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Background Pyoderma gangrenosum begins as a painful erythema with induration, vesicles, or hemorrhagic pustules, which develops into serous ulcers. In addition to ulcerative colitis and myelodysplastic syndrome, surgical intervention may also induce this disease. Case presentation A 90-year-old man had previously undergone video-assisted thoracic surgery left upper lobectomy for left lung cancer. Blood tests on the 6th postoperative day showed elevated levels of white blood cells and C-reactive protein. The wound appeared red and drained pus; however, the wound culture was negative for bacteria. A skin biopsy was performed on the 13th postoperative day, and the patient was diagnosed with pyoderma gangrenosum. Tacrolimus hydrate ointment was administered, symptoms gradually improved around the 18th postoperative day, and the erythematous area shrank. The patient was discharged on the 50th postoperative day. Six months after lung surgery, a pacemaker was implanted in the left subclavian region. On the 6th postoperative day, the wound appeared reddish-brown and exudate was observed. On the 10th postoperative day, wound dehiscence was observed, and the pacemaker was removed. The patient was diagnosed with recurrent pyoderma gangrenosum and was re-treated with ointment. On the 29th postoperative day, a leadless pacemaker, which can be implanted with a small incision, was selected for treating arrhythmia. The patient was discharged 7 days after the second implantation. Conclusion We report a recurrent pyoderma gangrenosum case following lung cancer surgery after pacemaker implantation as the second surgery, in which disease recurrence could be prevented by changing to a leadless pacemaker. Surgery and other invasive procedures should be avoided in pyoderma gangrenosum patients.

INTRODUCTION The laparoscopic approach for elective femoral herniorrhaphy is well established. However, femoral hernias often present as incarcerations and require emergency repair surgery, mainly using the open approach. This study aimed to retrospectively analyze the efficacy of the laparoscopic approach for incarcerated femoral hernias. METHODS Data of patients who underwent emergency surgery for incarcerated femoral hernia between April 2016 and August 2021 were retrospectively analyzed. Laparoscopy was performed whenever possible; however, conversion to an open approach remained a fallback option for when laparoscopic repair was not possible. In laparoscopic repair, incarcerated femoral hernias reduced using traction, water pressure, and preperitoneal methods. Data of patients who underwent open repair and laparoscopy were then compared. RESULTS During the observation period, 20 patients underwent emergency surgery for incarcerated femoral hernia. Eleven patients subsequently underwent repair using a laparoscopic approach, and eight underwent repair using an open approach. Only one patient underwent intestinal resection without hernia repair due to perforated bowel. Operative time for laparoscopic repair was longer. Mesh repair was performed in 18 patients. Four patients each in the laparoscopic repair and open group required intestinal resection. CONCLUSION Incarcerated femoral hernias can be safely repaired using the laparoscopic approach.

Key Clinical Message Splenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management. However, noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event.

A 70-year-old woman with pancreatic ductal adenocarcinoma was initially treated by distal pancreatectomy (DP). Thirty-five months later, another tumor appeared in the pancreatic head and was treated by pancreaticoduodenectomy. Histopathological findings identified both tumors as pancreatic ductal adenocarcinoma pStage IA. Computed tomography (CT) of the chest 16 months after the second pancreatectomy revealed a ground-glass opacity in segment 3 of the right lung. Chest CT 23 months after the second pancreatectomy revealed a nodular shadow in segment 1a of the right lung. Chest CT 39 months after the second pancreatectomy revealed a nodular shadow in segment 5 of the left lung. These lesions were treated by video-assisted thoracoscopic surgery partial resection. Histopathological and immunohistochemical features (positive for cytokeratin (CK)7 and CK20, negative for transcription factor-1) for these three lesions and the secondary pancreatic ductal adenocarcinoma were similar, indicating a diagnosis of lung metastasis from the second pancreatic ductal adenocarcinoma. The patient has remained alive and free of new metastases for 8 years after initial DP, 3 years after the last lung resection. This patient has survived over the long term after undergoing three resections of lung metastases from resected pancreatic ductal adenocarcinoma.

