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Background Robotic distal gastrectomy (RDG) has been increasingly used for the treatment of gastric cancer (GC). However, whether RDG has a clinical advantage over laparoscopic distal gastrectomy (LDG) is yet to be determined. Thus, this study aimed to assess the feasibility and safety of RDG for the treatment of GC as compared with LDG. Methods In total, 157 patients were enrolled between February 2018 and August 2020 in this retrospective study. We then compared the surgical outcomes between RDG and LDG using propensity score-matching (PSM) analysis to reduce the confounding differences. Results After PSM, a clinicopathologically well-balanced cohort of 100 patients (50 in each group) was analyzed. The operation time for the RDG group (350.1 ± 58.1 min) was determined to be significantly longer than that for the LDG group (257.5 ± 63.7 min; P P = 0.092 and P = 0.061, respectively). In addition, postoperative hospital stay was statistically slightly shorter in the RDG group as compared with the LDG group (12.0 ± 5.6 vs. 13.0 ± 12.3 days; P = 0.038). Conclusions Our study confirmed that RDG is a feasible and safe procedure for GC in terms of short-term surgical outcomes. A surgical robot might reduce postoperative severe complications and length of hospital stay.

Myxofibrosarcoma is a soft tissue sarcoma that occurs in elderly patients. Primary myxofibrosarcoma rarely arises in the mesentery; this is the fourth known case of myxofibrosarcoma presenting as a mesenteric tumor. A 62-year-old male with a mesenteric myxofibrosarcoma presented with an abdominal mass; his symptoms were frequent urination and a sense of abdominal pressure. He was admitted for further examination. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a mesenteric lesion. The preoperative diagnosis was a suspected malignant myxoid tumor. We performed a curative resection with wide margins. The histopathological and immunohistochemical findings confirmed that the tumor was mesenteric myxofibrosarcoma. The postoperative course was uneventful, and there have been no signs of relapse for three years to date after surgery. It is difficult to make a definitive diagnosis of mesenteric myxofibrosarcoma using only CT or MRI. However, when the preoperative findings suggest a malignant mesenteric tumor, then the best practice is resection with sufficient margins.

Patients after esophagectomy for esophageal squamous cell carcinoma (SCC) occasionally develop metachronous SCC in the residual esophagus. Although most of these second primary lesions are detected as superficial cancer at follow-up endoscopy, it is often difficult to perform endoscopic resection for these lesions near the site of anastomosis. The objective of this study was to evaluate the effectiveness of argon plasma coagulation (APC) for superficial SCC in the residual esophagus after esophagectomy. Twelve patients (involving 15 s primary lesions) received APC for superficial SCC in the residual esophagus after esophagectomy. These lesions were difficult to perform endoscopic resection and they were treated using APC. There was no treatment-related complication. Complete remission (CR) was achieved in 13 (86.6%) of the 15 lesions: CR was achieved in 11 lesions (73.3%) after the first APC course, and in another 2 lesions (13.3%) after two or more APC courses. Of the 2 patients with persisting residual tumor, 1 patient received 12 times repeated-APC courses over 6 years, and eventually achieved local control without metastasis, the other patient received radiotherapy and cervical esophagectomy after treatment failure with APC. All patients survived except for one patient who died of old age and another patient who died of tongue cancer. APC was a safe treatment that was easy to perform. APC was concluded to be an effective treatment for superficial SCC in the residual esophagus after esophagectomy when endoscopic resection was difficult.

Background Killian-Jamieson diverticulum (KJD) is a rare diverticulum arising from a muscular gap in the anterolateral wall of the proximal cervical esophagus. The first choice of treatment for KJD remains controversial due to its rare incidence. Here, we report two cases of KJD for which we performed different surgery: diverticulectomy in one case and diverticulopexy in the other. Case presentation Case 1 involved a 58-year-old woman presenting progressive pharyngeal discomfort for the past year. She was diagnosed as KJD using endoscopic and radiographic findings. She underwent diverticulectomy with cricopharyngeal and proximal esophageal myotomy. Staple line leakage developed at 1 month after surgery and was successfully treated conservatively. At 5 months after surgery, she was asymptomatic. Case 2 involved a 77-year-old woman presenting dysphagia for the past 2 years. She had a history of bilateral breast cancer and had hypertension, asthma, and osteoporosis. Taking her age and medical history into account, we selected diverticulopexy with cricopharyngeal and proximal esophageal myotomy. The postoperative course was uneventful. At 2 years after surgery, she remained free of dysphagia. Conclusion The first choice of surgery for KJD is diverticulectomy. In a high-risk patient, diverticulopexy is a reasonable treatment. We recommend the addition of myotomy as a part of any surgical treatment.

