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A 78-year-old man presented to our hospital with loss of appetite and epigastric discomfort. Computed tomography (CT) revealed dilation of the main pancreatic duct and three cystic lesions in the pancreatic neck, body, and tail. Endoscopic ultrasonography showed a mural nodule 5 mm enhanced with Sonazoid in a cyst. Therefore, the patient was diagnosed with intra-ductal papillary mucinous neoplasm (IPMN) and underwent distal pancreatectomy. Macroscopic examination of the cut surface of the resected specimen showed no solid tumors in the pancreatic parenchyma. The histopathological diagnosis of the cysts was IPMN with low-grade dysplasia. Ten months after surgery, the serum carbohydrate antigen 19-9 level was elevated, and CT showed multiple peritoneal and pulmonary nodules, suggesting peritoneal dissemination and lung metastases. Since recurrence of pancreatic cancer was suspected, repeat histopathological examination of the resected specimen was performed, revealing small clusters of atypical epithelial cells diffusely spreading in the pancreatic tissue. The diagnosis was changed to invasive ductal carcinoma (pT2N1bM0, stage IIB). Invasive pancreatic cancer that does not form a solid mass, and shows diffuse spreading with small clusters is extremely rare. Imaging diagnosis and histopathological examination should be carefully performed in such cases.

We encountered a rare case of a pancreatic head tumor protruding into the portal vein, later diagnosed histopathologically as primary leiomyosarcoma of the portal vein. A 59-year-old woman visited our hospital because of an elevated amylase level during a medical checkup. Computed tomography showed a moderately contrasted, well-defined mass of 35-mm diameter in the pancreatic head with protrusion into the portal vein. Endoscopic ultrasonography revealed a well-defined and hypoechoic mass. Fluorodeoxyglucose-positron emission tomography showed a high accumulation of fluorodeoxyglucose in the pancreas head. We performed a subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection. Gross findings of the fixed specimen showed a white solid, multinodular mass in the pancreatic parenchyma with protrusion into the portal vein. Histopathological examination showed proliferation of spindle-shaped eosinophilic cells with intricate bundle-like growth, indicating leiomyosarcoma. Examining the tumor location and invasion suggested portal vein as the origin. Although portal vein primary leiomyosarcoma is rare, leiomyosarcoma should be considered as a differential diagnosis in pancreatic head tumors with protrusion into the portal vein. Precise macroscopic and histopathological examinations can help determine the definitive diagnosis and origin of leiomyosarcoma.

Background Emergency appendectomy is often performed for de Garengeot hernia. However, in some cases, there may be a chance to perform an appendix-preserving elective surgery. Case description A 76-year-old woman presented to our hospital with complaints of a right inguinal swelling, which we diagnosed as a de Garengeot hernia using computed tomography (CT). B-mode ultrasonography (US) of the mass showed an appendix 4–6 mm in diameter with a clear wall structure; color Doppler US showed pulsatile blood flow signal in the appendiceal wall. Twenty-eight days later, herniorrhaphy with transabdominal preperitoneal repair (TAPP) was performed without appendectomy. Another 70-year-old woman presented to our hospital with complaints of a painful bulge in the right inguinal region. The diagnosis of de Garengeot hernia was made using CT. B-mode US showed an appendix 5 mm in diameter with a clear wall structure. Color Doppler US showed a pulsatile blood signal in the appendiceal wall. Seven days later, herniorrhaphy with TAPP was performed without appendectomy. Conclusion De Garengeot hernia is often associated with appendicitis; however, an appendix-preserving elective herniorrhaphy can be performed if US and intraoperative findings do not suggest appendicitis or circulatory compromise in the appendix.

A 74-year-old woman underwent right hemicolectomy and partial ileal resection for ascending colon cancer with synchronous peritoneal metastasis. Histopathological examination showed moderately differentiated adenocarcinoma with mucinous component, pT4b N3 M1, and Stage IV. Postoperative chemotherapy comprising 36 courses of mFOLFOX6 with bevacizumab was administered. Twenty-two months after the surgery, computed tomography (CT) revealed a 20 mm nodular lesion adjacent to the gastric wall, and laparoscopic resection of the nodule was performed. Thirty-nine months after the second surgery, CT showed a 24 mm nodular lesion involving the liver parenchyma, and partial hepatectomy involving the nodule was performed. Histopathological examination of the nodules resected by the second and third surgeries showed the same features as the primary ascending colon cancer. The nodules were diagnosed as metachronous peritoneal metastases. The patient followed up without chemotherapy after the second and third surgery, showed no recurrence for 26 months after the third surgery. Fortunately, more than 7 years have passed since the primary tumor resection. Hence, surgical resection for synchronous and repeated metachronous peritoneal oligometastases from colon cancer can offer long-term survival. J. Med. Invest. 69 : 302-307, August, 2022.

