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Purpose: We propose a treatment strategy for obturator hernia repair using a self-fixating mesh. An obturator hernia is a relatively rare type of abdominal hernia with a high mortality rate, with surgery being the only treatment option. Various approaches to repairing obturator hernia using meshes and tackers have been proposed. Nonetheless, postoperative complications such as chronic inguinal pain and hemorrhage have been reported with tacker-fixated mesh approaches. Although the self-adhesive property of a self-fixating mesh enables tacker-less hernia repair, it is rarely used in inguinal hernia repair. Tacker-less repair reduces the likelihood of chronic pain development; however, the difficulty in handling the mesh in the abdominal cavity must be overcome. Methods: We have been using a self-fixating mesh (PG mesh; ProGrip™ laparoscopic self-fixating mesh) for obturator hernia repair since April 2020. In two cases preceding the introduction of the PG mesh for obturator hernia repair, we experienced difficulty attaching the PG mesh; nevertheless, we successfully performed obturator hernia repair by simplifying the method, using three steps, to attach the PG mesh. Results: Between April 2020 and September 2021, we encountered seven cases of obturator hernia. Of these cases, five were repaired using the PG mesh. Postoperatively, one patient had a small subcutaneous hematoma with no postoperative complications, including chronic pain and hemorrhage. The postoperative recovery time was not prolonged, and there was no recurrence of symptoms during the observation period. Conclusion: PG mesh appears to be suitable for obturator hernia repair.

We report a patient with inoperable hilar cholangiocarcinoma due to invasion at the umbilical portion who survived more than 4 years after right portal vein embolization and administration of S-1(50 mg/day). A 64-year-old male patient was immediately hospitalized for liver dysfunction and a high level of HbA1c. The disease was diagnosed as hilar cholangiocarcinoma mainly extending along the right hepatic duct. We made a request for operation to Nagoya University. He received right portal vein embolization in order to grow the residual liver but was deemed inoperable because of invasion at the umbilical portion. He refused chemotherapy but accepted administration of S-1(50 mg/day). Approximately 3 months after starting S-1, his ALP level normalized and about 9 months later stenting tube was lost. Subsequently, he returned to his job. Approximately 2 years and 2 months later, administration of S-1 was interrupted due to a harmful side effect. After approximately 13 months without S-1, the levels of CA19-9 and ALP again became elevated and administration of S-1 was restarted. He was temporarily hospitalized for abdominal pain and fever, but quickly recovered. Although CA19-9 and ALP levels re-normalized, he died after returning home. We emphasize the possibility of maintaining long-term health by minimal- dose S-1 therapy for inoperable hilar cholangiocarcinoma.

We report the y-shape+1 method, which is a retraction of the liver method, independent of the position of the costal arch. Additionally, we report changes in liver enzymes induced by different methods of liver retraction. Three Penrose No. 6 drains were cut into 6 cm pieces. Penrose 1 was fixed with a thread attached to the end and Penrose 2 in a y-shape. A knitting thread with needles was prepared, and a loop was made at the end of the thread. The needle thread was passed over the abdominal wall and through the Penrose 2. The needle thread was passed over the diaphragmatic leg and through the Penrose 3. The thread was pulled over the abdominal wall and diaphragmatic leg and fixed to the end of Penrose 1 out of the body, and the liver was drained. The rate of change in liver enzymes from the preoperative to postoperative stages was examined separately in the Penrose and Nathanson groups. In the y-shape+1 technique, retraction of the liver can be performed regardless of the position of the rib arch; however, intracorporeal suture ligation is necessary. This method is useful when the conventional Penrose method is inappropriate because of the position of the rib arch.

Non-ampullary duodenal tumors are relatively rare; however, in recent years, they have been encountered more frequently. We analyzed the surgical outcomes and clinicopathological findings in 20 patients who underwent surgery based on preoperative diagnoses of non-ampullary duodenal tumors at our hospital between January 2011 and April 2021. We performed surgery for 3 cases of GIST, 4 cases of adenoma, and 13 cases of adenocarcinoma. The average age of the patients was 64.3 years and the male-to-female ratio was 17:3. The location of the tumor was the blub in 5 cases, the superior duodenal angle in 2 cases, the descending portion in 9 cases, the horizontal portion in 3 cases, and the ascending portion in 1 case. The histological type of adenocarcinoma was tub1 in all cases of early cancer, whereas in advanced cancer, there were many cases with histological types other than tub1. Various surgical procedures from duodenal local resection to pancreatoduodenectomy can be performed for treating non-ampullary duodenal tumors depending on the tumor location and the necessity of lymph node dissection. It is important to establish a treatment policy that considers both curability and invasiveness.

