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We analyzed the short-term outcomes and nutritional assessment of gastric cancer surgery patients who underwent exercise intervention after gastrectomy.Gastric cancer patients who underwent gastrectomy at our department from January 2021 were included in the study. Postoperative exercise intervention(lower limb training) was performed in gastric cancer patients aged 75 years or older(group H: 7 patients)and compared retrospectively with gastric cancer patients younger than 75 years(group L: 10 patients)who did not receive exercise intervention. The rate of decrease in each index after 1 week was compared between the 2 groups.Postoperative complications(yes/no) were 3/4(42.8%)in group H and 2/8(20.0%)in group L(p=0.59); postoperative hospital stay was 11.5(10.8-21.3) days in group H and 11.0(9.0-14.0)days in group L(p=0.37). The percentage decrease in each index was as follows: for BMI in groups H/L: 2.9/5.6%(p=0.17), grip strength in groups H/L: 2.4/－7.6%(p=0.07), skeletal muscle mass in groups H/L: －2.3/7.0%(p=1.00), PNI in groups H/L: 26.6/18.1%(p=0.12).In this study, no significant differences were noted in postoperative complication rates or postoperative hospital stay between groups H and L.

Lessons Learned The 3-year disease-free survival rate of the twice-daily regimen was not inferior to that of the conventional three-times-daily regimen, and the twice-daily regimen did not lead to an increase in adverse events. The effectiveness of the twice-daily regimen highlights an increased number of treatment options for patients. This will facilitate personalized medicine, particularly for elderly or frail patients who may experience more severe side effects from the combination therapy. Background Tegafur-uracil (UFT)/leucovorin calcium (LV) is an adjuvant chemotherapy treatment for colorectal cancer. We conducted a multicenter randomized trial to assess the noninferiority of a twice-daily compared with a three-times-daily UFT/LV regimen for stage II/III colorectal cancer in an adjuvant setting. Methods Patients were randomly assigned to group A (three doses of UFT [300 mg/m2 per day]/LV [75 mg per day]) or B (two doses of UFT [300 mg/m2 per day]/LV [50 mg per day]). The primary endpoint was 3-year disease-free survival. Results In total, 386 patients were enrolled between July 28, 2011, and September 27, 2013. The 3-year disease-free survival rates of group A (n = 194) and B (n = 192) were 79.4% and 81.4% (95% confidence interval, 72.6–84.4–74.5–85.9), respectively. The most common grade 3/4 adverse events in group A and B were diarrhea (3.9% vs. 7.3%), neutropenia (2.9% vs. 1.6%), increase in aspartate aminotransferase (4.0% vs. 3.9%), increase in alanine aminotransferase (6.2% vs. 6.8%), nausea (1.7% vs. 3.4%), and fatigue (1.1% vs. 2.3%). Conclusion Group B outcomes were not inferior to group A outcomes, and adverse events did not increase.

Paraduodenal hernia is traditionally repaired via conventional laparotomy. Recently, several reports described the repair of paraduodenal hernia via laparoscopic surgery with multiple ports. Due to development of the technique and devices for laparoscopic surgery, single-incision laparoscopic surgery (SILS) has been applied to various operations, including cholecystectomy, appendectomy, and procedures for colorectal cancer. Here, we report treatment of a left paraduodenal hernia via SILS. A 23-year-old man presented with abrupt onset of abdominal pain, nausea, and vomiting. Computed tomography revealed a mass of intestinal loops enveloped by a thin capsule on the left of the abdominal cavity. Blood circulation in the jejunal loops was preserved, and no dilatation of the jejunum was observed. Physical and radiographic examination indicated the possibility of left paraduodenal hernia; we performed paraduodenal hernia repair using SILS. After we confirmed that there was no strangulation or gangrenous change in the bowel on laparoscopic examination, we reduced the incarcerated jejunum loops via an atraumatic method. The postoperative course was uneventful, and the patient was discharged 8 days after the operation. This disease affects relatively young patients, rendering this operation attractive from the viewpoint of cosmetic benefits and minimal invasion. Paraduodenal hernia repair via SILS is feasible, safe, and may constitute an alternative method for paraduodenal hernia without necrotic change.

A 67-year-old woman reporting lower abdominal pain and anemia was examined. Small intestinal tumor was diagnosed by small intestinal radiographic contrast study and small intestinal endoscopy, and we decided to perform a laparoscopic partial resection of the small bowel. Since she was obese patients(BMI 36.3, abdominal wall 6 cm)at high risk of postoperative incisional hernia, we devised a way to make the wound smaller. We judged thick abdominal wall make umbilical wound larger in single port surgery. We performed multi-port surgery by using one 15 mm trocar, and removed small intestinal tumor from 15 mm port incision. In addition, to prevent incisional hernia, we used a trocar with a wound closure assist function for securely closing the port wound in all layers. Histopathological diagnosis was neuroendocrine tumor. The patient is being followed up without recurrence and without incisional hernia. In partial small bowel resection of obese patient, the use of a 15 mm port to minimize wound site and the use of trocar with a wound closure assist function may lead to prevent incisional hernia.

This study reports a 66-year-old female presenting abdominal pain. Gastrointestinal endoscopy showed the presence of a type 3 tumor in the lesser curvature of the stomach, and biopsy revealed poorly differentiated adenocarcinoma. CT images displayed thickening of the stomach wall and enlarged paraaortic lymph nodes, left supraclavicular lymph nodes, and left iliac lymph nodes. FDG-PET/CT scan showed abnormal accumulation at the same site. The patient was diagnosed with unresectable highly advanced gastric cancer(cT4aN2H0P0M1[LYM], Stage Ⅳ). She was treated with combination chemotherapy of S-1 and CDDP(SP). Tumor markers normalized(CA19-9 11,158→20 U/mL)after 3 courses with a marked reduction of lesions. After 5 courses of chemotherapy, the tissue biopsy did not reveal any cancer and a complete response(CR) was achieved. Adverse events of diarrhea and loss of appetite were observed. Subsequently, chemotherapy was discontinued after 6 courses, and CR remained for the next 5 years. Thus, we experienced a rare case of unresectable advanced gastric cancer with distant lymph nodes metastasis, showing long-term recurrence-free survival after receiving 6 courses of SP chemotherapy.

