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Due to the overwhelming spread of SARS-CoV-2 and its disruption of the healthcare system, delays and reduced numbers were reported for colorectal cancer screening, colonoscopies, and surgery during the COVID-19 pandemic. This multicenter retrospective study investigated the still poorly understood impact of the COVID-19 pandemic on colorectal cancer treatment in Japan.This study was organized by the Clinical Study Group of Osaka University, which comprised 32 major institutions in Osaka. We retrospectively analyzed the number of surgeries and colonoscopies performed and the characteristics of patients who underwent surgery for colorectal cancer between March 2019 and February 2021. We compared data collected before and during the COVID-19 pandemic. We also assessed the methods used for detecting colorectal cancer, including fecal occult blood test, abdominal symptoms, and anemia.The COVID-19 pandemic caused reductions in the annual numbers of surgeries (3569 vs 3198) and colonoscopies (67 622 vs 58 183) performed in the 2020 fiscal year, compared to the 2019 fiscal year. During the COVID-19 pandemic, a significantly lower proportion of patients were treated for clinical stages ≤I (24.2% vs 26.9%;The COVID-19 pandemic reduced the number of colonoscopies and surgeries performed for colorectal cancer and hindered the detection of asymptomatic early-stage cancers, and its impact varied by hospital size.

Background & ObjectiveAbnormal lung development is the main cause of morbidity and mortality in neonates with congenital diaphragmatic hernia (CDH), a common birth defect (1:2500) of largely unknown pathobiology. Recent studies discovered that inflammatory processes, and specifically NF-κB associated pathways are enriched in human and experimental CDH. However, the molecular signaling of NF-κB in abnormal CDH lung development and its potential as a therapeutic target requires further investigation.Methods & ResultsUsing sections and hypoplastic lung explant cultures from the nitrofen rat model of CDH and human fetal CDH lungs, we demonstrate that NF-κB and its downstream transcriptional targets are hyperactive during abnormal lung formation in CDH. NF-κB activity was especially elevated in the airway epithelium of nitrofen and human CDH lungs at different developmental stages. Fetal rat lung explants had impaired pseudoglandular airway branching after exposure to nitrofen, together with increased phosphorylation and transcriptional activity of NF-κB. Dexamethasone, the broad and clinically applicable anti-inflammatory NF-κB antagonist, rescued lung branching and normalized NF-κB signaling in hypoplastic lung explants. Moreover, specific NF-κB inhibition with curcumenol similarly rescuedex vivolung hypoplasia and restored NF-κB signaling. Lastly, we showed that prenatal intraperitoneal dexamethasone administration to pregnant rat dams carrying fetuses with hypoplastic lungs, significantly improves lung branching and normalizes NF-κBin vivo. Conclusions: Our results indicate that NF-κB is aberrantly activated in human and nitrofen CDH lungs. Anti-inflammatory treatment with dexamethasone and/ or specific NF-κB inhibition should be investigated further as a therapeutic avenue to target lung hypoplasia in CDH.

The levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung's disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry.Mean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2 mm, coronal 2 mm, and sagittal 3 mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9).MRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46 mm) compared with L-IA (2.97±0.55 mm) and controls (2.87±0.32 mm), p0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°-19°), versus L-IA and controls, both zero degrees (range 0°-5°), p0.0001, respectively.LA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately.

