[A Case of Sigmoid Colon Cancer with Horseshoe Kidney].

We reported a case of sigmoid colon cancer with horseshoe kidney. A 79-year-old man had lower abdominal pain and underwent colonoscopy. The results of colonoscopy revealed sigmoid cancer. Preoperative computed tomography revealed horseshoe kidney. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅱa(The 9th Edition). He has not recurred 22 months later after operation. Surgery for colorectal cancer with congenital anomalies of the urinary tract requires attention to intraoperative secondary injuries. Therefore, preoperative evaluation using 3D-CT is useful tool for safety. Operating the proper dissecting normal layer would make safe laparoscopic operation possible without unexpected injuries.

[A Case of Resected Type 4 Rectal Cancer with Difficulty in Preoperative Diagnosis].

We reported a case of Type 4 rectal cancer performed laparoscopic surgery. A 73-year-old man had diarrhea and constipation and underwent colonoscopy. From the first colonoscopy, histological findings of biopsy showed non-neoplastic cells. The results of colonoscopy strongly suggested the possibility of Type 4 rectal cancer. Therefore, we performed colonoscopy twice and he was diagnosed Type 4 rectal cancer. Computed tomography revealed no distant metastasis. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅲc(The 9th edition). He then received adjuvant chemotherapy but was relapsed at bones and lymph nodes. He died 18 months later after surgery.

[A Case of Appendiceal Metastasis from Hilar Cholangiocarcinoma with Acute Perforated Appendicitis and Cholecystitis].

An 88-year-old woman had been diagnosed with hilar cholangiocarcinoma for 3 years since she received metallic stents for malignant biliary obstruction, and observed without any aggressive medical treatment. She was admitted to our hospital for further investigation of her abdominal pain. Abdominal CT showed an enlarged gallbladder, fluid collection in the right paracolic gutter, and swollen appendix. Laboratory tests showed high-grade inflammation. She was diagnosed with acute perforated appendicitis with acute cholecystitis. Laparoscopic cholecystectomy and appendectomy were performed. Perforation was confirmed intraoperatively in the appendix wall and accumulation of pus was found in the right paracolic gutter. There were no macroscopic findings of metastasis and peritoneal dissemination. Microscopic examination of the resected appendix showed adenocarcinoma cells positive for CK7 and negative for CK20 and CDX2, and were predominantly infiltrated from the muscular layer to the serosa of the appendix wall, with a diagnosis of appendiceal metastasis from hilar cholangiocarcinoma. Metastatic appendiceal carcinoma is rare, and appendiceal metastasis from hilar cholangiocarcinoma is extremely rare. Herein, we report a rare case of metastatic appendiceal carcinoma from hilar bile duct cancer with acute perforated appendicitis and cholecystitis along with findings of previous literature.

[A Case of Rectal GIST Resected using the TAMIS Method].

We reported a case of rectal gastrointestinal stromal tumor(GIST)performed transanal surgery. A 46-year-old woman was pointed out uterinal cancer and lower rectal GIST. After operation for uterine cancer, GIST was treated. Because of the patent's opinion for anal preservation, chemotherapy with imatinib for 3 months was performed and local resection was done by transanal minimally invasive surgery(TAMIS). The histopathological diagnosis was low-grade GIST and immunostaining showed the tumor was positive for c-kit, CD34, DOG-1 and α-SMA. Because capsule of the GIST was damaged intraoperatively, imatinib therapy was started and she has no recurrence after 2 years.

[A Case of Rectal Cancer with Protein-Losing Gastroenteropathy].

We report a case receiving laparoscopic surgical resection of rectal cancer with protein-losing gastroenteropathy. A 58- year-old man was referred to our hospital because of melena, diarrhea, and anorexia. He showed septic shock, anemia, and hypoproteinemia. CT scan showed a rectal tumor with regional lymph node swelling and a cavernous lung lesion with a pulmonary embolus. Ninety-five days after admission to intensive care, he was introduced to our department because of the disappearance of a lung lesion indicating a lung abscess. Colonoscopy showed a cauliflower-like type 1 rectal cancer lesion. He experienced laparoscopic low anterior resection 121 days after admission. He was discharged without problems 66 days after the operation. After 8 months of surgery and no chemotherapy, he had no recurrence of rectal cancer. Colon cancer with protein-losing gastroenteropathy is rare and shows a typical cauliflower-like type 1 tumor appearance. Hypoproteinemia can be improved after resection of colon cancer.

