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Mixed neuroendocrine non-neuroendocrine neoplasm (MiNEN) of the pancreas is a rare entity, and obtaining a preoperative diagnosis is difficult. We present a 70-year-old man in whom the possibility of MiNEN was successfully discovered preoperatively by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Immunostaining revealed positive results for the neuroendocrine markers chromogranin A and synaptophysin. We considered the possibility for MiNEN before surgery. He underwent distal pancreatectomy with splenectomy. Immunohistochemical examination of the tumor cells showed a wide range of positivity for trypsin as well as for chromogranin A and synaptophysin. Considering that ≥ 30% tumors ware positive for both acinar and neuroendocrine markers, the patient was diagnosed with MiNEN. MiNEN is a malignant tumor that requires early detection and treatment but is a rare disease for which no method has been established. We found that EUS-FNA and immunostaining are effective diagnostic methods for MiNEN.

A 16-y-old Japanese female was referred to our hospital with a suspicion of infected retroperitoneal cyst. Abdominal CT MRI revealed a 38-mm diameter retroperitoneal cyst under the left diaphragm. Because a retroperitoneal bronchogenic cyst was suspected, total resection was planned. In addition, preoperative 3D reconstruction using multidetector CT provided a detailed location of the lesion. Based on the anatomical position, we decided that single-incision laparoscopic surgery with an anterior approach through the umbilicus would be the optimal choice. The lesion was completely resected without intraoperative complications. Histopathological examination confirmed the diagnosis of bronchogenic cyst. Postoperatively, the surgical wound became completely unnoticeable, and there was no incisional hernia or cyst recurrence at the 2-y follow-up.

Background/Aim: We previously reported three items that preoperatively predicted complicated appendicitis (body temperature, C-reactive protein, and fluid retention around the appendix). In this study, we aimed to compare other predictors to confirm the usefulness of our predictors with those of previous reports on the items as predictors of complicated appendicitis preoperatively (criteria A which consist of 8 items, criteria B which consist of 7 items). Patients and Methods: We retrospectively evaluated 417 adult patients who underwent surgery for acute appendicitis between January 2013 and December 2019 and compared our items with criteria A and criteria B according to the results of the area under the receiver operating characteristic curve (AUC), homogeneity, discriminatory ability, and Akaike information criterion (AIC). Results: The AUC for the sensitivity to diagnose complicated appendicitis according to according to our criteria, as well as criteria A, and criteria B was 0.823, 0.839, and 0.856, respectively. The discriminatory ability linear trend χ(2) of our criteria and those of criteria A and B were 128.9, 121.1, and 142.5, respectively. The homogeneity likelihood ratios χ(2) calculated using the Cox regression model, which indicate homogeneity, were 146.4, 143.6, and 172.8, respectively. The AIC of each criterion was 397.0, 345.8, and 369.0, respectively. Conclusion: Although the criteria B were the best, it was possible to predict complicated appendicitis preoperatively by all criteria. Above all, our criteria have only three items, therefore they have the advantage of making it possible to make decisions quickly with a certain degree of accuracy, regardless of the degree of experience.

Highlights • Diagnosing GIST is difficult due to the absence of clinical symptoms. • GIST should be considered when sudden abdominal pain and a mass are present. • We present a case of a GIST with partial resection and drainage surgery. • Ensuring local resection and proper chemotherapy increases long-term survival., Introduction Early diagnosis of small intestinal gastrointestinal stromal tumours (GISTs) is difficult. These tumours often present with peritonitis and intraperitoneal bleeding due to rupture. We experienced a case of a tumor that grows to 12 cm asymptomatic. Presentation of case A 46-year-old man presented with sudden abdominal pain. Computed tomography revealed free air in the abdominal cavity, a 12-cm sized dilatation in the small intestine, and pooled residues. He was diagnosed with perforation of the gastrointestinal tract, and emergency surgery was performed. Inside the abdominal cavity, approximately 500 mL of bloody ascites was observed. A diverticulum-like mass measuring approximately 12-cm long was observed on the jejunum approximately 30 cm from the Treitz ligament. There was a large hematoma inside the mass, and perforation was recognised at the neck of the diverticulum. Partial resection of the jejunum and intraperitoneal drainage were performed. Immunohistochemistry revealed that the tumour was positive for KIT and CD34, and GIST was diagnosed. The patient was discharged on postoperative day 10 without significant complications. The patient did not relapse while taking imatinib as an adjuvant chemotherapy. Discussion Gastrointestinal stromal tumours are the most common mesenchymal tumours of the gastrointestinal tract and may undergo increased diverticulum-like growth, as seen in this case. Local resection and proper chemotherapy increase long-term survival, suppress tumour growth, and reduce the risk of relapse. Conclusion Diagnosing GIST can be difficult due to the absence of clinical symptoms. It is necessary to ensure local resection and careful long-term follow-up.