Background. The extent of lymph node dissection in advanced colorectal cancer varies according to regional guidelines. D3 lymphadenectomy is routinely performed in Japan but is associated with several risk factors. Metastases of the main lymph nodes (No.253 lymph nodes), which are located at the root of the inferior mesenteric artery, are rare in left-sided colorectal cancer. Tumor depth (T4) is an identifier of No.253 lymph node metastasis (LNM) risk, but other risk factors associated with No.253 LNM are unclear. This study was undertaken to investigate the frequency of No.253 LNM and to identify other clinicopathological risk factors associated with No.253 LNM in left-sided colorectal cancer. In this study, we aimed to evaluate the clinical benefit of routine D3 lymphadenectomy in surgically treated advanced colorectal cancer. Methods. A retrospective database of patients with colorectal cancer who underwent D3 dissection and R0 resection at Kurume University Hospital from 1978 to 2017 was constructed and used to search for the frequency and risk factors of No.253 LNM to investigate long-term prognosis. Clinicopathological factors associated with No.253 LNM, including age, sex, tumor location, T stage, tumor diameter, carcinoembryonic antigen levels, and various dissected lymph nodes, were analyzed. Results. Among 1,614 consecutive patients, No.253 LNM was observed in 23 cases (1.4%). The presence of three or more regional LNMs was an independent risk factor for No.253 LNM (odds ratio: 26.8). The 5-year overall survival rate was 49.1% in the No.253 LNM-positive group and 78.4% in the No.253 LNM-negative group (p=0.002). Conclusion. In left-sided colorectal cancer, No.253 LNM was a poor prognosis factor, and three or more regional LNMs were a risk factor for No.253 LNM. The No.253 LNM-positive group had a poor prognosis, but there are cases of long-term survival, with a 5-year survival rate of 49%. D3 lymphadenectomy is suitable when three or more metastatic LNs are identified prior to surgery.

Background/aim The aim of this study was to investigate the effects of preoperative chemotherapy on the healthy, metastasis-free part of the liver in colorectal cancer patients with liver metastasis, and the relationship between chemotherapy and postoperative complications. Patients and methods Our study included 90 cases of colorectal cancer liver metastasis resected after preoperative chemotherapy. The patients were divided into three groups according to the received chemotherapy regimen: 20 cases received mFOLFOX6, 54 cases a combination of mFOLFOX6 with bevacizumab, and 16 cases a combination of mFOLFOX6 and cetuximab or panitumumab. Results The mean numbers of sinusoidal injuries for each chemotherapy type were compared. The group treated with the combination of mFOLFOX6 and bevacizumab showed a lower extent of sinusoidal injury relative to other groups; this intergroup difference became increasingly remarkable as the number of chemotherapy cycles increased. Complications of various extents were found in all three groups, but no significant differences were observed between the three groups. Conclusion In cases where preoperative chemotherapy was extended over a long period, combined use of bevacizumab was thought to be effective because of stabilization of disturbed liver hemodynamics resulting from sinusoidal injury suppression effects, allowing effective distribution of anti-cancer agents to tumors.

Background and aims: The aim of this study is to exploratively evaluate the effect of Tsumura Daikenchuto Extract Granules (DKT, TJ-100) on abdominal symptoms, body weight, and nutritional function following colorectal cancer surgery. Methods: The subjects included 20 patients for curative resection of colorectal cancer. A TJ-100 administration group (n = 10) and non-administration group (n = 10) were randomized and compared. In the administration group, TJ-100 was administered from 2 days prior to surgery up to 12 weeks following surgery. The endpoints included body weight gain, Gastrointestinal Symptom Rating Scale (GSRS), and blood biochemical factors. For the purpose of observing safety, drug adverse events were evaluated including liver function tests. Results: Excluding one patient, we compared 9 cases in the administration group and 10 cases in the non-administration group. No obvious adverse events were observed in any of the cases. In the comparison of body weight gain, the TJ-100 administration group showed significantly higher values at 2, 4, and 12 weeks following the surgery. There was a tendency for lower stable GSRS scores in the administration group overall, with no statistically significant difference. Conclusion: It is suggested that TJ-100 can be safely administered in the perioperative period for cases undergoing colorectal cancer surgery, potentially preventing weight loss during the early postoperative period., Interventional Medicine and Applied Science, 11(2), pp.84-88; 2019

In colorectal cancer (CRC), the indication for immune checkpoint inhibitors is determined by the microsatellite instability status of the tumors. However, an optimal biomarker for their indication has not been fully identified to date. This study aimed to establish the clinicopathologic importance of the Immunoscore (IS) in CRC and to clarify the relationships between the IS, programmed death-ligand 1 (PD-L1) expression, and tumor-associated macrophages. In 132 cases, CRC was diagnosed and surgically treated in our department from 2009 to 2010. Immunohistochemical staining using primary antibodies PD-L1, CD3, CD8, CD68, and CD163 was performed. The IS was determined according to the proposal of an international task force. Statistical analyses were performed to investigate the correlation between the IS, clinicopathologic variables, and expression of immune checkpoint molecules. The overall survival (OS) and relapse-free survival (RFS) in the high-IS group (I3–4) were significantly better than in the low-IS group (I0–2) (OS: P = 0.0420; RFS: P = 0.0226). The positivity rate for PD-L1 on tumor cells (tPD-L1) was only 0.8%, whereas that for PD-L1 on interstitial tumor-infiltrating mononuclear cells (iPD-L1) was 18.2%. The iPD-L1-positive group showed significantly better survival in terms of both OS and RFS than the iPD-L1-negative group (OS: P = 0.0278; RFS: P = 0.0253). The findings showed significant correlation between the IS and iPD-L1 expression (P