During choledochal cyst (CC) excision, the hepaticojejunostomy anastomosis (HJA) can be performed conventionally (CHJA) or with a Carrel patch (CPA). CPA can increase CHD diameter to 10-13 mm, preventing anastomotic stenosis and intrahepatic bile duct (IHBD) stones but may be at risk for malignant transformation.The medical records of 83 cystic-type CC with CHD ≤ 9 mm followed up for at least 20 years were reviewed retrospectively. Available excised CC specimens (70/83) were re-examined blindly for pre-malignant changes. A questionnaire about suturing narrow lumens was conducted.All 83 had pancreaticobiliary maljunction. Group data were similar. Anastomoses were CPA (n = 43) and CHJA (n = 40). Mean diameter for CPA was 11.4 mm (range: 10-13 mm); for CHJA was 7.4 mm (range: 5-9 mm). Mean follow-up was 27.7 years (range: 20-42). Postoperative anastomotic stenoses were less after CPA: 1/43 (2.3%) versus 5/40 (12.5%) (p = 0.10), but CHJA had significantly more postoperative IHBD stones: 0% versus 4/40 (10.0%) (p 0.05). All IHBD stone patients had anastomotic stenosis. Excised specimens showed no pre-malignant cytology. Lumen diameter ≤ 9 mm was considered challenging by 10/10 surgical trainees and ≤ 7 mm by 16/22 pediatric surgeons.CPA appears to be oncologically safe because of the absence of malignant transformation for at least 20 years.

Purpose: Here, we establish a tracheal occlusion (TO) model with rat lung explants in nitrofen-induced pulmonary hypoplasia in congenital diaphragmatic hernia (CDH). Methods: We extracted lungs from rats on embryonic day 18. We mimicked TO in the lung explants by tying the trachea. We assessed lung weight, morphometry, and abundance of Ki-67, Active caspase-3, and Prosurfactant Protein C (proSP-C) with immunofluorescence. Results: Lung weight was higher in TO+ than TO– on day 1. Abundance of Ki-67 was higher in TO+ than TO– (0.15 vs. 0.32, p=0.009 for day 1, 0.07 vs. 0.17, p=0.004 for day 2, 0.07 vs. 0.12, p=0.044 for day 3), and Active caspase-3 was higher in TO+ than TO– on day 2 and day 3 (0.04 vs. 0.03 p=0.669 for day 1, 0.03 vs. 0.13 p p=0.008 for day3). However, proSP-C protein abundance was lower in TO+ than TO– (67.9 vs. 59.1 p=0.033 for day 1, 73.5 vs. 51.6 p=0.038 for day 2, 83.1 vs. 56.4 p=0.009 for day 3). Conclusions: The TO model in lung explants mimics the outcomes of current surgical models of TO and further studies can reveal the cellular and molecular effects of TO in CDH lungs.

We herein reported a case of advanced gastric cancer (GC) with para-aortic lymph node (PALN) metastases who successful achieved downstaging following systemic chemotherapy and underwent curative laparoscopic conversion surgery. A 74-year-old male patient diagnosed with advanced GC and PALN metastases [cT4N3M1(LYM), stage IVA] was administered chemotherapy and immunotherapy for 28 months. After 27 courses of nivolumab as third-line chemotherapy, PALN enlargement was resolved, for which conversion surgery was planned. Subsequently, laparoscopic distal D2 gastrectomy with sampling para-aortic lymphadenectomy was performed, after which a pathological diagnosis of type V moderately differentiated tubular adenocarcinoma with mucinous adenocarcinoma, stage ypT3 (SS), ly1c, and v0, was established. The pathological proximal and distal tumor margins were negative. One lymph node metastasis was observed (No. 6; 1/25). The sampled lymph nodes were negative (No. 16a1: 0/2). The therapeutic effect was categorized as Grade 1a. The postoperative course was uneventful, with the patient receiving nivolumab to control for potential PALN metastases. Postoperatively, no recurrence was observed over 11 months. Laparoscopic conversion gastrectomy was successfully performed in a patient with advanced GC that was originally unresectable, suggesting that minimally invasive surgery may be a good option for originally unresectable advanced GC that becomes resectable.

