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Introduction: The learning curve for totally extraperitoneal repair (TEP) is longer and steeper than that for transabdominal preperitoneal repair (TAPP) due to the preperitoneal view to which the surgeon is not accustomed and the limited working space. The aim of this study was to clarify the learning curve for SILS‐TEP. Methods: A retrospective analysis of 80 consecutive patients with unilateral inguinal hernia was performed. All patients underwent elective SILS‐TEP performed by a single learning surgeon with a teaching assistant between July 2016 and March 2018 at Kinki Central Hospital. Results: The operative time decreased gradually after 20 cases and stabilized after 40 cases. The first 40 cases were categorized as the learning period group, and the remaining 40 cases were categorized as the experienced period group. More patients received antithrombotic therapy in the experienced period than in the learning period (P < 0.05). The median operative time was 107 and 60 min in the learning period and the experienced period, respectively (P < 0.05). There were no significant differences in blood loss peritoneal injury, conversion to a different procedure, postoperative hospital stay, complications, and recurrence between the two groups. No major complications or hernia recurrence were noted during follow‐up. Conclusions: The learning curve for SILS‐TEP might take 40 cases to reduce the operative time. SILS‐TEP can be performed safely by a learning surgeon with a teaching assistant. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to evaluate the efficacy of single‐incision laparoscopic surgery for totally extraperitoneal repair (SILS‐TEP) of irreducible inguinal hernias and incarcerated inguinal hernias. Methods: We performed a retrospective analysis of 194 patients, including 16 with irreducible or incarcerated hernia, who had undergone SILS‐TEP from May 2016 to December 2017 at Kinki Central Hospital. The outcomes of patients with irreducible or incarcerated hernia and those with reducible hernia were compared. For irreducible or incarcerated hernia, laparoscopic exploration with hernia reduction through an intraumbilical incision was performed. If no bowel resection was needed, one‐stage SILS‐TEP was performed. If bowel resection was required, two‐stage SILS‐TEP was performed 2–3 months after the bowel resection. Results: Of the 16 patients, 8 had an irreducible hernia, and 8 had an incarcerated hernia. The eight patients with an incarcerated hernia underwent emergency surgery, and among these patients, two needed single‐incision laparoscopic partial resection of the ileum followed by two‐stage SILS‐TEP. Fourteen patients, excluding the two patients who required single‐incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by one‐stage SILS‐TEP. Among these 14 patients, one with an irreducible hernia required conversion to Kugel patch repair. The operative outcomes were generally comparable between the two groups. However, the operative time was longer for unilateral hernia, and more seromas were seen in the irreducible or incarcerated group. No other major complications or cases of hernia recurrence were noted in this study. Conclusions: SILS‐TEP, which offers good cosmetic results, can be safely performed for irreducible or incarcerated inguinal hernia. [ABSTRACT FROM AUTHOR]

A 78-year-old man was diagnosed as HER2-positive unresectable advanced gastric cancer(cT4aN3M1[LYM], Stage Ⅳ). After 2 courses of first-line chemotherapy(S-1 plus oxaliplatin plus trastuzumab), PR was achieved. The treatment could not be continued due to adverse events after 5 courses, thus second-line chemotherapy was conducted. Corresponding to the physical condition. The third-line chemotherapy was also introduced. However, we clinically judged PD because of amount of ascites and chemotherapy was terminated. After that, he has survived for more than 2 years without chemotherapy, and endoscopy and CT showed the disappearance of the tumor, metastatic lymph nodes, and ascites at 41 months after diagnosis. Looking back on the changes in tumor markers, it was possible that he had already achieved CR at the first-line chemotherapy.

A 78-year-old man was diagnosed with lymph node metastasis 2 months after surgery for gastric neuroendocrine carcinoma. He received chemotherapy(CDDP plus CPT-11)and showed partial response(PR)after 3 courses of the regimen. Serum CEA increased 5 months after surgery, thus nab-paclitaxel plus ramucirumab was administered. Although the lymph node kept shrinked after 2 courses of the regimen, the lymph node was detected 12 cm of the size in CT after 5 courses of the regimen. He started to receive nivolumab. The lymph nodes showed PR after 4 courses, and complete response after 6 courses of the regimen for 1 year and 4 months until now.