A rare case of extranodal NK/T-cell lymphoma(ENKL)with small intestinal perforation is reported. A 92-year-old man was admitted for a loss of consciousness. Computed tomography(CT)scan revealed the presence of an intraperitoneal abscess that was drained. Two days later, the drained fluid changed to intestinal juice, and intestinal perforation was suspected. The patient underwent surgery which revealed a 1 cm perforation site in the ileum. A high fever continued after surgery, and malignant lymphoma was diagnosed from pathological findings; however, further treatment could not be performed. He died 24 days after the operation. Pathological dissection revealed metastasis of ENKL at the systemic lymph nodes.

Although postoperative early oral feeding in the enhanced recovery after surgery (ERAS) program for pancreaticoduodenectomy (PD) is deemed safe, the assessment of oral intakes has been insufficient. This study aimed to investigate postoperative oral intakes and the effectiveness of an ERAS program incorporating early enteral nutrition (EN).In total, 203 patients with PD were enrolled retrospectively. The first group (group E1; n = 61) comprised 11 ERAS care elements, whereas the second group (group E2; n = 106) comprised 19 elements. The control group (group C; n = 36) was managed using traditional care before ERAS was implemented. Postoperative energy and protein requirements were estimated at 25-30 kcal per kilogram of ideal body weight and 1.2-1.5 g per kilogram of ideal body weight, respectively, and were investigated along with the length of hospital stay (LOS).The oral energy and protein intakes from the diets in the ERAS groups at postoperative day 7 significantly increased compared with those in group C. Intakes in groups E1 and E2 were not significantly different and provided30% of the requirements. However, the total intakes, which were compensated by EN, were maintained at80% of the requirements. LOS was significantly shorter in groups E1 (31 days) and E2 (19 days) than in group C (52 days).Postoperative early oral energy and protein intakes of this modified ERAS program failed to meet the dietary requirements. However, early EN compensated for the shortages and contributed to the reduction of LOS.

Background: Complicated appendicitis is an indication for emergency surgery. Therefore, the predictive factors for appendicitis based on the patient background needs identification. Previously, factors predicting non-complicated and complicated appendicitis were reported. However, most of those reports were deemed unsuitable as a standard for emergency use, since those comprised too many items as predictors. We previously reported three items that preoperatively predicted complicated appendicitis (body temperature, C-reactive protein, and fluid retention around the appendix). In this study, we re-evaluated different cases to confirm the usefulness of these three items can for accurately predicting complicated appendicitis preoperatively. In addition, we compared the effectiveness of these predictor items with those reported by other researchers.Methods: We retrospectively evaluated 417 adult patients who underwent surgery for acute appendicitis between January 2013 and December 2019, and compared our predictor items with those used in previous reports on the preoperative prediction of complicated appendicitis (criteria A consisting of eight predictor items and criteria B consisting of seven predictor items). Results: The area under the receiver operating characteristic curve (AUC) for the sensitivity to diagnose complicated appendicitis according to our criteria, criteria A, and criteria B were 0.823, 0.839, and 0.856, respectively. The AUC of our criteria and criteria A were similar (P = 0.356); those of criteria A and B were also similar (P = 0.352). However, the AUC of criteria B was statistically higher than that of our criteria (P < 0.05).Conclusion: Diagnostic criteria B were statistically the best predictor items for characterizing complicated and uncomplicated appendicitis. However, like criteria A and B, the AUC of our criteria exceeded 0.8, and only involved three predictor items; therefore, they can be considered useful predictors.

