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INTRODUCTION: Intradiaphragmatic abscesses are extremely rare; therefore, making a correct preoperative diagnosis is difficult. Furthermore, their pathogenesis is not well understood because of the limited number of reported cases.CASE PRESENTATION: A 62-year-old Japanese male who had undergone cholecystectomy for acute cholecystitis complicated by cholelithiasis 1 year previously presented to our hospital with a fever and right chest pain. Laboratory investigations revealed an elevated inflammatory response. Preoperative computed tomography suggested an intra-abdominal abscess and right pyothorax, and surgical drainage was performed via laparoscopic and thoracoscopic approaches because there was no laboratory improvement after intravenous antibiotic therapy. Intraoperative findings showed a localized bulge in the right diaphragmatic dome without an abscess in the liver or the subdiaphragmatic area. A whitish pus was drained through an incision. By contrast, in the thoracic cavity, serous pleural effusion, fibrin precipitation, and localized bulge on the same diaphragmatic site as the abdominal bulge were found without abscess formation. Pus was not drained by puncture aspiration, and no incision was made. The pus culture was positive for Escherichia coli. A combined abdominal and thoracic approach allows for correct diagnosis and appropriate treatment. The patient’s general condition improved postoperatively, and he remained well without evidence of recurrence of the intradiaphragmatic abscess 18 months later for follow-up chest computed tomography.CONCLUSIONS: Despite the extremely rare nature of the disease, if an intradiaphragmatic abscess is suspected preoperatively, a combined abdominal and thoracic approach may be useful for making the correct diagnosis and carrying out appropriate treatment.

Aim In response to the rising use of laparoscopic surgery, recent studies have shown that laparoscopic multivisceral resections for locally advanced colon cancer are safe, feasible, and provide acceptable oncological outcomes. However, the usefulness of laparoscopic multivisceral resection remains controversial. Here, we aimed to compare short‐term and long‐term outcomes between laparoscopic and open multivisceral resection approaches for treating locally advanced colon cancer. Methods We retrospectively collected data on 1315 consecutive patients admitted to the National Hospital Organization, Osaka National Hospital, for surgical treatment of colorectal cancer between 2010 and 2017. We assessed invasiveness in terms of operating times, blood loss, and complications. Oncological outcomes included 5‐year survival rates and recurrences. Results We included 85 patients that underwent a colectomy with a multivisceral resection for locally advanced colon cancer; of these, 38 were treated with a laparoscopic approach and 47 were treated with an open approach. Compared to the open surgery group, the laparoscopic group had significantly less blood loss (median volume: 25 vs 140 mL, P <0.001), a lower complication rate (10.5% vs 29.8%, P = 0.036), and shorter hospital stays (12 vs 15 days, P = 0.028). After excluding patients with stage Ⅳ colon cancer, the groups showed similar pathologic outcomes and no significant differences in 5‐year disease‐free survival (73.9% vs 67.4%; P = 0.664) or 5‐year overall survival (75.8% vs 67.7%; P = 0.695). Conclusion A laparoscopic approach for locally advanced colon cancer could be less invasive than an open approach without affecting oncological outcomes in selected patients. A laparoscopic approach for locally advanced colon cancer could be less invasive than an open approach without affecting oncological outcomes. Our findings suggested that laparoscopic multivisceral resection is a promising option, even when the tumor has progressed locally.

Esophageal sarcoma is an extremely rare tumor, and a recommended treatment strategy remains unestablished. The present report describes, to the best of our knowledge, the first reported case of unresectable esophageal sarcoma treated with chemoradiotherapy (CRT) followed by salvage robot-assisted minimally invasive esophagectomy (RAMIE). An 82-year-old man presented with dysphagia for solid foods. An esophagogastroduodenoscopy revealed an elevated tumor in the middle thoracic esophagus at a distance of 30-35 cm from the incisors, with preserved endoscopic passage and no additional lesions in the stomach or duodenum. A biopsy demonstrated sarcoma. Enhanced computed tomography showed a middle thoracic esophageal mass, with bulky mediastinal lymph nodes (nos. 101R and 106recR) invading the trachea. No distant metastases were detected, and tumor marker levels remained within normal limits. The patient was diagnosed with esophageal sarcoma with mediastinal lymph node metastases. As the metastatic nodes demonstrated airway invasion, definitive CRT (dCRT) was selected. The regimen consisted of radiotherapy (50.4 Gy in 28 fractions) and fluorouracil plus cisplatin. Following dCRT, the tumor and lymph nodes decreased in size, and a partial response was achieved, making the tumor resectable. Salvage RAMIE with two-field lymphadenectomy, including cervical lymph node dissection of stations 101R and 101L and upper mediastinal dissection, including station 106recR, was subsequently performed, followed by gastric tube reconstruction via the posterior mediastinal route. Pathological examination of the resected specimen revealed no residual tumor. Although a therapeutic effect was observed, a limitation remains in that a definitive diagnosis could not be fully established. A total of 14 months have passed since the initiation of treatment, with no evidence of recurrence. In conclusion, this patient with unresectable locally advanced esophageal sarcoma achieved a complete pathological response after multidisciplinary treatment, with no recurrence observed during the short-term follow-up period.