Signet ring cell carcinoma (SRCC) is a rare pathological type of colorectal cancer, of which the clinicopathological features and genetic background have not yet been fully investigated. Previous research has focused on the optimization of colorectal cancer treatment utilizing consensus molecular subtyping (CMS). However, it is not known what type of CMS would be designated to SRCC treatment. In the current study, of 1,350 patients diagnosed with colorectal cancer who underwent surgery, 14 were diagnosed with SRCC. The case-control cohort that fit the clinical background of the SRCC case was constructed. Statistical comparison between the SRCC group and the case-control cohort was performed among clinicopathological variables. SRCC and well to moderately adenocarcinoma case mRNA were submitted to microarray analysis and CMS analysis. Compared with the case-control cohort, the SRCC group was located more in the right-sided colon, the lymphatic invasion was more severe and the peritoneal dissemination was more frequent. The cancer-specific survival and the progression-free survival were significantly worse in the SRCC group compared with the case-control cohort. Microarray and CMS analysis identified that one SRCC case was significantly well assigned in the CMS 4 group and the other case was assigned in the CMS 1 group. Gene set analysis revealed the upregulation of EMT related genes and the downregulation of fatty acid, glycolysis, differentiation, MYC, HNF4A, DNA repair genes. In conclusion, the clinical characteristics of SRCC are severe but there is a possibility of the presence of different phenotypes according to CMS analysis.

The geriatric nutritional risk index (GNRI) is widely used for nutritional assessment in older inpatients and is associated with postoperative complications and cancer prognosis. We investigated the use of GNRI to predict long-term outcomes in hepatocellular carcinoma of all etiologies after hepatectomy. Overall, 346 patients were examined after propensity score matching. We dichotomized the GNRI score into high GNRI (> 98: N = 173) and low GNRI (≤ 98: N = 173) and evaluated recurrence-free survival (RFS) and overall survival (OS) between both groups. Clinicopathological characteristics between the low- and high-GNRI groups were similar after propensity score matching except for the components of the GNRI score (body mass index and serum albumin level), Child–Pugh score (comprising serum albumin level), and preoperative alpha-fetoprotein level (p p p = 0.0030, and p = 0.0007, respectively). High GNRI was associated with significantly better RFS and OS (p = 0.0003 and p = 0.0211, respectively; log-rank test). Multivariate analysis revealed that GNRI is an independent prognostic factor of RFS and OS (low vs. high; hazard ratio [HR], 1.8284; 95% confidence interval [CI] 1.3598–2.4586; p p = 0.0335, respectively). GNRI is an objective, inexpensive, and easily calculated assessment tool for nutritional status and can predict prognosis of hepatocellular carcinoma after hepatectomy.

Background We investigated the correlation between surgery-related factors and the incidence of leakage after low anterior resection (LAR) for lower rectal cancer. Methods A total of 630 patients underwent colorectal surgery between 2011 and 2014 in our department. Of these, 97 patients (15%) underwent LAR, and are the subjects of this retrospective study. Temporary ileostomy was performed for each patient.Results Anastomotic leakage occurred in 21 patients (21.7%). Univariate analysis showed that operative duration (p=0.0051), transanal hand-sewn anastomosis (p=0.0141), and operation procedure (p=0.0191) were significantly associated with the incidence of leakage. Multivariate analysis showed that underlying disease (p=0.044), transanal hand-sewn anastomosis (p=0.0188), and drain type (p=0.0251) were significantly associated with the incidence of leakage. The propensity score analysis results showed that closed drainage was associated with 6.3 times more postoperative blood loss (mls) in patients experiencing anastomotic leakage compared with open drainage, in the inverse probability of treatment-weighted analysis.Conclusions Our results showed that underlying disease, transanal hand-sewn anastomosis, and the drain type may be risk factors for developing anastomotic leakage after LAR for lower rectal cancer. The notable finding was that the type of drainage was related to the incidence and volume of anastomotic leakage: open drainage was correlated with the incidence of leakage, and closed drainage was correlated with the volume of anastomotic leakage.

Background We investigated the correlations between surgery-related factors and the incidence of anastomotic leakage after low anterior resection (LAR) for lower rectal cancer. Methods A total of 630 patients underwent colorectal surgery between 2011 and 2014 in our department. Of these, 97 patients (15%) underwent LAR and were enrolled in this retrospective study. Temporary ileostomy was performed in each patient. Results Anastomotic leakage occurred in 21 patients (21.7%). Univariate analysis showed a significant association between operative duration (p = 0.005), transanal hand-sewn anastomosis (p = 0.014), and operation procedure (p = 0.019) and the occurrence of leakage. Multivariate regression reanalysis showed that underlying disease (p = 0.044), transanal hand-sewn anastomosis (p = 0.019) and drain type (p = 0.025) were significantly associated with the occurrence of leakage. The propensity-score analysis showed that closed drainage were 6.3 times more likely to have anastomotic leakage than open drainage in relation to the amount of postoperative drainage (ml), according to the inverse probability of treatment-weighted analysis. Conclusions Our results indicate that underlying disease, transanal hand-sewn anastomosis, and closed drain may be a risk and predictive factors for anastomotic leakage after LAR for lower rectal cancer. The notable finding was that closed drainage was related to the occurrence of anastomotic leakage and closed drainage was correlated with less volume of postoperative drain discharge than open drain.