Diaphragmatic resection may be required beneath the diaphragm in some patients with liver tumors. Laparoscopic diaphragmatic resection is technically difficult to secure in the surgical field and in suturing. We report a case of successful laparoscopic hepatectomy with diaphragmatic resection. A 48-year-old man who underwent laparoscopic partial hepatectomy for liver metastasis of rectal cancer 20 months ago underwent surgery because of a new hepatic lesion that invaded the diaphragm. The patient was placed in the left hemilateral decubitus position. The liver and diaphragm attachment areas were encircled using hanging tape. Liver resection preceded diaphragmatic resection with the hanging tape in place. Two snake retractors were used to secure the surgical field for the inflow of CO2 into the pleural space after diaphragmatic resection. The defective part of the diaphragm was repaired using continuous or interrupted sutures. Both ends of the suture were tied with an absorbable suture clip without ligation. In laparoscopic liver resection with diaphragmatic resection, the range of diaphragmatic resection can be minimized by performing liver resection using the hanging method before diaphragmatic resection. The surgical field can be secured using snake retractors. Suturing with an absorbable suture clip is conveniently feasible. Supplementary Information The online version contains supplementary material available at 10.1007/s13691-021-00506-x.

Purpose: The high incidence of scarring and vascular compromise after failed hypospadias repair greatly compromises salvage urethroplasty. Pedicled soft tissue reinforcement (STR) is presented for enhancing the potential for success.Methods: The impact of lateral reinforcement of the scarred urethral plate to boost thickness and perfusion at the time of curvature correction (called CHARGE by the authors) and covering the neourethra at the time of urethroplasty (NUC) used as STR during salvage tubularized incised plate urethroplasty performed between 2003 and 2019 were assessed by retrospective review of the medical records of 8 cases of failed hypospadias repair. Results: Types of hypospadias were perineal/penoscrotal (n=7), and mid-shaft (n=1). Indications for salvage surgery included residual penile curvature (n=5), urethral diverticulum >15mm (n=3), urethral dehiscence (n=1), and urethral stricture (n=1). Salvage surgery was single-stage (urethroplasty at the same of curvature correction; n=1) or multi-stage (n=7; two-stage: n=4, three-stage: n=3). All cases had NUC and 4/8 had CHARGE. All salvage repairs were successful with no incidence of postoperative complications after mean follow-up of 3.9 years (range: 1.6-6.4 years) after the last procedure.Conclusion: STR most likely enhanced tissue perfusion/pliability which ensured the success of salvage urethroplasty for failed hypospadias repair.

Anorectal malformations (ARM) represent a broad spectrum of patients with different level of the rectum and type of a fistula. Standardized approaches are usually successful, but patients occasionally present with an unusual course of fistula which requires a modified surgical strategy. We present here three male ARM patients with an atypical fistula which did not have connection with the urinary tract, but ran near the fistula. Case 1 has a low-type ARM with a rectoscrotal fistula running deep and partly involved in the corpus spongiosum. Anorectoplasty was performed through an anterior sagittal incision and the anterior wall of the fistula was laid open leaving the posterior wall undetached. Case 2 was diagnosed with an intermediate-type ARM with a long rectoscrotal fistula running near and parallel the urethra. Posterior sagittal anorectoplasty (PSARP) was performed leaving the fistula untouched. Case 3 presented with an intermediate-type ARM with a rectoperineal fistula adherent to the urethra. The patient was treated by PSARP leaving the fistula and part of the muscle coat of the rectum in situ. All the cases were smoothly discharged and no urological complication nor problem associated with the residual fistula was observed at the latest follow-up (17 months-2 years). Preoperative distal colostography with the aid of diverting colostomy was importantly useful for deciding surgical procedure.

Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSONIRS sensors were applied to the forehead and flanks for cerebral rSOMean ages at surgery were N: 5.2 ± 8.2 days, MOp: 2.4 ± 2.9 years, and MMI: 3.8 ± 4.3 years. Despite significantly shorter operative times in N (169 ± 94 min; p 0.0001), PD was significantly worse; PD(C-rSO

Lenvatinib is reported to have a stronger angiogenesis-inhibiting effect in hepatocellular carcinoma(HCC)than sorafenib, but in many cases dose reduction and withdrawal are required due to the occurrence of adverse events. We report 12 cases of using lenvatinib for advanced HCC in our hospital together with a case of rapid re-growth due to withdrawal of lenvatinib. In 2 cases, metastases of HCC were controlled and radically resected. All patients required lenvatinib withdrawal due to Grade 3 adverse event, except for 2 cases that started with dose reduction. There were 3 cases in which drug withdrawal was required for 2 weeks or more, and in 2 of them, rapid re-growth of tumor was observed during the drug withdrawal and the treatment could not be continued. Although the use of lenvatinib may results in tumor shrinkage, suggesting that prolonged drug withdrawal may make disease management difficult. It is important to manage adverse events and minimize days of drug withdrawal by reducing the dose and systematically discontinuing the drug.