The study presents the case of a 71-year-old woman who visited a nearby hospital for epigastric pain and weight loss. A CT scan showed a mass in the gallbladder, and the CEA level was high, so she was referred to our hospital for further investigation. Abdominal US, CT, and MRI suggested gallbladder cancer with para-aortic metastasis, and the histological findings on the EUS-FNA confirmed the diagnosis. Since surgical resection was not indicated, chemotherapy was performed(gemcitabine plus cisplatin). After 10 courses of chemotherapy, CT and MRI showed downsizing of para-aortic lymph nodes, and no accumulation of FDG was found on FDG-PET. Confirming the downstaging of cancer, conversion surgery, comprising an extended cholecystectomy and a lymph node resection, was performed. The pathological diagnosis showed no lymph node metastasis. No recurrence was observed after 12 months of surgery. Initially, unresectable gallbladder cancer with para-aortic lymph node metastasis was indicated to be compatible with preoperative chemotherapy and conversion surgery.

A 52-year-old man underwent total gastrectomy for gastric cancer and chemoradiotherapy for thoracic paraaortic lymph node metastasis. He also underwent esophageal stent implantation for stenosis. He was admitted to our hospital with fever and breathing difficulty and was diagnosed with infectious pericarditis. He showed symptoms of shock due to cardiac tamponade. After pericardial drainage, his vital signs improved. When signs of infection are detected in patients with a history of chemoradiotherapy or stent implantation, we should consider infectious pericarditis due to esophageal pericardial fistula and apply immediate drainage of cardiac tamponade.

The patient was a 60-year-old man who underwent distal gastrectomy for gastric cancer. The pathological diagnosis was Stage ⅡB. He received adjuvant chemotherapy(capecitabine plus oxaliplatin: CapeOX)for 6months and the postoperative course was uneventful. One year and 3 months after surgery, he visited the outpatient department for acute lower back pain. Blood tests showed elevated ALP(3,752 U/L), LDH(308 U/L), and CA19-9(69.4 U/mL)levels. Bone scintigraphy showed multiple bone metastases to the femora, ischium, iliac bone, vertebrae, sternum, costae, and scapulae in a super bone scan. The onset of disseminated intravascular coagulation(DIC)was observed later. The patient was diagnosed with disseminated carcinomatosis of the bone marrow. Radiation therapy was performed and anti-RANKL monoclonal antibody was administered for the bone metastases. Recombinant human soluble thrombomodulin was administered for DIC. He received chemotherapy( TS-1 plus cisplatin: SP)but died 4 months after the diagnosis. The prognosis of disseminated carcinomatosis of the bone marrow is extremely poor. We report this case along with a literature review.

Malignant stricture and fistula of the esophagus and tracheobronchus adversely affect the quality of life(QOL)in patients with advanced esophageal cancer. Stenting is one ofthe therapies available for these patients. We investigated the outcomes ofesophagus and tracheobronchial stenting in our institution. Eight patients with advanced esophageal cancer underwent double stenting from 2010 to 2016. Among them, 4 patients underwent double stenting as planned. One patient underwent an emergency tracheal stenting because ofstenosis ofthe trachea caused by esophageal stenting. Three patients underwent tracheobronchial stenting later on because ofan increase in the tumor size after esophageal stenting. Dysphagia score was improved in 5(67.5%)out ofthe 8 patients. Respiratory symptoms were improved in all patients, and 4 patients(50.0%) were discharged. The median survival time after esophageal stenting was 70.5 days. Esophagus and tracheobronchial stenting for advanced esophageal cancer was useful for the improvement of the QOL.