遺伝性球状赤血球症は赤血球の膜異常に起因する疾患で，溶血性貧血，黄疸および脾腫を呈する．治療として中等度～重症例に対し脾臓摘出術が施行されるが，脾組織の散布による異所性脾や残存副脾による再燃がまれに問題となる．今回，我々は脾臓摘出17年後に骨盤内副脾腫大にて再燃し，腹腔鏡下副脾摘出術を施行した遺伝性球状赤血球症の1例を経験したため報告する．症例は21歳の女性で，4歳時に遺伝性球状赤血球症および胆石症に対し脾臓摘出，胆嚢摘出術を受けている．術後17年目に黄疸の再燃にて当院血液内科を受診し，腹部骨盤CTにて骨盤内に8 cm大の腫瘤を指摘され，脾シンチグラムにて同部位に集積を認めた．骨盤内副脾腫大による遺伝性球状赤血球症の再燃と診断され，腹腔鏡下副脾摘出術が施行された．患者は術後6日目に軽快退院した．本疾患は副脾の存在にて，術後数年以上経過してからも再燃の可能性があることを念頭においたフォローアップが必要である．

原発性胆嚢管癌の4例を経験した. 症例1は70歳の男性で, 胆嚢結石症の診断で胆嚢摘出術を施行し, 切除標本で胆嚢管癌と診断され, 2期的に胆管切除, D2郭清を施行した. 組織学的にはpat C, tub1, fm, n1, 2(-)で, 術後9年目に他病死したが再発はなかった. 症例2は61歳の男性で, ERCPで中部胆管の狭窄を認め, 胆管癌の診断にて肝床, 胆嚢, 胆管切除 (D2)を施行. pat C Bm, tub1, ss, n2(+)であった. 術後9年4か月の経過で再発なく生存している. 症例3は54歳の男性で, 経皮経肝胆嚢造影で胆嚢管に不整な途絶を認め, 生検にて胆嚢管癌と診断され, 肝床, 胆嚢, 胆管切除(D2)を施行した. pat C Bm, tub2, ss, n1, 2(-)であったが, 術後16か月目に癌性胸膜炎のため死亡した.症例4は70歳の女性でCTにて胆嚢管腫瘍を認め, 生検で腺癌と診断され, 肝床, 胆嚢, 胆管切除 (D2)を施行した. pat C, pap, ss, n1, 2(-)で, 術後1年の経過で再発なく生存している.

症例は64歳の女性. 背部痛を主訴に近医受診. 腹部超音波検査施行し胆嚢底部から体部にかけて壁の肥厚を認め, 胆嚢癌の疑いにて当院紹介となった. CT, ERCPにて胆嚢底部から体部に壁の肥厚を認め胆嚢癌と診断し, 膵頭十二指腸切除, 肝S4a, S5切除, 横行結腸合併切除術を施行した. 免疫組織化学染色検査, 電子顕微鏡検査から内分泌細胞癌と診断した. 術後2か月で退院し, 外来followしていたが術後3か月目の経動脈性門脈造影下CT (CTAP) で多発性肝転移を認め, FAM (5-Fu+EPI+MMC) によるリザーバー肝動注を2クール施行したところ肝転移巣は消失した. 術後1年目に全身性骨転移をきたし死亡した. 胆嚢の内分泌細胞癌は本邦19例のみのまれな疾患であり早期より転移をきたす予後不良の疾患である. 肝転移に対し化学療法が奏功した報告はなく, 試みる価値のある治療法であると考えられた.

症例は63歳,女性.右乳頭血性分泌,右腋窩腫瘤を主訴に当院受診.生検にて乳腺扁平上皮癌の診断を得たため,胸筋温存乳房切除術を施行した.術後病理組織学的検索にてsquamous cell carcinomaの診断を得た.病理学的に腫瘍部と皮膚との交通を認めず術後の全身精査で他に原発巣を認めなかったため,乳腺原発と考えられた.エストロゲンレセプター,プロゲステロンレセプターは陰性であった.術後9カ月の現在再発を認めず経過観察中である.