The etiology of anorectal malformations (ARM) is complicated because of the spectrum of anomalies seen clinically, many of which are isolated and seemingly unique. Recent studies suggest that ARMs result from abnormal cloacal membrane (CM) development that contributes to disrupt normal local muscle and nerve development. If CM maldevelopment is severe, the rectal pouch lies above the pelvic floor, resulting in asymmetric and/or deviated musculature, so a midline incision is likely to cause trauma or be detrimental. Autonomic nerve plexuses can be associated with a fistula tract in ARMs and are also at risk for damage during surgery and contribute to genitourinary complications. Understanding the anatomy and development of the perineum is crucial for treating the broad spectrum of anomalies associated with ARMs and may assist in predicting/managing other related morbidity.

The safety and success of laparoscopic choledochal cyst surgery (LapCC) depends upon two critical elements during the hepaticojejunostomy anastomosis (HJA). These may be termed the Difficulty of Differentiation (DOD) and the Difficulty of Suturing (DOS). The type of imaging system (2 or 4 K) used may influence either of these. We compared outcomes of LapCC using 2 or 4 K imaging systems.LapCC were performed at a single institution by the same team using a 2 K system (2009-2018; n = 26) and a 4 K system (2018-2019; n = 11) were compared. 4 K cases were chosen to match 2 K cases to minimize bias. Five independent senior pediatric surgeons scored DOD and DOS blindly from intraoperative video recordings of LapCC using a subjective 5-point scale (5: impossible, 4: difficult, 3: tedious, 2: slow, and 1: easy) and rated their over all impression as +1 if 4 K was better, 0 if they were the same, and -1 if 4 K was worse. Total HJA anastomosis time (TAT) and TAT/suture were also calculated.LapCC was performed in 37 age/weight/HJA diameter matched children. Scores for DOD (p0.001) were lower with 4 K with less variance, although there was no difference in DOS (p = 0.08). Operative time (p = 0.03) and duration of hospitalization (p 0.001) were significantly shorter with 4 K. 4 K was rated +1 unanimously. There was no difference in TAT (p = 0.17) and TAT/suture (p = 0.22). There was one HJA leak with 2 K (3.8%) and no complications with 4 K.Improved resolution with 4 K improved the progress of surgery as reflected by shorter operative time and duration of hospitalization, enhancing the performance of LapCC in children.III.

Refinement of organoid technology is important for studying physiology and disease of the intestine. We aimed to optimize defined serum-free conditions for human infant small intestinal (SI) organoid culture with predetermined doses of Wnt3a and Rspo1 from surgical specimens. We further assessed whether intestinal specimens could be stored before use as a source of organoids. Different doses of Wnt3a and Rspo1 in a serum-free medium were tested to establish a condition in which surgically resected SI cells grew as organoids over multiple passages. The expression of marker genes for stem and differentiated cells was assessed by quantitative polymerase chain reaction. We also investigated the organoid-forming efficiency of cells in degenerating intestines stored at 4 °C for various intervals post-resection. We determined the doses of Wnt3a and Rspo1 required for the continuous growth of infant SI organoids with multi-differentiation potential. We revealed that, despite the time-dependent loss of stem cells, tissues stored for up to 2 days preserved cells capable of generating amplifiable organoids. SI cells can be grown as organoids under defined conditions. This could provide a reproducible and customizable method of using surgical specimens for the study of intestinal maturation and their relevance to pediatric diseases.

