma (PRMC) is a rare cystic lesion occurring mostly in women with a histological analogy to ovarian mucinous cystadenoma. The tumor is difficult to detect during early stages because it causes symptoms only when it grows large enough to be palpable or to displace the adjacent internal organs. The primary treatment is resection, but the optimal surgical approach remains poorly known. We report the case of a 41-year-old woman who complained of right-sided intermittent abdominal pain. Imaging studies revealed a right retroperitoneal smooth cystic lesion (50 mm) without invasive features. Laparoscopic resection was then performed. During surgery, a right retroperitoneal mass with no connection to neighboring tissues was found. The tumor, wrapped by retroperitoneal fat tissue, was resected and removed from the body without exposure. Furthermore, histopathological findings indicated PRMC. The patient was discharged without any complications and observed to have no recurrence 6 months postoperatively.

A Rare Case of Primary Retroperitoneal Cystadenoma with a Mural Nodule and High Serum CA19-9 Level.

BACKGROUND Primary retroperitoneal mucinous cystadenoma (PRMC) is a rare benign tumor that occurs in the retroperitoneal space. PRMC is difficult to preoperatively diagnose, and final diagnosis requires surgical resection. CASE REPORT A 39-year-old female was referred to our hospital with a chief complaint of tension and pain in the left flank. Imaging findings revealed a large, thick-walled unilocular cystic mass dorsal to the descending colon and ventral to the left kidney. Moreover, a content-rich mural nodule measuring 20 mm was detected on the caudal wall of the cyst, which was suspected to be malignant. The tumor was successfully resected. The cystic wall was composed of thick, scarred fibrous tissue, and the inner surface was lined with a single layer of mucinous epithelium with little atypia. The mural nodule mainly comprised necrotic tissue with no epithelium. Serum carbohydrate antigen 19-9 (CA19-9) level was high (109 U/mL) preoperatively, but it returned to normal levels postoperatively. Importantly, CA19-9 expression was also confirmed using immunohistochemistry. To the best of our knowledge, this is the first case of PRMC with elevated serum CA19-9 levels confirmed by immunohistochemistry. CONCLUSIONS PRMC is only diagnosed by surgical resection. If imaging studies indicate signs of malignancy, surgeons should not hesitate to surgically confirm the diagnosis.

Chylous Ascites Accompanying Internal Hernia after Total Gastrectomy with Roux-en-Y Reconstruction.

We report the case of a 69-year-old man with a history of esophagogastric junction cancer (Barrett's esophageal cancer; pT1b [SM], N0, M0, pStage IA) that was surgically resected 2 years prior to the present episode. Recurrence was not observed during follow-up. Following complaints of dysphagia and abdominal pain, computed tomography revealed signs of internal hernia. Thus, laparoscopic exploration was performed. Intraoperatively, accumulation of chylous ascites accompanying the internal hernia through the jejunojejunostomy mesenteric defect was observed, which was successfully treated with laparoscopic hernia reduction and defect closure by sutures without intestinal resection. Here, we discuss the case and report that along with previous studies, our study suggests that chylous ascites might be a reliable sign of intestinal viability for herniated intestines.

A laparoscopic resection of lung cancer metastatic to transverse colon: A case report and review of the literature.

Metastatic colon cancer from primary lung cancer is usually a part of systemic dissemination, suggesting limited prognosis. However, surgical intervention for symptomatic patients such as hemorrhage is sometimes required. Surgeons must carefully determine the surgical indication in view of prognosis and quality of life.

Splenic marginal zone lymphoma treated with laparoscopic splenectomy: A case report.

INTRODUCTION: Splenic marginal zone lymphoma (SMZL) is rare subtype of malignant lymphoma that is classified as a low-grade B cell lymphoma. Splenectomy is usually chosen for both diagnosis and treatment, which often leads to the resolution of abdominal symptoms and cytopenia. CASE PRESENTATION: We presented the case of a 73-year-old woman who complained of spontaneous perspiration and fatigue. She was referred to our hospital for further treatment of enlarged intraabdominal lymph nodes and splenomegaly. The level of soluble Interleukin-2 receptor was elevated, and malignant lymphoma was suspected. Endoscopic ultrasound fine-needle biopsy of intraabdominal lymph node revealed B cell lymphoma. For a definitive diagnosis, as well as treatment, laparoscopic splenectomy was successfully performed. The histopathological finding was compatible with SMZL. The patient was discharged without any complications and observed to have no recurrence at eight months postoperatively. CONCLUSION: Patients with SMZL is usually expected to have good prognosis with splenectomy. However, careful follow-up is required for aggressive transformation can occur and result in worse prognosis.

A sclerosing angiomatoid nodular transformation (SANT) mimicking a metachronous splenic metastasis from endometrioid cancer and ovarian cancer.

INTRODUCTION: Sclerosing angiomatoid nodular transformation (SANT) of the spleen has been considered a differential diagnosis of splenic lesions since it was originally reported. However, preoperative diagnosis of SANT is often difficult and histopathological examination by surgical resection is required. CASE PRESENTATION: Because of a new splenic lesion, a 48-year-old woman was suspected of having metachronous solitary splenic metastasis during her postoperative follow-up for endometrioid and ovarian cancer that occurred 3 years previously. Because there was no metastasis to other sites, laparoscopic splenectomy was successfully performed for diagnosis and treatment. Histopathological examination revealed that the splenic lesion consisted of three distinct splenic vessels, thereby indicating SANT without any cancer cells or lymphoproliferative disorders. CONCLUSION: Splenectomy should be considered for the diagnosis and treatment of incidentally detected splenic lesions during follow-up for malignancy.