A 75-year-old man underwent laparoscopic ileocecal and partial small bowel resections for the management of appendiceal cancer. The pathological diagnosis was cecal cancer(T4b[ileum, abdominal wall],N0[0/13], M0, pStage Ⅱc). After 4 months of surgery, he suddenly experienced abdominal pain and vomiting and was presented to our emergency room. He was diagnosed with bowel obstruction following which, conservative treatment was initiated through a nasogastric ileus tube implantation; however, he did not show any improvement. Subsequently, he underwent experimental laparotomy on the 18th day of the disease. Intraabdominal examination revealed herniated small intestine through a mesenteric defect, which was closed following repositioning of the herniated small intestine. The postoperative course was good, and the patient was discharged on the 10th day after surgery. No recurrence of intestinal obstruction has been observed after 1 year and 6 months. Closure of the mesenteric defect, although not commonly performed in laparoscopic colorectal surgery, is worth considering because of the risk of developing an internal hernia requiring surgical treatment, as in our case.

The presence of multiple contaminant species in surface waters makes surface water treatment difficult to accomplish through a single process. Herein, we evaluated the ability of an integrated adsorption/ultrafiltration (UF) membrane filtration system to simultaneously remove phosphates and dissolved organic matter (DOM). When bare powdered activated carbon (PAC) and PAC impregnated with amorphous ferrihydrite (FHPAC) adsorbents were compared, FHPAC showed a greater adsorption rate and capacity for phosphate. FHPAC had a phosphate adsorption capacity of 2.32 mg PO43−/g FHPAC, even when DOM was present as a competing adsorbate. In a lab-scale hybrid FHPAC-UF system (i.e. integrated adsorption by FHPAC with UF membrane filtration), irreversible membrane fouling was ca. three times lower than that in a PAC-UF system. When membrane fouling in the PAC-UF system was described with pore blockage models, we found that the main cause of fouling was bacterial deposition on the membrane surface. CLSM analysis determined that the chemical composition of foulants in the PAC-UF system included higher proportions of proteins, nucleic acids, and alpha-polysaccharides than that in the FHPAC-UF system. Overall, FHPAC’s ability to undergo ligand exchanges with DOM helped to reduce the nutrients and bacteria that cause biofouling to accumulate on the membrane surface.

We report a rare case of hepatic fibrolamellar hepatocellular carcinoma(FLC). A 25-year-old Vietnamese male experienced loss of appetite and abdominal pain. He was referred for further examination of a 20 cm tumor in the left lobe of the liver detected in mass screening ultrasonography. He tested negative for HBs-antigen and HCV-antibody. The serum PIVKA- Ⅱ level was elevated. Liver function test findings were normal. The arterial phase of contrast enhanced abdominal CT revealed a 20×30 cm tumor that was well-enhanced, except for a central scar in the left lobe of liver. Enhanced MRI showed a high intensity tumor. T2-weighted MRI showed an iso-intensity tumor with a low-intensity central fibrous scar. Upon diagnosing the patient with FLC, we performed left hepatic trisegmentectomy. Pathological findings of the surgical specimen showed eosinophilic large neoplastic cells surrounded by fibrous stroma arranged in a lamellar fashion. This confirmed the diagnosis. FLC, which occurs in noncirrhotic livers of young patients, is a distinct clinicopathological variant of hepatocellular carcinoma. Hepatectomy for FLC should be accompanied with regional lymphadenectomy because of its association with lymph node metastasis. We also reviewed cases reported in Japan.

The patient was a 73-year-old man, diagnosed as advanced gastric cancer with para-aortic lymph nodes(PAN)metastasis. He was treated by 3 courses of neoadjuvant chemotherapy(NAC)with S-1 and oxaliplatin(SOX therapy). CT showed significant reduction of both primary tumor and metastatic lymph nodes. We performed distal gastrectomy with D2 plus PAN dissection. The histopathological findings showed no residual viable tumor cell. The pathological effect of chemotherapy was judged Grade 3(pCR)in both primary tumor and dissected lymph nodes. He is alive without recurrence 21 months after surgery.

The patient is 77-year-old man. He received open cholecystectomy and choledocholithotomy when he was 74 years old. Because postoperative diagnosis was small cell neuroendocrine carcinoma(NEC), the resection of gallbladder bed and hilus lymph nodes were performed. During the follow up period, the liver metastases and portal vein tumor thrombosis appeared. Therefore, chemotherapy was performed according to small cell lung cancer. In addition to chemotherapy, radiation therapy was performed for the purpose of local control. He is still alive about 3 years after the first operation. This case suggested the efficacy of multidisciplinary treatment including operation, chemotherapy, and radiation therapy in NEC of gallbladder patient with liver metastasis.

A 72-year-old woman was transferred to our hospital after being diagnosed with retroperitoneal and ovarian tumors. Abdominal computed tomography revealed a well-defined mass lesion measuring 35 mm on the dorsal side of the descending part of the duodenum that was surrounded by the head of the pancreas and inferior vena cava. In addition, a cystic mass measuring 90 mm was found in the pelvis. Hence, the patient was diagnosed synchronous retroperitoneal tumor and teratoma. Laparoscopic retroperitoneal tumor resection and right adnexectomy were performed. The pathological findings indicated that the retroperitoneal tumor was a diffuse large B-cell lymphoma and the pelvic tumor was a mature cystic teratoma of the ovary. On the basis of the computed tomography findings, we judged that the tumor had a poor tendency to infiltrate and could be peeled off and resected using laparoscopic surgery. In this rare case, the retroperitoneal tumor and mature teratocarcinoma were simultaneously resected laparoscopically.