This study compared the effectiveness of 1-day vs 3-days antibiotic regimen to prevent surgical site infection (SSI) in open liver resection. We performed a randomized controlled non-inferiority trial in 480 patients at 39 hospitals across Japan (registered as UMIN000002852). Patients with hepatocellular carcinoma scheduled to undergo resection were randomly assigned to receive either a 1-day regimen for antimicrobial prophylaxis, or a 3-day regimen. The primary endpoint was the incidence of SSI. Among 480 randomized patients, 232 assigned to the 1-day regimen and 235 to the 3-day regimen were included in the full analysis set. Baseline characteristics of the two groups were well balanced. SSI was diagnosed in 22 patients (9.5%) in the 1-day group vs 23 patients (9.8%) in the 3-day group (difference, – 0.30; 90% CI – 4.80 to 4.19% [95% CI – 5.66% to 5.05%]; one-sided P = 0.001 for non-inferiority), meeting the non-inferiority hypothesis. In both groups, remote site infection (16 [6.9%] vs 22 [9.4%], P ˂ 0.001 for non-inferiority) and drain-related infection (5 [2.2%] vs 4 [1.7%], P ˂ 0.001 for non-inferiority) were comparable. To prevent SSI in liver cancer surgery, a 1-day regimen of flomoxef sodium is recommended for antimicrobial prophylaxis because of confirming the non-inferiority to longer usage.

Malignant pleural mesothelioma (MPM) is an aggressive form of malignant tumor that originates in the pleural mesothelioma and presents as a local disease in the affected hemithorax. Small intestine metastasis is a rare complication. Herein, the case of a patient with jejunal intussusception caused by small intestine metastasis of MPM has been reported. A 72-year-old man with MPM was admitted to our hospital for abdominal pain. Computed tomography revealed small intestine intussusception. An emergency surgery was performed, and the tumor and intussusception were located in the upper jejunum. Histopathological examination of the resected jejunum revealed that the tumor was a small intestinal metastasis of the MPM from the chest wall. This case showed that MPM may metastasize to the small intestine, and metastatic tumors may cause intussusception.

The outcome of surgery in patients who have recovered from severe coronavirus disease 2019 (COVID-19) is unknown. Herein, we present a case of an emergency operation for acute pan-peritonitis due to perforation of the descending colon diverticulum in a patient who recovered from severe COVID-19 pneumonia. A 59-year-old man, who had recovered from severe COVID-19 pneumonia ~6 months previously, developed acute pan-peritonitis due to perforation of a diverticulum in the descending colon. Emergency surgery was performed, and the perforation was sutured and closed. He was discharged from the hospital 13 days postoperatively. There was no relapse of COVID-19 during the perioperative period of peritonitis surgery. General perioperative management may, therefore, be sufficient in patients who have recovered from COVID-19.

Lymphoepithelial cyst (LEC)is a rare disease. Clear diagnostic criteria have not been established, and the number of cases is expected to increase in the future. In particular, LEC in the pancreatic accessory spleen has not been reported in the past, and this report documents it for the first time.

Background/aim Right ventricular cardiac metastasis from colorectal cancer (CRC) is rare and clinically silent. There is no standardised treatment. To date, only twelve cases have been reported in the literature. This is a case report and literature review of right ventricular cardiac metastasis from CRC. Case report A 75-year-old woman with a history of CRC treated with sigmoidectomy followed by liver and lung metastasectomy presented with a right ventricle tumour. Biopsy showed metastatic adenocarcinoma not suitable for resection because multiple lung metastases coexisted. The metastases were controlled for a prolonged duration by chemotherapy with capecitabine plus bevacizumab. According to the review of 13 cases, the median age of metastatic CRC that involves the right ventricle is 71 years and the primary site is half the colon and rectum. Half of cases have non-cardiac metastases at cardiac metastasis diagnosis. Chemotherapy is more suitable than resection in cases with metastases other than heart because resection of the right ventricle has a high risk. Conclusion Cardiac right ventricular metastasis from CRC can be controlled by capecitabine plus bevacizumab.

A step-up approach and continuous drainage using NPWT was an effective strategy for the treatment of severe necrotizing pancreatitis. A 62-year-old woman developed severe necrotizing pancreatitis after endoscopic retrograde cholangiopancreatography, extending from the left anterior pararenal space to the interior renal pole. Endoscopic transluminal drainage and percutaneous catheter drainage were unsuccessful in controlling the disease. We proceeded with video-assisted retroperitoneal necrosectomy, at the pancreas and splenic hilum, and drainage, with two additional surgical drains located at the left inferior renal pole and, subcutaneously, at the incision wound. NPWT enhanced fluid drainage and facilitated surgical wound closure, which was infected and opened. Four subsequent endoscopic necrosectomy procedures were required, at the site of the draining fistula, to achieve complete resolution of fluid collection and wound closure.

