[Objective] To clarify the risk factors associated with early tumor recurrence in recurrent cases after curative resection for Stage Ⅱ/Ⅲ colorectal cancer.

[Methods] A retrospective review was performed of 164 cases of grossly radical colectomy for Stage Ⅱ/Ⅲ colorectal cancer during the period between 2000 and 2016. We divided these cases to two groups (recurrent within one year; group E, and recurrent after a year: group L) and compared the clinicopathological features of the two groups.

[Results] The overall early tumor recurrence rate was 45.1% of the recurrent colorectal cancer (74/164 cases). Univariate analysis identified three factors as risk factors for early tumor recurrence; pathological T4 (pT4), venous invasion, and pN3. Multivariate analysis selected two independent risk factors for early tumor recurrences; pT4 (OR = 1.89, p = 0.038), and pN3 (OR = 5.66, p = 0.029).

[Conclusion] pT4 and pN3 are considered as the risk factors for early tumor recurrence after curative resection for colorectal cancer.

Purpose: A prospective study was performed to examine the efficacy of infiltration anesthesia (IA) on the inguinal pain after a transabdominal preperitoneal repair (TAPP) for primary unilateral adult inguinal hernias.

Methods: One hundred four patients were randomly divided into two groups, 52 cases who received IA (0.75％ ropivacaine) (IA group), and another 52 cases without IA (Non-IA group) during the period from August 2018 to April 2019. In the IA group, we injected 20 ml of 0.75％ ropivacaine into the affected inguinal floor before the peritoneal incision. The degree of pain was evaluated with visual analogue scale (VAS) scores for the affected inguinal lesion in postoperative days (PODs) 1 and 14 and by the quantity of postoperative analgesics required.

Results: There were no significant differences between the two groups for all compared items: the VAS scores for the groin pain at PODs 1 and 14, the amount of postoperative analgesics used, operation time, bleeding volume, postoperative hospital stay, VAS scores of the port site pain, VAS scores of patient satisfaction or complications.

Conclusion: IA in the inguinal floor was not effective to reduce the inguinal pain in TAPPs.

We report herein on the case of a 79-year-old male breast cancer patient who had been receiving LH-RH agonist therapy with Leuprorelin Acetate for prostate cancer for 4 years and 8 months. He had a history of an operation for colon cancer. His enhanced thoracic CT examination showed an 8 mm tumor under the left nipple and a swelling associated with metastatic cancer in the left axillary lymph node which was diagnosed based on a core needle biopsy. His ultrasonic echo indicated a small hypoechoic mass in the left breast and a huge hypoechoic mass in the left axilla. There was no integration with his bone scintigraphy and serum tumor marker levels of CEA and CA15-3 were undetectable. The patient underwent a simple mastectomy and lymph node dissection. The histopathological diagnosis was invasive ductal carcinoma, solid tubular carcinoma, ER >80%, PR 1%, HER2 0, Ki-67 31.1%, PSA(-). After surgery, tamoxifen was administered as adjuvant therapy. There has been no evidence of recurrence for 20 months after the surgery.

The patient was a 74 year-old female. At the age of 44, a right mastectomy and lymph node dissection was performed for breast cancer in another hospital, with no postoperative adjuvant treatment. Twenty-nine years after surgery, she suffered from respiratory distress and visited our hospital. Due to difficulty in swallowing, oral ingestion was impossible, so she was admitted. On the chest X-ray examination, a large amount of pleural effusion was found in the thoracic cavity, and a thoracoscopic pleural biopsy was performed. The pathological finding was metastasis from breast cancer. Esophageal barium contrast imaging showed narrowing of the lower esophagus and extremely poor extensibility. An upper gastrointestinal endoscopic examination revealed that the esophagus had extensive wall pressure without extensive lesions on the periphery. A PET/CT examination showed strong accumulation in the thoracic esophagus. A similar strong accumulation was also observed in the mediastinal lymph node, right pleura and epicardium. A chemotherapy regimen involving EC × 4 (triweekly) and Doc × 4 (triweekly) was instigated. After obtaining a cPR, the patient elected to undergo hormonal therapy. A CDK4/6 inhibitor and aromatase inhibitor were started, and image evaluation after 3 months of oral administration gave almost cCR findings. The patient is still under continuous dosing and is still able to maintain normal oral food intake.