Here, we report a case of ascending colon cancer successfully treated with laparoscopic right hemicolectomy in a 74- year-old man with a medical history of hemophilia A. He was admitted to our hospital because of bloody stool and diagnosed with type 2 ascending colon cancer based on colonoscopy findings. Preoperatively, blood transfusion and administration of recombinant factor Ⅷ products were performed. Surgery involved laparoscopic right hemicolectomy plus group 3 lymph node dissection. No complications, such as bleeding, occurred during hospitalization. The patient was discharged on postoperative day 8. There have been a few reports of laparoscopic surgery for patients with hemophilia. However, this case suggests that it can be safely performed with planned factor Ⅷ supplementation in the perioperative period.

Abdominal incisional hernia is a frequent complication of major abdominal operations. Our method of performing mesh repair under the anterior lamina of the rectus sheath (MUAR) involves placing mesh between the dorsal surface of the anterior rectus sheath and the rectus abdominis muscle. We evaluated the short-term and long-term outcomes of our MUAR method. The subjects of this retrospective study were 80 patients with abdominal incisional hernia, who underwent MUAR at our hospital between August, 2009 and September, 2018. We investigated the rate of recurrence and postoperative complications in these patients, who were followed-up postoperatively for at least 18 months. Patients who completed all visits were then followed-up further with questionnaires. The recurrence rate after MUAR was 0%. Postoperative complications consisted of subcutaneous wound infections in two patients (2.5%), successfully treated with wound cleansing and antibiotics; and subcutaneous hematoma in three patients (3.8%), which was spontaneously absorbed in two patients, and removed in one. There were no other complications, such as seroma, intestinal obstruction, mesh infection and bulging, or prolonged postoperative pain. Mesh repair under the anterior lamina of the rectus sheath is simple and safe with positive short-term and long-term outcomes, suggesting that it is a good option for incisional hernia repair.

BackgroundWe assessed the impact of anorectal malformation (ARM) on the kidneys of children with dilating vesicoureteral reflux (D-VUR) ≥grade III using a simple dimercaptosuccinic acid (DMSA) scintigraphy scan based renal dysfunction score (RDS).MethodsThe medical records of 121 patients with D-VUR treated between 2000 and 2014 were reviewed retrospectively. After excluding patients with secondary D-VUR (n=18), presence of ARM was used to create two groups: ARM+ (n=12 cases; 15 ureters) and ARM– (n=91 cases; 131 ureters). Types of ARM, grades of D-VUR, bladder and bowel dysfunction (BBD) and RDS were compared.ResultsPatient demographics, mean follow-up, grades of D-VUR and history of urinary tract infections were not significantly different. BBD was significantly higher in ARM+ (41.7% versus 7.7%, p=0.0006). RDS was significantly higher in ARM+ (p=0.036). Grades of D-VUR were significantly lower in ARM– with low RDS (p=0.008). During follow-up, changes in DMSA uptake over time were not observed in ARM+.ConclusionsWhile renal cortical lesions were correlated with grade of D-VUR in ARM– and RDS was significantly higher in ARM+, BBD did not appear to contribute to progressive renal dysfunction as is commonly believed. In fact, no progression in renal cortical lesions was observed in ARM+ based on RDS data. Renal cortical lesions may possibly be a feature of ARM, a topic that warrants further study.

Aim: To assess nonoperative management (NOM) of uncomplicated appendicitis (UC-appy) in children to determine factors influencing prognosis and review the literature. Materials and Methods: All UC-...