A 59-year-old man visited our department because of cholecystectomy. Preoperative CT revealed a tumor shadow measuring 50 mm in front of the right iliopsoas muscle. MRI showed a low signal intensity on T1-weighted images and a slightly high signal intensity on the T2-weighted image. PET-CT showed accumulation of FDG(SUVmax 5.39)in the tumor but no other abnormal accumulations. We performed tumor resection for diagnostic purposes because malignancy could not be ruled out owing to the large size of the mass. Intraoperative findings showed a well-circumscribed margin of the tumor without invasion to other tissues. The retroperitoneum was incised circumferentially along the tumor under laparoscopic guidance, and the tumor was resected. Histopathological and immunostaining findings were consistent with leiomyosarcoma. In laparoscopic surgery, the surgical margin is observed in detail through the magnifying effect. Therefore, laparoscopic surgery can be a surgical option for tumors that may be completely excised based on preoperative findings.

A colonoscopy to investigate fecal incontinence revealed a type 3 tumor in the rectum of a 67-year-old man. Histological findings demonstrated rectal adenocarcinoma. CT revealed multiple metastases in the liver, and the patient was diagnosed as having rectal cancer(Rb, Ant, type 3, T3, N3, M1a[H2], cStage Ⅳa). No intestinal stenosis due to the tumor was found, and chemotherapy(FOLFIRI plus bevacizumab)was initiated. After 5 courses of the chemotherapy, a thrombus was found in the superior mesenteric vein on enhanced CT. The patient had no subjective symptoms, and anticoagulation therapy was started after admission. After confirming the shrinkage of the thrombus, laparoscopic abdominoperineal resection(prxD3)was performed to remove the primary tumor. The thrombus did not grow during the perioperative time and disappeared after 6 months. For the next 2 years, no new thrombus was detected. Mesenteric vein thrombosis is a notable complication of chemotherapy with bevacizumab.

A 65-year-old man was diagnosed with agammaglobulinemia at the age of 53 years. To investigate the cause of the increased CRP value, CT was performed and revealed thickening of the walls of the ascending colon and rectum. Colonoscopy revealed tumors and stenoses in the ascending colon and rectum. Both tumors were found to be adenocarcinomas in histological examinations. The preoperative diagnosis of the ascending colon and rectal cancers was cT4aN0M0, cStageⅡb. Preoperatively, we administered 10.0 g of immunoglobulin intravenously. We performed laparoscopic right hemicolectomy and high anterior resection with D3 dissection of the lymph node. On postoperative day 1, we again administered 10.0 g of immunoglobulin intravenously. The patient recovered uneventfully and was discharged on postoperative day 13. Laparoscopic colectomy for patients with agammaglobulinemia can be performed safely by administering immunoglobulin during the perioperative period.

A 69-year-old man underwent a Miles operation with D3 lymph node dissection for rectal cancer. The pathological diagnosis was adenocarcinoma(Rb, A, ly2, v3, N2M0P0H0, Stage Ⅲb). Adjuvant chemotherapy was added for 6 months after the rectal resection. Metastasis in the left lung was detected 1 year and 10 months after rectal resection for which large segmental resection was performed. Without the onset of any new lesions, the patient underwent subsequent follow-up examinations. Abdominal CT performed for increased tumor marker levels observed at 6 years and 8 months after rectal resection revealed a mass suggestive of pancreatic ductal adenocarcinoma for which distal pancreatectomy was performed. The pathological diagnosis was metastasis to the pancreas from the rectal cancer as the tumor cells were immunohistochemically negative for cytokeratin 7 and positive for cytokeratin 20. There has been no indication of recurrence for 13 months after the pancreatic surgery. Resectable pancreatic metastasis from colorectal cancer is rarely reported. However, pancreatic resection may result in long-term survival in some cases. Patients that tolerate pancreatectomy and have no metastasis in the other organs should be considered good candidates for pancreatic resection. We present this case with a review of the literature.

Intrahepatic bile duct dilatation was detected in a 63-year-old man based on abdominal ultrasonography. The computed tomography and magnetic resonance imaging scans showed an intrahepatic cystic lesion in the hilar bile duct that led to intrahepatic bile duct dilatation. As a result, intraductal papillary neoplasm of the bile duct(IPNB)was suspected. Moreover, the intrahepatic bile duct dilatation was confirmed by endoscopic retrograde cholangiopancreatography(ERCP). Biliary and brushing cytology indicated that the cystic lesion was class Ⅱ and class Ⅲ, respectively. Radiological imaging test did not rule out the possibility of a malignant lesion. Hence, a radical left hepatectomy was performed. Histopathological examination of the resected specimen indicated that it was a non-malignant cystic biliary hamartoma. Cystic biliary hamartoma or the von Meyenburg complex is a relatively rare disease. Although this disease is categorized as benign, differential diagnosis between benign and malignant forms is difficult, and this is an important clinical issue.

