Katsuhito Suwa

Internal hernia through a peritoneal defect in the pouch of Douglas: Report of a case.

INTRODUCTION Internal hernia is a rare entity which can cause intestinal obstruction. The most common type of internal hernia is the paraduodenal hernia which accounts for 53% of cases, and the internal hernia within the pelvis account for 7%. Perineal hernia, which is classified as pelvic hernia, usually occurs due to weakening of the pelvic floor musculature and thus, should be distinguished from the internal hernia caused by peritoneal defects in the pelvic cavity. PRESENTATION OF CASE We present a case of 28-year-old female who presented intestinal obstruction. Conservative therapies failed and she required emergency laparotomy. The operative findings revealed a peritoneal defect of 2cm in diameter in the pouch of Douglas, through which the ileum was incarcerated and strangulated. The incarcerated bowel was reduced, and the intestinal color quickly returned to normal. Therefore a primary closure of the peritoneal defect was performed and the postoperative course was uneventful. DISCUSSION A PubMed search for the case of internal hernia through a defect in the pouch of Douglas revealed only three, making this an extremely rare condition. CONCLUSION Because of rarity of this hernia, the etiology is unknown. However, our patient is a young female with no history of pregnancy, abdominal surgery, or trauma, therefore the cause of the peritoneal defect is considered congenital.

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome, gastropleural fistula and pleural empyema: Report of a case

INTRODUCTION Bochdaleks diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD). PRESENTATION OF CASE A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed. DISCUSSION A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition. CONCLUSION In dealing with adult BDH, possible post-repair ACS should be considered.

Local excision of rectal schwannoma using transanal endoscopic microsurgery: A case report.

Highlights • Extremely rare rectal schwannoma was successfully treated by TEM.• Only 11 cases of anorectal schwannoma have been reported.• TEM is a feasible approach for local excision of rectal tumors.

Is fascial defect closure with intraperitoneal onlay mesh superior to standard intraperitoneal onlay mesh for laparoscopic repair of large incisional hernia?: IPOM-Plus versus sIPOM for large IH

The ideal surgical technique for large incisional hernia repair has not yet been identified. The aim of this study was to evaluate surgical outcomes of standard intraperitoneal onlay mesh (sIPOM) versus fascial defect closure with intraperitoneal onlay mesh (IPOM‐Plus) for large incisional hernia repair.

Large gastrointestinal stromal tumor and advanced adenocarcinoma in the rectum coexistent with an incidental prostate carcinoma: A case report

INTRODUCTION Gastrointestinal stromal tumors (GISTs) are the leading mesenchymal neoplasia in the gastrointestinal tract, but GIST arising from the rectum is rare. When a secondary neoplasia coexists in the vicinity of a rectal GIST, more aggressive treatment strategies may be needed to cure the diseases. PRESENTATION OF CASE We herein describe a 76-year-old man with a large gastrointestinal stromal tumor along with an advanced adenocarcinoma in the rectum that coexisted with prostate carcinoma. Preoperative examination revealed an advanced adenocarcinoma of the upper rectum and a large pelvic mass suggestive of a GIST or a neuroendocrine tumor arising from the anterior wall of the lower rectum. To eradicate the tumor, total pelvic exenteration with ureterocutaneous fistula was carried out after obtaining written informed consent. Immuhistochemical studies revealed the concurrence of an advanced rectal cancer (T3, N1, M0) and a malignant GIST (c-kit-positive, CD34-positive, vimentin-positive, and CAM5.2-negative), and an incidental prostatic acinar adenocarcinoma. The patient was given adjuvant chemotherapy with imatinib and remains disease-free as of 12 months after surgery. DISCUSSION A PubMed search for the case of coexistence of GIST with two other malignancies revealed only four cases, making this very rare condition. CONCLUSION Radical surgery with perioperative adjuvant chemotherapy using tyrosine kinase inhibitors is the choice for treatment of large GISTs with a malignant potential. Our report suggests that aggressive surgical approach would be feasible, when a secondary tumor is present near the GIST.

Safety and Efficacy of Trifluridine-Tipiracil Hydrochloride Oral Combination (TAS-102) in Patients with Unresectable Colorectal Cancer.

Aim: To retrospectively examine efficacy and safety of oral combination of trifluridine and tipiracil hydrochloride (TAS-102) as the second-line therapeutic agent for unresectable colorectal cancer. Patient and Methods: Treatment outcomes of 17 patients who had received TAS-102 at our Institution from January 2015 to January 2017 were analyzed. The indications for second-line TAS-102 treatment were intolerance to other multi-drug combination (four patients) or patient refusal of the standard second-line therapy (13 patients). Results: Among 17 patients who received TAS-102 as second-line therapy, partial response was observed in two (12%) and stable disease in two (12%). Outcomes of TAS-102 given as second-line therapy were: median overall survival of 5 months, response rate of 12% and disease control of 24%. Overall, no adverse events other than neutropenia were noted. Conclusion: Our findings suggest a beneficial role of TAS-102 in second-line therapy for unresectable colorectal carcinoma.