Refractory gastroesophageal reflux disease can develop after proximal gastrectomy and esophagogastrostomy. We introduce a new method that combines distal gastrectomy and Roux-en-Y reconstruction to treat refractory reflux esophagitis in patients who have undergone proximal gastrectomy and esophagogastric anastomosis reconstruction. This novel method may be useful not only for alleviating the symptoms of gastroesophageal reflux disease but also for preventing future esophageal malignancies arising from long-term reflux esophagitis.

Previous studies highlighted that aminopeptidase N (APN)/CD13 acts as a scavenger in the survival of hepatocellular carcinoma (HCC) stem cells by reducing reactive oxygen species (ROS) levels. Hence, it has been proposed that APN/CD13 inhibition can increase cellular ROS levels and sensitize cells to chemotherapeutic agents. Although ubenimex, also known as bestatin, competitively inhibits proteases such as APN/CD13 on the cellular membrane and it is clinically used for patients with acute myeloid leukemia and lymphedema, research has demonstrated that higher concentrations of the agent induce the death of APN/CD13 + HCC stem cells. In this study, we developed a poly(ethylene glycol)–poly(lysine) block copolymer–ubenimex conjugate (PEG- b -PLys(Ube)) to increase the efficacy of reagents in APN/CD13 + cancer stem cells. Exposure to PEG- b -PLys(Ube) increased the intracellular ROS concentration by inhibiting APN enzyme activity, permitting the induction of apoptosis and attenuation of HCC cell proliferation. In addition, PEG- b -PLys(Ube) exhibited a relatively stronger antitumor effect in mice than PEG- b -PLys alone or phosphate-buffered saline. Moreover, an isobologram analysis revealed that combinations of fluorouracil, cisplatin, or doxorubicin with PEG- b -PLys(Ube) exhibited synergistic effects. This study demonstrated that PEG- b -PLys(Ube) does not impair the properties of ubenimex and exerts a potent antitumor effect.

Background Laugier’s hernia is a very rare atypical femoral hernia and is challenging to diagnose preoperatively. Herein, we report a rare case of inguinal and Laugier’s hernias treated with laparoscopic transabdominal preperitoneal repair. Case presentation A 63-year-old man was admitted to our hospital with right groin swelling for 4 years. Computed tomography revealed an indirect inguinal hernia with protrusion of the small intestine. The preoperative diagnosis was right indirect inguinal hernia; Laugier’s hernia was unknown. The patient underwent laparoscopic transabdominal preperitoneal repair. During the surgery, part of the perivesical adipose tissue penetrated the lacunar ligament. It was located medial to the typical site of a femoral hernia. Thus, Laugier's hernia was diagnosed. Finally, laparoscopic transabdominal preperitoneal repair was performed for Laugier's hernia and inguinal hernia. The postoperative course was good, without recurrence. Conclusions To our knowledge, this is the first reported case of inguinal and Laugier’s hernia treated with laparoscopic transabdominal preperitoneal repair. Surgeons should be mindful that inguinal hernias can occur concurrently with other types of hernias, such as femoral hernias, including atypical variants like Laugier's hernia. Additionally, they should actively consider laparoscopic approaches such as transabdominal preperitoneal for femoral hernias. These approaches are beneficial for precise diagnosis, confirming the presence of other hernias, and simultaneously treating all coexisting inguinal hernias.

Background Capicua transcriptional repressor-double homeobox 4 sarcoma (CDS) is a rare and aggressive malignant soft tissue tumor that typically arises within the soft tissues. We report an exceptionally rare case of a gastric CDS successfully resected despite its extensive invasion into surrounding organs. Case presentation A 48-year-old male presented with a progressively enlarging abdominal mass. Upper gastrointestinal endoscopy revealed a large ulcerative tumor on the posterior gastric wall. Biopsy results initially suggested a neuroendocrine cell carcinoma. Contrast-enhanced computed tomography showed a 20 cm tumor protruding from the posterior stomach wall, directly invading the pancreas and colon. We performed a multivisceral resection (stomach, pancreatic tail, spleen, and transverse colon) achieving an R0 resection. Pathological examination of the permanent specimen revealed small round cells with high nuclear-to-cytoplasmic ratios. Immunohistochemical staining confirmed the diagnosis of CDS. The patient recovered well and was discharged on postoperative day 33. Conclusions This case report describes the first detailed account of a surgically resected aggressive CDS originating from the stomach.