Highlights • A lymphoepithelial cyst (LEC) of the pancreas is a benign and rare lesion. • A pancreatic LEC is difficult to be diagnosed and differentiate from the malignancy preoperatively. • We summarized the imaging features of pancreatic cysts to differentiate from the malignancy., Introduction A lymphoepithelial cyst (LEC) of the pancreas is a benign and rare lesion that is difficult to diagnose preoperatively based on imaging studies. Presentation of case We report a case of a 49-year-old man who presented with weight loss and diarrhea. The serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were slightly elevated to 6.7 ng/mL (reference value

Highlights • A definitive preoperative diagnosis of intestinal endometriosis is challenging. • Intestinal endometriosis should be considered when examining premenopausal women. • Surgery should be considered in patients presenting with intestinal obstruction., Introduction Endometriosis is characterized by the presence of endometrial tissue outside the uterus. However, the presence of endometriotic lesions in extrauterine locations at the terminal ileum is unusual and a preoperative diagnosis of intestinal endometriosis has proved challenging. Presentation of case A 49-year-old woman visited a local hospital complaining chiefly of vomiting. Computed tomography (CT) revealed an intestinal obstruction, and she was subsequently referred to and admitted to our hospital. After insertion of an ileus tube and contrast infusion, a crab-like stenosis was observed at the end of the ileum. Although its cause was unknown, we believed this stenosis to be the source of obstruction. Another CT at our hospital showed findings of obstructive ileus with a beak sign at the proximal ileum. Laparoscopic examination was performed to investigate the cause of ileus. Since the tumor at the terminal ileum was suspected to be malignant, we converted to laparotomy and performed an ileocecal excision with lymph node dissection. Based on the intraoperative pathological examination, a diagnosis of endometriosis was suspected. Another mass was found in the rectum but we ended the operation at this point. Postoperatively, the patient was referred to a gynecologist for the management of endometriosis. She was discharged on postoperative day 9 without significant complications. Conclusion The non-specific preoperative clinical and radiological findings of ileal endometriosis make it difficult to distinguish it from other diseases. Although rare, ileal endometriosis should be considered as a differential diagnosis of intestinal obstruction in women of reproductive age.

Aim No effective therapies for extrahepatic metastases from hepatocellular carcinoma (HCC) have yet been identified. Previous studies suggested a potentially promising antitumor effect of combination therapy of S-1, a novel oral dihydropyrimidine dehydrogenase inhibitor, and interferon (IFN)-α. The present study aimed to investigate the clinical efficacy of single agent S-1 and S-1/IFN-α for HCC patients with extrahepatic metastases in a randomized, open-label, multicenter trial. Methods A total of 103 patients with HCC with extrahepatic metastases were randomly assigned to the S-1/IFN-α group, receiving the combination of S-1 and IFN-α, or the S-1 group, receiving the single agent of S-1. Clinical efficacy and adverse events were compared between the two groups. Results A total of 49 patients in the S-1/IFN-α group and 51 patients in the S-1 group were included in the efficacy analysis. The response rate was 22.4% (11/49) in the S-1/IFN-α group and 13.7% (7/51) in the S-1 group; there was no significant difference. Overall and progression-free survival in the two groups were also not significantly different (1-year overall survival 50.8% vs. 72.4%, median progression-free survival 127 days vs. 157 days). The incidence of grade ≥3 adverse events in the S-1/IFN-α group was 62.7% (32/51), which tended to be higher than in the S-1 group (43.1% [22/51]). Conclusions Oncological outcomes in both treatment groups were favorable compared with previous reports, though there was no significant beneficial effect of adding IFN-α to S-1 for the treatment of HCC patients with extrahepatic metastases.

INTRODUCTION Although laparoscopic surgery uses relatively small incisions, incisional hernia after surgery is not uncommon. However, the incidence of incisional hernia and its risk factors are not well known. The purpose of our study was to investigate risk factors for incisional hernia after laparoscopic colorectal cancer surgery. METHODS The study group consisted of 212 patients who underwent laparoscopic colorectal cancer surgery at Hiroshima Prefectural Hospital between November 2008 and October 2013. Diagnosis of incisional hernia was performed by postoperative CT. The visceral fat area (VFA) and subcutaneous fat area at the level of the umbilicus were calculated using an image analysis system. For statistical analysis, Fisher's exact test or Student's t-test were used for univariate analysis, and logistic regression analysis was used for multivariate analysis. The cut-off value for risk factors was calculated from the receiver-operator curve. RESULTS Incisional hernia was observed in 18 patients (8.5%). On univariate analysis, female sex (P = 0.04), older age (P = 0.02), subcutaneous fat area (P 25 kg/m2 (P 110 cm2 (P

