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Purpose Even though minor, stoma-related complications significantly impact quality of life, they are often excluded from clinical analyses that compare short-term postoperative outcomes of loop ileostomy (LI) and loop colostomy (LC). This study compares stoma-related complications between LI and LC after rectal resection, including minor complications, and discusses the characteristics of diverting stoma (DS) types. Methods A retrospective review was conducted in patients who underwent DS construction after rectal resection. Data on patient background and postoperative short-term outcomes, including stoma-related complications and morbidity after stoma closure, were collected and compared between LI and LC groups. Morbidities of all severity grades were targeted for analysis. Results A total of 47 patients (27 LI, 20 LC) underwent DS construction following rectal resection. Overall stoma-related complications, incidence of skin irritation, high-output stoma, and outlet obstruction were found to be significantly higher in the LI group. In addition, high-output stoma and outlet obstruction were absent in the LC group. Regarding morbidity after stoma closure, operation times and surgical site infections were significantly higher in the LC group while anastomotic leakage after DS closure occurred (2 cases; 15%) in the LC group but not the LI group. Conclusion Because stoma-related complications were found to be significantly higher in the LI group, and even these minor complications may impair patient’s QOL, early LI closure is recommended. For LC, stoma-related morbidities are lower but post-closure leakage is a calculated risk.

The activities of non-haematopoietic cells (NHCs), including mesenchymal stromal cells and endothelial cells, in lymphomas are reported to underlie lymphomagenesis. However, our understanding of lymphoma NHCs has been hampered by unexplained NHC heterogeneity, even in normal human lymph nodes (LNs). Here we constructed a single-cell transcriptome atlas of more than 100,000 NHCs collected from 27 human samples, including LNs and various nodal lymphomas, and it revealed 30 distinct subclusters, including some that were previously unrecognized. Notably, this atlas was useful for comparative analyses with lymphoma NHCs, which revealed an unanticipated landscape of subcluster-specific changes in gene expression and interaction with malignant cells in follicular lymphoma NHCs. This facilitates our understanding of stromal remodelling in lymphoma and highlights potential clinical biomarkers. Our study largely updates NHC taxonomy in human LNs and analysis of disease status, and provides a rich resource and deeper insights into LN and lymphoma biology to advance lymphoma management and therapy.

Background Primary liposarcoma arising from the liver is exceedingly rare. There have been very few reports documenting primary hepatic liposarcoma, especially of the pleomorphic subtype. Surgery is currently the only established treatment method, and the prognosis remains poor. In this report, we present an unusual case of hepatic liposarcoma of the pleomorphic subtype with literature review. In addition, we discuss theories regarding pathogenesis and the pathological and clinical features of primary hepatic liposarcoma to better outline this rare entity. Case presentation An asymptomatic 65-year-old female was found to have a right hepatic mass on a computed tomography scan 2 years after surgical resection of the left adrenal gland and kidney for adrenocortical carcinoma. Laboratory examinations were unremarkable. Magnetic resonance imaging demonstrated a 16-mm mass in the right hepatic lobe. Adrenocortical carcinoma metastasis was suspected. Laparoscopic partial hepatectomy completely removed the tumor with clear margins. Macroscopically, the surgical specimen contained a nodular, yellow–white mass lesion 20 mm in diameter. On pathologic examination, pleomorphic, spindle-shaped tumor cells containing hypochromatic, irregularly shaped nuclei of various sizes formed fascicular structures. Scattered lipoblasts intervened in varying stages. Mitotic cells were frequent. Ki-67 labeling index was 15%. Immunohistochemically, the tumor cells were diffusely positive for vimentin and focally positive for CD34 and alpha-SMA; lipoblasts were focally positive for S-100. Tumor cells were nonreactive for SF-1, inhibin alpha, desmin, HHF35, HMB45, Melan A, MITF, c-kit, DOG1, cytokeratin AE1/AE3, h-caldesmon, STAT6, CD68, MDM2, CDK4, c17, DHEAST, 3BHSD, CD31, Factor 8, and ERG. From these findings, primary hepatic liposarcoma of pleomorphic subtype was diagnosed. The tumor recurred intrahepatically 3 years later, and the patient died 5 months after recurrence. Conclusions In our report, we discussed the rarity, theories regarding pathogenesis, and a review of the literature of this atypical condition. To the best of our search, this is the 14th case of primary hepatic liposarcoma and the 2nd case of the pleomorphic subtype reported throughout the world. Further research regarding the etiology of this unusual clinical entity is warranted to establish effective diagnostic and management protocols.

Background An open abdomen with frozen adherent bowels is classified as grade 4 in Björck’s open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management. Case presentation A 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy. Conclusions Primary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.

Background: Transmediastinal esophagectomy for esophageal cancer occasionally causes postoperative accumulation of pleural effusion despite the preservation of the mediastinal pleura. Transhiatal chest drainage has been reported to be useful for thoracic esophagectomy; however, its use in transmediastinal esophagectomy remains unelucidated. This study aimed to evaluate the effectiveness and safety of transhiatal chest drainage in transmediastinal esophagectomy.Methods: This retrospective study included patients who underwent transmediastinal esophagectomy for esophageal cancer from 2018 to 2021. Transhiatal chest drainage involved the insertion of a 19-Fr Blake® drain from the abdomen to the left thoracic cavity through the hiatus. We assessed its effectiveness and safety by the daily drainage output, accumulation of postoperative pleural effusion, frequency of postoperative thoracentesis, and other complications. The drainage group comprising 24 patients was compared with the non-drainage group comprising 13 patients in whom a transhiatal chest drainage tube was not placed during transmediastinal esophagectomy.Results: The median daily output of the transhiatal chest drainage was 230 mL on day 1, 385 mL on day 2, and 313 mL on day 3. The number of patients with postoperative pleural effusion was significantly reduced from 10/13 (76.9%) in the non-drainage group to 4/24 (16.7%) in the drainage group (p=0.001). The frequency of thoracentesis in the drainage group was significantly lower than that in the non-drainage group (p=0.002). There were no significant differences in the occurrence of other postoperative complications.Conclusions: Transhiatal chest drainage could evacuate pleural effusion effectively and safely after transmediastinal esophagectomy.