We encountered a rare case that involved the superficial spreading type of early gastric cancer coexisting with multiple hyperplastic polyps. An 81-year-old Japanese woman with a history of Helicobacter pylori infection was diagnosed with gastric cancer (cT1bN0M0), which presented as a wide, nodular, aggregated protrusion that was associated with multiple pedunculated and sessile polyps. Distal gastrectomy was performed, and the resected specimen involved an 8 cm × 4 cm nodular aggregated protruding lesion and 15 polyps that were 2-20 mm in size. Histopathological examination revealed that the nodular aggregated protruding lesion was a mucosal adenocarcinoma and that the multiple polyps were hyperplastic. The coexistence of multiple hyperplastic polyps and mucosal adenocarcinoma with nodular aggregated protrusions suggested that the mucosal adenocarcinoma had developed from a fusion of multifocal hyperplastic lesions. This may have occurred via a hyperplasia-carcinoma sequence related to the Helicobacter pylori infection. The superficial spreading type of early gastric cancer has a potential developed from a fusion of multifocal hyperplastic polyps.

Background De Garengeot hernia, wherein the appendix is present within a femoral hernia, is a rare disease; therefore, the clinicopathological features remain to be clarified. This study aimed to reveal the clinicopathological characteristics of De Garengeot hernia. Case presentation Six patients who underwent appendectomy and herniorrhaphy between 1999 and 2018 were included. The incidence of De Garengeot hernia was 3.2% among the 182 femoral hernias that required surgery during the study period. The median age of the patients was 78 years, and five patients were women. The median body mass index was 20.1. Patients frequently had fever or elevated CRP level. Preoperative diagnoses based on computed tomography were femoral (n = 3), inguinal (n = 2), and De Garengeot (n = 1) hernias. Emergency and elective surgeries were performed in four and two patients, respectively. Histopathological examination of the resected appendix showed gangrenous appendicitis (n = 3), perforated appendicitis (n = 2), and appendiceal ischemia (n = 1) in the patients. Postoperatively, one patient developed sepsis. Conclusions Preoperative diagnosis of De Garengeot hernia is often difficult, and patients frequently have severe appendicitis. Precise diagnosis is required, and emergency surgery should be considered depending on the severity of appendicitis.

Because appendiceal diverticulitis (AD) has a high risk of perforation, precise diagnosis is important for patients with suspected acute appendicitis (AA). In this study, we aimed to reveal the characteristics of computed tomography (CT) images of AD. CT images were comparatively analyzed in patients who underwent appendectomy and had histopathologically proved AD (n = 23) or AA (n = 365) to reveal specific findings of CT image for AD and determine sensitivity and specificity of CT for AD. Univariate analysis showed that maximal diameter of the appendix in AD was significantly smaller than that in AA. Multivariate analysis showed that saccular structure of the appendix wall, cecum or ascending colon diverticulum and peri-appendiceal or -cecal fluid collection were significant independent indicators of AD. Based on that saccular structure of the appendix wall which was the most important specific finding, the sensitivity and specificity of CT for AD were 48% and 99%, respectively. The saccular structure of the appendix wall, cecum or ascending colon diverticulum and peri-appendiceal or -cecal fluid collection in CT suggest AD in patients with suspected AA. The sensitivity and specificity of CT for diagnosing AD were 48% and 99%, respectively.