AIM To study the utility of single-incision totally extraperitoneal inguinal hernia repair with intraperitoneal inspection. METHODS A 2 cm transverse skin incision was made in the umbilicus, extending to the intraperitoneal cavity. Carbon dioxide was insufflated followed by insertion of laparoscope to observe the intraperitoneal cavity. The type of hernia was diagnosed and whether there was the presence of intestinal incarceration was confirmed. When an intestinal incarceration in the hernia sac was found, the forceps were inserted through the incision site and the intestine was returned to the intraperitoneal cavity without increasing the number of trocars. Once the peritoneum was closed, totally extraperitoneal inguinal hernia repair was performed, and finally, intraperitoneal observation was performed to reconfirm the repair. RESULTS Of the 75 hernias treated, 58 were on one side, 17 were on both sides, and 10 were recurrences. The respective median operation times for these 3 groups of patients were 100 min (range, 66 to 168), 136 min (range, 114 to 165), and 125 min (range, 108 to 156), with median bleeding amounts of 5 g (range, 1 to 26), 3 g (range, 1 to 52), and 5 g (range, 1 to 26), respectively. Intraperitoneal observation showed hernia on the opposite side in 2 cases, intestinal incarceration in 3 cases, omental adhesion into the hernia sac in 2 cases, severe postoperative intraperitoneal adhesions in 2 cases, and bladder protrusion in 1 case. There was only 1 case of recurrence. CONCLUSION Single-incision totally extraperitoneal inguinal hernia repair with intraperitoneal inspection makes hernia repairs safer and reducing postoperative complications. The technique also has excellent cosmetic outcomes.

We present a case of preoperatively diagnosed gallbladder torsion (GT) that was successfully treated by single-incision laparoscopic cholecystectomy. An 80-year-old woman presented with sudden pain and a palpable mass in the right upper quadrant. Contrast-enhanced CT revealed ischemic changes, a swollen gallbladder with a V-shaped distortion of the extrahepatic ducts, and the gallbladder in an abnormal anatomical position; clinical findings indicated GT. We performed single-incision laparoscopic cholecystectomy and intraoperatively found that the floating gallbladder was twisted counterclockwise by 180° around the cystic duct. After an uneventful postoperative course, the patient was discharged on postoperative day 7. Laparoscopic cholecystectomy for a GT was first performed in 1994, and since then, 28 cases, including ours, have been treated laparoscopically. Laparoscopic cholecystectomy for GT could be the standard treatment for this condition, and single-incision laparoscopic cholecystectomy may be a good surgical option for patients with GT because of its anatomical characteristics.

Highlights • Although sclerosing angiomatoid nodular transformation (SANT) of the spleen is a new entity defined as a benign pathologic lesion, it is very difficult for ruling out the malignancy in preoperative imaging studies. • Even when accumulation of fluorodeoxyglucose increased slightly during the follow-up period and suggested the possibility of malignant diseases, it is necessary to make a diagnosis of splenic SANT comprehensively., Introduction Sclerosing angiomatoid nodular transformation (SANT) of spleen is a new entity defined as a benign pathologic lesion. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) shows weak accumulation, thereby ruling out the malignancy in preoperative diagnosis is difficult. Herein, we reported a case of shrinking SANT with increased FDG accumulation during a 5-year follow-up period, which was treated by laparoscopic splenectomy. Presentation of case A 64-year-old female had been referred to our hospital for the evaluation of a splenic tumor. Initial contrast-enhanced computed tomography (CT) showed a well-defined, and ovoid hypoattenuating lesion, measuring 52 mm in diameter in the spleen. Initial PET/CT revealed accumulation of FDG in the tumor (maximum standardized uptake value [SUVmax]: 2.8). The mass was diagnosed as SANT, and the patient was followed-up every 6–12 months for 5 years. Follow-up PET/CT revealed increased accumulation of FDG (SUVmax: 3.5). As it was suspicious considering the differential diagnosis, including malignant lymphoma and inflammatory pseudotumor, she underwent laparoscopic splenectomy. The pathological results showed three types of vessels including capillaries, ectatic small veins, and sinusoids-like vessels, consistent with the features of SANT. Discussion A SANT may have features that resemble those of malignancy, including the growing mass and the increase of FDG accumulation. Conclusion Although the preoperative diagnosis of SANT is difficult, it is necessary to make a diagnosis of SANT comprehensively, even when accumulation of FDG increased slightly during the follow-up period and suggested the possibility of malignant diseases.