A 74-year-old man underwent a laparoscopic total gastrectomy and Roux-en-Y reconstruction for gastric cancer. On the 2^nd postoperative day, back pain and acute respiratory failure occurred. A detailed examination revealed left mediastinal empyema and mediastinitis due to esophagus jejunum anastomotic leakage: artificial ventilation management and chest cavity puncture drainage treatment were performed immediately. From the 9^th postoperative day, perfusion drainage therapy using a thoracic drain tube was started, and ventilator management could be withdrawn after 5 days. Disappearance of the leakage was confirmed by esophagography on the 29^th day. Oral intake was resumed and the patient was discharged from our hospital on the 44^th day after surgery. There have been few reports of cases of mediastinitis/mediastinal empyema which have caused intrathoracic perforation due to anastomotic leakage after a total gastrectomy, and perfusion drainage therapy was considered as one treatment option for avoiding any reoperation.

A 63-year-old man who had undergone pancreatoduodenectomy with modified Child reconstruction for pancreatic carcinoma at the age of 39 visited a nearby clinic because of abdominal fullness. Gastrointestinal endoscopy revealed he had a remnant gastric carcinoma, and the patient was referred to our hospital. An abdominal contrast-enhanced CT scan revealed infiltration of the pancreatojejunostomy site by remnant gastric carcinoma. We therefore performed an operation. Intraoperative findings showed that the remnant gastric carcinoma had invaded the pancreatojejunostomy. We performed a total gastrectomy with combined resection of the pancreatojejunostomy with a preserving choledochojejunostomy.

Although a Grade B pancreatic fistula occurred after surgery, the patient was discharged from our hospital on the 32^nd postoperative day. A CT scan revealed peritoneal dissemination 10 months after surgery, but the patient is still alive 11 months after surgery.

These are 9 reported cases of resected malignant remnant gastric carcinoma after a pancreatoduodenectomy including 2 cases of combined resection of the original pancreatogastrostomy. To the best of our knowledge our case is the first resected case of malignancy-associated remnant stomach and pancreatojejunostomy involving remnant gastric carcinoma following a pancreatoduodenectomy.

A fifty-year-old man, diagnosed as having stage Ⅳ gastric cancer (metastasis of the para-aortic lymph nodes and left supraclavicular lymph nodes), received nine courses of S-1 plus oxaliplatin. The metastatic lymph nodes decreased in size, and we performed a gastrectomy with a D2 – No. 10 + No. 16a2/b1 lymph node dissection. Histopathological findings showed gastric cancer to Stage ⅡA and he underwent adjuvant chemotherapy with S-1. One year after the first surgery, an abdominal CT scan revealed metastasis to the spleen. The patient received one course of capecitabine plus oxaliplatin and eight courses of paclitaxel plus ramucirumab. After the chemotherapy regimens, the size of the tumor remained stable and the patient underwent a splenectomy. He received postoperative adjuvant chemotherapy and has been alive without relapse. We consider that this is informative for conversion surgery in cases of gastric cancer.

A 38-year-old man was admitted to our hospital for abdominal distension and vomiting. Abdominal CT scan revealed that ileum stenosis was the cause of the intestinal obstruction. The patient underwent placement of an indwelling intestinal tube for decompression of the distended bowel, and ileal stenosis was suspected based on an intestinal series. Through colonoscopy, stenosis was detected at the ileum, 75 cm proximal from the ileocecal valve. The cause of the stenosis was diagnosed as a non-specific intestinal ulcer. We performed endoscopic marking at the anal side of the stenosis to execute single incisional laparoscopic surgery for resection of the lesion. During the procedure, the stenotic lesion could be detected at the preoperative marking point by single incisional laparoscopy. Additionally, another stenosis was found at 10 cm oral to the diagnosed stenosis. Partial resection of the small intestine, including the two stenotic lesions, was performed. Both stenotic lesions were diagnosed as being non-specific intestinal ulcers (UI-Ⅱ) with infiltration of inflammatory cells. We report herein on a case of ileum stenosis caused by a non-specific small intestinal ulcer that was successfully treated with single incisional laparoscopic surgery after intestinal endoscopic marking.