Chemotherapy is performed for the recurrence of gastric cancer in many cases. We report a case of recurrent lymph node metastasis successfully treated with chemoradiotherapy and chemotherapy. A man in his 60s underwent total gastrectomy and D2 dissection in 2009. The pathological diagnosis was poorly differentiated adenocarcinoma, T4a, int, INF b, ly2, v2, LN#2: 2/3, #3: 1/4, #7, 8, and 9: 3/4, stage III B. Although we administered S-1/UFT as postoperative adjuvant chemotherapy, a strong rash appeared and the patient ceased chemotherapy. Eight months later, the rash had disappeared. We started chemotherapy with paclitaxel(PAC). CT performed 1 year postoperatively showed celiac lymph node(#9)metastasis. Chemoradiotherapy( RT+PAC)and additional CPT-11(98mg)and CDDP(49mg)treatment were administered. The lymph node (#9)was cicatrized after 8 cycles. Forty-two months after the end of treatment, the patient has had no recurrence. It is thought that chemoradiotherapy is an effective cure for local recurrence of gastric cancer.

An 80-year-old woman was treated with low anterior resection and D3 lymph node dissection for rectal carcinoid in August 2007. Pathological diagnosis was a tumor 23 × 22 mm in size with muscularis propria invasion, ly1, v0, n1 (No. 251[1/12]). Partial hepatectomy was performed for liver metastasis in March 2010 and September 2011. In June 2013, an isolated tumor of 17 mm in diameter was detected between the inferior vena cava and the stomach using abdominal ultrasonography. The tumor was diagnosed as pancreatic head lymph node metastasis using abdominal enhanced computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET); fluorodeoxyglucose (FDG) uptake was noted at the site of the tumor, but not at other parts of the body. Curative resection was the chosen treatment option. Open surgery was performed in September 2013, and a tumor 30 mm in diameter located at the ventral side of the inferior vena cava, lateral side of the portal vein, and cranial side of duodenum was resected. No surrounding tissue infiltration was found. Pathological analysis of the resected specimen indicated lymph node metastasis of the rectal carcinoid. The patient has been disease free for 9 months after surgery.

We report a case of long-term survival after combination chemotherapy and surgical resection of a cancer of unknown primary site[ CUPs]. A septuagenarian female was identified as having high blood levels of carcinoembryonic antigen (CEA) during follow-up monitoring of asthma. Endoscopy and imaging studies including computed tomography (CT) and positron emission tomography (PET)-CT revealed a malignant lymph node adjacent to the abdominal aorta; however, no other lesion was detected. Therefore, we performed CT-guided biopsy and diagnosed the lesion to be a lymph node metastasis of poorly differentiated adenocarcinoma. As we considered this as a systemic disease, the patient received 2 courses of combination chemotherapy with 5-fluorouracil( 5-FU)/cisplatin( CDDP) and achieved a partial response (PR). Later, the patient received S-1 therapy as second-line chemotherapy and S-1/irinotecan( CPT-11) as third-line chemotherapy in an outpatient clinic. However, the tumor continued to grow, and therefore, we decided to perform surgical resection. Histopathological examination of the resected specimen yielded a diagnosis of metastatic adenocarcinoma of the lymph node. The patient has been well without any signs of recurrence for more than 9 years since surgery. As CUPs is generally associated with poor prognosis, this case raises the possibility that combination therapy might improve convalescence.

A 63-year-old man visited our clinic with a chief complaint of a left axillary mass, and after a series of examinations, gastric cancer was diagnosed. Histopathological examination revealed a human epidermal growth factor receptor (HER)-2- positive( immunohistochemistry[ IHC], 2+; fluorescence in situ hybridization[ FISH], positive) poorly differentiated adenocarcinoma, and SPT therapy( S-1 at 120 mg/m2/day+cisplatin[ CDDP] at 60 mg/m2+trastuzumab at 8 mg/kg) was initiated. The primary lesion and swollen lymph nodes initially decreased markedly in size; however, the lymph node swelling worsened at 186 days( 6.2 months) after the initiation of treatment. Progressive disease( PD) was diagnosed, and SPT therapy was terminated. One cycle of S-1+docetaxel was administered as second-line therapy, but the regimen was changed to docetaxel monotherapy due to adverse effects. After 5 cycles of this treatment, the primary lesion had decreased in size and the lymphadenopathy disappeared. Positron emission tomography( PET)-computed tomography (CT) revealed fluorodeoxyglucose( F18)( FDG) accumulation only in the primary lesion, and therefore, with the patient's informed consent distal gastrectomy was performed approximately 14 months after the first treatment. The postoperative diagnosis was gastric cancer fStage IA (T1a, N0, and M0). Here, we discuss a case of HER2-positive gastric cancer with references. Among the advanced recurrent gastric cancers tested between April 2011 and February 2013, 16.4% (11/67) were HER2-positive.