Highlights • Laparoscopic extraction of a giant peritoneal loose body is a good adaption, even if with no symptom., Introduction A peritoneal loose body is a rare finding and is sometimes founded incidentally during laparotomy or autopsy. A giant peritoneal loose body, measuring more than 50 mm, is very rare, and only a few cases of laparoscopic extraction of these giant bodies have been reported in the literature. Presentation of case A 70-year-old man presented for evaluation of urinary frequency. He had no history of previous abdominal surgery or trauma. Computed tomography of the abdomen and pelvis showed a giant oval-shaped mass with calcification of the luminal core, measuring 58 mm in diameter. Magnetic resonance imaging revealed a lesion with low intensity in T1-/T2-weighted images. Exploratory laparoscopy was performed. During the procedure, a yellow-white, oval-shaped mass with a “Boiled egg” appearance was discovered in front of the rectum. The mass was freely floating in the peritoneal cavity, without attachment to any intraperitoneal organs. The giant peritoneal loose body was extracted through a small incision, using an enlarged trocar site. Discussion Most peritoneal loose bodies are small, not exceeding 2 cm in diameter, and are asymptomatic. Only a few cases of giant peritoneal loose bodies exceeding 5 cm have been reported. Conclusion A giant peritoneal loose body is very rare and laparoscopic extraction was a useful technique. We report a case of a giant peritoneal loose body and review previously published series.

The aim of this study was to evaluate the significance of the Ki67 labeling index and p53 status as prognostic and predictive indicators of operable estrogen receptor (ER)-positive and human epidermal growth factor receptor 2 (HER2)-negative breast cancer. Among 697 consecutive patients with primary breast cancer who underwent curative surgery between 2002 and 2013, 308 patients with ER-positive and HER2-negative breast cancer were assessed. The results of the multivariate Cox analysis demonstrated that a high Ki67 labeling index was significantly associated with a short recurrence-free interval (RFI) (p=0.004) and was marginally associated with a worse overall survival (p=0.074). A positive p53 status was not associated with worse outcomes. To validate the cut-off values of the Ki67 labeling index for identifying patients who may benefit from additional chemotherapy, prognostic factors were investigated in breast cancer patients treated postoperatively with endocrine therapy alone. Analysis of receiver operating characteristic curves demonstrated that a Ki67 labeling index cut-off of 20.0% was optimal for predicting recurrence among patients who did not receive adjuvant chemotherapy. The 5-year RFIs for patients with Ki67

Intussusception in adulthood is unusual. We describe herein a rare case of adult ileoileal intussusception caused by an ileal lipoma, which was diagnosed preoperatively and was confirmed at the operation to have reduced spontaneously. A 68-year-old woman experienced sudden-onset colicky pain in the upper abdomen accompanied by vomiting and was brought to our hospital by ambulance. Physical examination revealed a distended abdomen and tenderness in the upper abdomen. Laboratory findings showed slightly elevated inflammatory parameters. Abdominal computed tomography (CT) showed a target sign in the ileum, which is a typical sign of intussusception. Additional caudal-side scans showed a homogenous and fatty mass measuring 2.5 cm that was considered to be the leading point for the invagination. These findings led to a pre-operative diagnosis of intussusception induced by a lipoma. The patient underwent emergency surgery. Laparotomy revealed a yellowish, soft ileal tumor measuring 2.5 cm in diameter and that the intussusception had already been reduced at laparotomy. Approximately 15 cm of the ileum's length, including the tumor, was resected, and an end-to-end anastomosis was performed. Adult intussusception caused by an ileal lipoma is a rare condition. However, CT is the most useful tool for making a definite preoperative diagnosis based on its typical findings.