In March X of 2018, a woman in her 70s vomited, developed a fever of around 38°C and became unable to ingest orally. She consulted a doctor who referred her to our hospital with a suspected diagnosis of bowel obstruction. Abdominal plain CT imaging revealed an intussusception with an advanced part of a lipoma and an intestinal obstruction. An ileus tube was placed but there was no improvement, and on the second day an emergency operation was performed. Upon laparotomy, bloody ascites was found, and about 60 cm of the intestinal tract had turned dark red. After checking the entire small intestine and confirming that there was no other obvious abnormality, the necrotic small intestine was resected. The postoperative course was good, the patient resumed oral intake from the 6th postoperative day, and was discharged on the 14th postoperative day.

A 71-years-old man underwent left nephrectomy and received chemotherapy for multiple metastases, in the lung, bone, and skin. He was admitted with vomiting and abdominal distension. Abdominal computed tomography (CT) revealed invagination and small intestine obstruction, and intestinal metastasis from his renal cell carcinoma (RCC) was suspected. We performed surgery after improving the intestinal distension with an ileus tube. A tumor was observed in the ileum 90 cm upstream from the ileocecal valve with anterograde invagination. We partially resected the small intestine together with the tumor, which was pathologically diagnosed as a clear cell carcinoma that metastasized from the RCC. Metastasis of RCC to the small intestine is a rare entity clinically. We report this case with other cases of small intestinal metastasis we have experienced.

A 67-year-old man developed upper abdominal pain and went to a clinic. A barium enema examination and upper gastrointestinal endoscopy showed no abnormalities between the esophagus and the duodenum. However, because blood tests indicated anemia, jejunal capsule endoscopy was performed, and it showed a tumor with ulceration in the proximal jejunum. Seven days passed after ingestion of the capsule, however, there was no sign of capsule excretion. Additionally, the patient began to suffer from upper abdominal pain and vomiting and consulted the clinic. After conservative treatment for several days, an abdominal CT scan showed that there was no possibility of natural excretion of the capsule due to constriction by the tumor, and the patient was referred to our hospital. Laparoscopic-assisted partial jejunectomy was performed to retrieve the capsule 17 days after it was swallowed. Intraoperative findings showed that there was a tumor reaching the serosal membrane located at the jejunum 20 cm from the Treitz ligament. The capsule existed at the oral side from the tumor. The jejunum was clamped in advance to prevent the capsule from falling into the oral side, and the capsule was collected with the resected jejunum, including the tumor.

A 61-year-old woman developed vomiting and anorexia during hospitalization for schizophrenia. Abdominal CT found an intestinal intussusception. Ultrasonic endoscopy revealed a protuberant lesion had developed fully around the jejunum near the Treitz ligament. On gastrointestinal contrast imaging, there was circumferential narrowing in the same area. We diagnosed an intussusception by a jejunal tumor and performed laparoscopic surgery on a standby basis. The tumor appeared at 15 cm from the Treitz ligament, and about 5 cm more was found on the anal side. Laparoscopic partial resection of the small intestine was performed. The tumor comprised small intestinal villous adenomas, which were mostly highly heteromorphic. Among them, a well-differentiated adenocarcinoma with striking structural heteromorphism was observed, but there was no invasion of the submucosa and vessels. An intussusception in adults is regarded as a relatively rare disease, among which intestinal stenosis due to small intestinal villous adenomas is rarely reported. We report herein on our case with a review of the relevant literature.

A renal tumor in a 57-year-old woman was identified during a medical checkup. Computed tomography (CT) suggested a cecum tumor. After examining the results of the imaging, we suspected a mesenchymal tumor. The tumor, removed with ileocecal resection, consisted of palisade-like spindle cells. Immunohistochemical staining showed the tumor cells to be positive for α-SMA, and desmin, and negative for c-kit, and S-100. The final diagnosis was a pedunculated extra-intestinal cecum leiomyoma. Pedunculated extra-intestinal leiomyomas are very rare, and preoperative diagnosis is very difficult. We could not rule out malignancy, so we believed that surgery was necessary.