Aim To evaluate the efficacy of a novel hydrogel sheet in preventing postoperative pancreatic fistula (POPF). Background Postoperative pancreatic fistula is a life‐threatening complication. As no study has reported the use of hydrogel sheets in preventing POPF, their effectiveness for that purpose remains unclear. Methods A novel hydrogel sheet made of polyvinyl alcohol (PVA) was prepared by the freeze‐thaw method. The pancreatic ducts and surrounding pancreatic parenchyma of rats were transected to induce a pancreatic fistula. Next, the sheet was attached to the transection site. Ascitic fluid amylase and lipase concentrations were measured. Neoveil®, a nonwoven polyglycolic acid (PGA) felt, is already clinically used as an absorbable reinforcing material at pancreatic transection sites. Neoveil® was used for comparison, as was VIEWGEL®, which is marketed as a wound dressing. Results The hydrogel sheet remained in place 48 hours postoperatively. The ascitic amylase concentrations in the control, VIEWGEL®‐treated, Neoveil®‐treated, and hydrogel‐treated rats, respectively, were 4992.4 ± 5355.7, 1068.4 ± 269.1, 730.2 ± 425.2, and 303.1 ± 240.1 IU/L; the ascitic lipase concentrations were 2279.8 ± 3395.2, 169.5 ± 100.6, 90.4 ± 71.0, and 86.8 ± 59.8 IU/L. The ascitic amylase and lipase levels were significantly lower in the hydrogel group than in the other groups (P, Highlight Kemmochi and colleagues developed a novel hydrogel sheet made of polyvinyl alcohol to prevent postoperative pancreatic fistula. Rat pancreases were transected to induce pancreatic fistula, and Viewgel®, Neoveil® or the hydrogel sheet were attached to the transected site. The hydrogel sheet showed a higher preventive effect than existing medical materials.

This paper reports the 5-year operational status of the third phase of the"All Japan E-Learning Cloud of the Training Program for Oncology Professionals"by tabulating the viewing trends of available lecture contents. In this phase, the goal was to train cancer genome medical professionals in this new, advanced medical technology field as well as train personnel to treat rarely encountered pediatric, adolescent/young adult, and other life stage cancers. Additionally, new lecture items have been added to the e-learning cloud in collaboration with 7 oncology specialist centers, contributing to the development of human capital in cancer care(including graduate student education)and faculty development for local medical professionals.

Drug resistance represents an obstacle in colorectal cancer (CRC) treatment because of its association with poor prognosis. rBC2LCN is a lectin isolated from Burkholderia that binds cell surface glycans that have fucose moieties. Because fucosylation is enhanced in many types of cancers, this lectin could be an efficient drug carrier if CRC cells specifically present such glycans. Therefore, we examined the therapeutic efficacy and toxicity of lectin drug conjugate therapy in CRC mouse xenograft models. The affinity of rBC2LCN for human CRC cell lines HT‐29, LoVo, LS174T, and DLD‐1 was assessed in vitro. The cytocidal efficacy of a lectin drug conjugate, rBC2LCN‐38 kDa domain of pseudomonas exotoxin A (PE38) was evaluated by MTT assay. The therapeutic effects and toxicity for each CRC cell line‐derived mouse xenograft model were compared between the intervention and control groups. LS174T and DLD‐1 cell lines showed a strong affinity for rBC2LCN. In the xenograft model, the tumor volume in the rBC2LCN‐PE38 group was significantly reduced compared with that using control treatment alone. However, the HT‐29 cell line showed weak affinity and poor therapeutic efficacy. No significant toxicities or adverse responses were observed. In conclusion, we demonstrated that rBC2LCN lectin binds CRC cells and that rBC2LCN‐PE38 significantly suppresses tumor growth in vivo. In addition, the efficacy of the drug conjugate correlated with its binding affinity for each CRC cell line. These results suggest that lectin drug conjugate therapy has potential as a novel targeted therapy for CRC cell surface glycans., rBC2LCN lectin showed affinity for colorectal cancer (CRC) cell surface. rBC2LCN‐PE38 suppressed subcutaneous CRC tumor growth rates in mouse models. Lectin drug conjugate therapy could be a novel therapeutic option for CRC.

Background and Aim The incidence of non‐alcoholic steatohepatitis (NASH)‐related hepatocellular carcinoma (HCC) is progressively increasing. However, the pathophysiology and etiology of NASH progression to HCC are unknown. We hypothesized that steatosis was the key factor in NASH‐related hepatocarcinogenesis and aimed to evaluate the effects of long‐term liver X receptor (LXR) agonist stimulation on hepatic steatosis induced by a high‐fat diet and oxidative stress. Methods We used an LXR agonist (T0901317) and CCl4 to induce hepatic steatosis and oxidative stress, respectively. C57BL/6 mice fed with a high‐fat diet were treated with either T0901317 + CCl4 (T09 + CCl4 group) or CCl4 alone (CCl4 group). T0901317 (2.5 mg/kg) and CCl4 (0.1 mL/kg) were intraperitoneally administered twice weekly for 24 weeks. Results The liver‐to‐body weight ratio was significantly higher in the T09 + CCl4 group than in the CCl4 group. Mice in the T09 + CCl4 group exhibited abnormal lipid metabolism and NASH‐like histopathological features. Additionally, all mice in the T09 + CCl4 group developed liver tumors diagnosed as well‐differentiated HCC. The genes identified via microarray analysis were related to NASH and HCC development. Conclusions By combining long‐term LXR agonist stimulation with oxidative stress and a high‐fat diet, we successfully reproduced liver conditions in mice similar to those in humans with NASH and progression to HCC. Our results provide new insight into NASH‐related HCC progression and therapy.