[A Case of Laparoscopic Surgery for Sigmoid Lymph Node Metastases after Surgery for Rectal Cancer].

Herein, we report a case of laparoscopic surgery for sigmoid lymph node metastases after surgery for rectal cancer. A 58- year-old man underwent laparoscopic surgery for rectal cancer. He underwent D2 lymph node dissection, and he was undergoing dialysis for renal disease as a complication of diabetes. CT imaging performed 15 months after surgery revealed recurrence of tumors in the sigmoid lymph nodes. Subsequently, laparoscopic removal of the sigmoid lymph nodes was planned, as the patient had no tumor recurrence at any other location, and because his condition was not suitable for chemotherapy. The postoperative course was uneventful, and the patient was discharged a few days after surgery.

[A Case of Superior Mesenteric Artery Syndrome Following Transverse Colon Cancer Surgery].

We reported a case of superior mesenteric artery(SMA)syndrome after decreased body weight and unstable oral intakes due to anastomotic leakage of postoperative transverse colon cancer. A 63-year-old man underwent laparoscopic left hemicolectomy and D3 lymph node dissection with a diagnosis of transverse colon cancer. He had postoperative anastomotic leakage and was discharged after conservative treatment on postoperative day 35. However, he had visited our hospital by the symptom of bowel obstruction caused by anastomotic stenosis and had been admitted twice. After second colonoscopic balloon dilation on postoperative day 129, he was diagnosed as anastomotic perforation and emergency reoperation was performed. In the postoperative course, he repeated vomiting and his body weight decreased and superior mesenteric artery syndrome was diagnosed. He improved after conservative treatment by fasting, a nasogastric intubation and total parenteral nutrition and was discharged 22 days after the diagnosis.

[A Case of Small Intestinal Cancer Resected by Laparoscopic Surgery].

We report a case of laparoscopic surgical resection of a small intestinal cancer. A woman in her 40s was referred to our department for prolonged abdominal problems(epigastralgia, nausea, diarrhea, and constipation). CT scan revealed a small intestinal tumor with dilatation of the oral side of the intestine. She was admitted to our hospital, and an ileus tube was introduced. One week after admission, she experienced laparoscopic partial resection of the small intestine. She was soon discharged without any problems and has had no recurrence of small intestinal cancer after 8 months of surgery without any adjuvant chemotherapy. Small intestinal cancer is frequently detected in an advanced stage, resulting in poor prognosis, but curative surgery can improve the prognosis. Optimal therapy for small intestinal cancer has not been established yet because it is rare. A multi-centered study of small intestinal cancer for the establishment of its diagnosis and therapy needs to be conducted.

Upregulation of TGF-ß1 and basic FGF in elastofibroma: an immunohistochemical analysis.

Elastofibroma is a rare tumour that occurs in the subscapular space, and it typically presents in middle-aged and older individuals. The aetiology of elastofibroma remains unknown. Recent, sporadic reports have shown, immunohistologically, that fibroblasts in elastofibroma may produce abnormal elastic and collagen fibres through the action of transforming growth factor-beta (TGF-ß), a factor that promotes fibroblast proliferation. However, that finding lacked quantitative measurements and controls. Therefore, in this study, we performed quantitative, immunohistochemical analyses of TGF-ß1 and basic fibroblast growth factor (bFGF) in three elastofibromas, and we compared them to ten dermatofibromas and keloids, and five normal skin. In elastofibroma specimens, 16-59 % fibroblasts were positive for TGF-ß1 in the cytoplasm, compared to 96 % in dermatofibroma, 93 % in keloid and 2 % in normal dermis specimens. Also, in elastofibroma specimens, 26-67 % of fibroblasts were positive for bFGF in the cytoplasm, compared to 97 % in dermatofibroma, 97 % in keloid, and 22 % in normal dermis specimens. Intriguingly, the tumour size and growth rate were proportional to the percentage of cells positive for bFGF. Finally, greater levels of bFGF expressions in fibroblasts were associated with larger sized elastofibromas. These results suggested that elastofibroma development depended on high expression of TGF-ß1 and bFGF.

Expression of Toll-like receptors 2 and 4 is downregulated after operation.