A 90-year-old man with anemia was referred to our hospital for further examination. A colonoscopy examination showed a whole circumference tumor at the transverse colon. A contrast enema revealed two apple-core signs at the transverse and the ascending colon. These findings led to the diagnosis of double colon cancer. We performed a laparoscopy-assisted right hemi-colectomy as a curative procedure. During the operation, we incidentally diagnosed intestinal malrotation because his duodenum descended directly and was joined to the jejunum with Ladd’s ligament. We found and transected the right branch of the middle colic artery at the inferior edge of the pancreas. We also transected the right colic artery and the ileocolic artery, along with the superior mesenteric artery (SMA). We achieved a D3 lymphadenectomy. Although the laparoscopic colorectal surgery proved to be very complicated with the intestinal malrotation, we successfully performed the appropriate lymphadenectomy and vessel dissections. A D3 lymphadenectomy along with the SMA from proximal to distal vessel dissection is safe and useful in laparoscopy-assisted right hemi-colectomy for the patients with intestinal malrotation.

We report herein on a rare case of the duplication of the ascending colon in an adult. A 73-year-old woman who visited a previous clinic with bloody stools was admitted to our hospital. Enhanced CT showed an 8 cm in diameter cystic lesion of the ascending colon supplied by the ileocolic artery with pooling of blood. A barium enema study revealed communication of the lesion with the ascending colon. On laparotomy, the cystic lesion was present at the ascending colon in the mesocolon, so we performed partial resection of the ascending colon including the cystic lesion. Histologically, we diagnosed duplication of the ascending colon with some inflammatory polyps.

A 71-year-old man presented to our hospital complaining of nausea. Abdominal CT revealed a thickened wall of the ascending colon and enlarged left testis with anemia. However, the patient rejected any further study. Seven months thereafter, the patient was referred to our hospital with left groin pain and swelling. Based on the CT findings and a physical examination, the patient was diagnosed as having an incarcerated groin hernia and underwent an emergency operation. However, based on the intraoperative findings a diagnosis of a left testicular tumor was made. After orchiectomy, immunopathological examination revealed metastatic adenocarcinoma from an ascending colon carcinoma. This case serves as an important reminder to consider metastatic testicular carcinoma in the investigation of all possible causes of testicular tumors.

We encountered a rare case of early transverse colon cancer and an enlarged para-aortic lymph node in a 69-year-old male patient. Colonoscopy revealed a stage 0–Ⅱa tumor at the transverse colon, and the tumor was resected with endoscopic submucosal dissection. Histopathologic findings revealed that the tumor was an adenocarcinoma and that the vertical margin was positive. Abdominal computed tomography (CT) revealed an enlarged para-aortic lymph node (#216), and positron emission tomography/CT revealed intense tracer uptake at the same lymph node (maximum standardized uptake value, 7.4). A diagnosis of transverse colon adenocarcinoma with #216 lymph node metastasis or a collision tumor (malignant lymphoma) was established. A laparoscopic transverse colectomy with D2 lymph node dissection and extraction of the #216 lymph node were performed. Histopathologic findings revealed that the transverse colon adenocarcinoma was T1bN0M0, pStage I, and that the resected para-aortic lymph node had grade 1-2 follicular lymphoma. To decide the treatment policy, it is important to perform a biopsy positively.

A 77 year-old-male patient with home mechanical ventilation because of amyotrophic lateral sclerosis (ALS), who had two previous episodes of endoscopic treatment for sigmoid volvulus, underwent Hartmann’s procedure at the time of the third event of volvulus. The procedure relieved the caregiver from hard labor of nursing.

Sigmoid volvulus commonly occurs in elderly patients with multiple complications. The endoscopic maneuver is the first choice because of its less-invasive nature, however, necrotic cases are an indication for emergency surgery. The elective surgery is also recommended after endoscopic therapy because of the high recurrence rate. ALS is a progressive neuromuscular disease that causes general weakness of the skeletal muscle and is associated with the development of severe dyspnea. It requires special attention if general anesthesia is required. There are many issues about the right to self-determination or the burden on the caregiver.

The surgical procedure on this patient protected the dignity of the patient, and improved the quality of life not only of the patient but also for the caregiver.