Background: Human intestinal innate myeloid cells can be divided into 3 subsets: HLA-DRCD14 cells, HLA-DRCD103 dendritic cells (DCs), and HLA-DRCD14CD103 cells. CD103 DCs generate Treg cells and Th17 cells in the ileum, but their function in the colon remains largely unknown. This study characterized CD103 DCs in the colon and investigated whether these cells are implicated in the pathogenesis of ulcerative colitis (UC). Methods: Normal intestinal mucosa was obtained from intact sites of patients with colorectal cancer (n = 24). Noninflamed and inflamed colonic tissues were obtained from surgically resected specimens of patients with UC (n = 13). Among LinCD45HLA-DR intestinal lamina propria cells, CD14 cells and CD103 DCs were sorted and analyzed for microRNA expression of cytokines and toll-like receptors by quantitative real-time polymerase chain reaction. In addition, IL-4/IL-5/IL-13/IL-17/IFN-γ production and Foxp3 expression by naive T cells cultured with CD14 cells and CD103 DCs were analyzed. Results: CD103 DCs in the normal colon showed lower expression of toll-like receptors and proinflammatory cytokines than CD14 cells. Coculture with naive T cells revealed that CD103 DCs generated Treg cells. CD103 DCs from patients with UC did not generate Treg cells, but they induced IFN-γ-, IL-13-, and IL-17-producing CD4 T cells and showed higher expression of IL6 (P < 0.0001), IL23A (P < 0.05), IL12p35 (P < 0.05), and TNF (P < 0.05). Conclusions: In patients with UC, CD103 DCs show the impaired ability to generate Treg cells, but exhibit a colitogenic function inducing Th1/Th2/Th17 responses. These findings show how human CD103 DCs could contribute to the pathogenesis of UC.

Controlling organic fouling and removing disinfection by-product (DBP) precursors remain challenges for the hybrid membrane process. Whether ferrihydrite (FH), an amorphous iron oxide, can achieve both targets when used as an adsorbent is unknown. Batch experiments of the integrated FH adsorption–microfiltration (MF) process were performed to study the effects of organic components on mitigating membrane fouling and reducing DBP formation, in comparison to powdered activated carbon (PAC). Both FH and PAC decreased the rate of initial organic fouling by removing DOM causing pore-fouling, which was probably polysaccharide-like compound. Afterwards, when cake fouling predominates, FH had smaller specific cake resistances than PAC. FH + MF was more effective for raw waters containing DOM with larger molecular sizes (>3 kDa) than PAC + MF. DBP formation potential in FH-treated waters is mostly lower than that in PAC-treated waters. This promotes a greater reduction of lifetime cancer risk from trihalomethanes (THMs) through the ingestion route when compared to MF and PAC + MF by lowering the formation potential of bromodichloromethane that produces a high unit risk among THM species. In general, FH exhibits better performance than PAC at small filtered volumes (

We report a patient who had Castleman's disease with lymphadenopathy during the treatment of gastric cancer. In May 2017, a 63-year-old man underwent gastrointestinal endoscopy, which revealed a tumor on the posterior wall of the lower part of the stomach. Based on a biopsy, he was diagnosed with suspected adenocarcinoma, Group 4. In June 2017, he visited our hospital, and endoscopic submucosal dissection(ESD)was performed. The pathological diagnosis of the resected specimens was L, Less, 20×10 mm, Type 0-Ⅱc, tub1, pT1a(M), UL(-), ly(-), v(-), pHM0, pVM0, pStage ⅠA. He was referred to our department for the treatment of abdominal lymphadenopathy. His lymphadenopathy was localized in the gastric lesser curvature as an enlarged lymph node 15mm in size, based on the findings of contrast-enhanced CT. On FDG- PET/CT, we found a slight accumulation of SUVmax 2.4 in the early phase in the same lymph node. We could not confirm a diagnosis, and we performed laparoscopic dissection of the lymph node for diagnosis and treatment. The size of the specimen was 14×14mm, surface was smooth, and lymph node was elastic and soft. We found lymphoid follicles with atrophic germinal center using HE staining. We also found increased hyperplastic blood vessels around the germinal center, and he was diagnosed with hypervascular Castleman's disease.

The patient was a 79-year-old man. He underwent endoscopic papillectomy for ampullary cancer when he was 70 years old. At the ages of 71 and 73 years, liver metastasis in segment 6 was detected, and radiofrequency ablation(RFA)was performed and adjuvant chemotherapy(gemcitabine, S-1)was administered. At the age of 79 years, recurrence of liver metastasis appeared. Because there were no other metastatic lesions, we performed S6 subsegmentectomy. Five months after the surgery, no recurrence was observed. In general, the prognosis of patients with ampullary cancer with distant metastasis is very poor. This case suggested the efficacy of multidisciplinary treatment, including surgery, RFA, and chemotherapy, in a patient with ampullary cancer with distant metastasis.

Metastasis of renal cell carcinoma to the pancreas is a relatively rare condition. We encountered 2 such cases. The first case was a 72-year-old man who underwent a left nephrectomy owing to left renal cancer in 2005. An abdominal dynamic CT scan 12 years after surgery revealed tumors in the pancreatic body and right kidney. A PET-CT scan revealed low intensity uptake of both tumors, and therefore, metastasis of the left renal cell carcinoma to the pancreas was suspected. We then performed partial resections of the pancreatic tail and right kidney. Pathologic findings confirmed that the pancreatic tumor and right renal tumor were metastases of the left renal cell carcinoma. The postoperative course was favorable, and the patient has been followed up in an outpatient setting for 10 months with no signs of recurrence. The second case was a 51- year-old woman with tumors in the left kidney and pancreatic head that were detected by abdominal contrast CT and MRI. We diagnosed the patient with left renal cell carcinoma with metastasis to the pancreas. We performed a radical nephrectomy of the left kidney and full pancreatectomy. Pathologic findings confirmed left renal cell carcinoma, pStage Ⅳ, with metastasis to the pancreas. The postoperative course was favorable without recurrence for 14 years. We report on two cases of metastasis of renal cell carcinoma to the pancreas in patients who underwent radical resections and had favorable postoperative courses, with some bibliographic consideration.