We have sugically managed three cases of cancer arising in the reconstructed stomach tube following operation for esophageal caner. Patient 1, a 63-year-old man who had undergone a subtotal esophagectomy with reconstruction by stomach tube via retrosternal route in 1973, was found to have type 3 advanced gastric cancer at the reconstructed stomach tube 9 year after the operation. The patient underwent a distal resection of the stomach tube, but died of local recurrence of stomach tube cancer 2 years and 2 months after second operation. Patient 2, a 62-year-old man who had undergone a subtotal esophagectomy with reconstruction by stomach tube via retrosternal route in 1977, was found to have a IIa+IIc type early gastric cancer at the reconstructed stomach tube 7 year after the operation. A distal resection of the stomach tube was carried out. The patient is still alive as of 4 years after the reoperation. Patient 3 was an 83-year-old woman who had undergone a subtotal esophagectomy with reconstruction by stomach tube via retrosternal route in 1972. Thirteen years later, type IIa early gastric cancer was detected in the reconstructed stomach tube and EMR was performed. The patient is still alive as of 2 years and 6 months after EMR. Two patients who were able to be detected having cancer by screening are living and well without any sign of recurrence. We think that long-term periodic endscopic examinations are mandatory for postoperative patients with esophageal cancer by entertaining the possible occurrence of the stomach tube.

Idiopathic portal hypertension (IPH) requires invasive measures to prevent rupture and bleeding of esophagogastric varices. However, the long-term results of shunt surgery for IPH have not been reported. In particular, the pros and cons of surgery that preserves the spleen and its long-term hematologic effects have not been described. The records of 15 patients who underwent distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for IPH between 1983 and 1998 was reviewed retrospectively. One patient died within 3 years of surgery, for a 3-year survival rate of 93%; the 10-year survival rate was 64%. Three patients (18%) suffered rebleeding from esophagogastric varices. The white blood cell and platelet counts were higher 3-5 years and 7-13 years postoperatively compared with preoperative values. Four of five patients who underwent postoperative computed tomography had a smaller spleen postoperatively. DSRS with SPGD provides long-term hemostasis for esophagogastric variceal bleeding in IPH and alleviates hypersplenism. DSRS with SPGD is an effective treatment for patients with IPH in whom long-term survival is expected.

Bronchopleural fistulas associated with empyema can occur as life-threatening sequelae after pulmonary resection, occurring most frequently after pneumonectomy. Three bronchopleural fistulas, 5-6 mm in diameter, were successfully treated using a fibrin glue-coated collagen patch (FGCCP) and fibrin glue (FG) at the site of a bronchopleural fistula. Through the clinical experiences, we introduce the methodology to perform the endobronchial closure of bronchopleural fistulas.Data were collected by reviewing the clinical charts of patients diagnosed with post-lobectomy bronchopleural fistula at Sapporo Minami-Sanjo Hospital from June 2004 to December 2010. Bronchopleural fistula was diagnosed by means of endoscopic visualization. Three cases of post-lobectomy and one case of post-pneumonectomy bronchopleural fistula were collected.A FGCCP fragment was packed within the fistula, and the fragment grasped with the forceps was kept in this position for approximately a minute, a time during which a FGCCP becomes adhesive, and the patch fragment was released. After releasing the patch fragment, the FG was applied directly on the FGCCP using a two-channel catheter.There have been few reports of the bronchoscopic closure of bronchopleural fistulas using a FGCCP and FG. Closure of small bronchopleural fistulas with the application of a FGCCP and FG may offer a valuable therapeutic alternative.

A right aortic arch is a rare congenital anomaly, with a reported incidence of around 0.1%. A patient with a right aortic arch underwent video-assisted thoracic surgery left lower lobectomy and mediastinal lymph node dissection for squamous cell carcinoma. There was no aortic arch or descending aorta in the left thoracic cavity, but the esophagus. There was no anomaly in the location or branching of the pulmonary vessels, the bronchi, and the lobulation of the lungs. The vagus nerve was found at the level of the left pulmonary artery. The arterial ligament was found between the left subclavian artery and the left pulmonary artery. The recurrent laryngeal nerve was recurrent around the left subclavian artery. A Kommerell diverticulum was found at the origin of the left subclavian artery. The patient experienced no complications. We conclude that video-assisted thoracoscopic lobectomy with mediastinal dissection is feasible for treating lung cancer with a right aortic arch.