Lateral lymph node dissection (LLND) is performed for advanced rectal cancers in Japan; however, it can cause sexual and urinary dysfunction. The incidence of lateral LN metastasis is estimated at 7–13.9%; therefore, excessive rectal surgery with LLND should be avoided, especially for prophylactic purposes. To identify the patients who require LLND, we examined metastases in perirectal LNs by using a one-step nucleic acid amplification (OSNA) assay to predict lateral LN metastases. Twenty-five patients who underwent surgery with bilateral LN dissection due to T3–T4 rectal cancers were prospectively included in this study. Twenty-two patients (88.0%) received preoperative chemotherapy. Among 1052 LNs from 25 patients (median 40 per case), 135 perirectal LNs (median 6 per patient) were divided into three pieces and analyzed by OSNA, reverse transcriptase-polymerase chain reaction for carcinoembryonic antigen mRNA, and pathological examination after surgery. These results were compared with the pathological diagnosis of lateral LNs. Lateral LN metastases were present in 4 of 25 patients (16.0%). All of these patients were positive by OSNA for perirectal LN metastases. The OSNA assay had a sensitivity of 100%, specificity of 86%, positive predictive value of 57%, and negative predictive value (NPV) of 100% for predicting lateral LN metastases. The findings from this prospective study suggest that the OSNA assay of perirectal LNs may be useful for determining when LLND is necessary because of its high NPV, even in patients treated with preoperative chemotherapy.

Sonographic assessment before congenital diaphragmatic hernia repair has rarely been studied. To evaluate the accuracy of preoperative ultrasound in measuring the defect size and in anticipating the presence of a rim and thereby to determine ultrasound’s usefulness in informing the surgical approach for definitive repair of congenital diaphragmatic hernia. We performed a retrospective review of the medical records of seven children with left congenital diaphragmatic hernia who had undergone ultrasound and definitive repair between 2014 and 2017 at our institution. The estimated defect size by ultrasound to the actual defect size measured intraoperatively for each case were as follows: 23 × 25 mm to 20 × 26 mm (case 1); 23 × 30 mm to 20 × 30 mm (case 2); 43 × 25 mm to 30 × 30 mm (case 3); 21 × 23 mm to 20 × 25 mm (case 4); 19 × 24 mm to 10 × 30 mm (case 5); 32 × 33 mm to 30 × 50 mm (case 6); and almost total absence to 40 × 50 mm (case 7). Presence or absence of each part of the diaphragm rim evaluated by ultrasound was almost identical with the actual intraoperative findings. According to the ultrasound findings, we performed a successful thoracoscopic repair in cases 1–5 with relatively small defects and presence of all parts of the rim or absence of only posterolateral rim. There was good concordance between ultrasound findings and operative findings regarding the size of the defect and presence or absence of the diaphragm rim.

Intensive treatment including surgery for patients with trisomy 13 (T13) remains controversial. This study aimed to evaluate the safety and efficacy of noncardiac surgical intervention for T13 patients. Medical records of patients with karyotypically confirmed T13 treated in the neonatal intensive care unit in Nagano Children's Hospital from January 2000 to October 2016 were retrospectively reviewed, and data from patients who underwent noncardiac surgery were analyzed. Of the 20 patients with T13, 15 (75%) underwent a total of 31 surgical procedures comprising 15 types, including tracheostomy in 10 patients and gastrostomy in 4. Operative time, anesthesia time, and amount of bleeding are described for the first time in a group of children with T13. All the procedures were completed safely with no anesthetic complications or surgery-related death. The overall rate of postoperative complications was 19.3%. Patients receiving tracheostomy had stable or improved respiratory condition. Six of them were discharged home and were alive at the time of this study. These results suggest at least short-term safety and efficacy of major noncardiac surgical procedures, and long-term efficacy of tracheostomy on survival or respiratory stabilization for home medical care of children with T13. Noncardiac surgical intervention is a reasonable choice for patients with T13.

This study aimed to identify the risk factors for postoperative complications after laparoscopic low anterior resection for the treatment of advanced rectal cancers. A prospectively maintained database was retrospectively analyzed. Oncological parameters in resected specimens and clinical risk factors for postoperative complications, including anastomotic leakage, were examined in patients with clinical stage II and III upper rectal cancer who underwent laparoscopic low anterior resection, including total mesorectal excision. Pathologic resection margins were negative in all patients. Postoperative complications occurred in 22 patients (25.9%), which is similar to incidence rates in previous studies. In multivariate analysis, tumor size (≥4 cm) and tumor category (T4) were independent risk factors for postoperative complications. Precise pretreatment diagnoses with locoregional evaluations are essential for the selection of appropriate patients for laparoscopic rectal resection. Despite quality results from laparoscopic low anterior resection for the treatment of advanced rectal cancer, we must attempt to reduce postoperative complications.

