[Case of Robot-Assisted Low Anterior Resection with Total Cystectomy for Rectal Cancer Invading the Urinary Bladder/Prostate in Collaboration with Urologists].

We present a case of a 72-year-old man diagnosed with rectal cancer invading the urinary bladder/prostate. Preoperative chemoradiotherapy substantially reduced the tumor size. In collaboration with urologists, robot-assisted low anterior resection with total cystectomy was performed using the da Vinci Xi system. Depending on the surgical situation, the colorectal surgeon and urologist could smoothly and rapidly play the role of a console surgeon. Although the first robot-assisted multi-organ resection of our institution, the surgery was completed safely without any complications. Although the patient developed urinary tract infection postoperatively, he recovered and was discharged after postoperative 23 days. In conclusion, robot-assisted surgery would be useful in pelvic surgery involving multiple departments such as colorectal surgery, urology, and gynecology.

[A Case of Lymph Node Metastasis of Intrahepatic Bile Duct Cancer Successfully Treated Using Multidisciplinary Therapy].

We report a case of lymph node metastasis of intrahepatic bile duct cancer that was successfully treated using chemotherapy and radiation therapy.A man in his 70s underwent hepatic resection for intrahepatic bile duct cancer, and abdominal CT 1 year 8 months after surgery revealed lymph node swelling(25mm in diameter)along the common hepatic artery.He was diagnosed with lymph node metastasis and began to receive chemotherapy.We administered gemcitabine(GEM), cisplatin, and S-1 for 6 months, and GEM and S-1 for 1 year 4 further months as combination therapy.One year 10 months after the start of chemotherapy, the size of the lymph node decreased to 13 mm.However, as FDG uptake was seen on FDG-PET, radiation targeted to the lymph node was applied(50 Gy/25 Fr).After completion of radiation therapy, the lymph node has not regrown even in the absence of treatment, and the patient survives 6 years after the primary operation(4 years 4 months since the start of chemotherapy for recurrence).This case suggested that multidisciplinary therapy might be useful for lymph node metastasis of intrahepatic bile duct cancer.

[A Long-Surviving Patient with Unresectable Gastric Cancer Treated with Multiple Rounds of Chemotherapyafter Gastrojejunostomyand Ileocolonostomy].

We report a long-surviving patient with unresectable gastric cancer treated with multiple rounds of chemotherapy after gastrojejunostomy and ileocolonostomy. The patient was a 79-year-old man. Endoscopic examination revealed a type 3 gastric cancer in the antrum and showed pyloric stenosis. We observed that the gastric tumor had invaded the transverse colon, pancreas, and duodenum, and was associated with peritoneal metastasis on the surface of the hepatoduodenal ligament and the posterior leaf of the transverse mesocolon. We performed gastrojejunostomy and ileocolonostomy to allow oral intake and to prevent ileus. The final diagnosis was fT4b(SI), N2, H0, P1, M0, CY0, Stage IV . The patient's oral intake was not sufficient following the operation, and therefore, he was treated with 8 courses of 5-FU plus PTX intravenously until disease progression was observed. Bi-weekly administration of CPT-11 and CDDP was chosen as the second-line chemotherapy. Grade 2 renal dysfunction was observed after 13 courses of this therapy, and therefore, we changed the regimen to CPT-11 monotherapy, repeating 18 courses until disease progression was observed. The patient was treated with 18 courses of S-1 monotherapy as the fourth-line chemotherapy, and then 2 courses of S-1 plus DTX. The patient died of progressive disease 4 years and 5 months after surgery. During chemotherapy, he maintained a good performance status and could be treated as an outpatient.

[Effectiveness of Irinotecan, S-1, and Bevacizumab for Rectal Cancer with Lung and Skin Metastases after Adjuvant Chemotherapy].