Limited pulmonary resection is performed mostly based on the size of lung cancer and ground-glass opacity (GGO). It has been proposed to determine the indication of segmentectomy according to hilar lymph node involvement. There is a potential risk of underestimation for lymph node involvement since there may be a skip mediastinal lymph node metastasis without hilar involvement. We propose to use standardized uptake value( SUV) max of primary lung cancer as an indicator of non-invasive lung cancer. None of 44 small-sized lung cancers with SUVmax lower than 1 had lymph node metastasis or vessel invasion. A small-sized lung cancer ≤ 2 cm with SUVmax ≤ 1 is indicated wedge resection if GGO area is greater than 75% of tumor. Segmentectomy is indicated if the GGO area is less than 75%. We also propose selective lymphadenectomy for small-sized lung cancer. The lower mediastinal lymphadenectomy may be omitted if a small-sized tumor is located in the right upper lobe or the left upper segment. The upper mediastinal lymphadenectomy may be omitted if a small-sized lung cancer is located in the lower lobe and if the lower mediastinal lymph node involvement is excluded.

SUMMARY. Despite advances in the treatment of esophageal carcinoma, the prognosis for this disease remains poor. Therefore, it is important to obtain a better understanding of the molecular basis of esophageal carcinogenesis. The purpose of this study was to clarify the roles of survivin in esophageal squamous cell carcinoma (ESCC). One hundred 22 ESCC surgical specimens resected from 1989 to 1999 were examined. Survivin expression was assessed by immunohistochemistry. Tumor cells were considered survivin-positive if the immunoreactivity was confined to the nucleus, and a scoring method was applied. Survivin-positive immunostaining was detected in 68 patients (56%). There was a significant association between survivin expression and pN (P = 0.0472). Moreover, the overall survival rate was worse in patients with survivin-positive tumors than in patients with survivin-negative tumors (P = 0.0189). The overexpression of survivin was associated with the overall survival rate and poor prognosis in patients with ESCC. Survivin may be targeted during cancer therapy because of its selective expression in malignant tissue.

Dopamine receptors (DRs) are members of seven transmembrane domain trimeric guanosine 5'-triphosphate (GTP)-binding protein-coupled receptor family. Through dopamine receptor activation, dopamine plays a significant role in regulating gene expression, such as induced tumor cell migration.We investigated DRD1 and DRD2 expressions in patients with esophageal squamous cell carcinoma (ESCC) for immunohistochemistry and analyzed differences between DRD1, DRD2, and DARPP-32 expressions of clinicopathological features in 122 patients with ESCC.DRD1 immunostaining correlated with the pathologic grade (P = 0.0127), and DRD2 immunostaining correlated with the pathologic stage (P = 0.0432) and pN classification (P = 0.0112). A significant correlation was found between DRD1 and DRD2 expression (P = 0.0292). However, no correlation was observed between DRD1/DRD2 expression and DARPP-32 expression (P = 0.4555 and 0.4774, respectively). No correlation was observed between the DRD1/DRD2 expression and patient prognosis. To find the cooperative role between DRD1, DRD2, and DARPP-32 expressions, patients were classified into the different groups. In the DRD2/DARPP-32 combination, the (+/-) group was significantly correlated with pathologic stage (P = 0.0006), lymph node metastasis (P = 0.0001), pT (P = 0.0287), and tumor size (P = 0.0202). Moreover, patients with this combination showed a lower survival rate compared with the other three groups (P = 0.0287).We conclude that DRD2/DARPP-32 expression is associated with tumor progression and that DRD2/DARPP-32 expressions may help predict prognosis in patients with ESCC.