A 67-year-old woman was diagnosed with rectal cancer using colonoscopy. Computed tomography revealed the so-called superior mesenteric vein rotation sign, and intestinal malrotation was suspected. We planned chemotherapy after the surgical resection of the primary cancer because she had multiple lung metastases. Laparoscopic high anterior resection with D3 dissection of lymph nodes was performed. Intraoperative findings showed a non-rotation type intestinal malrotation and severe intra-abdominal adhesion. However, careful releasing operation enabled the typical approach of laparoscopic surgery for rectal cancer. The postoperative course was generally good, and she was discharged on the 17th postoperative day. The pathological diagnosis was rectal cancer(T3, N0, M1a, pStage Ⅳ). In laparoscopic surgery for colorectal cancer with intestinal malrotation, determining the anatomy of blood vessels and the site of the tumor before surgery is important. Furthermore, awareness that some cases have severe intra-abdominal adhesions even without a history of laparotomy is necessary.

Inappropriate activation of T helper (Th) cells, such as Th1 and Th17 cells, is implicated in the pathogenesis of chronic inflammatory disorders including ulcerative colitis (UC). CX3CR1high macrophages contribute to intestinal homeostasis through various mechanisms in mice. However, whether mononuclear phagocytes with regulatory functions are present in the human colon is not clearly defined. We investigated whether innate myeloid cells that suppress activation of effector T cells exist in the human intestinal mucosa. Among intestinal lamina propria cells, Lin− HLA-DRhigh CD14+ CD163high cells were subdivided into CD160low and CD160high cells. Both subsets produced high levels of IL-10. CD163high CD160high cells suppressed effector T cell proliferation, whereas CD163high CD160low cells induced Th17 differentiation. Patients with UC exhibited increased numbers of CD163high CD160low cells, while showing profoundly decreased numbers of CD163high CD160high cells. In this context, CD163high CD160high cells had higher CD80/CD86 expression and lower IL10RB expression, and these cells did not suppress effector T cell proliferation. The CD163high CD160high subset in normal intestinal mucosa inhibits inappropriate Th1/Th17 responses through suppression of their proliferation, and its number and suppressive activity are impaired in patients with UC. These findings indicate how human innate immune cells might prevent UC development.

The impact of anti-tumor necrosis factor alpha (TNFα) treatment for Crohn’s disease (CD) on surgical outcomes is still controversial. The aim of this study was to assess the feasibility of laparoscopic surgery for CD patients treated preoperatively with anti-TNFα agents. We investigated, retrospectively, the clinical features and surgical outcomes of 35 consecutive CD patients who underwent laparoscopic surgery after receiving scheduled anti-TNFα treatment preoperatively. We compared the surgical outcomes of an “early surgery group”, comprised of patients who underwent surgery less than 3 years after the initiation of anti-TNFα treatment, with those of a “late surgery group”, comprised of patients who underwent surgery more than 3 years after the initiation of anti-TNFα treatment. The mean operating time and blood loss were 203 min and 259 mL, respectively. The rates of conversion to open surgery and postoperative complications were 8.6 and 11.4 %, respectively. Operating time and blood loss were correlated with the interval between the initiation of anti-TNFα agent treatment and the time of surgery. The proportion of patients with acquired resistance to anti-TNFα agents and the rate of conversion to open surgery were higher and operating times were longer in the late surgery group than in the early surgery group. Laparoscopic surgery can be performed safely for CD patients treated preoperatively with anti-TNFα agents, although operating times may be longer and estimated blood loss (EBL) greater for those who have been on prolonged anti-TNFα treatment.

Background: Leucine-rich repeat-containing G-protein-coupled receptor 5 (LGR5) is a target of Wnt signalling and considered both a cancer stem cell marker and intestinal stem cell marker. We found first some splice variants of LGR5 in human intestine and elucidated the functional feature of full-length LGR5 (LGR5FL). Methods: Reverse transcript PCR using mRNA extracted from intestine revealed the existence of LGR5 splice variants. We designed an antibody that recognises only LGR5FL and assessed immunohistochemically the distribution of LGR5FL-positive cells and Ki-67-positive cells in clinical samples. Results: Two LGR5 splice variants were expressed in the human intestine crypt cells; one lacked exon 5 and the other lacked exons 5–8. Only LGR5FL appeared during cell cycle arrest, whereas the transcript variants appeared when the cell cycle was proceeding. Immunohistochemistry and in situ hybridisation showed that LGR5FL-positive cells were negative for Ki-67. Comparing prechemotherapy and post-chemotherapy specimens, the population of LGR5FL-positive cells significantly increased with therapy (P

Colonic epithelial cells are covered by thick inner and outer mucus layers. The inner mucus layer is free of commensal microbiota, which contributes to the maintenance of gut homeostasis. In the small intestine, molecules critical for prevention of bacterial invasion into epithelia such as Paneth-cell-derived anti-microbial peptides and regenerating islet-derived 3 (RegIII) family proteins have been identified. Although there are mucus layers providing physical barriers against the large number of microbiota present in the large intestine, the mechanisms that separate bacteria and colonic epithelia are not fully elucidated. Here we show that Ly6/PLAUR domain containing 8 (Lypd8) protein prevents flagellated microbiota invading the colonic epithelia in mice. Lypd8, selectively expressed in epithelial cells at the uppermost layer of the large intestinal gland, was secreted into the lumen and bound flagellated bacteria including Proteus mirabilis. In the absence of Lypd8, bacteria were present in the inner mucus layer and many flagellated bacteria invaded epithelia. Lypd8(-/-) mice were highly sensitive to intestinal inflammation induced by dextran sulfate sodium (DSS). Antibiotic elimination of Gram-negative flagellated bacteria restored the bacterial-free state of the inner mucus layer and ameliorated DSS-induced intestinal inflammation in Lypd8(-/-) mice. Lypd8 bound to flagella and suppressed motility of flagellated bacteria. Thus, Lypd8 mediates segregation of intestinal bacteria and epithelial cells in the colon to preserve intestinal homeostasis.