Background A 4-week administration of tegafur/gimeracil/oteracil (S-1) followed by a 2-week rest is the standard adjuvant chemotherapy for surgically resected advanced gastric cancer. This study aimed to evaluate the oncological feasibility of a 2-week S-1 administration followed by a 1-week rest, which is frequently applied in clinical practice to reduce toxicity and improve drug adherence. Methods We retrospectively enrolled patients with stage II/III gastric cancer who received S-1 adjuvant chemotherapy following radical gastrectomy from 2006 to 2016 in three institutions. Two-week and 4-week regimen cohorts were compared for relative dose intensity (RDI) as a primary outcome, and treatment completion rate, adverse event incidence, overall survival (OS), and relapse-free survival (RFS) as secondary outcomes. Confounders were adjusted for using propensity score matching (PSM). Results One hundred and thirty-four patients received the 2-week regimen and 121 patients received the 4-week regimen. Ninety-five patients were extracted from each group after PSM. The RDIs of S-1 in the 2-week and 4-week cohorts were 73.5 and 69.9%, respectively (p = 0.35), which were not significantly different. The treatment completion rate (54.7 vs. 53.7%, p = 1.0), incidence of grade ≥3 adverse events (7.4 vs. 12.6%, p = 0.33), 3-year OS (76.4 vs. 82.7%, p = 0.78), and 3-year RFS (71.3 vs. 73.4%, p = 0.70) did not significantly differ between both cohorts. Conclusions The 2-week S-1 adjuvant chemotherapy could not improve drug adherence in terms of RDI, but its relapse rates were not significantly different compared with those of the 4-week regimen. The 2-week regimen might be considered as an option depending on the patient’s status.

Background. Recently, chronic hepatitis E has been reported in solid organ transplant (SOT) recipients in European countries. Previously, we clarified the prevalence of hepatitis E virus (HEV) infection in Japanese liver transplant recipients and identified 2 chronic hepatitis E patients infected by blood transfusion. However, the rate of HEV infection in recipients of SOTs other than liver in Japan remains unclear, so we conducted a nationwide survey to clarify the prevalence of chronic HEV infection in Japanese heart and kidney transplant recipients. Methods. A total of 99 heart and 2526 kidney transplant recipients in 17 hospitals in Japan were examined for the presence of the IgG class of anti-HEV antibodies as well as for serum HEV RNA. Results. The prevalence of anti-HEV IgG among heart and kidney transplant recipients was 7.07% (7/99) and 4.08% (103/2526), respectively. One heart transplant patient (1.01%) and 11 kidney transplant patients (0.44%) were found to be positive for HEV RNA. The HEV isolates from all viremic patients were typed as genotype 3. Four patients developed chronic hepatitis E after transplantation. Three patients were treated with ribavirin; their liver enzymes normalized, and HEV RNA became negative immediately. Sustained virologic response was achieved in all cases. Conclusions. This is the first nationwide survey of HEV infection in Japanese heart and kidney transplant recipients. The prevalence of anti-HEV IgG and HEV RNA in heart and kidney transplant recipients in Japan was lower than that in European countries. Of note, 42% of viremic transplant patients developed chronic hepatitis.

Highlights • Diagnosis of intestinal metastasis of malignant melanoma is difficult because it usually made after appearing symptoms of bowel obstruction. • Emergency surgery for malignant melanoma of small intestine are often performed without enough examination preoperatively. • Malignant melanoma tends to metastases to the small intestine simultaneously and multiply. • When treating small intestinal metastasis of malignant melanoma, location and number of the metastasis should be understood., Introduction Malignant melanoma sometimes metastasizes to small intestine, and could cause various clinical symptoms, including intussusception. Among the acute abdomen cohort in Japan, it is quite rare to encounter this entity. Presentation of case A 68-year-old male patient was admitted to our hospital with chief complaints of abdominal pain and vomiting. He underwent tumor resection for malignant melanoma of the primary lesion at left foot base, local recurrence and brain metastasis during the last five years. At admission, abdominal X-ray demonstrated small bowel obstruction. An ileus tube was inserted, and contrast media enema study showed crab-like shadow defect was observed in the advanced part. Enhanced computed tomography showed intussusception in the proximal jejunum caused by a tumor of 5 cm in diameter in the advanced part. No other intestinal lesion was found. Diagnosis of intussusception caused by solitary metastasis of malignant melanoma was made. Laparoscopic partial resection of the small intestine was performed. Postoperative course was uneventful, and patient was followed in outpatient clinic without further treatment with any recurrence of disease for one years. Discussion Malignant melanoma tends to metastases to the small intestine simultaneously and multiply. It bothers surgeons to decide range of small intestinal resection at emergency surgery. In the present study, preoperative examination allowed the adequate range of intestinal resection including location and number of metastases before operation. Conclusion When an acute abdomen caused by intestinal metastasis of malignant melanoma was consulted, surgeon should make effort to identify location and number of metastatic lesion, preoperatively.