A new classification of SMARCA4-deficient tumors was proposed recently for thoracic malignancies, and the tumors have some histopathological characteristics similar to those of carcinosarcoma. We encountered a case of SMARCA4-deficient rectal carcinoma with a sarcomatoid component. A 46-year-old man presented to our hospital with a prolapsing anal mass. Colonoscopy revealed an irregular, nodular, and elevated lesion in the rectum, and the biopsy revealed a moderately differentiated adenocarcinoma. Abdominoperineal resection of the rectum was performed. A macroscopic image of the resected specimen showed a complex tumor 3.5 cm × 3 cm in size with a papillary protrusion and an irregular ulcerative lesion. Histopathological examination revealed that the tumor was composed of moderately/poorly differentiated adenocarcinoma and atypical spindle cells. The adenocarcinoma component was positive for epithelial markers (AE1/AE3 and carcinoembryonic antigen) and showed deletion of SMARCA2 and SMARCA4, while the spindle cells expressed mesenchymal markers (α-smooth muscle actin and vimentin). The pathological diagnosis was poorly differentiated adenocarcinoma with a sarcomatoid component, pT3N2bM0, stage IIIc. Although our case had histological characteristics of carcinosarcoma, immunostaining revealed a deficiency of SMARCA4. This case presented a SMARCA4-deficient colorectal carcinoma with a sarcomatoid component, which was histopathologically similar to carcinosarcoma.

An 83-year-old man visited our hospital because of difficulty swallowing. Gastroscopy revealed multiple ulcers and a reddish depression in the lesser curvature of the middle stomach. The initial biopsy showed regenerative atypia, so a gastroscopy was repeated every 3 months thereafter because of suspected malignancy. A biopsy performed 12 months after the initial gastroscopy revealed a well-differentiated adenocarcinoma. After determination of the planned oral resection line by two negative biopsies, laparoscopic distal gastrectomy was performed. The resected specimen showed a 0 - IIa + IIc lesion composed of well-to-moderately differentiated tubular adenocarcinoma, including hand-shaking-type gastric cancer. The oral resection margin was positive due to widespread mucosal extension; therefore, an additional total gastrectomy was needed. Cases of well-differentiated adenocarcinoma and its superficial extension may be difficult to diagnose via endoscopy and biopsy.

Several studies have analyzed late complications associated with totally implantable venous access ports (TIVAP) implantation via the internal jugular vein (IJV); however, the reported results are inconclusive. The aim of the study is to elucidate the characteristics and risk factors of late complications associated with TIVAP implantation via the IJV. The study included 482 patients who underwent TIVAP implantation for long-term chemotherapy and/or nutritional support between April 2012 and December 2017. Most patients (95.2%) had malignant diseases. Events requiring TIVAP removal were defined as TIVAP-related complications. The median TIVAP and global follow-ups were 319 days (IQR 152–661) and 218,971 catheter days, respectively. The 3-year cumulative TIVAP availability rate was 70%. There were 44 complications (incidence of 9.1%; 0.201 complications/1000 catheter days). Infectious, catheter-related, and port-related complications occurred in 21, 14, and 9 patients, respectively with infectious complications occurring earlier and more frequently than catheter- and port-related complications. Multivariate analysis revealed that age < 65 years and presence of non-gastrointestinal diseases were significant unfavorable factors for TIVAP-related complications. Patients with 1 and 2 of these factors had an elevated risk (2.2 and 5.4 times, respectively) compared with those without. Among the late complications associated with TIVAP implantation via the IJV, infectious complications occur earlier and more frequently than catheter- and port-related complications. Patients with an age < 65 years and having non-gastrointestinal diseases have a significantly high risk of TIVAP-related complications.

Purpose Controversy exists over whether bacterial flora within the appendix differs between patients with and without appendicitis. To examine these potential differences, we cultured the appendiceal luminal microbiota of patients with and without acute appendicitis, and identified the bacterial species therein. Methods Fifty-seven patients with acute appendicitis and 37 patients without acute appendicitis who underwent curative resection of colorectal cancer and prophylactic appendectomies (control group) were included. Appendicitis patients were classified into the phlegmonous group or the gangrenous appendicitis group histopathologically. There was no patient with perforated appendicitis. Aerobic isolates were identified using standard identification schemata, and anaerobic isolates were identified according to the Japanese guidelines. Results There were no significant differences among the three groups in the median number aerobe species present per patient. However, the median number anaerobe species in the gangrenous appendicitis group was significantly higher than that of the control group and the phlegmonous appendicitis group. In addition, the incidence of patients with Bacillus species, Fusobacterium nucleatum, and Bilophila wadsworthia increased as the disease progressed from phlegmonous to gangrenous appendicitis. Conclusion The present results suggest that increased diversity of anaerobes and the translocation of Bacillus species, F. nucleatum, and B. wadsworthia are associated with the progression of acute appendicitis.

