We report a case of a 51‒year‒old man who presented with right lower abdominal pain. On physical examination, a palpable, tender mass was detected in the right lower abdomen. Contrast‒enhanced computed tomography (CT) revealed a 15‒cm mass in the right lower abdominal wall, supplied by the right inferior epigastric artery, with internal hemorrhage and necrotic areas. Radiological findings were inconclusive for malignancy. As there was no evidence of distant metastasis or invasion into adjacent organs, the tumor was considered resectable, and surgical resection was performed. Histopathological examination confirmed the diagnosis of synovial sarcoma. Given the high risk of recurrence and metastasis associated with synovial sarcoma, adjuvant chemotherapy was administered postoperatively. The patient remains alive without recurrence 1 year after surgery.

The patient was a 72-year-old woman with a history of surgery for uterine, bladder, left breast, and rectal cancers. The patient was admitted to the emergency department due to abdominal pain and vomiting. Abdominal and pelvic computed tomography showed a mass lesion and bowel obstruction at the end of the ileum, and positron emission tomography showed a mass lesion with accumulation in the same area of the pelvis. The patient was referred to our department for surgical treatment. The tumor at the end of the ileum invaded the ileal conduit, abdominal wall, right-sided colon, and mouth of the ileum, and a right hemicolectomy of the colon was performed. Another mass was palpated in the pelvic jejunum during examination, and partial resection of the small intestine was performed simultaneously. The tumor at the end of the ileum was diagnosed as diffuse large B-cell lymphoma, whereas the jejunal tumor was diagnosed as tubular adenocarcinoma. Synchronous double cancer of malignant lymphoma of the ileum and carcinoma of the jejunum is rare. Herein, we report this case and review the relevant literature.

A 59-year-old man presented with abdominal mass and weight loss. Computed tomography revealed a 20 cm mass in the vicinity of the left kidney. A tumor biopsy was performed and diagnosed with leiomyosarcoma. We performed tumor resection. The tumor invaded the surrounding tissues, and a lumpectomy with resection of the left kidney and left adrenal gland was performed. Pathologically, there was a slight suspicion of tumor exposure, so radiotherapy was administered to the dissected surface. There was no evidence of local recurrence or metastasis after 12 months.

PURPOSE: Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy. METHODS: A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM). RESULTS: After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174 min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0 ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9 days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394). CONCLUSION: Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

INTRODUCTION: Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. PRESENTATION OF CASE: A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein. DISCUSSION: There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely. CONCLUSION: Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis.

BACKGROUND: Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices. METHODS: We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017. RESULTS: Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis. CONCLUSIONS: Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon's skill. The appropriate indications must be established with more case registries because our experience is limited.

INTRODUCTION AND IMPORTANCE: We describe the case of a patients with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was treated by laparoscopic repair. CASE PRESENTATION: An 82-years-old man with history of HCC with hepatitis C virus-related liver cirrhosis (Child-Pugh B). The patient was treated RFA to HCC for segment 4, 5, 6, 8. After 16 months from latest RFA for segment 8, the patient was admitted to our hospital because of mild dyspnea. Computed tomography revealed a diaphragmatic herniation of bowel loops into the right thoracic cavity. The patients electively underwent laparoscopic repair of the diaphragmatic hernia. The patient was discharged from hospital without any post-operative complications. CLINICAL DISCUSSION: The only treatment to diaphragmatic hernia is surgery, but liver cirrhosis patients limits this possibility. For the surgical treatment of patients with severe cirrhosis, the operation should be carefully assessed. We believe that a laparoscopic approach should be used for repairing diaphragmatic hernia. In the present case, we considered that a laparoscopic approach was safer and more feasible than open laparotomy. CONCLUSION: Diaphragmatic hernia is a rare late-onset complication associated with RFA for HCC. And patients with HCC often have severe liver dysfunction and cirrhosis. A laparoscopic approach is safe and minimally invasive for sever cirrhosis patients.

BACKGROUND: Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure. METHODS: We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients. RESULTS: Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7-14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10-16 days). CONCLUSION: The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

We herein present an innovative technique of laparoscopic posterior mesh rectopexy (LPMR) for full-thickness rectal prolapse and report the clinical outcomes in our institution. Ten consecutive patients who were treated with our latest LPMR technique using mesh with an anti-adhesion coating from June 2014 to May 2017 were retrospectively analyzed. All patients were women with a mean age of 63.6 years (range, 39 to 82 y). The median operative time and blood loss volume were 197.5 minutes (range, 156 to 285 min) and 0 mL (range, 0 to 152 mL), respectively. No perioperative complications occurred, including surgical site infection, pneumonia, urinary dysfunction, and intestinal obstruction. The median follow-up duration was 768 days (range, 396 to 1150 d). During the follow-up, the cumulative incidence of full-thickness rectal prolapse and any mesh-related complications was 0. It may be possible to eliminate retroperitoneal closure using a mesh with an anti-adhesion coating. Our LPMR technique appears safe and acceptable.

郭清すべきリンパ節領域の同定が可能か検討するために、腹腔鏡手術予定の結腸癌患者50例を対象に、カラー蛍光内視鏡システムであるPINPOINTシステムを用いて、術中蛍光リンパ流・リンパ節診断を行い、臨床病理因子と比較検討を行った。手術前日あるいは前々日の内視鏡検査時に、インドシアニングリーンを腫瘍直下の粘膜下に局所注射を行った。経口リンパ流の有無については、手術開始時の蛍光状態で判定した。その結果、手術前日あるいは前々日の内視鏡検査による有害事象は認めなかった。手術開始時の蛍光リンパ流は、50例中39例で確認することができた。上行結腸癌13例では、蛍光リンパ流に沿った領域リンパ節に転移をきたす可能性が示唆された。横行結腸癌8例でも、同一の腫瘍局在であっても、症例ごとに異なる領域リンパ節に移転する可能性が示唆され、病理学的に転移陽性であった。術前の画像検査にてリンパ節腫大を認めない28例中、蛍光リンパ流を確認できなかったのは4例で、リンパ節腫大を認めた22例では7例であった。

The purpose of this study was to evaluate the prognostic significance of programmed cell death-ligand 1(PD-L1)expression and CD8+T cells in the immune microenvironment. From January 2011 to December 2011, we retrospectively examined 31patients with Stage III colorectal cancer. PD-L1expression and CD8+T cell counts were evaluated by immunohistochemical study using whole-tumor slides. PD-L1expression in cancer cells(PDCC)and in tumor-infiltrating stromal cells(PDSC)was divided into high(H)and low(L)groups. CD8+T cells were counted in the core of the tumor(CDCT)and in the invasive margin of the tumor area(CDIM), and divided into high(H)and low(L)groups. Based on a median follow-up time of 69.3 months, the 5-year overall survival and disease-free survival of all patients were 74.2% and 64.5%, respectively. The overall survival was significantly longer for patients in the CDIM-H group(82.6%)than those in the CDIM-L group(50.0%; p= 0.034). Patients in the PDSC-H group also tended to have superior overall survival than those in the PDSC-L group(84.2% and 58.3%, respectively, p=0.094). In conclusion, both CD8+T cells and tumor-infiltrating immune cells with PD-L1may indicate antitumoral function in patients with Stage III colorectal cancer.