Total or proximal gastrectomy of the upper-third early gastric cancer (u-EGC) often causes severe post-gastrectomy syndrome, suggesting that these procedures are extremely invasive for patients without pathologically positive lymph node (LN) metastasis. This study aimed to evaluate the clinical applicability of a stomach function-preserving surgery, local resection (LR), with prophylactic left gastric artery (LGA)-basin dissection (LGA-BD).The data of patients with u-EGC (pathologically diagnosed as T1) were retrospectively analyzed. Total gastrectomy was performed in 30 patients, proximal gastrectomy in 45, and subtotal gastrectomy in 6; the LN status was evaluated assuming that the patients had already underwent LR + LGA-BD. This procedure was considered feasible in patients without LN metastases or in patients with cancer in the LGA basin. The reproducibility of the results was also evaluated using an external validation dataset.Of the 82 eligible patients, 79 (96.3%) were cured after undergoing LR + LGA-BD, 74 (90.2%) were pathologically negative for LN metastases, and 5 (6.1%) had LN metastases, but these findings were only observed in the LGA basin. Similarly, of the 406 eligible tumors in the validation dataset, 396 (97.5%) were potentially curative. Tumors in the lesser curvature, post-endoscopic resection status, and small tumors (20 mm) were considered to be stronger indicators of LR + LGA-BD as all subpopulation cases met our feasibility criteria.More than 95% of the patients with u-EGC might be eligible for LR + LGA-BD. This function-preserving procedure may contribute to the development of u-EGC without pathological LN metastases, especially for tumors located at the lesser curvature.

Automatic surgical workflow recognition is a key component for developing the context-aware computer-assisted surgery (CA-CAS) systems. However, automatic surgical phase recognition focused on colorectal surgery has not been reported. We aimed to develop a deep learning model for automatic surgical phase recognition based on laparoscopic sigmoidectomy (Lap-S) videos, which could be used for real-time phase recognition, and to clarify the accuracies of the automatic surgical phase and action recognitions using visual information. The dataset used contained 71 cases of Lap-S. The video data were divided into frame units every 1/30 s as static images. Every Lap-S video was manually divided into 11 surgical phases (Phases 0–10) and manually annotated for each surgical action on every frame. The model was generated based on the training data. Validation of the model was performed on a set of unseen test data. Convolutional neural network (CNN)-based deep learning was also used. The average surgical time was 175 min (± 43 min SD), with the individual surgical phases also showing high variations in the duration between cases. Each surgery started in the first phase (Phase 0) and ended in the last phase (Phase 10), and phase transitions occurred 14 (± 2 SD) times per procedure on an average. The accuracy of the automatic surgical phase recognition was 91.9% and those for the automatic surgical action recognition of extracorporeal action and irrigation were 89.4% and 82.5%, respectively. Moreover, this system could perform real-time automatic surgical phase recognition at 32 fps. The CNN-based deep learning approach enabled the recognition of surgical phases and actions in 71 Lap-S cases based on manually annotated data. This system could perform automatic surgical phase recognition and automatic target surgical action recognition with high accuracy. Moreover, this study showed the feasibility of real-time automatic surgical phase recognition with high frame rate.

Background: Transmediastinal esophagectomy for esophageal cancer occasionally results in the postoperative accumulation of pleural effusion despite the preservation of the mediastinal pleura. Transhiatal chest drainage has reported utility in thoracic esophagectomy; however, its use in transmediastinal esophagectomy remains unelucidated. This study aimed to evaluate the effectiveness and safety of transhiatal chest drainage in transmediastinal esophagectomy.Methods: This retrospective study included patients who underwent transmediastinal esophagectomy for esophageal cancer from 2018 to 2020. The transhiatal chest drainage involved the insertion of a 19-Fr Blake® drain from the inferior hepatic space to the left thoracic cavity through the hiatus. The drainage group comprising 13 patients was compared with the non-drainage group comprising 13 patients in whom a transhiatal chest drainage tube was not placed during transmediastinal esophagectomy.Results: The frequency of thoracentesis in the drainage group was significantly lower than that in the non-drainage group (p = 0.03). There were no significant differences between the two groups in terms of the occurrence of other postoperative complications, duration of oxygen administration, and postoperative hospital stay.Conclusions: Transhiatal chest drainage could evacuate pleural effusion effectively and safely after transmediastinal esophagectomy. Therefore, this procedure is clinically useful in transmediastinal esophagectomy for esophageal cancer.

General surgeons are at high risk for work-related musculoskeletal disorders (WRMSDs), especially in their neck and back. The prevalence and risk factors for surgeons' WRMSDs in Japan have not been well surveyed.A cross-sectional questionnaire survey on WRMSDs was conducted among general surgeons in Japan. Surgeons were asked about the presence and degree of neck, shoulder, and back disability in relation to open and laparoscopic surgery.The questionnaire was sent to 174 general surgeons in 21 hospitals and 106 (60.9%) responded. The prevalence of WRMSDs in the last month was 65.1%, and the prevalence at least once in a lifetime was 79.2%. The rate of WRMSDs of the neck and back was higher after open surgery (44.3%, 42.5%) than after laparoscopic surgery (28.2%, 31.1%), but there was no marked difference in shoulder pain. Age was the strongest risk factor for WRMSDs, and the pain scores, prevalence of chronic pain, and rate of WRMSD-related absence from work tended to increase with age.A questionnaire survey of surgeons in Japan showed that about 80% of surgeons suffer from WRMSDs. Countermeasures for WRMSDs among surgeons are urgently desired to ensure that limited numbers of surgeons work in the operating theatre throughout their career.Registry name: a survey of surgeons' musculoskeletal pain associated with performing surgery. University of Tsukuba Institutional Review Board registration number: 1519.