Splenic cysts are rare and tend to have elevated tumor markers, of which carbohydrate antigen (CA) 19-9 is the most frequently elevated. Therefore, splenic cysts with elevated serum carcinoembryonic antigen (CEA) levels and without CA19-9 elevation are extremely rare. A 26-year-old woman presented with sudden upper abdominal pain while sleeping. Contrast-enhanced computed tomography (CT) showed an 85-mm simple splenic cyst in the upper pole and a moderate amount of ascites around the spleen. The serum levels of CEA, but not CA19-9, were elevated. Spontaneous rupture of a splenic cyst was diagnosed. We performed elective laparoscopic unroofing. The histological findings revealed a stratified squamous epithelium on the inner surface of the cystic wall. On immunohistochemical examination, the squamous epithelium was found to be positive for cytokeratin (CK)7, negative for calretinin, and positive for CEA. The histological diagnosis was an epidermoid cyst. Three months after the operation, the elevated serum tumor marker levels of CEA were normalized. Splenic cysts with high levels of CEA and low levels of CA19-9 are extremely rare. Laparoscopic unroofing is a useful operative procedure for ruptured splenic cysts with elevated levels of serum tumor markers.

We describe a case of a mucosal prolapse syndrome (MPS)-like inflammatory polyp protruding from the appendiceal orifice, mimicking an appendiceal neoplasm. A 48-year-old man presented with lower abdominal pain and elevated white blood cell count and C-reactive protein level. Computed tomography showed a swollen appendix with multiple small saccular lesions and periappendiceal fat stranding and small saccular lesions in the ascending colon and cecum. Ultrasonography showed a swollen appendix 25 mm in diameter with multiple saccular structures and a periappendiceal high-echoic area, suggesting appendiceal diverticulitis. Colonoscopy revealed an erythematous lesion protruding from the appendiceal orifice. An ileocecal resection was performed based on a preoperative diagnosis of appendiceal diverticulitis and tumor. Histopathological examination of the appendix showed multiple mucosal herniations with infiltration of inflammatory cells, indicating appendiceal diverticulitis. The tumor was characterized by glandular duct hyperplasia and stromal expansion with smooth muscle hyperplasia and was diagnosed as an inflammatory polyp resembling an MPS lesion. Although several studies have shown the macroscopic and endoscopic appearance of MPS-like inflammatory lesions associated with colonic diverticular disease, this case was the first to present an inflammatory polyp associated with appendiceal diverticulitis in which the lesion protruding from the appendiceal orifice was masquerading as an appendiceal neoplasm.

This unicentric, retrospective cohort study aimed to identify the optimal cutoff values of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19–9 (CA19-9) for the prognosis in patients with stage II/III colon cancer. After excluding 43 patients with CA19-9 levels

Due to prognostic heterogeneity within a stage of gastric cancer (GC), identification of patients with a high risk for recurrence after resection is important. We aimed to identify the prognostic significance of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels in patients with Stage I, II, and III GC who underwent R0 gastrectomy.A total of 794 patients were included in this study after excluding 72 patients with CA19-91.0 U/mL. Receiver operating characteristic curves were drawn to assess the optimal cut-off values of CEA and CA19-9 for disease recurrence.The optimal cut-off values of CEA and CA19-9 levels were 2.9 ng/mL and 46.3 U/mL, respectively. Multivariate analysis for relapse-free survival (RFS) showed that stage of GC, CA19-9 levels, postoperative adjuvant chemotherapy, and venous invasion were significant independent factors. The RFS and overall survival (OS) of patients with CA19-9 ≥ 46.3 U/mL were significantly lower than those with CA19-9 46.3 U/mL in Stage III GC. However, the RFS of GC patients with CA19-9 ≥ 463 U/mL tended to be better than those with CA19-9 levels between 46.3 and 463 U/mL.The RFS and OS of patients with CA19-9 ≥ 46.3 U/mL were significantly lower than those with CA19-946.3 U/mL in Stage III GC. However, there was no value dependency of extremely elevated CA19-9 on RFS. Further risk stratification can be obtained by measuring preoperative serum CA19-9 in stage III GC.