Summary: Background: Groin hernias are frequently seen in clinical practice. The purpose of this study was to determine the rate of patients who might have latent groin hernia. Methods: During laparoscopic abdominal surgery, we observed the area around the groin lesion and attempted to evaluate the degree of recess at myopectineal orifice. The classification defining the recess was as follows: Grade 0: no recess, Grade I: slight recess with a visible bottom, Grade II: deep recess with an invisible bottom, Grade III: other organ invaginated into the recess, and Grade IV: confirmed bulging on the body surface. Results: From 2009 to 2011, 46 patients were enrolled. A recess around myopectineal orifice were detected in 20 patients. The lesions were as follows: 11 on the lateral side of the inferior epigastric artery (IEA), five on the internal side of the IEA, three at both sites and one found at the femoral ring. According to the grade classification of these groin hernias, 26 (57%) were Grade 0, 14 (30%) Grade I, 4 (9%) Grade II, 1 (2%) Grade III, and 1 (2%) Grade IV. Conclusions: This study showed that rate of patients with asymptomatic latent groin hernias is relatively high in Japanese. Keywords: Groin hernia, Latent hernia, Laparoscopic surgery

Aim Cancer‐associated fibroblasts (CAFs) generated by bone marrow‐derived mesenchymal stem cells (BM‐MSCs) play an important role in cancer progression. In this study, we investigated the relationships of BM‐MSCs and CAFs in resected gastric cancers with the clinicopathological factors of patients. Methods We analyzed 120 gastric cancer patients who underwent gastrectomy. Immunostaining was performed with an anti‐CD271 antibody (BM‐MSCs) and anti‐α‐smooth muscle actin (αSMA) antibody (CAFs). Staining intensity was used to divide patients into low and high expression groups. Observation sites in cancer tissues were invasive, central, and whole portions. Results Expression of αSMA was significantly related to depth of tumor invasion (T), lymph node metastasis (N), lymphatic invasion (ly), venous invasion (v), and stage. Expression of CD271 was significantly related to v, stage, stromal volume, and tumor infiltration pattern (INF). Overall survival (OS) of the high expression group was significantly lower than that of the low expression group for both αSMA and CD271. Multivariate analysis showed that N, αSMA (whole), and CD271 (invasive) were independent prognostic factors. Conclusions Cancer‐associated fibroblasts and BM‐MSCs are related to the progression, invasion, and prognosis of gastric cancer and may be therapeutic targets of gastric cancer., We immunohistochemically examined bone marrow‐derived mesenchymal stem cells and cancer‐associated fibroblasts in gastric cancer tissues and obtained results indicating that they were associated with tumor infiltration and stroma, and closely related to prognosis.

Inflammatory bowel diseases (IBDs), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic intestinal diseases of unknown etiology that present with variable disease extents and outcomes. The use of biomarkers for the diagnosis and management of IBDs is considered beneficial. Palmitoleic acid (PO) is an adipose tissue-derived mono-unsaturated free fatty acid that potentially serves as a lipokine in metabolic and inflammatory diseases. The aim of this study was to investigate the significance of PO levels in the serum of patients with UC and CD. The study included patients with UC (n = 22), patients with CD (n = 35), and controls (n = 22). The levels of serum PO were analyzed using gas chromatography. The association of serum PO levels with the clinical features and disease outcomes in IBD was examined. Serum PO levels were significantly higher in patients with CD than in controls, whereas no difference in these levels was observed between patients with UC and controls. Serum PO levels were significantly associated with the CD activity index. Additionally, high serum PO levels were associated with an increased risk of surgical intervention requirement during follow-up. In a pilot study with a few patients, high PO levels were observed in the mesenteric tissue in the active disease site of patients with CD (n = 7) compared with those with colon cancer (n = 6). Elevated serum PO levels might serve as a marker for local inflammation and prognosis in patients with CD., Scientific Reports, 11, art. no. 16260; 2021

Objective We analyzed the cases of gastric cancer patients who underwent surgical treatment during the 16 years from 1997 to 2012 at our department to clarify these trends. Methods The subjects were 810 patients who underwent surgery for gastric cancer between 1997 and 2012. We divided the cases into the early-period group (1997–2006) treated before the introduction of laparoscopy, and the late-period group (2007–2012). We compared the clinicopathological factor and survival rates between the early- and late-period groups. Results The average patient age was higher in the late-period group than in the early-period group. Tumor localization showed an increased proportion in the U-region in the late period, and histological type in the late period showed a higher proportion of poorly differentiated cases. The cases receiving adjuvant chemotherapy increased in the late period. The five-year survival rate in the late-period group was shown to be equivalent to that in early-period group. Although the proportion of poorly differentiated cases was increased in late-period group, their survival rate was equivalent, probably because of the use of adjuvant chemotherapy. Conclusions Distinct characteristics were seen over the period of 16 years. It is important to continue the analysis of surgical outcomes to identify trends that need to be addressed.