Risk Factors for Early Postoperative Small Bowel Obstruction After Anterior Resection for Rectal Cancer: Methodological Issues: Reply

Dear Editor, We thank Dr Weng J et al. for their interest in our study [1] and are pleased to address two issues raised in their letter [2]. Concerning the first query on multivariate analysis, the risk factors with p values of less than 0.05 used from the univariate analysis may have had a large effect on outcome. Accordingly with the suggestion, we performed an additional multivariate analysis using variables with p value of less than 0.2 in the univariate analysis (male sex, previous abdominal surgery, low tumor, open surgery, low anterior resection (LAR), D3 node dissection, defunctioning ileostomy, prolonged operation time, and pT3B). The results indicated that defunctioning ileostomy formation (odds ratio (OR) 5.38, 95% CI 1.37–24.17, p = 0.0152) and D3 node dissection (OR 10.55, 95% CI 1.72–208.29, p = 0.0076) were independent risk factors for early postoperative small bowel obstruction. The results were similar to those mentioned in our article, showing that in our study the effect of p value, though potentially large, did not significantly affect the findings. The second issue raised by Weng J et al. regarded wide 95% CIs for LAR and D3 dissection indicating multicollinearity. We calculated correlation coefficients among all variables and all were lower than 0.7. Thus, we considered that LAR and D3 dissection, though having wide 95% CIs, do not need to be omitted in the analysis. As mentioned by Weng J et al., we did emphasize that the limitation of our study is its exploratory nature and the small sample size. Further investigation is mandatory.

Laparoscopic surgical challenge for T4a colon cancer

For patients with T4a colon cancer, the risk of peritoneal dissemination after surgery remains unclear. Seven hundred and eleven patients with T3 or T4a colon cancer, 80 years of age or younger, underwent curative resection (open surgery in 512 and laparoscopic surgery in 199) at the four Jikei University hospitals between 2006 and 2012. Their risk factors for peritoneal dissemination after surgery were evaluated retrospectively. Number of lymph node metastases, postoperative liver metastases and postoperative peritoneal dissemination events in the T4a group were significantly greater than the number in the T3 group. Peritoneal dissemination after surgery developed in four patients (0.7%) in the T3 group and in six patients (5%) in the T4a group. Risk factors for peritoneal dissemination consisted of macroscopic type (P = 0.016), serosal invasion (P = 0.017) and number of lymph node metastases (P = 0.009) according to the Cox proportional hazards regression model. However, tumor diameter and surgical approach (laparoscopic vs open) were not significant factors for peritoneal dissemination. There were no significant differences between the postoperative relapse‐free survival rates for each surgical approach within the T3 or T4a group. Because of comparable postoperative peritoneal dissemination in T3 and T4a colon cancer by the surgical approach (laparoscopic or open), laparoscopic surgery for patients with T4a colon cancer seems justified.

Topic: Perineal Reconstruction.

Background: A perineal hernia (PH) is a challenge for surgeons and may develop after conventional abdominoperineal resection (APR), Recently several different surgical approaches and techniques of repair have been reported, however, the standard technique has yet to be established. We present two cases of PH after APR; the PHs were successfully repaired with KugelTM patch (M size, 11 x 14 cm) through a trans perineal approach.

A Case of Poorly Differentiated Early Rectal Adenocarcinoma with Tubulo-Villous Adenoma

症例は42歳の男性で, 主訴は便への血液の付着. 注腸X線および内視鏡検査で直腸 (Ra) に表面不整でひだの集中を伴う約20mm大のIspを認め, 生検で低分化腺癌を認めた. 対麻痺を有するため, ハルトマン手術を施行した. 病理組織学的診断は腺管絨毛腺腫内低分化腺癌であり, 深達度はsm2, 第1群リンパ節に転移を認めた. 両端に腺管絨毛腺腫が存在し, その中央に低分化腺癌が位置する極めてまれな分布形態を示し, 免疫染色では癌部にのみ一致したp53蛋白の過剰発現を認めた. K-ras癌遺伝子の点突然変異は, 腺管絨毛腺腫, 癌部のいずれにも認めなかった. 本症例は, 組織像および分子生物学的検討よりadenoma-carcinoma sequenceを経由した低分化腺癌と考えられ, 低分化腺癌の発生を考察するうえで貴重な症例であった.