Among the phlorotannins of seaweed polyphenols, eckols which have a dibenzodioxin linkage are known to have various physiological functions. The purpose of this study was to investigate the intestinal epithelial absorption of eckols using Caco-2 cell monolayers of the small intestinal membrane model. Each compound permeated from the apical (AP) side to the basolateral (BL) side in the monolayers was identified and quantitated by liquid chromatography-mass spectrometry with electrospray ionization. In the transport assays using five types of eckols (eckol, fucofuroeckol A, phlorofucofuroeckol A, dieckol, and 8,8'-bieckol), only the monomeric eckol showed limited transepithelial absorption with relatively small apparent permeability values (0.30 ± 0.04 × 10−8 cm/s). Analyzing the Hanks’ balanced salt solution in the receiver on the BL side showed that phloroglucinol was detected in all experimental sections using eckols, and it's concentration increased with time over the course of the incubation. The other molecules corresponding to the unconjugated and conjugated metabolites of eckols were not detected in the AP and BL sides through the assays. These results suggest that eckols, including monomeric eckol, may be decomposed into phloroglucinol in the intestinal epithelium and the resulting phloroglucinol permeates to the BL side.

Clostridium cellulovoransproduces multi-enzyme complexes called cellulosomes capable of efficiently degrading cellulosic biomass. There are three xylanase genes containing a sequence corresponding to a dockerin domain that are necessary for constructing cellulosomes in the genome. Among the xylanases encoded by these genes, xylanase B (XynB) contains a catalytic domain belonging to glycoside hydrolase family 10 and a carbohydrate-binding module (CBM) at the N-terminus, making it a member of CBM family 22. In this study, XynB was cloned, overexpressed, purified and crystallized. XynB was crystallized using the hanging-drop vapour-diffusion method in the presence of 0.2 Msodium acetate trihydrate, 0.1 MTris–HCl pH 8.5, 32%(w/v) PEG 4000 at 293 K. X-ray diffraction analysis revealed that the crystal diffracted to 1.95 Å resolution and belonged to space groupP212121, with unit-cell parametersa = 74.28,b= 77.55,c= 88.20 Å, α = β = γ = 90°. The data-evaluation statistics revealed high quality of the collected data, thereby establishing a solid basis for determination of the structure of cellulosomal xylanase fromC. cellulovorans.

Using unused biomass, such as inedible brown macroalgae, as an alternative energy and chemical feedstock is important because these materials are cultivated easily and do not compete with food products. In this study, carbon electrodes modified with titanium dioxide (TiO2) were fabricated and utilized for the photocatalyzed electrochemical oxidation of alginate, a structural polymer derived from brown macroalgae. A prototype fuel cell comprising a TiO2-modified carbon sheet (TiO2/C) electrode immersed in an alkaline solution containing 0.2% (w/v) alginate was irradiated with artificial solar light, yielding a maximum power output of 81 μW cm−2 at an irradiation intensity of 150 mW cm−2. Furthermore, optical absorption and high-performance liquid chromatography analyses of the alginate solution after continuous fuel cell operation for 24 h showed that (1) artificial solar irradiation of the TiO2/C anodes enhances the oxidation of alginate to generate species with CO groups and (2) the generated species include those of lower molecular weights compared to those of the alginate polymer, possibly comparable to that of the constituent monomer unit of alginate. These results suggest that the oxidation pathway includes glycosidic bond cleavage of the alginate polymer chain in a manner similar to alginate oxidation using much harsher oxidizing agents.

Background An inguinal hernia is a common disease; however, a malignant tumor within the inguinal hernia sac is rare, and perforated colon cancer in the hernia sac is extremely rare. Case presentation A 73-year-old man presented to our hospital with high fever and painful bulging of the lower abdomen. Computed tomography showed air-containing fluid in the abdominal wall, as well as localized wall thickness of the sigmoid colon in the left groin. An emergency operation revealed a huge subcutaneous abscess and a hard mass of the sigmoid colon within an indirect inguinal hernia sac. Sigmoidectomy and hernia repair using the Marcy method were performed. Lymph node dissection was performed through a transrectal abdominal incision. Histopathological examination of the resected specimen revealed moderately differentiated adenocarcinoma invading the serosal layer with lymph node metastasis. Conclusions Incarcerated inguinal hernia with perforated colon cancer is rare; an emergent operation should accordingly be performed based on infection control, oncological principles, and secure hernia repair.