A 50-year-old woman with a chief complaint of bloody stools was diagnosed with rectal cancer via colonoscopy. Laparoscopic rectal anterior resection with D3 lymph node dissection was performed in June 2014. The pathological diagnosis was pStage III a(Ra, pT3, N1)cancer, and the patient received 8 courses of XELOX as postoperative adjuvant chemotherapy. During follow-up at 12 months after surgery, chest computed tomography revealed a mass in the left lingular segment measuring 25mm in diameter and multiple small nodules in both the lungs, indicating lung metastases. We found several subcutaneous nodules with a maximum diameter of 10mm in her abdomen and the back of head. We removed 3 subcutaneous nodules for the purpose of diagnosis and treatment in June of 2015. The pathological findings were consistent with cutaneous metastases of rectal cancer. The patient received a 1 course of IRIS and 5 courses of IRIS plus bevacizumab. Subsequently, the lung metastases disappeared and no new skin lesions were detected. We suggest that this case could be a good reference in determining the appropriate treatment for rectal cancer having lung or cutaneous metastases.

[A Case of Cholangiocarcinoma with Intestinal Malrotation Treated with Pancreaticoduodenectomy].

We report a case of cholangiocarcinoma with intestinal malrotation that was treated with pancreaticoduodenectomy. The patient was a 74-year-old man, who underwent laboratory screening and was subsequently found to have elevated γglutamyl transpeptidase levels. Preoperative ultrasonography revealed intrahepatic bile duct dilatation. Endoscopic retrograde cholangiopancreatography demonstrated a filling defect in the common bile duct and cytology of the bile demonstrated the presence of an adenocarcinoma. On preoperative computed tomography (CT), the SMV was located on the left side of the SMA, which showed the SMV rotation sign. Additionally, the small intestine and the colon were deviated to the right and left side of abdominal cavity, respectively. We diagnosed the patient with cholangiocarcinoma with intestinal malrotation and preduodenal portal vein involvement using the CT scan, and performed pancreaticoduodenectomy. Since the ligament of Treitz was absent during surgery, we diagnosed this as a case of the nonrotation type of malrotation. The postoperative course was uneventful and the patient was discharged from the hospital 42 days after the surgery. Anomalies of the portal venous system are so rare that recognition of its variation is important in order to avoid accidental injuries during the operation.

Retrograde endoscopic submucosal dissection for early thoracic esophageal carcinoma.

Although the standard treatment for intramucosal esophageal cancer without lymph node metastasis is endoscopic submucosal dissection (ESD), we sometimes encounter patients who are not able to undergo a transoral endoscopic examination. Here, we report a surgical procedure consisting of transgastric retrograde ESD to treat early esophageal cancer (T1a-EP, N0, M0) because of a stricture after hypopharyngeal cancer surgery. This retrograde ESD procedure can be a safe and effective treatment option for early esophageal cancer. This is the first report of a surgical retrograde ESD method for esophageal cancer.

[Complete response of advanced rectal cancer with combined therapy of S-1 + chemo-radiation plus FOLFIRI--a case report].

A 64-year-old man was admitted to general practitioner because of dyschezia. He was diagnosed with lower rectal cancer by colonoscopy and referred to our hospital for therapy. At first, in spite of multiple liver metastases, we tried a resection of primary lesion in order to control of breeding, dyschezia and pain. However, we had to give up the resection, so we made sigmoid colostomy only. One month after the operation, a combination chemo-radiotherapy using S-1 was performed for controlling of local symptom. S-1 (120 mg/day) was administered on days 1-14, and 21-35. Radiation (2 Gy) was administered on days 1-5, 7-12, 14-19, 21-26, 28-33, and 35-40, a total of 60 Gy. One month after this therapy, the tumor was remarkably reduced and the reduction was judged as partial response. Moreover after 6 courses of FOLFIRI, the reduction was judged as complete response. Local control therapy (S-1+chemo-radiation) plus systemic therapy (FOLFIRI) is one of the promising effective therapies for advanced rectal cancer.