Key Clinical Message There are very few reports of esophageal carcinoma producing granulocyte colony‐stimulating factor (G‐CSF). G‐CSF‐producing esophageal squamous cell carcinoma is an extremely aggressive carcinoma. Leukocyte counts, neutrophil counts, and serum C‐reactive protein levels may be markers of its progression.

Pharmacologic thromboprophylaxis is recommended for preventing pulmonary embolism according to some abdominal surgery guidelines. However, few reports have so far described pharmacologic thromboprophylaxis after pancreatic surgery. In addition, concern remains regarding postoperative bleeding due to pharmacologic thromboprophylaxis. We investigated the safety and efficacy of enoxaparin, a low-molecular-weight heparin, as postoperative pharmacologic thromboprophylaxis after pancreatic surgery. In this record-based retrospective study, the sample population comprised 151 consecutive patients who underwent pancreatic surgery and received enoxaparin postsurgery at our institute between November 2009 and March 2014. The primary outcome was the incidence of symptomatic pulmonary embolism after surgery, and the secondary outcome was the incidence of bleeding as an adverse effect of enoxaparin injection. No symptomatic pulmonary embolism events occurred during the study. Major and minor bleeding events were experienced in 5 (3.3%) cases each. Four of these major events were caused by the rupture of a pseudoaneurysm with a pancreatic fistula not related to enoxaparin, and all events were treated safely with no mortalities in the study period. We found no factors related to minor bleeding with enoxaparin injection in a statistical comparison. The use of enoxaparin is considered to be safe and effective for pulmonary embolism prophylaxis after pancreatic surgery.

Although the incidence of living donor death is low in Japan, statistics show one living liver donor death in more than 7000 living liver transplants. Thus, medical transplant personnel must recognize that the death of a living organ or tissue transplant donor can occur and develop an appropriate risk management program. We describe how Nagasaki University Hospital established and implemented a Donor Advocacy Team (DAT) program: a risk management program for initiation in the event of serious, persistent, or fatal impairment of an organ, tissue, or cell transplantation from a living donor. The purposes of the DAT program are as follows: To address (1) and (5), actions, such as reporting and responses to the government, mass media, transplant-related societies, and organ transplant networks, have been established to ensure implementation.

Introduction Round ligament varicosities (RLV) are not well-known and they are usually caused by pregnancy. Although the groin swelling of RLV mimics an inguinal hernia, it is difficult to distinguish between them through clinical examination alone, and there have been few published reports on this topic, especially from Asia. Case presentation A 37-year-old Japanese woman complained of left groin swelling for 2 weeks at her 28th week of gestation of her first pregnancy. According to a physical examination, she had a soft, painless swelling in the superficial inguinal ring of the left groin. An inguinal hernia was suspected and she was thus scheduled to undergo herniorrhaphy. However, since she had varicosities in the left labia majora, she first underwent color Doppler ultrasonography and a final diagnosis of round ligament varicosities was this made. Her symptoms resolved after delivery of her baby. Discussion We herein report 10 cases of RLV in pregnant Japanese women who were initially suspected of having an inguinal hernia. All of them were suspected to suffer from inguinal hernias after a clinical examination by their attending gynecologist. All of them were diagnosed using gray scale and color Doppler ultrasonography, treated with conservative management, and the symptoms resolved in all cases after the delivery. Conclusion This is the largest report from Asia regarding RLV. To avoid unnecessary surgery in pregnant women, surgeons must be aware of this entity make an accurate diagnosis based of the findings of Doppler ultrasonography., International Journal of Surgery Case Reports, 36, pp.122-125; 2017

Highlights • An internal hernia after retroperitoneal laparoscopic nephrectomy is rare. • Retroperitoneal approach has the risk of making mesocolic defects directly. • To prevent internal hernia, we should close the mesenteric defects intraoperatively., Introduction Small bowel obstruction (SBO) caused by an internal hernia through a mesocolon after retroperitoneal laparoscopic nephrectomy (RLN) is rare. Presentation of case A 66-year-old man who had undergone RLN with bladder cuff excision for a left renal pelvic cancer. After the surgery, he experienced SBO repeatedly. Contrast-enhanced computed tomography (CT) and gastrografin contract radiography through a long tube showed an internal hernia through the mesocolon to the retroperitoneal space where the resected left kidney had been located. We performed a subsequent surgery for the internal hernia. Postoperative course was uneventful and currently he has no recurrence of herniation 6 months post-operatively. Discussion Mesenteric defects that cause an internal hernia can be created inadvertently during RLN when the colon is mobilized medially, and the kidney is being detached from retroperitoneum. The removal of a kidney leads to a potential retroperitoneal space to which small intestine can migrate. While there is no absolute necessity in mobilizing the colon during the retroperitoneal laparoscopic approach, there is still a risk of making mesocolic defects directly in the retroperitoneal space. Conclusion We need to perform operations with sufficient anatomical knowledge of retroperitoneal fascia and careful surgical techniques. The critical thing to prevent an internal hernia following RLN is to close the mesenteric defects intraoperatively. It is also important to suspect an internal hernia and do proper examinations promptly when patients had the symptoms of SBO after nephrectomy.