We herein report a case of application of sugar to the edematous stoma for obstructive rectal cancer. A 70-year-old male patient was diagnosed with rectal cancer, bowel obstruction and multiple lung metastases. Colostomy was performed. Seven days after operation, severe edema and congestion of stoma continued. We started spraying of sugar to stoma, and a few days later, edema and congestion of stoma improved. Before discharge, stoma size markedly reduced. Steady state of stoma and achievement the ability to self-care their stoma is important for introduction of chemotherapy. Application of sugar to reduce edema of rectal prolapse and prolapsed stoma have reported. Although the number of reported cases is still small, effectiveness of sugar to reduce edema of stoma have reported. In our case, application of sugar to the stoma is effective in reduction of edema. Application of sugar might be effective in reduction edema of stoma.

An 89-year-old woman with complete blindness presented with a right lower abdominal tumor and weight loss. The CT scan showed a huge mass approximately 9 cm in diameter in the ileocecum, invading the right urinary tract and right iliac artery and vein. Findings of the TCS biopsy led to the suspicion of ileocecal carcinoid. Another punch biopsy specimen acquired under general anesthesia indicated mucinous cell carcinoma. When she suffered from right leg pain approximately 3 months later, we provided radiation therapy(50 Gy)because of intolerance to UFT. Consequently, pain disappeared, and the tumor size decreased significantly. We administered TS-1 but discontinued it because of intolerance. Further, 2.8 years after the first medical examination, the tumor recurred, and she developed ileus. We performed ileocolectomy, and pathological findings indicated that the adenocarcinoma in the appendix had progressed from goblet cell carcinoid(sig, si[right ovary], ly1b, v1a, n0). Four years after the first medical examination, CEA had elevated rapidly, and lung metastases were found. She died approximately 4.2 years after the first medical examination. The last measured CEA level had been 596.7 ng/mL. Starting from the lowest level at the first examination, the CEA level had slowly elevated until before the operation and rapidly elevated postoperatively. Immunopathological findings showed that the operated specimen stained diffusely for CEA, without any mucinous component. We suspected that radiation therapy modified goblet cell carcinoid to adenocarcinoma.

Malignant esophageal stenosis adversely affects the quality of life(QOL)on account of poor oral intake. Endoscopic esophageal stenting is one of palliative therapy for improve QOL because of minimally invasive and simple procedure. We investigated the outcomes of esophageal stenting in our institution. Twenty patients with malignant esophageal stenosis who underwent esophageal stenting in our institution between April 2014 and December 2019 were included in this study. Six(30%)out of 20 patients showed fistula. Dysphagia score was improved significantly before and after stenting(3.3± 0.6 vs 1.8±0.9, p0.01). Complications associated with stenting occurred in 6(30%)cases. Thirteen(65%)patients were able to be discharged from the hospital, but 7(35%)patients including 4 with fistula were outcomes of death in the hospital. Esophageal stenting for malignant esophageal stenosis improved food ingestion and QOL. The prognosis in the case of malignant esophageal stenosis with fistula is extremely poor.

The present case pertained to a 70-year-old woman. The fecal occult blood test was positive. Colonoscopyrevealed rectal cancer. She underwent the first operation of low anterior resection. Pathological diagnosis was carcinoid, se, ly2, v0, n1. Approximately2 months later, multiple liver metastases were found. Because of strong enhancement at angiography, transarterial chemoembolization(TACE)was selected. After 3 rounds of TACE, we operated the residual liver metastasis approximately1 year and 7 months after the first operation. However, approximately8 years and 9 months after the first operation, multiple liver metastases were found again. Hepatic arterial infusion(HAI)was chosen because tumors showed weak en- hancement on CT. First, we tried high-dose HAI(5-FU 1 g/dayat 1-3 and 5-7, amount: 6 g/week), and liver metastases was almost in CR. However, extrahepatic metastasis was found on PET-CT. Because of rapid growth, we operated the growing lymph node. Pathological diagnosis was diffuse large-cell type B-cell malignant lymphoma. Thus, we extended the interval of HAI(weekly, biweekly, and monthly)and simultaneously4 courses of R-THP-COP(R: rituximab, THP: pirarubicin, C: cyclophosphamide, O: vincristine, P: prednisolone)therapyfor malignant lymphoma was administered. She is now an outpatient. Liver metastases continue to be in CR at approximately1 year and the IL-2R value is almost within normal range.