A 69-years-old woman, who was suffering from jaundice, was admitted to this hospital for a medical workup. Investigations revealed hilar bile duct strictures, and the patient was diagnosed as having hilar cholangiocarcinoma Bismuth type ⅢA. The patient underwent a right hepatic trisegmentectomy plus a caudal lobectomy with portal vein reconstruction, extrahepatic bile duct resection, and regional lymphadenectomy. As the patient developed hepatic encephalopathy on the third postoperative day, contrast-enhanced computed tomography (CT) was performed, which revealed thrombotic obstruction of the portal vein at the site of the anastomosis. On the same day, a central venous catheter was placed in the portal vein after removal of the portal vein thrombus via a per-mesenteric venous approach. As the thrombosis recurred despite continuous urokinase intravenous infusion through the indwelling catheter, the indwelling catheter was replaced with an indwelling intravascular sheath on postoperative Day 6. Intravenous urokinase infusion was administered through a catheter that was placed in the sheath, which led to complete disappearance of the thrombus by postoperative Day 14. The sheath was removed under local anesthesia, and the patient had an uneventful course thereafter; she was discharged home on postoperative Day 56. Carcinomatous dissemination recurred 6 months post surgery, and the patient died of the primary disease with recurrent hepatic metastasis, but no recurrence of the portal vein thrombosis.

A 69-year-old man with a distal cholangiocarcinoma underwent pancreaticoduodenectomy in our hospital. He developed bile leakage in the absence of the pancreatic fistula on postoperative day 7, which was treated conservatively by local drainage, and he was discharged on postoperative day 27. Seventeen days after discharge, he visited to our hospital again because of hematemesis. Enhanced abdominal computed tomography showed a 6-cm pseudoaneurysm without intraabdominal hemorrhage near the stump of the gastroduodenal artery, for which emergency angiography was performed, and the pseudoaneurysm was successfully treated by transcatheter arterial embolization. The patient was discharged on postoperative day 5 without complications. Few reports describe large pseudoaneurysms after pancreaticoduodenectomy, and the current case was the largest among the case reports in the past. We considered that vascular packing using the falciform ligament of the liver may be a useful technique to prevent rupture of the aneurysm.

An 82-year-old male was followed up by the physician in our hospital because he had been suffering from chronic hepatitis C, hepatocellular carcinoma and a cystic lesion of the pancreatic tail. Abdominal CT showed an irregular and poorly enhanced tumor measuring 18 mm in diameter and dilatation of the distal main pancreatic duct. FDG-PET showed a slight uptake by the pancreatic tail. The levels of serum CEA, CA19-9, and Span-1 were elevated. The patient was admitted to our department with a diagnosis of pancreatic tail carcinoma. He underwent a distal pancreatectomy with splenectomy. Histopathological examination revealed that the tumor in the distal pancreas was a moderately differentiated adenocarcinoma and the cystic tumor was a true cyst. In addition, a neuroendocrine tumor measuring 2 mm in diameter was incidentally detected near the pancreatic cancer. The patient’s postoperative course was uneventful and he was discharged from our hospital on postoperative day 11. He received adjuvant chemotherapy with S-1 for 6 months, and he was alive without recurrence 13 months after surgery. Since a ductal adenocarcinoma with a neuroendocrine tumor in the pancreas is a relatively rare occurrence, we report on this case with some bibliographical comments.

The patient was a 91-year-old man who had been under observation for an intraductal papillary mucinous neoplasm (IPMN) of the pancreatic head diagnosed approximately 17 years earlier. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) showed a nodular lesion in the IPMN, and the patient was admitted to our hospital. We diagnosed the patient as having intraductal papillary mucinous carcinoma (IPMC) and performed subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). Histopathological examination revealed that the tumor was a noninvasive IPMC. The postoperative course was uneventful and the patient was discharged from the hospital on the 15th postoperative day. The patient remains alive and in good general condition, with no signs of recurrence for at least 12 months after the surgery. It is unclear how long a patient with branch-duct IPMN should be followed up for. To the best of our knowledge, he is the oldest person reported until date to have undergone SSPPD for IPMN in Japan. Herein, we report a case of IPMC resected in an elderly man after 17 years of observation, with some discussion of the relevant literature.

