Risk factors for the recurrence of stage II perforated colorectal cancer: A retrospective observational study.

BACKGROUND: Patients with perforated colorectal cancer (PCRC) experience higher recurrence rates than those with non-perforated tissue. We identified the promoting factors of stage II PCRC recurrence after R0 surgery. METHOD: This retrospective observational study included patients treated for colorectal cancer at a single facility between 2007 and 2016, and compared the clinicopathological features of patients with perforating versus non-perforating stage II tumors who underwent R0 resection, while focusing on recurrences. RESULTS: Thirty-two and 112 patients (predominantly men) with perforating and non-perforating tumors, respectively, were included. The perforated group had significantly higher proportions of T4 tumors than the non-perforated group (44% vs. 15%). The perforated group had significantly lower numbers of resected lymph nodes than the non-perforated group (6 vs. 17). Seven of 17 patients with follow-up data in the perforated group experienced recurrence (41%), versus 19 of 104 in the non-perforated group (18%). In the non-perforated group, male sex (89% vs. 60%, p = 0.030), T4 stage (32% vs. 9%, p = 0.029), and fewer resected lymph nodes (12.5 vs. 18.6, p = 0.003) were significantly associated with recurrence; however, no such influences on recurrence were observed in the perforated group. The recurrence sites in the perforated group were mostly local (6 patients, 86%). Conversely, recurrences in the non-perforated group were mostly distant; 8 of 19 patients (42%) had liver metastasis and 1 (5%) had lung metastasis. CONCLUSION: Patients with stage II PCRC experienced higher recurrence rates regardless of clinicopathological features and had high local recurrence rates indicating possible local tumor cell dispersal owing to perforation.

Treatment outcomes of Kugel repair for obturator hernias: a retrospective study.

BACKGROUND: We examined the validity and applicability of the Kugel repair approach for obturator hernias, whereby we placed a Kugel patch through the preperitoneal space after placing a short 5-cm skin incision just medial to the anterior iliac spine and 2 cm cranial to the expected origin of the internal inguinal ring. METHODS: We studied patients who underwent surgical Kugel repair for obturator hernias at the Department of General Surgery, Saitama Medical University between 2007 and 2017. We examined the operating time, length of hospital stay, postoperative complications, and mortality rate. RESULTS: Fifty-eight patients with obturator hernias presented with symptoms of small bowel obstruction. A Kugel approach was used in 53 patients and a midline approach was used in 5 patients with preoperative peritonitis. Of the 53 patients managed using the Kugel approach, 39 did not require intestinal resection; a mesh was used in all these patients. In the remaining 14 patients, intestinal resection was required and performed using the same approach; subsequently, a mesh was used successfully in 6 of these 14 patients. The overall median operating time was 47 min; the corresponding values for procedures with and without intestinal resection were 39 and 68 min, respectively. In terms of postoperative complications, operative mortality was not noted among patients without intestinal perforation; however, superficial surgical site infection developed in 2 patients. Among the 5 patients with preoperative peritonitis who underwent exploratory laparotomy via a midline incision, intestinal perforation was detected during surgery, and all patients required intestinal resection; none of the patients had received a mesh, and 2 patients died after surgery. CONCLUSIONS: The Kugel repair approach was possible even in patients with obturator hernia requiring intestinal resection. However, for patients with perforations, open surgery should be performed after securing the surgical field through a midline incision.

Necrosis of the small intestine leading to a diagnosis of polyarteritis nodosa: a case report.