The use of endoscopic submucosal dissection(ESD)for the treatment of duodenal tumors has increased recently. ESD is less invasive than surgical resection of duodenal tumors. However, a high rate of complication, including perforation and bleeding, has been reported to be associated with ESD. Here, we report the minimally invasive surgical procedure called "endoscopy guided single-incision laparoscopic partial duodenectomy" for the treatment of duodenal tumors, along with its and safety and treatment outcomes. Five patients were included in this study. We mounted the LAP PROTECTORTM and EZ access®in the umbilical incision. Single-incision laparoscopic surgery was performed using 3 trocars(5mm)that were placed into the EZ access®. First, we mobilized the duodenum and pancreatic head from the retroperitoneum using the laparoscopic "Kocher maneuver". Next, the peritumoral site was marked by an endoscopic procedure using a clip and electric needle knife. Using an endoscope, we performed laparoscopic full-thickness resection of the duodenal wall including the tumor. The defect in the duodenal wall was then closed by suturing.

We report a case of metastasis to the small intestine from squamous cell carcinoma of the lung with fistula formation in the adjacent small intestine as well as an analysis of reported cases in Japan of small intestinal metastasis from lung cancer invading other organs. A 63-year-old man was diagnosed with squamous cell carcinoma of the lung as a result of pneumonia. Chemoradiotherapy was administered and sequential chemotherapy was performed, but a single brain metastasis of right parietal lobe was detected 6 months later. Tumor resection was performed. Twelve months after the lung cancer diagnosis, metastasis of the small intestine was detected. Single-incision laparoscopic surgery with partial resection of the small intestine was performed. The tumor had invaded the abdominal wall and 2 parts of the small intestine and had formed a fistula with part of the small intestine. Subsequently, peritoneal dissemination recurred and the patient received the best supportive care. There are 10 reported cases in Japan of small intestinal metastasis from lung cancer invading other organs. Analysis of the reported cases indicates a poor prognosis for patients with fistula. Resection can improve prognosis in patients with primary lung cancer and without distant metastasis. Surgical resection should be considered even if metastasis in the small intestine from lung cancer has invaded other organs.

A case of a skin ulcer caused by bevacizumab(Bmab)is reported here, which recurred with re-administration of bevacizumab. A 69-year-old male patient was diagnosed with cecal cancer, multiple liver metastases, multiple lung metastases, and bone metastasis. Resection of the cecal cancer was performed, and the patient was post-operatively treated with XELOX and Bmabchemotherapy. After the second cycle of chemotherapy, a skin ulcer developed. The ulcer improved after cessation of chemotherapy, debridement, and treatment with antibiotic medication. In spite of re-administration of XELOX chemotherapy, the skin ulcer healed completely, however, the dermatopathy recurred after re-administration of Bmab. Bmab chemotherapy is associated with various risks, including dermatopathy and protracted wound healing, and some cases of skin ulcers caused by Bmab have been reported. Because the skin ulcer was suspected to be cutaneous actinomycosis, Bmab chemotherapy was reintroduced while the patient was treated using antibiotic agent feeding, but the skin ulcer reoccurred. Reported cases of skin ulcers caused by Bmab in Japan show that skin ulcers often recur after re-administration of Bmab. Therefore, if skin ulcers caused by Bmab develop, re-administration of Bmabshould be considered carefully.

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. We report a case of laparoscopy-assisted surgery for descending colon cancer in a patient with PDM. An 88-year-oldfemale patient complaining of abdominal pain was diagnosed with bowel obstruction, and referred to our hospital. A computed tomography(CT)scan showed bowel obstruction due to descending colon cancer. After decompression of the colon by insertion of a transanal drainage tube, she underwent laparoscopy-assistedleft hemicolectomy. Intraoperatively it was observed that the descending colon was not fixed to the retroperitoneum, and the patient was diagnosed with persistent descending mesocolon. The accessory middle colic artery and the inferior mesenteric vein branched radially. In patients with PDM, the inferior mesenteric artery often branches radially. However, the various morphologies of branching of the accessory middle colic artery and the inferior mesenteric vein have not been reported. It is not clear whether the radial branching of the accessory middle colic artery and the inferior mesenteric vein is characteristic of patients with PDM. We should however expect radial branching of the accessory middle colic artery and the inferior mesenteric vein in such cases.