Introduction: Obstetric severe perineal laceration can frequently occur as a surgical site infection (SSI), which sometimes leads to rectovaginal fistula after repair. We encountered a rare case of a rectoperineal fistula 5 months after repair of a severe perineal laceration.Case presentation: The patient was a 39-year-old woman who underwent repair of a fourth-degree perineal laceration after vaginal delivery. Five months after primary repair, she presented with perineal swelling and pain followed by uncontrollable flatulence or passage of feces at the perineum, which was finally diagnosed as a rectoperineal fistula. Transperineal repair with fistulous tract excision was performed for the rectoperineal fistula. Closure of the rectum, perineal body, and vagina was performed layer-by-layer constructing a thick perineum to prevent anal dysfunction. The fistula was successfully closed, and the patient did not show any symptoms of fecal incontinence 6 months after surgery.Discussion: As the rectoperineal fistula might have resulted in SSI at the primary repair of the obstetric injury, the delayed occurrence of the rectoperineal fistula was unusual. A perineal approach should be performed for complete fistulous tract excision, reconstruction of a robust perineal structure, and preservation of anal sphincter function.

Rectal prolapse typically presents in elderly women with protruding full-thickness rectum from the anus. Rectopexy using mesh is known to be a highly curative treatment for rectal prolapse, however, this procedure carries the risk of severe complication as mesh erosion.A 78-year-old woman who had undergone laparoscopic posterior rectopexy 4 years earlier visited the outpatient clinic with a complaint of bloody stool. A colonoscopy and computed tomography revealed that part of the mesh had migrated into the rectal lumen at 8 cm from the anal verge. Based on the above findings, a diagnosis of mesh erosion into the rectum was made. Complete removal of the mesh and tacker with rectal resection was performed. Before rectopexy, the patient had severe fecal incontinence, and her anal sphincter function was decreased, therefore, Permanent colostomy was indicated instead of anastomosis. In the resected specimen, the mesh was folded and placed in the mesenteric fat of the posterior wall of the rectum, with the corner of the edge of the mesh protruding into the inside lumen.Mesh erosion typically occurs when using mesh made of synthetic mesh and non-absorbable threads; it might induce chronic irritation and friction due to mesh shrinkage.To prevent mesh erosion, it is important to pay attention to the mesh materials used and ensure secure fixation.

Background Persistent pancreatic leakage (PL) due to disconnected pancreatic duct syndrome (DPDS) is associated with severe morbidity and mortality and it usually treated with internal drainage. However, in cases without localized fistula formation, internal drainage is challenging to perform. We report an original one-stage surgical approach for nonlocalized persistent PL, namely, the “intentional internal drainage tube method”. Case presentation A 49-year-old woman whose main pancreatic duct was penetrated during endoscopic retrograde cholangiopancreatography experienced severe PL. Peritoneal lavage and a second operation involving central pancreatectomy failed to relieve the symptoms, and nonlocalized PL persisted due to DPDS. Although we attempted a radical resection of the pancreatic remnants as a third strategy, the highly inflamed tissue and massive bleeding prevented the completion of the procedure. We sutured the pancreatic head margin and performed a pancreaticojejunostomy to the distal margin. Because these two cut margins could possibly be the source of the persistent PL, we created a hole at the Roux-en-Y jejunal limb, and a silicone drainage tube was inserted into the peritoneal space via this hole. Postoperatively, we continuously suctioned the intentional internal drainage tube, and the residual PL cavity gradually diminished. Even after removal of the tube, the residual PL drained internally into the jejunum through this hole. Conclusions We present this intentional internal drainage tube method as a novel alternative approach for the management of nonlocalized PL consequential of DPDS. Due to the simplicity and minimally invasive nature of this method, we propose this technique may also be used to treat various types of nonlocalized persistent PL or be used prophylactically for central pancreatectomy.

BACKGROUND: Stomal mucocutaneous separation (SMS) is a serious and common short-term and long-term complication of ostomy surgery, but optimal methods to help prevent it have not been established. The authors hypothesized that seromuscular-dermal (SM-D) suturing may be better than all layer-dermal (AL-D) suturing to help prevent SMS. METHODS: This retrospective study evaluated the short-term SMS rate of patients who underwent colostomy or ileostomy surgery between 2015 and 2019. Patient demographics, medical and surgical history variables, as well as SMS outcomes were abstracted. Postoperative SMS severity was categorized by extent as follows: grade A (mild), grade B (moderate), and grade C (severe). RESULTS: In total, 105 patients (AL-D group, 45 patients; SM-D group, 60 patients) were enrolled in the study. SMS occurred in 24 patients (23%). The overall SMS rate was 18% (n = 11) in the SM-D group and 29% (n = 13) in the AL-D group (P = .202). The occurrence of severe (grade C) or moderate and severe SMS (grades B + C) in the SM-D compared with the AL-D group was significantly different (2% vs 16% [P = .011] and 10% vs 24% [P = .047], respectively). A history of steroid use was a risk factor for moderate and severe SMS (P = .016, odds ratio 5.694). Stomal height ≤1 cm was a a risk factor for all cases of SMS (P = .037, odds ratio 2.650). AL-D suture technique and a history of steroid use were independent risk factors for severe and moderate plus severe SMS (P = .021, odds ratio 12.844 and P = .027, odds ratio 4.808, respectively). CONCLUSION: In this study, use of the AL-D suturing technique and a history of steroid use were independent risk factors for the short-term development of moderate or severe SMS. Patients whose stoma was secured using the SM-D technique had a significantly lower rate of moderate or severe SMS.