BACKGROUND: Polyarteritis nodosa is a disease that presents with necrotizing vasculitis in small and medium-sized arteries. It may occur in various organs, but approximately half of cases have gastrointestinal involvement. Prognosis is not favorable once organ dysfunction begins as evidenced by gastrointestinal symptoms; thus, treatment with steroids should be promptly initiated. We report the case of a patient who presented with necrosis of the small intestine, which was pathologically diagnosed as polyarteritis nodosa and treated successfully with steroids. CASE PRESENTATION: An 18-year-old Japanese woman reported a sudden onset of abdominal pain and vomiting that led her to visit our emergency department, where she was evaluated by a physician. On physical examination, tenderness to palpation in the upper umbilical region was noted, and diagnostic imaging with computed tomography showed emphysema of the wall of her small intestine. She was diagnosed as having necrosis of the small intestine requiring urgent surgery. No strangulations were noted intraoperatively but approximately 20 cm of her small intestine was necrotized. The surrounding arteries were examined and no palpable pulse was observed; therefore, segmentectomy of the necrotized regions was performed. Pathological findings revealed active vasculitis with fibrinoid necrosis, as well as destruction, fibrogenesis, and luminal stenosis of the elastic lamina found in the muscular arteries. A diagnosis of polyarteritis nodosa was confirmed as the cause of the necrosis of her small intestine. No recurrence of polyarteritis nodosa symptoms was observed when she was administered 40 mg of prednisolone daily. CONCLUSION: In cases of idiopathic intestinal necrosis or perforation, systemic diseases such as polyarteritis nodosa should be considered in the differential diagnosis.

Mesh penetrating the cecum and bladder following inguinal hernia surgery: a case report.

BACKGROUND: Tension-free repair using mesh is a common inguinal hernia surgical procedure. However, various complications such as mesh-related infection and recurrence may develop as a result. Moreover, although rare, there are also reports of intestinal obstruction caused by adhesion of the mesh to the intestinal wall and cases of mesh migration into various organs. Here, we report our experience with a patient in whom mesh extraction was performed due to migration of mesh into the intestinal tract following inguinal hernia surgery and formation of a fistula with the bladder. CASE PRESENTATION: Our patient was a 63-year-old Japanese man who had a history of operative treatment for right inguinal hernia during early childhood. Because a relapse subsequently occurred, he was diagnosed as having recurrent right inguinal hernia at the age of 56 years for which operative treatment (the Kugel method) was performed. He presented to our hospital 6 years later with the chief complaint of lower abdominal pain. Computed tomography findings revealed a mass shadow in contact with his bladder and cecal walls, and enteric bacteria were detected in his urine. Furthermore, because lower gastrointestinal endoscopic findings confirmed mesh in the cecum, we performed operative treatment. The mesh had migrated into the cecum and a fistula with his bladder had formed. We removed the mesh through ileocecal resection and partial cystectomy. CONCLUSIONS: It appeared that a peritoneal defect occurred when the mesh was placed, allowing the mesh to migrate into our patient's intestinal tract. Because contact between the mesh and the cecum resulted in inflammation, a fistula formed in his bladder. It is important to completely close the peritoneum when placing the mesh.

Postoperative recurrence and risk factors of colorectal cancer perforation.

PURPOSE: The common causes of colorectal perforation are benign. However, perforated colorectal cancer confers a risk of recurrence in the long term because of the malignant nature of the disease. In addition, the recurrence rate can also increase because of dissemination of cancer cells, reduced extent of lymph node dissection to prioritize saving life, and other reasons. METHODS: We evaluated the clinical features and postoperative recurrence in patients with perforated colorectal cancer who developed general peritonitis and underwent emergency surgery during a 7-year period between April 2007 and March 2014. RESULTS: During the study period, 44 patients had colorectal cancer perforation. The cancer sites were the ascending colon in 6 patients, transverse colon in 1, descending colon in 4, sigmoid colon in 15, and rectum in 18. The disease stage was stage II in 18 patients, stage III in 15, and stage IV in 7. Among 22 patients who could be followed up, 8 had postoperative recurrence. The recurrence rates were 18.2% for stage II cancer and 54.5% for stage III. Postoperative recurrence was more likely to occur in the patients positive for lymph node metastasis, those with poorly differentiated adenocarcinoma, those with T4 cancer, and those who did not receive postoperative adjuvant chemotherapy. CONCLUSION: The recurrence rate was higher in the patients with perforated colorectal cancer than in those who underwent surgery for common colorectal cancer. The prognosis can be expected to improve by performing standard surgical procedures, to the maximum extent possible, followed by postoperative adjuvant chemotherapy.