Congenital absence of the portal vein (CAPV) is a rare malformation in which intestinal and splenic venous blood bypasses the liver and drains into systemic veins. CAPV is classified into two types based on the absence (type I) or presence (type II) of portal venous flow into the hepatic parenchyma and is associated with multiple other anomalies such as usually benign hepatic tumors. There have been only two case reports describing hepatocellular carcinoma (HCC) in patients with CAPV type II to date. We report the third such patient. A 50‐year‐old woman was referred to our hospital for management of a giant hepatic tumor. Contrast‐enhanced computed tomography (CECT) indicated a huge mass occupying the right lobe of the liver; the radiological diagnosis was HCC. CECT also demonstrated that the superior mesenteric vein (SMV) and the splenic vein (SpV) joined to form a shunt draining into the left renal vein and that a hypoplastic portal vein branched from the confluence of the SMV and SpV and drained into the liver, indicating that the CAPV was type II. Liver resection was successfully performed to treat the HCC, and the pathological diagnosis was well‐differentiated HCC. Seven months after the operation, a recurrent small HCC was detected and treated with radiofrequency ablation without complications. The patient has been carefully followed for 6 months to date without any evidence of further recurrence. Patients with CAPV are predisposed to developing HCC and require close surveillance. A 50‐year‐old woman was diagnosed with a giant hepatocellular carcinoma (HCC) that was associated with congenital absence of the portal vein (CAPV) type II. Patients with CAPV type II are predisposed to developing HCC and require close surveillance.

PurposePancreaticoduodenectomy (PD) concomitant with portal vein resection (PVR) often develops into digestive varices with an occurrence rate of 30–50%, and the variceal bleeding is sometimes untreatable and results in fatality. Against this issue, splenic artery (SpA) ligation during PD-PVR is emerging as an easy and effective prophylactic surgical option. The aim of this study was to investigate the significance of SpA ligation in the development of digestive varices in patients undergoing PD-PVR.MethodWe retrospectively investigated 97 patients with PDAC who received PD-PVR in two hospitals. Vascular reconstruction of the splenic vein (SpV) was not performed in either hospital. We assessed the occurrence rate of digestive varices in these patients in association with the performance of SpA ligation.ResultsThe occurrence rate of digestive varices was 23%. SpA ligation was the only significant decreasing factor for the development of digestive varices (odds ratio 0.3, p = 0.035). Although SpV resection was not a significant risk factor for the development of digestive varices in all patients, SpV resection was a significant risk factor for the development of digestive varices in patients without SpA ligation, as demonstrated in previous reports. SpA ligation did not increase surgical complications or impair pancreatic function.ConclusionPD-PVR surgery was accompanied by a 23% incidence of digestive varices, and SpA ligation significantly decreased the development of digestive varices without causing clinically significant complications.Trial registrationNo.18196 (Osaka International Cancer Institute) and no. 19006 (National Hospital Organization Osaka National Hospital)

Previous studies highlighted that aminopeptidase N (APN)/CD13 acts as a scavenger in the survival of hepatocellular carcinoma (HCC) stem cells by reducing reactive oxygen species (ROS) levels. Hence, it has been proposed that APN/CD13 inhibition can increase cellular ROS levels and sensitize cells to chemotherapeutic agents. Although ubenimex, also known as bestatin, competitively inhibits proteases such as APN/CD13 on the cellular membrane and it is clinically used for patients with acute myeloid leukemia and lymphedema, research has demonstrated that higher concentrations of the agent induce the death of APN/CD13.sup.+ HCC stem cells. In this study, we developed a poly(ethylene glycol)-poly(lysine) block copolymer-ubenimex conjugate (PEG-b-PLys(Ube)) to increase the efficacy of reagents in APN/CD13.sup.+ cancer stem cells. Exposure to PEG-b-PLys(Ube) increased the intracellular ROS concentration by inhibiting APN enzyme activity, permitting the induction of apoptosis and attenuation of HCC cell proliferation. In addition, PEG-b-PLys(Ube) exhibited a relatively stronger antitumor effect in mice than PEG-b-PLys alone or phosphate-buffered saline. Moreover, an isobologram analysis revealed that combinations of fluorouracil, cisplatin, or doxorubicin with PEG-b-PLys(Ube) exhibited synergistic effects. This study demonstrated that PEG-b-PLys(Ube) does not impair the properties of ubenimex and exerts a potent antitumor effect.