Background Various minimally invasive surgery (MIS) procedures are used for gastric submucosal tumors (SMTs), and their technical difficulties vary. Preoperative understanding of difficulties is crucial; however, objective indicators are lacking. Methods Gastric SMTs requiring MIS (n = 36) were retrospectively analyzed. Preoperative factors were evaluated using a multivariate linear regression analysis. A scoring system was then constructed, and its feasibility was evaluated. Results Three factors were identified and scored based on the weighted contribution for predicting surgical time: tumor location (cardia, score of “2”; posterior wall of fundus, “1”); tumor size (greater than 4 cm, “1”); and tumor growth appearance (intraluminal, “1”). The summed scores could stratify the surgical time stepwise in each score, and patients who scored higher than 3 had larger intraoperative blood loss and a longer hospital stay. Conclusion Our scoring system predicted surgical difficulties and may, therefore, be useful in selecting appropriate surgical approaches for gastric SMTs.

This is the first study to compare the long-term outcomes between neoadjuvant chemotherapy + surgery and definitive chemoradiotherapy with proton beam therapy for locally advanced esophageal squamous cell carcinoma. We reviewed patients with clinical stage IB–III esophageal squamous cell carcinoma (UICC 7th edition) who underwent neoadjuvant chemotherapy + surgery or definitive chemoradiotherapy with proton beam therapy (2009–2017). Overall survival, progression-free survival, and recurrence or regrowth rates were compared between the two treatment groups. Subgroup analyses of overall survival according to baseline characteristics were also performed. Forty-three patients received neoadjuvant chemotherapy + surgery (median follow-up 47.4 months) and 60 received definitive chemoradiotherapy with proton beam therapy (median follow-up 51.5 months). Baseline characteristics were similar between the groups except for sex, tumor location, and cT classification. The neoadjuvant chemotherapy + surgery and definitive chemoradiotherapy with proton beam therapy groups had similar 3-year overall survival rates (73.1% and 61.7%, respectively, hazard ratio: 0.88, 95% confidence interval 0.49–1.58, p = 0.66), 3-year progression-free survival rates (46.5% and 45%, respectively, hazard ratio: 1.03, 95% confidence interval 0.62–1.70, p = 0.92), and recurrence or regrowth rates (53.5% vs. 50.0%, p = 0.84). In the subgroup analysis, favorable survival was observed after definitive chemoradiotherapy with proton beam therapy for cT1–2 disease (hazard ratio 2.58, 95% confidence interval 0.84–7.99) and after neoadjuvant chemotherapy + surgery for cT3 or higher disease (hazard ratio 0.32, 95% confidence interval 0.15–0.67, p-for-interaction = 0.002). Long-term outcomes were comparable between the treatments. The choice of the treatment according to cT classification might affect survival.

Background Present treatment strategy for unresectable locally advanced (UR-LA) pancreatic ductal adenocarcinoma (PDAC) patients is controversial. Hence, a triple-modal therapy, which is a multidisciplinary strategy, was designed for patients with UR-LA PDAC by adding hyperthermia to conventional chemoradiotherapy at our institution. In this study we aimed to evaluate the effectiveness of this strategy. Methods Data of 21 UR-LA PDAC patients who underwent the triple-modal treatment were retrospectively analyzed for evaluating the safety and oncological effect of the treatment. The treatment schedule included, five concurrent infusions of gemcitabine (800 mg/m2) followed by hyperthermia (1 h) and X-ray (2 Gy) or proton beam radiation (2.7 Gy) on days 1, 8, 15, 29, and 36. Additional radiotherapies applied a total dose of 50 Gy/25 fr for X-ray radiation or 67.5 Gy/25 fr for proton beam radiation. Results Median overall survival (OS) was 23.6 months. Conversion surgery was performed in 5 patients (23.8%), and a R0 margin could be achieved in 4 of them; however, their median OS (16.3 months) tended to be shorter than that of the patients who did not undergo resection (23.6 months, p = 0.562). Further, the median OS of patients who underwent proton beam radiation (28.0 months) was significantly longer than that of patients who underwent X-ray radiation (13.9 months, p = 0.045). Most adverse events were manageable, except for one grade 3 gastric ulcer. The median tumor size and marker reduction rates were −17% and −91%, respectively. The tumor responses were partial response, stable disease, and progressive disease in 3, 15, and 3 patients, respectively. Conclusion Triple-modal strategy, especially when combined with proton beam radiation, is feasible and results in favorable survival outcomes in patients with UR-LA PDAC.

Objective Laparoscopic surgery for diverticular colovesical fistula (CVF) is technically challenging, and the incidence of conversion to open surgery (COS) is high. This study aimed to review our experience with laparoscopic surgery for diverticular CVF and identify preoperative risk factors for COS. Results This was a single institution, retrospective, observational study of 11 patients (10 males and 1 female) who underwent laparoscopic sigmoid colon resection with fistula resection for diverticular CVF from 2014 to 2019. Preoperative magnetic resonance imaging (MRI) was performed to evaluate the fistula location in the bladder, patency of the rectovesical pouch (i.e., the destination of dissection procedure between sigmoid colon and bladder) and estimate the contact area between the sigmoid colon and bladder. The relationship between preoperative variables and COS incidence was analyzed between completed laparoscopy and COS groups. The overall incidence of postoperative morbidity (Clavien–Dindo classification Grade II or higher) was 36% (4/11). Severe morbidity, reoperation, and mortality were not observed. The incidence of COS was 27% (3/11). Posterior bladder fistulas were significantly associated with COS. CVFs located on the posterior bladder appears to be a risk factor for COS. Identifying risk factors for COS preoperatively could help guide the intraoperative course.

Background When considering “early stoma closure”, both standardized inclusion/exclusion criteria and standardized methods to assess anastomosis are necessary to reduce the risk of occult anastomotic leakage (AL). However, in the immediate postoperative period, neither have the incidence and risk factors of occult AL in patients with diverting stoma (DS) been clarified nor have methods to assess anastomosis been standardized. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage. Methods This was a single institutional prospective observational study of patients who had undergone rectal resection with the selective use of DS between May and October 2019. Fifteen patients had undergone CE and CT to assess for AL on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7. Results The incidence of occult AL on postoperative day 7 was 6 of 15 (40%). Hand-sewn anastomosis, compared with stapled anastomosis, was a significant risk factor. Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate. Conclusions Hand-sewn anastomosis appeared to be a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.