The transcriptional factor hypoxia-inducible factor 1alpha (HIF-1alpha) controls angiogenesis and metabolism by upregulating hypoxia-induced genes, such as the vascular endothelial growth factor (VEGF) gene and the glucose transporter (GLUT-1) gene. In addition to its regulation by oncogenes or tumor suppressor genes such as HER2, p53, VHL, and PTEN, overexpression of HIF-1alpha is induced by hypoxia. Increased HIF-1alpha expression is associated with malignant potential, and with patient prognosis and response to chemoradiotherapy in some cancer types.We investigated the association between HIF-1alpha expression and clinicopathological characteristics, including the expression of VEGF and p53 proteins, in gastric cancer. Furthermore, we analyzed the impact of HIF-1alpha, VEGF, and p53 protein expression on resistance to chemotherapy in advanced gastric cancer.Among 146 specimens from patients with gastric adenocarcinoma, 89 (61.0%), 52 (35.6%), and 102 (69.9%) were positive for HIF-1alpha, p53, and VEGF expression, respectively. The increased expression of HIF-1alpha protein correlated significantly with the increased expression of p53 (P0.0001) and VEGF (P = 0.0007). However, overexpression of these proteins was not associated with prognosis or clinicopathological status, with the exception of infrequent distant metastases. Furthermore, overexpression of these proteins was not associated with chemosensitivity in these patients with gastric cancer.Our results indicate that overexpression of HIF-1alpha correlates significantly with p53 and VEGF protein expression in patients with gastric cancer; however, this overexpression shows no association with clinicopathological status, patient prognosis, or chemosensitivity.

Effective chemotherapy for advanced gastric cancer is yet to be established. Taxanes, novel anticancer drugs which bind to beta-tubulin and prevent disruption of microtubules, are newly approved and promising agents for advanced and recurrent gastric cancer. To predict the chemoresistance to a taxan in gastric cancer, we examined the genetic mutations of the beta-tubulin gene.Fifty pairs of gastric tumor and normal mucosa tissues were obtained from operations and the genomic DNA was extracted from each specimen. The four exons of the beta-tubulin gene were amplified for DNA mutations by single-strand conformation polymorphism (SSCP) methods and sequencing analysis.Nine (18%) of 50 patients with gastric cancer had two kinds of silent variations of the beta-tubulin gene in exon 4. Three kinds of intronic variations were detected in exons 1, 2, and 3. However, no genetic alterations that would change the beta-tubulin protein structure were detected in any of the 50 gastric tumors.Our findings indicate that mutations of the beta-tubulin gene, which might be a contraindication for chemotherapy based on taxans, were very rare events in gastric cancer.

We report an 82-year-old Japanese woman with basal cell carcinoma of the left nipple and areola extending into the lactiferous duct. The patient developed a small papular lesion of the left areola about 1 year before admission. The lesion, which had slowly progressed to involve the nipple, had become symptomatic showing weeping and bleeding. Mammography revealed microcalcification in the nipple. Although Paget's disease was suspected from these clinical features, histologically basal cell carcinoma was diagnosed. There was no axillary lymphadenopathy, and no evidence of distant metastasis. The lesion of the nipple and areola was resected with a 2 cm free margin along with the underlying mammary tissue. The patient has remained well without signs of recurrence for 2 years after surgery. We reviewed cases of basal cell carcinoma of the nipple or areola and discuss considerations and problems of this rare tumor.

Diverticulitis of the appendix is a relatively rare entity. We have great difficulties in making diagnosis for the disease, and consequently the patients with the disease are often operated on under preoperative diagnosis of acute appendicitis. We experienced a case of diverticulitis of the appendix, in which the diverticula contained fish bones and crab claws. A 38-year-old man was admitted to the hospital because of right lower quadrant pain. Acute appendicitis was diagnosed by physical examination, ultrasonography and abdominal CT, and an appendectomy was performed. Diverticulitis of the appendix was found in the resected specimen. Retrospective study revealed that sonographic findings of this case had typical characteristics of diverticulitis. It is thought that we are able to diagnose diverticulitis of the appendix preoperatively in patients who are suspected to have acute appendicitis, if we pay careful attention to the possible existence of the disease.

Docetaxel, one of the most effective anticancer drugs for gastric cancer, targets beta-tubulin, the major protein in mitotic spindles. Eight isotypes of beta-tubulin, with tissue and organ-specific expression, have been identified in mammalian cells. We examined class III beta-tubulin expression in gastric cancer and assessed its relationship with sensitivity to docetaxel-based chemotherapy. A total of 115 paraffin-embedded gastric tumors were analyzed by immunohistochemistry for class III beta-tubulin expression. Twenty patients with advanced gastric cancer received preoperative docetaxel-based chemotherapy. Their biopsied specimens, obtained by endoscopy before chemotherapy were examined for class III beta-tubulin expression. The relationship between expression and chemosensitivity was assessed. Forty-two (36.4%) of 115 cases were confirmed to be positive for class III beta-tubulin expression. There was no association between clinicopathological status and prognosis. Among the patients positive for class III beta-tubulin expression, only 16.7% showed no response to chemotherapy, while 64.3% responded to the chemotherapy in the negative group. Our results suggest that class III beta-tubulin is a simple and useful predictive marker for the clinical response to docetaxel-based chemotherapy in gastric cancer.