A Case of a Fixed Giant Peritoneal Loose Body outside the Peritoneum and near the Rectovesical Excavation.

A peritoneal loose body (PLB) is tissue completely separated from other intraperitoneal organs. It is rare and usually found incidentally during laparotomy, examination, or autopsy. PLBs are usually located free in the peritoneal cavity and not in the extraperitoneal space. They are thought to originate when epiploic appendices are released into the abdominal cavity after ischemic necrosis. We report a case of a giant PLB outside the peritoneal cavity, adjacent to the rectovesical excavation, that was identified preoperatively inan asymptomatic 83-year-old man undergoing evaluation for cholecystolithiasis. Computed tomography revealed a mass with well-defined margins in the rectovesical excavation. The mass (diameter, 60 mm) consisted of a calcified core and peripheral soft tissue and did not appear to invade adjacent organs. Although there were no symptoms or tumor growth over time, we scheduled a laparoscopic extraction for definitive diagnosis. On laparoscopic exploration, a white ovoid mass was found in the rectovesical excavation; there was no invasion of adjacent organs. We diagnosed a giant PLB. Postoperative recovery was uneventful. Most PLBs are asymptomatic and do not require surgery, except when symptoms are present, when the PLB is large, or when malignancy is suspected. PLB is rarely extraperitoneal and is usually freely mobile; however, in our patient, it was fixed and outside the abdominal cavity, near the rectovesical fossa. Although it could not be diagnosed preoperatively as being extraperitoneal, imaging findings were typical of PLB; thus, it was possible to remove the mass laparoscopically without bowel resection.

A Rapidly Growing Small-Intestinal Metastasis from Lung Cancer.

Small-intestinal metastasis from lung cancer, although relatively rare, often causes intestinal obstruction, gastrointestinal perforation, and gastrointestinal bleeding, making it an oncological emergency. Many patients have undergone emergency surgery for treatment of rapid progression of an intestinal metastatic lesion; however, information on changes in such metastases is lacking. We analyzed data from 4 patients with small-intestinal metastases from lung cancer who were treated during a 10-year period (January 2011 to December 2020) and for whom data on change in tumor diameter were available. The average rate of growth in tumor volume was 1.48-fold (range, 1.31- to 1.78-fold) during a median observation period of 22 (4-39) days, a rapid increase. Histopathological analysis showed that, in patients with a high degree of primary tumor atypia, rapid tumor growth may be caused by intratumoral hemorrhage, which was the reason for the rapid increase in tumor volume.

Evaluation of the Efficacy of Sorafenib on Overall Survival in Patients with Hepatocellular Carcinoma using FT Rate: A Devised Index.

INTRODUCTION: Transcatheter arterial chemoembolization (TACE) is the first-line treatment for intermediate stage hepatocellular carcinoma (HCC) and prolongs survival in HCC patients. However, repeated TACE results in diminished therapeutic response. In addition, the superiority of sorafenib to TACE monotherapy or combined therapy in patients with HCC is still controversial. The prognosis of HCC has many variables and, thus, the effect of a specific treatment is difficult to evaluate. The frequency of treatments per year (FT rate) used in this study was obtained by dividing the total number of radiofrequency ablations and TACE or transcatheter arterial infusion treatments by the years of survival. The aim of this study was to evaluate the overall survival (OS) of TACE versus sorafenib using the FT rate. METHODS: We compared the OS of patients with recurrence of HCC receiving repeated TACE monotherapy (CON) with those receiving therapy switched from TACE to sorafenib (SOR). In addition, a one-to-one FT rate matching cohort consisting of matched SOR (mSOR) and matched CON (mCON) was determined using the propensity score matching method, and OS in the cohort was evaluated. Factors influencing survival were evaluated using Cox proportional hazard regression analysis in all patients and the FT rate matched cohort. RESULTS: In the FT rate matched cohort, the cumulative survival rate was significantly higher in the mSOR group compared with the mCON group. Multivariate regression analysis of the FT rate matched cohort showed the FT rate and sorafenib to be significant variables for survival with a hazard ratio (HR) of 2.86 (p < 0.001) and 0.42 (p = 0.008), respectively. CONCLUSION: Early switching from TACE to sorafenib therapy may prolong OS in HCC patients unresponsive to TACE. The present study indicates that the FT rate is potentially a useful index in evaluating the outcome for patients at various stages and treatment regimens. FUNDING: Bayer Yakuhin, Ltd.

Prosthetic repair of an incarcerated groin hernia with small intestinal resection.