Preoperativedifferential diagnosis between tracheobronchial remnant (TBR) and other typesof congenital esophageal stenosis (CES) is challenging, even when usingendoscopic ultrasonography (EUS). This report is the first to demonstrate theuse of transabdominal (external) ultrasound during balloon dilatation todiagnose TBR in CES. This simple technique is a promising diagnostic tool forTBR as an alternative to EUS.

Primary hepatic angiosarcoma is a rare type of tumor with a poor prognosis. To the best of our knowledge, curative surgery of a metastatic gastrointestinal angiosarcoma from a hepatic angiosarcoma has not been reported previously. In the present report, a case of colonic metastasis from a primary hepatic angiosarcoma is discussed. A rapidly growing mass was identified in the liver of an 84-year-old Japanese male who underwent a subsegmentectomy of the liver. Microscopic examination determined that the mass was an angiosarcoma composed of sheets of spindle cells. Immunohistochemical studies confirmed the diagnosis with positive CD31 staining, which indicated the endothelial nature of the malignancy. A total of 14 months following surgery, the patient did not exhibit any symptoms; however, follow-up positron emission tomography and computed tomography images revealed a mass in the cecum. The patient underwent an ileocolectomy, and the microscopic and immunohistochemical findings indicated that the mass was a metastasized colorectal angiosarcoma. At a 4-year post-surgery follow-up appointment the patient was alive with no evidence of recurrence or metastasis.

Laparoscopic surgery for locally advanced colorectal cancer suspected of direct invasion to adjacent organs or structures remains controversial because of its high conversion rate, inadequate oncologic clearance and surgical outcomes. This study retrospectively evaluated the short-term outcomes of laparoscopic multivisceral resection for colorectal cancer and investigated the factors influencing conversion to open surgery. Between 2010 and 2015, 39 patients who underwent laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures were included. The conversion rate, resection margin status, surgical results, and morbidity and mortality rates were evaluated. We also investigated the factors influencing conversion. The conversion rate was 28 %. The resection margin was negative in all cases. The median operative time was 247 min, and the median blood loss was 80 ml. The postoperative mortality rate was 0 %, and the morbidity rate was 28 %; complications of Grade 3 or more were observed in 2 patients (5 %). The factors influencing conversion were ≥2 adherent organs (p = 0.028) and clinical suspicion of direct invasion to adjacent organs (cT4b) (p = 0.076). Laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures is feasible in selected patients. Conversion is more likely with ≥2 adherent organs and cT4b.

症例は58歳，男性．下血を主訴に近医受診しS状結腸癌の診断にて開腹術施行するも広範な膀胱浸潤を認め根治術は困難と判断され試験開腹となった．その後，当院外科へ紹介となり泌尿器科による膀胱浸潤の評価では膀胱全摘が必要と診断された．術前化学療法としてmFOLFOX6を計6サイクル施行したところ，CT検査にて腫瘍径は33％の縮小が認められ，また膀胱鏡検査では粘膜面は正常化していた．S状結腸癌（SI:膀胱）の術前診断にてS状結腸切除術を施行し，膀胱筋層までを可及的に切除した．摘出標本の病理組織学的診断では膀胱壁に悪性細胞を認めず，tub2，pSS，pN0，cH0，cP0，cM0，StageIIであった．膀胱浸潤を認める原発巣に対する術前化学療法により膀胱温存術が可能となり患者のQOLの低下を防止できた．

A 55-year-old man was annually followed up for a large hepatic cyst. In 2006, a 20-mm nodule was detected in contact with the cyst that gradually grew thereafter. By 2013, the mass had expanded to 90 mm, and a percutaneous biopsy revealed a solitary fibrous tumor (SFT). Surgical resection was subsequently performed, and the patient has since been doing well for 11 months, without recurrence. SFT of the liver is a rare neoplasm; only 44 cases have been reported to date. This is the first report to describe the long-term progression of hepatic SFT from the time of its development.