This retrospective study was undertaken to assess the changes in the clinical status of patients with generalized myasthenia gravis (MG) treated with extended thymectomy and to identify prognostic variables that may be of significance in optimizing patient selection.We reviewed the clinical outcomes of 17 patients who underwent extended thymectomy for MG. Main factors influencing the outcome are changes in clinical stage and medication requirement before and after thymectomy, age, sex, duration of disease, stage of disease, antibody status, histological characteristics of the thymus, and duration of follow-up.There was remission in 4 patients (23.5%), improvement in 9 patients (53%), and no change in 4 patients (23.5%). Patients in Osserman stage IIB and with a higher rate of decrease in acetylcholine receptor (AchR) antibody ratio showed a greater degree of postoperative improvement. Age of the patient, sex, presence or absence of thymoma, and time elapsed between diagnosis and operations were not found to be significant prognostic factors.The present study demonstrated that extended thymectomy for MG is an effective therapy with no great morbidity or mortality. Patients in preoperative stage IIB and with higher rate of change in the AchR antibody titer showed the greatest degree of postoperative improvement.

Purpose: Pigment epithelium–derived factor (PEDF), which has recently been shown to be the most potent inhibitor of angiogenesis in the mammalian eye, is also expressed in the pancreas. Previously, we have screened the expression of PEDF by immunohistochemical analysis and showed that low expression of PEDF is associated with increased risk of hepatic metastasis and short survival. The purpose of this study was to investigate whether PEDF gene is a potent tumor suppressor and a potential candidate for cancer gene therapy. Experimental Design: We investigated both in vitro and in vivo growth characteristics of human pancreatic adenocarcinoma cell lines that were stably transfected to overexpress human PEDF and therapeutic effects of lentivirus-based vectors expressing PEDF on tumor growth in murine s.c. tumor model. Results: We discovered that cells secreted PEDF protein in the media and this exhibited strong inhibitory effects on proliferation and migration of human umbilical vein endothelial cells. The size of PEDF-overexpressing pancreatic adenocarcinoma tumors was significantly smaller than that of control tumors in s.c. tumor models. Moreover, the growth of PEDF-overexpressing pancreatic adenocarcinoma cells was significantly suppressed in comparison with control cells in peritoneal metastasis models. In gene transfer models, intratumoral injection of a lentivirus vector encoding PEDF (LV-PEDF) caused significant inhibition of tumor growth. The antitumor effect observed after treatment with LV-PEDF was associated with decreased microvessel density in tumors. Conclusion: Our data suggest that PEDF may exert a biological effect on tumor angiogenesis and PEDF gene therapy may provide a new approach for treatment of pancreatic adenocarcinoma.

SUMMARY. We performed a multi-institutional analysis of E2F1 and cyclin D1 expression in cases of esophageal squamous cell carcinoma (ESCC). Cyclin D1 and E2F1 are involved in the transition of cell cycle phases and associated with tumor progression. However, no previous studies have concurrently analyzed combined E2F1 and cyclin D1 expression. The purpose of this study was to clarify the relationship of E2F1 and cyclin D1 in ESCC. We studied 122 patients with primary ESCC who underwent surgical tumor resection. Immunohistochemical analyses were performed for E2F1 and cyclin D1. A statistical analysis of immunohistochemistry results, clinicopathological features, and prognosis was performed. E2F1/cyclin D1 (-/-) tumors were present in 31 patients (25.4%) and correlated with reduced tumor progression. In these patients, pT (P=0.0001), pN (P

Pigment epithelium-derived factor (PEDF) is expressed in several normal organs and identified as an inhibitor of neovascularization. In the present study, we screened the expression of PEDF immunohistochemically and investigated its correlation with clinicopathological features in patients who underwent surgery for ductal pancreatic adenocarcinoma. Of the 80 patients, 22 cases (27.5%) were positive for PEDF. A significant association was found between the PEDF expression and low microvessel density (P = 0.0003). No correlation was found between PEDF expression and age, gender, depth of invasion, tumor diameter, lymphatic invasion, venous, invasion or histopathological grading. The patients in pathological stage II had a significantly higher incidence of PEDF-positive expression than those in pathological stage III or IVA (P = 0.0418). PEDF immunoreactivity was inversely associated with liver metastasis (P = 0.0422). The survival of patients that were PEDF positive was significantly longer than that of those with negative expression (P = 0.0026). Multivariate analysis using the Cox regression model indicated that PEDF-positive expression was an independent favorable prognostic factor (risk ratio, 0.394; P = 0.0016). We conclude that PEDF expression suggests a more favorable prognosis than in patients whose carcinomas lack PEDF expression.