BACKGROUND: Toll-like receptors (TLR) that recognize microbial pathogens play a critical role in innate immunity; however, their expression and function after surgery remain unknown. The aim of this study was to examine TLR2 and TLR4 expression on monocytes and their responses to each agonist after surgical insults. METHODS: Blood samples were obtained from 83 patients who underwent gastrointestinal surgery. TLR2, TLR4, and inducible nitric oxide synthase expressions on peripheral blood mononuclear cells (PBMCs) were analyzed by flow cytometry. Macrophage-activating lipopeptide-2 or lipopolysaccharide-induced tumor necrosis factor-alpha and interleukin-6 production was measured by enzyme-linked immunosorbent assay. RESULTS: TLR2 and TLR4 decreased and showed the lowest values on the postoperative days 3 and 1, respectively. Macrophage-activating lipopeptide-2-stimulated tumor necrosis factor-alpha and interleukin-6 production was decreased immediately after the operation (P<.05), increased to a maximum value on postoperative day 1, and then decreased gradually. Lipopolysaccharide-stimulated tumor necrosis factor-alpha production was also suppressed immediately (P<.05) after operation then showed a gradual increase to maximum values on postoperative day 3. Inducible nitric oxide synthase in cultured PBMC that was obtained immediately after operation was upregulated (P<.05). CONCLUSION: Expressions of TLR2 and TLR4 were downregulated by operation, and agonist-induced cytokine production was suppressed transiently and soon increased through the activation of PBMC. The present study may offer new insights for postoperative modulation of innate immunity under surgical stress.

Effect of mucosal suture on the healing of mucosal defect in laparoscopic intragastric surgery.

BACKGROUND: The efficacy of mucosal suturing for the healing of a mucosal defect in laparoscopic intragastric surgery (LIGS) for gastric lesions is not yet known. METHODS: We prospectively studied ten patients who underwent mucosal resection by LIGS for gastric tumors: four patients with early gastric cancer and six with gastric adenoma. Patients were randomly divided into two groups: group I (n = 5); patients who underwent mucosal resection by LIGS with mucosal defect suturing and group II (n = 5); patients who underwent mucosal resection by LIGS without mucosal defect suturing. We performed endoscopy on day 10, and 1 month, 2 months, and 3 months after the operation to observe the healing process of the mucosal defect. The ulcer stage by endoscopy was classified as active, healing, or scarring according to the classification of Sakita and colleagues. Patients were given an H(2)-blocker daily until the mucosal defect improved to the scarring stage. RESULTS: There were no significant differences in sex, age, tumor location, size of mucosal resection, or the incidence of Helicobacter pylori infection between groups I and II. The ulcer stages in group I were significantly lower than those in group II on day 10, and 1 month, 2 months, and 3 months postoperation. The medication cost (H2-blocker) in group I was significantly lower than that in group II. CONCLUSION: Mucosal defect suturing after mucosal resection by LIGS promotes more rapid healing of mucosal defects and reduces drug costs for patients.

Multidetector CT of high-risk patients with occult gastrointestinal stromal tumors.

OBJECTIVE: Stromal tumors are an important cause of occult gastrointestinal bleeding in patients who are middle aged or older. This study evaluated the size at which stromal tumors become symptomatic and necrotic and examined the role and limitations of multidetector CT in detecting gastrointestinal stromal tumors. MATERIALS AND METHODS: Two hundred seventy-one patients with stromal tumors were retrospectively studied to examine the size of symptomatic, necrotic, or malignant stromal tumors. Next, five asymptomatic family members with germline c-kit mutations were prospectively screened to evaluate the role and limitations of multidetector CT. RESULTS: In this retrospective study, two thirds of the patients with stromal tumors had symptoms and signs that were correlated with tumor size. Stromal tumors larger than 3 cm were accompanied by necrosis, whereas this finding was rare for those smaller than 3 cm. In the prospective screening, multidetector CT with IV infusion of contrast material showed gastrointestinal stromal tumors of more than 2 cm as slightly enhanced intramural or extramural nodules and also detected most gastrointestinal stromal tumors between 1 and 2 cm. Stromal tumors of less than 3 cm were not accompanied by necrosis and appeared as slightly enhanced homogenous tumors with the administration of contrast media. CONCLUSION: Screening with multidetector CT should be feasible for detecting symptomatic stromal tumors of unknown location in the gastrointestinal tract.