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

We report 2 cases of human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer successfully treated with a combination therapy of S-1, cisplatin( CDDP), and trastuzumab followed by curative resection. Case 1 involved a 62-year-old man with type 3 HER2-positive gastric cancer spanning the antrum of the stomach to the duodenal bulb and directly invading the pancreatic head( cT4b[ Panc] N3H0P0M0, Stage IIIC). We diagnosed it as an unresectable cancer, and selected S-1, CDDP, and trastuzumab for combination chemotherapy. S-1 (120 mg/body/day) was administered orally for 2 weeks, followed by 1 drug-free week as a course, and CDDP (60 mg/m2) and trastuzumab (8 mg/kg loading dose and 6 mg/kg maintenance) were administered by intravenous infusion on day 1. After the third course, significant tumor and lymph node reduction was observed; however, pyloric stenosis developed. Distal gastrectomy with D2 lymphadenectomy was performed. Case 2 involved a 62-year-old woman with type 4 HER2-positive gastric cancer from the angle of the stomach to the duodenal bulb and directly invading the pancreatic head (cT4b [Panc] N2H0P0M0, Stage IIIC). After the third course of combination therapy, significant tumor reduction and disappearance of lymph nodes metastasis was observed. We diagnosed the patient as having a resectable cancer, and performed distal gastrectomy with D2 lymphadenectomy.

We report a case in which recurrent pancreatic metastasis of renal cell carcinoma( RCC) in the remnant pancreas was resected 6 years after subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). A 74-year-old man underwent right nephrectomy for RCC in 1991, left partial nephrectomy for left renal RCC metastasis in 1996, and SSPPD for pancreatic RCC metastasis in 2007. In November 2012, he was referred to our hospital with a tumor in the remnant pancreas, as seen on abdominal computed tomography (CT). Partial pancreatectomy for the recurrent metastatic RCC in the remnant pancreas was performed in January 2013. The tumor was histologically diagnosed as metastasis from clear cell RCC in the remnant pancreas. The postoperative course was uneventful, and the blood glucose level after surgery was well controlled using an oral hypoglycemic agent.

We examined the effectiveness of volume replacement using a lateral tissue flap (LTF) in breast-conserving surgery for a good cosmetic outcome.We analyzed the results of 130 patients with breast cancer who underwent breast-conserving surgery with replacement using an LTF from 2006 to 2010 with cosmetic evaluations performed according to the criteria of the Japanese Breast Cancer Society. We examined scores with regard to the following possible contributing factors: partial resection (Bp) or quadrantectomy (Bq), diameter of the specimen, body mass index (BMI), axillary lymphadenectomy, postoperative irradiation, and position of the tumor.The scores for cases with Bp and non-postoperative irradiation were higher than those for Bq and postoperative irradiation cases, though they were not significant factors in multivariate analysis. A negative correlation was seen between score and diameter of the specimen, whereas there was no significant correlation with BMI. There was no significant difference between scores of cases with or without an axillary lymphadenectomy. However, the score for the extended upper-outer area including the upper and outer borders was significantly higher than scores for other portions. In multiple regression analysis, cases with a tumor diameter less than 4 cm in the extended upper-outer area or less than 2 cm in other areas showed good adaptation.Tumor location and diameter are important factors for cosmetic evaluation of volume replacement using an LTF.

The expression of carcinoembryonic antigen (CEA) mRNA was assessed in 102 lymph nodes (LNs) obtained from seven colorectal cancer patients by both the conventional non-quantitative RT-PCR and quantitative RT-PCR. The number of CEA-expressing cells was calculated compared with CEA-expressing MKN-45 cell line as a standard control. Using the quantitative RT-PCR, the relative number of CEA-expressing cells ranged between 1.3x103 and 5.7x106 in 16 histologically positive LNs and between 2.3x101 and 8.1x105 in 10 histologically negative and RT-PCR positive LNs. In both histologically and RT-PCR negative LNs, the relative cell number was