Molecular assays are currently the most widely used method to quantify pathogenic viruses in water; however, their performance is often disrupted by matrices present in environmental samples. The present study used ferrihydrite (Fh) treatment to mitigate inhibition of RT-qPCR virus detection from environmental water concentrates. Fh treatment was performed to improve the detection of spiked Aichi virus 1 (AiV) and Qβ bacteriophage (Qβ) in commercial humic acids and seawater concentrates. The optimal Fh doses were found to be 200, 500, and 1000 mgFe/L for humic acid concentrates at UV254 of 1.5, 3.0, and 6.0 cm-1 respectively, whereas this value was 1000 mgFe/L for the seawater concentrates at UV254 of 1.5 cm-1. At these optimal doses, the recoveries of spiked AiV and Qβ ranged from 2% to 12% in the humic acid and seawater concentrates, respectively. In addition, high levels of indigenous viruses (including AiV ≥ 2.81 log10 copies/mL and pepper mild mottle virus ≥ 2.77 log10 copies/mL) were detected from seawater concentrates after Fh treatment, while none were detected without Fh treatment. Fh treatment effectively mitigated the inhibitive effects from environmental water samples.

A 70-year-old man was referred to our hospital and admitted after abdominal computed tomography(CT)examination revealed a tumor in the retroperitoneum. The specific blood test findings were poor, and surveillance CT demonstrated a wellcircumscribed, enhanced mass measuring 40mm with calcification behind the horizontal portion of the duodenum. The tumor presented with a slightly high signal in low signal, T2 in T1, and it showed a diffusion decrease in DWI; the simple abdominal MRIrevealed heterogeneous accumulation of SUVmax 3.0 only for the lesion in FDG/PET-CT. Specific findings did not lead to a diagnosis, although EUS-FNA lower aspiration biopsy cytology was performed. Laparoscopic tumorectomy was performed to help determine the treatment strategy. Histopathological examination indicated that the tumor was composed of multiple lymph follicles with concentric layers of mantle zone cells, showing an onion skin-like lesion and atrophic germinal centers. The germinal centers had penetrating arterioles with hyalinized vessel walls, and Castleman's disease(hyaline vascular type)was therefore diagnosed. In this case, it was difficult to diagnose Castleman's disease before surgery. Surgical excision is a diagnostic as well as a curative method for management of this disease.

We report 2 resected cases of patients with non-isolated splenic metastasis of colon cancer. Case 1: A 67-year-old man who underwent partial transverse colectomy and partial hepatectomy for transverse colon cancer and liver metastasis. Approximately 18 months after the operation, splenectomy and partial hepatectomy were performed for metastasis to the spleen and liver. After partial hepatectomy for another recurrence, no signs of new recurrence have been observed for 42 months after splenectomy. Case 2: A 53-year-old woman who presented with bloating. CT and MRI scans revealed masses of the ileocecum, both ovaries, and spleen. We performed right hemicolectomy, total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, para-aortic lymphadenectomy, omentectomy, and splenectomy. Histological findings showed cecal cancer metastasizing to the bilateral ovaries and spleen. Metastatic splenic tumor is relatively rare(0.3-7.3%). Splenectomy was reported to be an effective treatment modality for isolated splenic metastasis, while that for non-isolated metastasis is uncertain. Surgical resection should be considered even in non-isolated splenic metastasis cases because of the evidence of long-term survival in case 1.

We report a patient with brain metastasis of rectal cancer who underwent metastatic tumor resection 3 times. In March 2012, a 76-years-old man, diagnosed with Stage III a rectal cancer, underwent Hartmann's operation. The lung metastasis was confirmed in July and November 2013, surgical resection for pulmonary metastasis was performed 2 times. In January 2016, he had difficulty of speaking, and isolated brain tumor was found. We performed surgical resection of brain metastasis in February 2016. In March and July 2016, the gamma knife radiosurgery was performed for other brain metastasis. In July 2016, he occurred nausea, headache and right identity hemi-blindness. Two new brain tumors were revealed. We performed surgical resection again. Three months after second brain surgery, he had dysarthria and a solitary brain tumor was confirmed. We performed third neurosurgical resection. All tumors of brain were found to be metastasis from rectal cancer in histological study. Currently, 16 months have passed since the first diagnosis of brain metastasis of this patient, and the quality of life was good relatively. The prognosis of the patients with brain metastasis is poor generally. However, this case suggested that multiple surgical resection of brain metastasis could improve prognosis and quality of life of patients. Accumulation of further cases is needed.

We report 2 cases of systemic steroid therapy for hyperbilirubinemia after right hepatic lobectomy for liver metastases from colorectal cancer.One of the patients was a 65-year-old man, diagnosed with transverse colon cancer with multiple liver metastases.After surgery for the primary lesion and chemotherapy(FOLFOX plus bevacizumab, FOLFIRI plus panitumumab), he underwent right hepatic lobectomy for the liver metastasis.His preoperative ICG 15 min was 8%.Conjugated hyperbilirubinemia without biliary stenosis occurred after the hepatectomy.Two courses of pulse steroid therapy were effective for only a limited period.After initiation of oral prednisolone therapy, his hyperbilirubinemia decreased.The other patient was a 66- year-old man with rectal cancer who underwent a low anterior resection.Postoperatively, a liver metastasis appeared.After CapeOX therapy, he underwent right hepatic lobectomy.His preoperative ICG 15 min was 5%.Conjugated hyperbilirubinemia occurred after hepatectomy.Pulse steroid therapy was effective for only a limited period.After initiation of prednisolone therapy, his hyperbilirubinemia decreased.In both cases, fatty changes in the liver were detected.Chemotherapy -associated hepatotoxicity may induce hyperbilirubinemia after hepatectomy.The effectiveness of systemic steroid therapy for hyperbilirubinemia is demonstrated by these cases.