Background Although secondary liver involvement of the lymphoma is common and occurs in 50% of patients with non-Hodgkin’s lymphoma, liver tumor rupture in malignant lymphoma is extremely rare. We report a case of a spontaneously ruptured secondary liver involvement of non-Hodgkin’s lymphoma that was successfully treated with transcatheter arterial embolization (TAE) to obtain hemostasis, and subsequent hepatectomy and systemic chemotherapy. To the best of our knowledge, this is only the second reported case of a ruptured hepatic lymphoma. Case presentation A 74-year-old man with sudden-onset right shoulder and upper quadrant pain was transferred to our hospital via an ambulance. His vital signs were stable. Contrast-enhanced computed tomography showed a large hypo-enhancing tumor (94 × 81 mm) in the posterior segment of the liver, with intratumoral extravasation and a 12 × 10 mm daughter tumor in segment 5 of the liver. Hemoperitoneum due to rupture of hepatocellular carcinoma with intratumoral hemorrhage was suspected, although the serum alpha-fetoprotein and protein induced by vitamin K absence-II levels were within normal range. TAE was used for hemostasis. Extended posterior segmentectomy including tumor resection in segment 5 was performed on day 23 after embolization. The postoperative course was uneventful. Pathological examination of the resected specimens revealed that the ruptured tumor was diffuse large B-cell lymphoma. Postoperative fluorodeoxyglucose positron emission tomography-computed tomography showed uptake in the left parotid gland, pancreas, and thoracic vertebra. Based on these findings, the final diagnosis was a ruptured secondary hepatic malignant lymphoma. Complete remission was achieved with chemotherapy. He remains alive 30 months after hepatectomy without evidence of relapse. Conclusions We report the first case describing a hepatic tumor rupture as the first presentation of a primary or secondary hepatic malignant lymphoma. The patient was successfully treated with TAE, hepatectomy, and subsequent systemic chemotherapy for non-Hodgkin’s lymphoma.

Aim Many studies support the role of carcinoembryonic antigen (CEA) as a strong indicator of the status of colorectal cancer patients, but evidence for carbohydrate antigen 19-9 (CA19-9) is poor. For this reason the study aimed to evaluate the prognostic value of preoperative serum CA19-9 levels in colorectal cancer patients. Method In all, 1190 colorectal cancer patients were included in this study, of whom 955 underwent a potentially curative resection. These were analysed for recurrence and survival. The 255 patients with Stage IV disease were analysed for metastatic status. Results Patients with an elevated preoperative CEA with Stage II and III disease showed a significantly poorer survival than those with normal levels. In contrast patients with elevated preoperative CA19-9 levels were associated with a significantly poorer survival irrespective of disease stage. Of the 255 patients with Stage IV disease, 92 (39.1%) had peritoneal dissemination at laparotomy observed more frequently in patients with an elevated CA19-9 (47.9%). Of the 955 patients having a curative resection, 18 (1.9%) developed peritoneal dissemination. In multivariate analysis, an elevated preoperative CA19-9 level was a significant risk factor for postoperative peritoneal recurrence. Conclusion After curative surgery for colorectal cancer the preoperative CA19-9 level is a strong prognostic indicator of higher risk of peritoneal dissemination.

The aim of the present study was to evaluate the significance of lung biopsy for the modification of the treatment strategy in breast cancer patients who develop lung nodules during follow-up after breast surgery. Of 53 consecutive patients who underwent lung biopsies in two institutions (Hiroshima University Hospital and Hiroshima Prefectural Hospital, Hiroshima, Japan) between 1997 and 2014, 45 underwent lung surgery and 8 underwent percutaneous or transbronchial tumor biopsy for lung nodules developing after curative surgery for breast cancer. The indications for lung biopsy included lung nodules for which a definitive diagnosis was difficult to achieve, and those for which the treatment strategy depended on the pathological diagnosis. The lung nodules were pathologically diagnosed as primary breast cancer metastases to the lungs in 25 (47%), primary malignant lung tumors in 21 (40%) and benign disease in 7 (13%) patients. Among the 25 metastatic patients confirmed by lung biopsy, phenotype discordance was observed in 6 patients (24%). A total of 3 patients with lung metastasis proven to have estrogen or progesterone receptor upregulation by lung biopsy received endocrine therapy. Univariate analysis revealed that patients with metastatic breast cancer confirmed by lung biopsy were significantly younger and had more locally advanced primary cancers diagnosed via clinical and pathological assessment compared with patients with other diseases. Therefore, mastectomy and axillary lymph node dissection were performed more frequently in the metastasis group compared with the others group. Multivariate analysis revealed that mastectomy (P