BackgroundIn the immediate postoperative period, neither have the incidence and risk factors of occult anastomotic leakage (AL) in patients with diverting stoma (DS) been clarified, nor have methods to assess anastomosis been standardized. Before introducing “early stoma closure”, both standardized inclusion and exclusion criteria and standardized methods to assess anastomosis are necessary. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage.MethodsThis was a single institutional prospective observational study of patients who had undergone rectal resection with DS between May and October 2019. All patients had undergone CE and CT to assess for anastomosis on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7ResultsThe incidence of occult AL on postoperative day 7 was 40%. Hand-sewn anastomosis, compared with stapled anastomosis, was a statistically significant risk factor (p=0.0406). Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate.ConclusionsHand-sewn anastomosis was a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.

Background Pancreatic acinar cell carcinoma (PACC), a rare variant of pancreatic malignancy, is generally managed the same way as pancreatic ductal adenocarcinoma (PDAC). Surgical resection is the gateway to curing it; however, once it metastasizes (usually to the liver, lungs, lymph nodes, or peritoneal cavity), systemic chemotherapy has been the only option, but with unfavorable results. Case presentation A 67-year-old man with symptoms of loss of appetite and weight underwent surgery for malignancy of the pancreatic tail extending into the entire pancreas. The pathological diagnosis was PACC following total pancreatectomy. Twenty-four months after the pancreatectomy, a solitary liver metastasis was treated by partial hepatectomy, and, subsequently, 4 months later, he presented with melena. Further examination revealed a type-2 rectal tumor. Histological examination following biopsy revealed it to be rectal metastasis of PACC, and it was treated by abdominoperineal resection. Subsequently, the patient did not have tumor recurrence as of 40 months after pancreatectomy. Conclusions This is a rare case of PACC presenting with metachronal metastases in the liver and rectum, and we successfully treated them by surgical resections. Since the malignant behavior of PACC is usually less than that of PDAC, surgical resection could be an option even for metastatic lesions when the number and extent of metastases are limited.

Background: Activities of nonhematopoietic cells (NHCs) reportedly underlie lymphomagenesis. In follicular lymphoma (FL), mesenchymal stromal cells (SCs) including follicular dendritic cells (FDCs) have been shown to facilitate FL expansion. However, comprehensive understanding of lymphoma NHC activities have been hampered by indefinite NHC heterogeneity even in normal human lymph node (LN). Indeed, human LN blood endothelial cells (BECs) and non-endothelial stromal cells (NESCs) have not been analyzed at single-cell resolution. Here, we aimed to construct a single-cell atlas of NHCs in human LN applicable to lymphoma researches. We also sought to reveal the landscape of stromal remodeling in lymphomas, particularly in FL, to advance understanding of stromal contributions in lymphomagenesis. Methods: We prospectively performed single-cell RNA sequencing of NHCs (>100,000 cells) extracted from 27 human samples including metastasis-free LN (MFLN; n=9), nodal FL (n=10), peripheral T-cell lymphoma (PTCL; n=5), and diffuse large B-cell lymphoma transformed from FL (tDLBCL; n=3). Data from MFLN samples were used for the construction of NHC atlas. Immunofluorescence (IF) staining was performed to investigate the existence and topological localizations of each NHC subcluster in the LN. Using the NHC atlas, we performed comprehensive comparative analysis with FL NHCs by differentially-expressed gene (DEG) and intercellular ligand-receptor analyses. We also investigated the prognostic impact of putative stroma-derived biomarkers using deposited microarray data of FL patients. Finally, we examined the applicability of the atlas to NHCs from other lymphoma subtypes by analyzing PTCL and tDLBCL NHCs. Data analysis was performed through multiple pipelines including Seurat, Monocle3, and CellphoneDB. Results: Graph-based clustering analysis revealed that the transcriptional features of NHC subpopulations in MFLN are detectable in FL NHCs. Unsupervised sub-clustering analysis of BECs, lymphatic endothelial cells (LECs), and NESCs revealed 10, 8, and 12 subclusters, respectively, including some lacking mouse counterpart. IF staining successfully identified each NHC subcluster and its localization in the LN. In FL NHCs, the proportion of arterial BEC subclusters markedly increased relative to MFLN, while the proportion of LECs decreased. In FL NESCs, the proportion of marginal reticular cells (MRCs) as well as FDCs greatly increased. DEG analysis revealed that the greatest changes in gene expression occurs in NESC subclusters, particularly in MRCs, T-zone reticular cells (TRCs), pericytes, and FDCs. Notably, in some NESC subclusters, we observed marked upregulation of genes relevant to solid cancers but previously not described in lymphomas (e.g. POSTN, EGFL6, and FAP). Combined interactome and DEG analysis revealed 60 FL-specific interactions between NHC subclusters and malignant B cells. For example, interactions mediated through stroma-derived CD70 were enhanced at medullary SC subclusters and SCs at LN capsule adventitia. Additionally, the CCR7-CCL19 interaction and interactions via B-cell activating factor (BAFF) were unexpectedly upregulated at non-TRC SC and medullary SC subclusters, respectively. Also, the CXCL13-CXCR5 axis was highly activated in MRCs, collectively indicating that non-FDC SCs vigorously participate in FL cell expansion and/or infiltration into extra-follicular lesions. Some intercellular interactions were functionally validated by in vitro binding assays. Based on this dataset, we identified putative stroma-derived biomarkers linked to unfavorable prognosis in FL patients including TDO2, encoding immune-modulators, and LY6H and LOX, tip cell markers. We finally confirmed that NHC subclusters identified in our atlas were also detectable in NHCs of more aggressive lymphoma subtypes including PTCL and tDLBCL. Notably, we found that extra-follicular SCs had further differentiated into follicular SCs in tDLBCL, likely representing a terminal form of stromal remodeling in FL. Conclusion: We constructed a comprehensive single-cell atlas of NHCs in human LN highly applicable to lymphoma NHC researches and revealed a total of 30 NHC subclusters. Our study largely updates NHC taxonomy in LNs and provides a rich resource and deeper insights into lymphoma biology, a contribution that should advance lymphoma management and therapy. Figure 1 Figure 1. Disclosures Usuki: Otsuka Pharmaceutical Co., Ltd.: Research Funding, Speakers Bureau; Novartis Pharma K.K.: Research Funding, Speakers Bureau; Ono Pharmaceutical Co., Ltd.: Research Funding, Speakers Bureau; Janssen Pharmaceutical K.K.: Research Funding; Celgene K.K.: Research Funding, Speakers Bureau; Takeda Pharmaceutical Co., Ltd.: Research Funding, Speakers Bureau; Nippon-Boehringer-Ingelheim Co., Ltd.: Research Funding; Mundipharma K.K.: Research Funding; Amgen-Astellas Biopharma K.K.: Research Funding; Nippon-Shinyaku Co., Ltd.: Research Funding, Speakers Bureau; Kyowa-Kirin Co., Ltd.: Research Funding, Speakers Bureau; Pfizer Japan Inc.: Research Funding, Speakers Bureau; Alexion Pharmaceuticals, Inc.: Research Funding, Speakers Bureau; Eisai Co., Ltd.: Speakers Bureau; MSD K.K.: Research Funding, Speakers Bureau; PharmaEssentia Japan KK: Research Funding, Speakers Bureau; Yakult Honsha Co., Ltd.: Research Funding, Speakers Bureau; Daiichi Sankyo Co., Ltd.: Research Funding, Speakers Bureau; Sumitomo-Dainippon Pharma Co., Ltd.: Research Funding; SymBio Pharmaceuticals Ltd.: Research Funding, Speakers Bureau; Gilead Sciences, Inc.: Research Funding; Bristol-Myers-Squibb K.K.: Research Funding, Speakers Bureau; Apellis Pharmaceuticals, Inc.: Research Funding; AbbVie GK: Research Funding, Speakers Bureau; Astellas Pharma Inc.: Research Funding, Speakers Bureau; Incyte Biosciences Japan G.K.: Research Funding; Chugai Pharmaceutical Co., Ltd.: Research Funding, Speakers Bureau; Sanofi K.K.: Speakers Bureau; Amgen K.K.: Research Funding.