One year previous to presenting, a 36 year-old female noticed a swelling in the medial upper right thigh. Although she could displace the swelling easily by herself, she finally visited our hospital because it became gradually more difficult to displace. The swelling was near the femoral artery inferior inguinal ligament, so she was hospitalized for surgery with the diagnosis of a right femoral hernia. Laparoscopic hernia surgery (transabdominal preperitoneal repair: TAPP) was performed. The hernia orifice was observed in the femoral ring, with incarceration of a dark red-colored cyst. After the cyst was displaced into the peritoneal cavity with extracorporeal manipulation, it was completely resected and the hernia orifice was repaired. Pathological examination of the cyst wall revealed the existence of ductal structure in some regions. Immunohistochemical staining of the region showed that both estrogen (ER)-positive glands and CD10 positive stroma existed there, which confirmed a diagnosis of endometriosis. Endometriosis accompanying a femoral hernia is extremely rare. Furthermore, no such case in which laparoscopic surgery has been performed has ever been reported in Japan with the exception of this case.

A 66-year-old female was admitted to our hospital with discomfort from a right inguinal mass. She had no inflammatory sign. Contrast-enhanced computed tomography suggested that her appendix was incarcerated into a right femoral hernia. We diagnosed the incarceration as a de Garengeot hernia, and planned emergency surgery. We observed inside the abdominal cavity using laparoscopy, but surprisingly cecum adipose fat was incarcerated into the right femoral hernia. We were able to release the incarcerated hernia by compressing the mass from the outside and pulling from the inside. When the adipose fat was released, contaminated ascites flowed from the hernia sac, and cecum adipose fat turned black. We performed cecum adipose fat resection, and planned a secondary and radical laparoscopic repair for the hernia. Forty days later, we performed a transabdominal preperitoneal repair (TAPP) and repaired the hernia. There has been no recurrence and no complications after the surgery. Cecum adipose fat incarcerated into a femoral hernia is a rare, and this is a first report of laparoscopic repair for an incarcerated femoral hernia which was treated with a TAPP procedure.

A 77-year-old woman visited our department with a mass in her right lower abdomen. Abdominal computed tomography revealed two hernia orifices. With the diagnosis of Spigelian hernia associated with an indirect inguinal hernia, an operation was performed. Both hernia orifices were near each other, and reinforcement using a Direct Kugel Patch was made through the same surgical wound. No signs of recurrence of either hernia have been observed during a one-month follow up. As the incidence of Spigelian hernias associated with inguinal hernias is expected to increase with the aging of the population, appropriate treatment and diagnosis are important. The method we used method seems to be an effective technique because it is simple and can cover both the orifices with a single mesh.

A 71-year-old man was admitted to another hospital with acute abdominal pain. He was diagnosed as having acute peritonitis associated with intestinal perforation and was transported to our hospital. We could not ask him about his condition in detail, because his consciousness was disturbed due to septic shock. We diagnosed his condition as diffuse peritonitis from a perforation of the small intestine based on his abdominal findings and computed tomography and performed an emergency operation. He had undergone laparoscopic surgery for an incisional hernia two years previously. During the operation, we found a caliber change at the middle of the small intestine and a perforation in the expanded small intestine, where it was in contact with the mesh used to repair the incisional hernia. We resected the small intestine from the perforation to the caliber change. In the postoperative findings of the specimen, we found a press-through-package (PTP) inside the caliber change and concluded that it had caused the acute abdomen. We report herein on a case of acute abdomen caused by accidentally ingestion of a PTP. In cases of acute abdomen in the elderly, we must remember the possibility of accidental ingestion of a foreign body.

We report herein on a case of esophageal hiatal hernia with an upside-down stomach which was successfully treated using laparoscopic surgery. The case involved a 72-year-old woman with a cataract presenting with a mediastinal abnormal shadow on chest X-ray, who was referred for further examination. Computed tomography and an upper gastrointestinal series showed an upside-down stomach and esophageal hiatal hernia with a partially incarcerated transverse colon. No esophagitis or gastric erosion was seen on endoscopy. Although there were no symptoms associated with esophageal hiatal hernia, we judged this patient to be a surgical candidate due to the risk of complications such as strangulation, bleeding and perforation. Using a laparoscopic approach, the stomach and transverse colon were reduced into the abdominal cavity, and the patient underwent a laparoscopic repair of the hiatal hernia and Toupet fundoplication with mesh reinforcement of the crural repair site. Her postoperative course was uneventful. We report on such a case and review the relevant literature.