We report herein a long-term survival case of liver metastasis after distal gastrectomy for gastric cancer. A 72-year-old woman, whom we performed distal gastrectomy with D2 lymph node dissection for type 2 gastric cancer at age 66, was diagnosed as pT2N1M0, stage II. No adjuvant therapy was performed. Liver metastasis was found 1 year and 7 months after surgery. PTX plus CPT-11 was performed. Six courses of therapy were done, and found cCR in the liver metastasis. A total of 23 courses of therapy were done. A recurrence of liver metastasis was found, transcatheter arterial chemoembolization (TACE), radiofrequency ablation( RFA)and operation were performed. She received S-1 plus CDDP, and cCR has been maintained for 6 years and 11 months after gastrectomy (5 years and 4 months after liver metastasis) suggesting that the interdisciplinary therapy was effective.

A patient is a 62-year-old man who was presented by epigastralgia. He was pointed out super advanced gastric cancer with paraaortic lymph node metastasis and pancreatic invasion by gastrointestinal endoscopy (GIS) and computed tomography (CT). We diagnosed as cT4N3M0, and started with chemotherapy as follows. S-1 (120 mg/day) was orally administered for 3 weeks followed by 2-week rest as one course, and CDDP (90 mg/body)was administered by intravenous drip on day 8. Partial response was indicated after 6 courses of this procedure. We changed the procedure to S-1 single treatment for 2 weeks followed by 2-week rest. After 12-course of this procedure, he was attacked by brain infarction, the procedure was interrupted for about 8 months. After rehabilitation, an S-1 single treatment was restarted. The main tumor and metastatic lymph node appeared no change before the interruption of S-1 single treatment. So, we considered that complete response was continued. S-1+CDDP and S-1 single regimen appears to be effective for super advanced gastric cancer.

A 40s male was performed proximal gastrectomy with D1+alpha dissection and interposition reconstruction for type 1 esophago-gastric junctional cancer in January 2002. Pathological findings were as follows: pap, se, ly0, v0, n1 (#3, 1/9) stage IIIA, curability B. Adjuvant chemotherapy by 5'-DFUR (800 mg/day) was done for 1 year. Bilateral pulmonary metastasis was detected in left S6 (3.8 cm) and right S10 (3 cm) in February 2006. After S-1 (120 mg/day) was administered for 4 courses, right pulmonary metastasis had become scar, and the other was remained and growing. S-1 (100 mg/ day 1-21)+CPT-11 (120 mg div day 1, 15) was done for 6 courses. However, the tumor was growing. As no other lesions but left pulmonary metastasis in S10, radical thoracoscopic left lower lobectomy with ND1 lymph node dissection was performed. Pathological finding was pulmonary metastasis from gastric cancer with no lymph node metastasis. There were no recurrences observed in May 2009 since gastrectomy was done 7 years ago, and 3 years since pulmonary metastasis was detected.

The first case is a man in his 30s with gastric cancer, of which clinical finding was T3N0M0P0M0 (Stage II), underwent a distal gastrectomy with D2 lymphadenectomy. CY1 was detected during the operation and the final findings was T3N2M0H0P0CY1 (Stage IV). After the operation, we administered 120 mg/day of S-1 for 38 months and the patient remains alive for 6 years and 2 months. The second case is a man in his 20s with gastric cancer, of which clinical finding was T3N0M0P0M0 (Stage IIIa), underwent a distal gastrectomy with D2 lymphadenectomy. CY1 was detected during the operation and the final findings was T3N2M0H0P0CY1 (Stage IV). After the operation, we administered 120 mg/day of S-1 for 13 months and the patient remains alive for 6 years and 2 months. A combination gastrectomy with D2 lymphadenectomy and postoperative chemotherapy was considered to be a radical treatment for CY1, Stage IV gastric cancer.