Introduction Anorectal malignant melanoma (ARMM) is a rare disease with a poor prognosis. In cases involving locally advanced disease, the treatment strategy is difficult, especially in octogenarian patients, because the prognosis is poor, despite the corresponding decrease or loss of the anal function. Presentation of case A 78-year-old woman was admitted to a local hospital with chief complaints of severe anal discomfort due to an egg-sized tumor that was protruding out of the anus and melena. A diagnosis of ARMM was confirmed based on the examination of biopsy specimens and imaging study showed swollen lymph nodes on the dorsal side of the middle rectum and left internal iliac lymph nodes. Laparoscopic abdominoperineal resection with left lateral lymph node dissection was performed. The examination of the resected specimen revealed two polypoid tumors with a maximum diameter of 38 mm and 14 mm with a metastatic lymph node of 62 mm in the mesorectum. The postoperative course was uneventful. Relapse and local recurrence free survival without any complaints was obtained for more than 12 months. Discussion With respect to locoregional disease control, it has been reported that abdominoperineal resection can obtain better control of local disease in comparison to local resection. Laparoscopic surgery is advantageous in its facilitation of an early postoperative recovery for elderly patient. Conclusion Laparoscopic abdominoperineal resection may control locoregional disease and improve the patient's QOL with early postoperative recovery. —even in septuagenarian patients—may become a treatment strategy for advanced ARMM.

Introduction and importance Well-leg compartment syndrome (WLCS) develops from abnormal positioning of the limb during surgery. There have been few reports of WLCS in rectal cancer patients, although the lithotomy position, which is widely applied for rectal surgery, is a risk factor for WLCS. Case presentation A 56-year-old man with rectal cancer underwent laparoscopic low anterior resection of the rectum, left lateral lymph node dissection and diverting ileostomy. The operation time was 393 min. The patient was in the head-down tilt lithotomy position and rotated to the right side. Postoperatively, he complained of left lower leg pain and swelling and difficulty moving his legs. The compartment pressure of his right and left lower legs was 80 mmHg and 120 mmHg, respectively. A diagnosis of bilateral WLCS was made, and fasciotomy of both lower legs was performed 2 h after surgery. Although he was able to live his daily life, mild numbness remained in his toes one year after surgery. Clinical discussion In addition to risk factors previously reported for WLCS, our review shows that the male sex and left side are associated with a greater risk of WLCS, especially in rectal surgery. Additionally, our review reveals that the type of rectal surgery leading to WLCS is almost always laparoscopic surgery. Conclusion Surgeons should be especially vigilant for WLCS when they encounter patients, especially males, who complain of left lower leg pain after laparoscopic rectal surgery., Highlights • Male sex, left leg, and laparoscopic are key factors for WLCS in rectal cancer. • Leveling the patient every 3 h is important for prevention of WLCS. • Surgeon's vigilance is vital for early diagnosis and resolution without sequela.