Background/aim Intraductal papillary mucinous neoplasm (IPMN) has a variety of histological and morphological appearances. Matrix metalloproteinases (MMPs) have been considered to be associated with tumor progression or poor prognosis. The aim of this study was to elucidate the molecular basis of IPMN variation in different types of lesions. Materials and methods The expression of MMP-1,2,7,9 in 51 cases of IPMN were investigated. The MMP score was calculated as the sum of the score of staining distribution and the score of the intensity staining. Results MMP scores were correlated with histological grade, histological subtype, and type of invasion. MMP high expression groups (MMP score ≥5) had worse prognosis than low-expression groups. Conclusion MMP expression varied between different types of IPMN, a result supporting differences in molecular basis of malignancies. These considerations may be helpful for optimal management or treatment according to various types of IPMN.

Background/aim Neoplastic spindle cells (NSCs) are believed to play a role in cancer invasion and metastasis, as well as in poor prognosis. The clinicopathological characteristics and prognostic relevance of NSCs was investigated in gallbladder cancer. Materials and methods Specimens were obtained from 62 patients with gallbladder cancer who underwent surgery. The emergence of NSCs and their correlation with clinicopathological factors, prognosis, and EMT markers was evaluated. Results The NSC grade correlated with tumor size, preoperative CA19-9, surgical margin, the degree of differentiation, the depth of invasion, lymph node metastasis, lymphatic invasion, vascular invasion, and perineural invasion. Multivariate analysis of overall survival showed that NSCs were an independent prognostic factor. A correlation between NSCs and EMT was also suggested. Conclusion NSCs are an independent prognostic factor for patients with postoperative gallbladder cancer, which also suggests a correlation between NSCs and EMT.

Mixed carcinoma of the pancreas is defined as the concurrent existence of pancreatic ductal carcinoma, acinar cell carcinoma, and/or islet cell carcinoma within the same neoplasm. We herein report a rare case of mixed ductal-acinar cell carcinoma in a 74-year-old man who was undergoing treatment for hypertension and diabetes at another hospital. After an abrupt worsening of his blood glucose control, the patient was referred to our hospital for further evaluation. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging revealed a tumor with a multilocular cystic lesion in the head of the pancreas. Endoscopic retrograde cholangiopancreatography revealed obstruction of the main pancreatic duct and dilation of the dorsal pancreatic duct; in addition, adenocarcinoma was detected in the pancreatic juice cytology. Based on the abovementioned findings, the patient was diagnosed with carcinoma of the pancreatic head and underwent subtotal stomach-preserving pancreaticoduodenectomy. Based on the histopathological and immunohistochemical findings, the patient was diagnosed with mixed ductal-acinar cell carcinoma. The patient was prescribed TS-1 as postoperative adjuvant chemotherapy upon discharge. However, treatment was discontinued 2 months later due to marked general malaise, and the patient succumbed to tumor recurrence in the residual pancreas 12 months after the surgery.

Background Heat shock protein 70 (HSP70) confers protection against heat shock, oxidative stress, infection, and inflammation in many cell types. A recent study reported that the induction of HSP70 was associated with morphologic protection against ischemia–reperfusion injury (IRI) in the rat small intestine. This study investigated the dynamics of HSP70 in leukocytes during intestinal IRI in a rat model. Materials and methods Serial blood samples were collected at 60-minute intervals up to 240 min from male Wistar rats (n = 15). The rats were divided into three groups of five each: the control group, the nonlethal IRI group, and the lethal IRI group. Rats belonging to the control group underwent a sham operation, and laparotomy was performed on rats in the lethal and nonlethal IRI groups. The nonlethal group experienced a 30-minute clamping of the superior mesenteric artery, and the lethal group experienced a 75-minute clamping of the superior mesenteric artery. The expression of HSP70 messenger RNA (mRNA) in leukocytes was measured by real-time quantitative polymerase chain reaction. Mixed-effects modeling of repeated measures was used to carry out the statistical analysis. The Bonferroni correction was applied to multiple comparisons. A P value Results The expression of HSP70 mRNA in leukocytes increased 60 min after reperfusion in both IRI groups, and it was 12.8 times higher in the lethal group and 3.6 times higher in the nonlethal group compared with the control group. The expression of mRNA in the lethal group was significantly increased compared with the nonlethal group and the control group at 120 and 180 min after reperfusion. At 120 min after reperfusion, the expression of HSP70 mRNA was 6.1 times higher in the lethal group than in the nonlethal group (P = 0.0075) and 17.7 times higher than in the control group (P = 0.0011). At 180 min after reperfusion, the expression of HSP70 mRNA was 6.8 times higher in the lethal group than in the nonlethal group (P = 0.0007) and 4.3 times higher than in the control group (P = 0.0032). Although the expression of HSP70 mRNA in the nonlethal group was elevated in the early stages of reperfusion, there was no difference between the nonlethal group and the control group (P = 0.0212 at 60 min). Conclusions The expression of HSP70 mRNA in leukocytes may be a clinically useful indicator for evaluating pathologic conditions in intestinal IRI.