A 69-year-old man was diagnosed with squamous cell carcinoma of the lung, and underwent right upper lobectomy in October 2000. Histological findings were as follows: 2.5 cm in diameter, moderately differentiated squamous cell carcinoma of the lung, ly0, v0, n0, pT1N0M0, stage IA. No adjuvant therapies were performed. Multiple lung metastases were detected on CT scan in June 2001, and four cycles of chemotherapy with cisplatin+vindesine (day 1: cisplatin 100 mg/body, days 1, 8 and 15: vindesine 3 mg/body) were performed. The metastases were completely disappeared on CT scan in December 2001. No relapse has been seen for six years and two months.

Intraductal papillary-mucinous carcinoma (IPMC) is a recently recognized pancreatic tumor and this is the first report to present two patients with IPMC complicating tumor thrombi in the portal vein. Two women, a 74- and a 55-year-old, each revealed a round, cystic and well-demarcated tumor of the pancreas in an abdominal computed tomography (CT). However, the inner lumen of the splenic and portal veins was insufficiently stained during iv-infusion of the contrast medium, suggesting the presence of tumor thrombi. Owing to this information, the presence of tumor thrombus was investigated and correctly identified during laparotomy, and it was completely removable together with the primary pancreatic tumor. The resected tumors showed expansive growth because mucin and tumor tissues rose up when they were cut. Microscopically, the tumor was diagnosed as adenocarcinoma without ovarian-like stroma, and the final diagnosis of branch type of IPMC was made for the two patients. However, within one postoperative year, both patients developed liver metastasis. Although IPMC is known as having a lower potential for metastasis or invasion, the tumor thrombi can form when it reveals an expansive growth suggesting a high inner pressure. In addition, a higher possibility for subsequent liver metastasis should be anticipated after the tumor forms a thrombus in the portal vein.

Background/aims: Brain metastasis, rarely observed as a tumor recurrence after curative surgery for thoracic esophageal cancers (TEC), has been increasingly observed with improvement of the clinical outcome of TEC., Methodology: Records of 254 TEC patients who developed recurrent cancers after curative surgery during 1984-2002 revealed 11 patients (4.3%) with symptomatic brain metastasis, which were classified as five without extra-cranial disease (Brain type) and six with other metastatic diseases (Systemic type)., Results: Brain metastases were significantly associated with an advanced clinical stage and perioperative chemotherapy, which had been undergone by 73% of the brain metastasis patients, but only 23% for non-brain metastasis patients (p = 0.0008). Comparing to Systemic type, Brain type showed longer duration from esophagectomy to brain metastasis and tended to be more effective for perioperative chemotherapy. All Brain type but only two Systemic type brain metastases were removed by surgery. The average survival after brain metastasis was 17.7 months for the Brain type patients (two alive without tumor recurrence), but only 38.5 days for the Systemic type patients. The histological hallmark of Brain type metastasis was medullary tumor growth with mature tumor vessels, while Systemic type showed invasive tumor growth with naive capillaries., Conclusions: Postoperative brain metastasis in TEC patients is not rare, especially in an advanced clinical stage following perioperative chemotherapy. Surgical removal of brain metastasis might be the most promising treatment unless tumor metastasis in other organs is evident.

The patient was a male in the sixties who received interferon therapy against hepatitis C. At first, the patient was pointed to having an increased alpha fetoprotein (AFP) level of 1104 ng/ml. Partial hepatectomy was performed against hepatocellular carcinoma (HCC) (segment 3, 44 mm in diameter) and diagnosed by further exams. The serum AFP level decreased to a normal range after hepatectomy for the time being. A rapid elevation of serum AFP level (11,293 ng/ml) was observed nine months after the surgery. No evidence of recurrence in the intra- and extra hepatic organs such as adrenal gland, lung, bone, and brain except for intra abdominal solitary lymph node metastasis was observed. Then the metastatic lymph node was removed surgically. After the removal of the lymph node, the serum AFP level decreased within a normal limit immediately. This patient currently survives without the disease for 30 months after the initial operation, and for 19 months after a resection of the meatastatic lymph node.