Serum microRNAs (miRNAs) have been shown to have potential for cancer diagnosis. The main objective of the present study was to identify a novel serum miRNA biomarker from patients with colorectal cancer (CRC). Microarray analysis of miRNA expression was performed using paired pre-operative and post-operative serum from 10 CRC patients. Expression of two miRNAs (let-7a and miR-199a-3p) was significantly decreased in the post-operative serum when compared to levels in the pre-operative serum (P=0.015 and 0.029, respectively). Quantitative real-time polymerase chain reaction (qRT-PCR) confirmed the decrease in the miRNAs in an extended number (n=30) of paired serum samples. Next, we examined the serum let-7a level in 32 non-cancer patients and 84 CRC patients but we found no significant difference (P=0.120). In contrast, miR199a-3p expression was significantly higher in the CRC patients than that in the non-cancer patients (P=0.016). Furthermore, clinical and pathological survey indicated that high expression of miR-199a-3p was significantly associated with deep wall invasion. Our data suggest that circulating miR-199a-3p could be a novel serum biomarker for CRC.

Summary Gut epithelial organoids are routinely used to investigate intestinal biology; however, current culture methods are not amenable to genetic manipulation, and it is difficult to generate sufficient numbers for high-throughput studies. Here, we present an improved culture system of human induced pluripotent stem cell (iPSC)-derived intestinal organoids involving four methodological advances. (1) We adopted a lentiviral vector to readily establish and optimize conditioned medium for human intestinal organoid culture. (2) We obtained intestinal organoids from human iPSCs more efficiently by supplementing WNT3A and fibroblast growth factor 2 to induce differentiation into definitive endoderm. (3) Using 2D culture, followed by re-establishment of organoids, we achieved an efficient transduction of exogenous genes in organoids. (4) We investigated suspension organoid culture without scaffolds for easier harvesting and assays. These techniques enable us to develop, maintain, and expand intestinal organoids readily and quickly at low cost, facilitating high-throughput screening of pathogenic factors and candidate treatments for gastrointestinal diseases., Highlights • We optimized conditioned medium preparation from L cells by lentiviral infection • We modified a protocol to differentiate iPSCs into small intestinal organoids • We succeeded in transducing a gene into organoids by 2D culture • We showed that intestinal human organoids self-proliferate in suspension culture, Takahashi et al. developed several user-friendly culture methods for human induced pluripotent stem cell (iPSC)-derived intestinal organoids. The methodological improvements include preparation of conditioned medium for organoid culture, efficient differentiation from iPSCs, gene transduction in organoids, and growth in suspension culture. This system will facilitate high-throughput screening of pathogenic factors and treatments for intestinal diseases using physiologically robust intestinal organoids.

To examine the regeneration of mesothelium under a bioresorbable membrane. A 1 cm2 piece of peritoneum was resected from both sides of the abdominal wall of retired female mice. A piece of hyaluronate and carboxymethyl-cellulose (Seprafilm®) was placed over the wound on one side and the other side was left uncovered. We evaluated the degree of adhesion and regeneration of mesothelial cells macroscopically and histologically using immunohistochemistry at different times. Macroscopically, the degree of postoperative adhesion in the treated site was significantly less than that in the untreated site. The membrane was left in place for 7 postoperative days (PODs). By POD 5, the regenerated peritoneum mesothelial cells covered part of the area and by POD 7, they had regenerated over almost all of that area in the abdominal wall. The anti-adhesion membrane worked as a physical barrier to prevent postoperative adhesion until the mesothelial cells had regenerated completely. To our knowledge, this is the first study conducted to assess the regeneration of peritoneum mesothelial cells under a bioresorbable membrane using immunohistochemistry.

A 70-year-old man presenting with melena was referred to our clinic. A clinical examination revealed a bulky tumor in the lower rectum. After ileostomy, 4 courses of capecitabine plus oxaliplatin (XELOX) therapy were administered as neoadjuvant chemotherapy. Computed tomography (CT) revealed significant reduction of the tumor. Laparoscopic super-low anterior resection with lateral lymph node dissection was performed. The pathological examination revealed no residual cancer cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year after the operation. Neoadjuvant chemotherapy with XELOX might be promising for patients with locally advanced rectal cancer.

Solitary fibrous tumor (SFT) are relatively rare neoplasms that usually arise in the thoracic cavity in adults. Although many cases of extrathoracic SFT have been recently reported, SFT from the omentum is rare. A 32-year-old woman consulted a gynecologist complaining of irregular vaginal bleeding. Magnetic resonance imaging (MRI) revealed a tumor in the omentum, and the patient was admitted to our department. The patient underwent laparoscopic tumorectomy. The tumor size was 48 × 35 × 30 mm, and grayish-white nodules were observed. Histological examination showed hyperplastic spindle-shaped tumor cells with a pattern-less arrangement. Immunohistochemical staining showed the tumor was positive for CD34 and bcl-2, slightly positive for alpha smooth muscle actin(a-SMA), and negative for S-100 and c-kit. Accordingly, a diagnosis of SFT was made. The patient has not shown any recurrence 12 months after surgery. Most SFTs are benign, although there are some reports of recurring tumors. There are no clear guidelines for the treatment of SFT because of its rarity. Therefore, close long-term follow-up should be performed.