No effective therapies for extrahepatic metastases from hepatocellular carcinoma (HCC) have yet been identified. Previous studies suggested a potentially promising antitumor effect of combination therapy of S-1, a novel oral dihydropyrimidine dehydrogenase inhibitor, and interferon (IFN)-α. The present study aimed to investigate the clinical efficacy of single agent S-1 and S-1/IFN-α for HCC patients with extrahepatic metastases in a randomized, open-label, multicenter trial.A total of 103 patients with HCC with extrahepatic metastases were randomly assigned to the S-1/IFN-α group, receiving the combination of S-1 and IFN-α, or the S-1 group, receiving the single agent of S-1. Clinical efficacy and adverse events were compared between the two groups.A total of 49 patients in the S-1/IFN-α group and 51 patients in the S-1 group were included in the efficacy analysis. The response rate was 22.4% (11/49) in the S-1/IFN-α group and 13.7% (7/51) in the S-1 group; there was no significant difference. Overall and progression-free survival in the two groups were also not significantly different (1-year overall survival 50.8% vs. 72.4%, median progression-free survival 127 days vs. 157 days). The incidence of grade ≥3 adverse events in the S-1/IFN-α group was 62.7% (32/51), which tended to be higher than in the S-1 group (43.1% [22/51]).Oncological outcomes in both treatment groups were favorable compared with previous reports, though there was no significant beneficial effect of adding IFN-α to S-1 for the treatment of HCC patients with extrahepatic metastases.

Although laparoscopic surgery uses relatively small incisions, incisional hernia after surgery is not uncommon. However, the incidence of incisional hernia and its risk factors are not well known. The purpose of our study was to investigate risk factors for incisional hernia after laparoscopic colorectal cancer surgery.The study group consisted of 212 patients who underwent laparoscopic colorectal cancer surgery at Hiroshima Prefectural Hospital between November 2008 and October 2013. Diagnosis of incisional hernia was performed by postoperative CT. The visceral fat area (VFA) and subcutaneous fat area at the level of the umbilicus were calculated using an image analysis system. For statistical analysis, Fisher's exact test or Student's t-test were used for univariate analysis, and logistic regression analysis was used for multivariate analysis. The cut-off value for risk factors was calculated from the receiver-operator curve.Incisional hernia was observed in 18 patients (8.5%). On univariate analysis, female sex (P = 0.04), older age (P = 0.02), subcutaneous fat area (P 0.01), VFA (P = 0.02), and BMI 25 kg/mAfter laparoscopic colorectal cancer surgery, a higher VFA and female sex are independent risk factors for incisional hernia.

Background Celiac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow. Case presentation A 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications. Conclusion The intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament.

We present a case of preoperatively diagnosed gallbladder torsion (GT) that was successfully treated by single-incision laparoscopic cholecystectomy. An 80-year-old woman presented with sudden pain and a palpable mass in the right upper quadrant. Contrast-enhanced CT revealed ischemic changes, a swollen gallbladder with a V-shaped distortion of the extrahepatic ducts, and the gallbladder in an abnormal anatomical position; clinical findings indicated GT. We performed single-incision laparoscopic cholecystectomy and intraoperatively found that the floating gallbladder was twisted counterclockwise by 180° around the cystic duct. After an uneventful postoperative course, the patient was discharged on postoperative day 7. Laparoscopic cholecystectomy for a GT was first performed in 1994, and since then, 28 cases, including ours, have been treated laparoscopically. Laparoscopic cholecystectomy for GT could be the standard treatment for this condition, and single-incision laparoscopic cholecystectomy may be a good surgical option for patients with GT because of its anatomical characteristics.

We aimed to demonstrate a single institution experience of treatment of pancreatic ductal carcinoma and to identify the role of radiation therapy. We assessed all patients who were diagnosed with pancreatic ductal carcinoma from January 2011 to December 2017. A total of 342 patients were enrolled. Thirteen, 131, 36, and 162 patients had stage I, II, III, and IV disease, respectively (UICC TNM, 7th edition). Among the patients with stages I-III disease, 94 underwent surgery, and the median overall survival (OS) was 33 months. Of patients with stages I-III disease who were not suitable for surgery, 58 patients received chemotherapy, and the median OS was 12 months. Among them, 17 patients received chemoradiotherapy added on chemotherapy and their OS was significantly better than that of patients who received chemotherapy alone. Of patients with stage IV disease, 111 received chemotherapy, and the median OS was 6 months. This study evaluated the demand, role, and outcome of each treatment modality and demonstrated a single institution experience of treatment of pancreatic ductal carcinoma. The demand and role of radiation therapy remained small; however, radiation therapy might have some importance as a local treatment.