PURPOSE: No consensus has been reached on the use of prostheses in a potentially infected operating field. In this study, we evaluated the validity of a mesh prosthesis for the repair of incarcerated groin hernias with intestinal resection. METHODS: Twenty-seven patients underwent operations for correction of incarcerated groin hernias with small intestinal resection at our hospital between January 2000 and March 2010. The patients were divided into two groups: those who underwent repair with a prosthetic mesh and those who underwent primary hernia repair. Patients with intestinal perforations, abscess formations, panperitonitis, and those who required colon resections were excluded. The length of the operation, blood loss, and incidences of surgical site infection, postoperative ileus, and recurrence were evaluated in each group. RESULTS: Of the 27 patients studied, 10 (37%) underwent tension-free repair with a mesh, and 17 (63%) underwent primary hernia repair. Although the patients who underwent primary hernia repair were significantly older than the patients who underwent mesh repair (P = 0.015), no statistically significant differences in morbidity, including surgical site infection, or mortality, were identified. CONCLUSION: Strangulated inguinal hernias cannot be considered a contraindication to the use of a prosthetic mesh even in cases requiring small-intestinal resection.

Malignant hepatic epithelioid hemangioendothelioma with abdominal pain due to rapid progression.

Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor. We report on a patient who underwent hepatectomy for malignant HEH associated with abdominal pain due to rapid progression. An 83-year-old man was admitted to Nippon Medical School Hospital because of acute, severe upper abdominal pain. Seven months before admission, a hepatic tumor, 3 cm in diameter, had been detected in the left lateral sector. The diagnosis was hepatic cavernous hemangioma. Abdominal ultrasonography revealed a heterogeneous hyperechoic tumor with a smooth border, 6 cm in diameter, in the left lateral sector (segment 3). Contrast-enhanced computed tomography of the abdomen showed that the tumor was enhanced from the early to the late phase. Abdominal angiography revealed a cotton wool-like appearance of the tumor. The diagnosis was hepatic cavernous hemangioma. A malignancy could not be ruled out because of the tumor's rapid growth, which had caused abdominal pain. Left hepatectomy was performed. Histopathological examination showed necrosis throughout the tumor. Slightly pleomorphic neoplastic cells with rounded, spindle-like nuclei and scant cytoplasm were sporadically found in vascular channels. Intracytoplasmic lumina occasionally contained red cells. Neoplastic cells were positive for factor VIII-related antigen, CD31, and CD34. The Mib-1 index was high. The tumor was diagnosed as malignant HEH. The postsurgical course was uneventful, and the patient was discharged on postoperative day 11. After 3 months, multiple metastatic tumors appeared in right hepatic lobe. Transcatheter arterial chemoembolization was performed.

Successful treatment of a spontaneous esophageal rupture in an elderly patient: a case report.

An 80-year-old woman was admitted to our hospital with severe chest and back pains after vomiting. Computed tomography (CT) of the chest revealed left-sided pneumothorax and pleural effusion. Some food was drained from an inserted chest tube, and we diagnosed spontaneous esophageal rupture (Boerhaave's syndrome). A left thoracotomy was performed 7 hours after the onset of symptoms. A 3-cm perforation was discovered in the lateral wall of the distal esophagus. The perforation was repaired with a primary two-layered closure and covered with pericardial fat. The patient had a good postoperative course and was discharged 1 month after surgery. This case suggests the importance of early surgical treatment, even in elderly patients with spontaneous esophageal rupture.

[Endoscopic hemorrhoidal ligation from the rectum].

Endoscopic hemorrhoidal ligation with a rubber band was carried out on 40 patients with internal hemorrhoids. All the patients were treated in the outpatient ward. Seven patients complained of mild to moderate aches in the early postoperative days, which were easily controlled by medication. One week after the treatment, no patient complained of pain. None of the patients had any postoperative bleeding. The results of this treatment were classified as good (no complaint or symptoms after the treatment), fair (at least some improvement), or poor (no change or worse than before the treatment). Twenty-nine of the 40 patients were classified as good, and the remaining 11 patients were fair. No patients were classified as poor. EHL is a harmless and painless procedure and is easily performed in the outpatient ward. When internal hemorrhoids of operative indication are detected by colonoscopy, EHL can be easily and simultaneously carried out.

Immunohistochemistry of Gastric Carcinomas and Associated Diseases: Novel Distribution of Carcinoembryonic Antigen and Secretory Component on the Surface of Gastric Cancer Cells 1.

Carcinoembryonic antigen (CEA) and secretory component (SC) were localized by peroxidase-labeled antibody immunocytochemistry in normal and abnormal human gastric mucosa. In normal epithelium, both glycoproteins were absent or only faintly present, but in intestinal metaplasia and carcinoma both were prominently present. CEA and SC on the surfaces of metaplastic epithelial cells were polarized. That is, CEA was expressed only on the microvillous surface and SC was expressed only on the basolateral surface. In gastric cancer, CEA and SC were distributed over the entire surface of the neoplastic cells. Thus, deviations from the normal differentiation and maturation of gastric epithelial cells were accompanied by abnormalities in surface expression of CEA and SC. These observations, together with compatible observations previously made in colonic neoplasia (DJ Ahnen, PK Nakane, and WR Brown, Cancer 49:2077, 1982), suggest that loss of polarity of surface membrane components is a characteristic of neoplastic epithelial cells.