Abdominoperineal resection (APR) is commonly performed as radical surgical treatment for low rectal cancer near the anus. To improve the postoperative quality of life (QOL), various sphincter-saving operations have been developed. In particular, intersphincteric resection (ISR) was devised as a new concept of sphincter-saving operation. Current protocols now focus on ISR, which differs from conventional hand-sewn coloanal anastomosis (CAA) after ultimate low anterior resection (LAR). However, the efficacy of ISR remains unclear. In this report, the surgical, oncological, and functional outcomes after ISR are reviewed. This review of the literature was conducted by searching the PubMed online database. Articles focusing on conventional hand-sewn CAA were excluded from this study. The mean mortality rate was

3521 Background: dCRT with 5-FU/MMC is a standard treatment for cStage II/III SCCA. S-1 is an oral fluoropyrimidine and has a greater effect on radiosensitivity. We conducted this trial of dCRT with S-1/MMC to determine the recommended dose (RD) of S-1 in dose-finding (phase I) part and to evaluate the efficacy and safety in confirmatory (phase II) part for cStage II/III SCCA. We reported the RD of S-1 and the 3-year survival at 2019 Gastrointestinal Cancers Symposium. We report the final data after 5-year follow-up. Methods: Eligibility criteria included histologically proven SCCA, cStage II/III (UICC 6th), PS 0-1, and age 20-80 years. dCRT consisted of MMC (10 mg/m2 on days 1, 29) and S-1 (60 mg/m2/d in level 0 and 80 mg/m2/d in level 1 on days 1-14, 29-42) with concurrent radiotherapy of 59.4 Gy/33fr. The dose-finding part adopted the 3+3 cohort design. The primary endpoint of confirmatory part was 3-year event-free survival (EFS). The sample size was 65 in the confirmatory part, with one-sided alpha of 5% and power of 80%, threshold and expected 3-year EFS as 60% and 75%. Key secondary endpoints were overall survival (OS) and progression-free survival (PFS) and colostomy-free survival (CFS), and adverse events. Final analysis was planned after 5-year follow-up for all pts. Results: From Feb/2010 to Mar/2015, 69 pts (3 in level 0 and 66 [7 in phase I and 59 in phase II] in level 1) were enrolled. Pts characteristics for level 1 were as follows: M/F, 12/54; Age, median 64 (range 33-80); cStage II/IIIA/IIIB, 29/9/28. Three in level 1 were ineligible and 63 eligible assigned to level 1 were included in efficacy analysis. In the dose-finding part, RD of S-1 was determined as 80 mg/m2/d. The complete response rate was 81% (95% CI, 69.1-90.0%) on central review. With a median follow-up of 5.4 years, 3- and 5-year EFS was 65.0% (90% CI 54.1-73.9%) and 63.4% (95% CI 50.2-73.9%). 5-year OS, PFS, and CFS were 84.1% (95% CI 72.5-91.1%), 84.1% (95% CI 72.4-91.1%), and 73.0% (95% CI 60.2-82.3%), respectively. In a univariable analysis, male sex (p = 0.045) prognosticated for poor OS and cT3 or T4 (p = 0.001), male sex (p = 0.019) and, PS 1 (p = 0.048) prognosticated for poor CFS. Nine (14.3%) of 63 pts at a dose level 1 developed recurrence or disease progression. Locoregional recurrence only and distant metastasis were observed in 1 pts (1.6%) and 8 pts (12.7%) respectively. Among all treated 65 pts, only 5 pts (7.7%) showed grade 3 late toxicities including jejunum obstruction, jejunum ulcer, proctitis, lower gastrointestinal hemorrhage, anal pain, radiation dermatitis, and ureteral stenosis. No Grade 4 or 5 late toxicities were observed. Conclusions: dCRT with S-1/MMC showed acceptable toxicities and favorable 5-year survival and could be a possible treatment option for pts with locally advanced SCCA. Clinical trial information: jRCTs031180002.

Anastomotic leakage is a major postoperative complication. While cell sheet technology has been gaining popularity in the clinical field, the utility of cell sheets for containing contaminated enteral perforation remains unclear. We established a new gastric perforation rat model and evaluated the efficacy of the myoblast cell sheet to prevent leakage. To establish a suitable rat model, perforations of various sizes were made in the stomach. We then pasted the sheet onto the perforated stomach in our new model. After the operation, the rats were sacrificed and analyzed macroscopically and histologically. Serum levels of C-related protein and hyaluronic acid in the peritoneal cavity washing lavage were also evaluated. An incision 5 mm in length was found to be the most suitable for evaluation of the cell sheet performance. In the rats where the cell sheet had been pasted onto the perforation site, we noted less adhesion in the abdominal cavity and a significant reduction in the hyaluronic acid levels in the peritoneal cavity washing lavage. We evaluated the efficacy of cell sheets for preventing leakage of enteral contents in a gastric perforation rat model. Myoblast cell sheets were able to markedly reduce the degree of both intra-abdominal adhesion and inflammation.