Posttransplantation lymphoproliferative disorder (PTLD) is a relatively rare and life-threatening complication after organ transplantation. From 1999 to 2012, 45 adult patients underwent heart transplantation at our hospital. Two of the patients developed PTLD after transplantation and required emergency surgery due to intestinal perforation. These cases were informative regarding the adequate surgical management of such cases. Both cases revealed Epstein-Barr virus-related PTLD. The optimal treatment of PTLD remains controversial, and PTLD with gastrointestinal perforation could be critical because the patients are already debilitated and immunocompromised after transplantation. Therefore, the nonspecific abdominal symptoms can be diagnostic for PTLD, and proper surgical intervention should be performed immediately. We present these two suggestive and rare cases in regard to the management of perforation with PTLD and a review of literature.

Circulating microRNAs (miRNAs) have been reported as a biomarker for human malignancies, including colorectal cancer (CRC). The purpose of this study was to identify a novel biomarker for CRC through examination of serum miRNAs from the patients with CRC. Microarray analysis of miRNA expression was performed using paired pre- and post-operative serum from 10 CRC patients. miR-103 and miR-720 decreased significantly in the post-operative serum when compared to pre-operative serum. With an extended scale validation by qRT-PCR (quantitative real-time polymerase chain reaction) in 30 CRC patients, we confirmed that serum miR-103 and miR-720 decreased significantly after surgery (P=0.0004, and P=0.0274, respectively). Next, we examined serum miR-103 and miR-720 levels in 32 non-cancer patients and 84 CRC patients, and we found that expression of these two miRNAs was significantly higher in CRC patients than non-cancer patients. Furthermore, clinical and pathological survey indicated that high expression of miR-103 was significantly associated with histological differentiation grade, and lymphatic invasion and high expression of miR-720 was significantly associated with male gender and lymph node metastasis. Our data suggest that circulating miR-103 and miR-720 show potential as novel serum biomarkers for CRC.

Single-incision laparoscopic surgery (SILS) is a promising new technique that is potentially applicable to Crohn's disease (CD). However, there is no consensus on the application of SILS for penetrating CD due to its complex pathology.We investigated the feasibility of SILS in 24 CD patients (12 with stricturing and 12 with penetrating CD) and compared the results between the two groups.There were 17 males and seven females [median age at the time of surgery, 41 (range 20-61) years old] included in the study. Sixteen patients underwent primary surgery, while eight received repeat surgery. Twenty patients had small bowel CD and four patients had ileocolonic CD. The indication for surgery was a fistula/abscess in 12 patients, stenosis in 10 and other indications in two cases. The total length of the operation and blood loss was 171 min (113-221 min) and 230 mL (30-400 mL) in the penetrating CD cases, and 149 min (111-186 min) and 90 mL (20-400 mL) in the stricturing CD cases. There were no significant differences in the length of the operation between the two groups, but the blood loss was significantly greater in the cases of penetrating CD. Conversion to open surgery was required in one patient with penetrating CD. Postoperative complications developed in one patient with stricturing CD.SILS could be performed safely not only in patients with stricturing CD, but also in those with penetrating CD.

Superior sulcus tumor( SST) is a rare type of lung cancer. Treatment usually consists of surgical resection after chemoradiotherapy. We report a case of a woman in her fifties who underwent carbon ion radiotherapy for SST. The patient complained of left shoulder pain, and imaging studies revealed a 5.2×3.5-cm local solid tumor at the apex of the left lung, invasion to the ribs, and no lymph node swelling. The level of tumor marker, carcinoembryonic antigen (CEA), was 5.7 ng/mL. Needle biopsy specimen revealed adenocarcinoma. The diagnosis was SST, T3N0M0, stage IIB. We did not detect Horner syndrome. Carbon ion radiotherapy at 66 Gy equivalent dose per 10 fractions was administered to the SST site. Subsequently, the tumor size decreased to 4.5×1.9-cm. The adverse effect was Grade 1 skin and pulmonary toxicity. Six months later, Grade 2 left shoulder connective tissue toxicity was observed; it was difficult to differentiate this from tumor recurrence. After 2.5 years from radiotherapy, the patient is free from recurrence. Carbon ion radiotherapy is effective and safe and can be considered as an important treatment option for SST.

Background & Aims Abnormal activity of innate immune cells and T-helper (Th) 17 cells has been implicated in the pathogenesis of autoimmune and inflammatory diseases, including Crohn's disease (CD). Intestinal innate immune (myeloid) cells have been found to induce development of Th17 cells in mice, but it is not clear if this occurs in humans or in patients with CD. We investigated whether human intestinal lamina propria cells (LPCs) induce development of Th17 cells and whether these have a role in the pathogenesis of CD. Methods Normal intestinal mucosa samples were collected from patients with colorectal cancer and noninflamed and inflamed regions of mucosa were collected from patients with CD. LPCs were isolated by enzymatic digestion and analyzed for expression of HLA-DR, lineage markers CD14 and CD163 using flow cytometry. Results Among HLA-DR high Lin − cells, we identified a subset of CD14 + CD163 low cells in intestinal LPCs; this subset expressed Toll-like receptor ( TLR ) 2 , TLR4 , and TLR5 mRNAs and produced interleukin (IL)-6, IL-1β, and tumor necrosis factor in response to lipopolysaccharide. In vitro co-culture with naive T cells revealed that CD14 + CD163 low cells induced development of Th17 cells. CD14 + CD163 low cells from inflamed regions of mucosa of patients with CD expressed high levels of IL-6 , IL-23p19 , and tumor necrosis factor mRNAs, and strongly induced Th17 cells. CD14 + CD163 low cells from the noninflamed mucosa of patients with CD also had increased abilities to induce Th17 cells compared with those from normal intestinal mucosa. Conclusions CD14 + CD163 low cells in intestinal LPCs from normal intestinal mucosa induce differentiation of naive T cells into Th17 cells; this activity is increased in mucosal samples from patients with CD. These findings show how intestinal myeloid cell types could contribute to pathogenesis of CD and possibly other Th17-associated diseases.