Aim The ImmuKnow (IK) assay enables the evaluation of peripheral blood CD4+ adenosine triphosphate activity to facilitate an objective assessment of the cellular immune function in immunosuppressed patients. However, it is unclear whether the IK assay is utilized during the acute postoperative periods following living donor liver transplantation (LDLT). Methods The IK values of 43 LDLT recipients were measured during the month following LDLT to evaluate the relationship between the measured IK values and infectious events. Results The IK values after LDLT were significantly increased compared with the IK values before LDLT ( P

We examined the programmed death-ligand 1 (PD-L1) expression in surgically resected pancreatic adenosquamous carcinoma (PASC) samples. Furthermore, the detection rate was also assessed using biopsy cases obtained from endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).Fifteen cases of PASC (six resected and nine EUS-FNA biopsied) from the Kurume University Hospital between 2009 and 2016 were used for the evaluation of PD-L1 expression. As a control group, 34 cases of pancreatic ductal adenocarcinomas (PDACs) were selected. To compare the positivity and intensity of PD-L1, two types of clones (SP263, E1L3N) were examined for immunostaining. Only the membrane expression of PD-L1 was regarded as positive. The PD-L1 expressions in the squamous cell carcinoma component (SCc), adenocarcinoma component (ACc), and immune cells were assessed separately. The ratio of PD-L1 expression was calculated by counting the positive tumor cells, and tumor proportion score (TPS) was applied (TPS; Null1%, low expression; 1 ≤ TPS ≤ 49% and high expression; ≥ 50%).PD-L1 expression was observed in five surgical PASC samples (83%). This shows that SCc presented a high expression in these cases. However, the overall TPS indicated a low expression. In contrast, only one case (3%) was positive for PD-L1 in PDACs, and the TPS indicated a low expression. No differences in PD-L1 expression were observed between the two clones, SP263 and E1L3N. High PD-L1 expression in the EUS-FNA sample was found in only one case (11%).Although assessment using the tumor cells of PASC samples obtained from EUS-FNA was difficult, this study suggests the selective expression of PD-L1 in the SCc of PASC. Furthermore, it was considered that immune checkpoint inhibitors could provide therapeutic effects selectively on the SCc for the entire range of TPSs, though the PD-L1 expression was low.

Introduction Laparoscopic colectomy with intracorporeal anastomosis is a minimally invasive surgical procedure for patients with colon cancer. However, there are often concerns about the presence of intraluminal exfoliated malignant cells in the intracorporeal anastomosis. This study investigated the relationship between colon cancer surgery and the incidence of intraluminal exfoliated malignant cells and several factors. Methods Eighty-nine consecutive patients who underwent either laparoscopic or open colectomy were prospectively studied in our department between 2007 and 2011. Before anastomosis, the proximal and distal lumens were irrigated with normal saline and subjected to cytological examination. Results In 27 patients (30.3%), exfoliated cancer cells were detected. On the distal side, the frequency of positive cytology findings of exfoliated malignant cells was significantly lower in the laparoscopic colectomy group than in the open colectomy group (P = 0.01). In the laparoscopic colectomy group, there were no cases of positive cytology findings for exfoliated malignant cells more than 100 mm from the primary tumor. The incidence of positive cytology more than 100 mm from the primary tumor was significantly lower than the incidence of positive cytology less than 100 mm from the primary tumor (P = 0.04). Conclusions Exfoliated malignant cells were detected at anastomosis sites in patients with colon cancer. On the distal side, laparoscopic colectomy may prevent the development of exfoliated malignant cells.

It is well known that the presence of end-stage liver disease increases the risk of developing hepatocellular carcinoma (HCC). Liver transplantation (LT) for patients within the Milan criteria has become a standard treatment for HCC in most developed centers worldwide. However, a major cause of death in cirrhotic patients with HCC after transplantation is tumor recurrence, including peritoneal recurrences, which develops rarely but presents a significant problem with regard to their management. Our experience includes two cases with HCC within the Milan criteria of peritoneal recurrences after living donor LT. Both patients had interventions for HCC in their medical history before LT, and we propose that these might have been a possible cause of the HCC peritoneal recurrence., Case Reports in Gastroenterology, 9(1), pp.29-35; 2015

Introduction Granulosa cell tumors (GCTs) are rare functional sex-cord-stromal ovarian neoplasms characterized by low malignancy potential and late relapse, which rarely metastasize to the liver. Presentation of case A 43-year-old female, who had undergone surgery to treat a GCT of the left ovary in 1976, complained of abdominal distention in May 2001. Imaging studies demonstrated masses in the right lobe of the liver, together with massive ascites. The patient's bloody ascites showed no cytological evidence of malignancy. A diagnostic laparoscopy was performed, and the biopsy specimen was histologically proven to be a recurrent granulosa cell tumor. The patient was successfully treated surgery followed by systemic chemotherapy. Her postoperative course was uneventful and systemic chemotherapy was repeated due to the suspicion of a recurrence in the pelvic cavity. Discussion GCTs which are rare malignant tumors of the ovary, tend to be associated with late recurrence. Although most recurrences occur within 10 years after the initial diagnosis, there are occasional reports of recurrences after 10 years have been. We experienced the rare case of a patient who relapsed 25 years after the initial diagnosis. Conclusion The long natural history of this disease highlights the importance of extended follow up for GCT patients. In addition, aggressive therapy including surgery and chemotherapy may contribute to a patient's long-term prognosis., International Journal of Surgery Case Reports, 12, pp.7-10; 2015