[A Case of cStage â £ Remnant Gastric Cancer after Proximal Gastrectomy with Double Tract Reconstruction Treated with Conversion Surgery].

Our patient was a man in his 70s who underwent proximal gastrectomy with double tract reconstruction in 2013. He was diagnosed with cStage Ⅳ unresectable remnant gastric cancer with paraaortic lymph node metastases in 2021. He was treated with 5 courses of S-1 plus oxaliplatin therapy. Computed tomography revealed that the lymph node metastases had decreased in size after treatment. We performed conversion surgery and achieved R0 resection. Furthermore, the elevated jejunum was preserved and total gastrectomy was possible without re-anastomosis. Postoperative adjuvant chemotherapy with S-1 was started and he remains alive without recurrence at 6 months postoperative.

[A Case of Recurrent Rectal Cancer with Acute Lower Extremity Arterial Occlusion during Treatment with Bevacizumab].

The patient was 40s male, who underwent laparoscopic low anterior resection for his upper rectal cancer with final pathology results of tub2, pT3(SS), no lymph metastasis and fStage Ⅱ. He was followed up without adjuvant chemotherapy. Half a year after surgery, tumor marker was elevated and CT scan revealed multiple liver metastases. He was treated with oxaliplatin, irinotecan, Leucovorin and 5-fluorouracil(FOLFOXIRI)plus bevacizumab because of RAS mutant type. In the third courses, he has pain in the lower extremities and was diagnosed with acute lower extremity arterial occlusion. Subsequently, chemotherapy was resumed with the exception of bevacizumab, in combination with DOAC, which resulted in tumor shrinkage and allowed resection of the liver metastases.

[A Case of Acute Circulatory Failure Due to Carbon Dioxide Embolization during Laparoscopic Hepatectomy].

A 78-year-old man who was diagnosed as having hepatocellular carcinoma(segment 4/8)underwent laparoscopic hepatectomy. About 5 hours after the start of the operation, SpO2 and systolic blood pressure suddenly dropped to 87% and 40 mmHg. EtCO2 level decreased to 8 mmHg and PaCO2 was 48.5 mmHg. Based on the discrepancy between the PaCO2 and EtCO2, the patient was diagnosed as having pneumoperitoneum-induced carbon dioxide embolism. The surgical procedure was immediately interrupted and the patient was hyperventilated with pure oxygen. After surgical interruption, general status was recovered to the normal condition. We carefully restarted the operation and completed it laparoscopically. The patient was discharged from the hospital on the 15th day without any postoperative complications. Carbon dioxide embolization is a serious life-threatening complication that requires careful monitoring.

[A Case of Long-Term Survival with Metachronous Hepatic and Pulmonary Metastases from Transverse Colon Cancer by Multidisciplinary Treatment].

A 64-year-old woman underwent right hemicolectomy for transverse colon cancer. Histopathological findings revealed T, type 2, 24×22 mm, tub2, pT2N1a(1/23)M0, and pStage Ⅲa. Postoperative adjuvant chemotherapy was not administered at the patient's request. One year after surgery, carcinoembryonic antigen(CEA)level was elevated, and Gd-EOB-DTPA- enhanced MRI revealed a nodule in segment 2 and 4/8 of the liver. Based on the diagnosis of hepatic metastasis, laparoscopic partial hepatectomy was performed. Three years after hepatectomy, CEA level was found to be elevated again, and chest CT showed a solitary pulmonary nodule in segment 7 of the right lung. With a diagnosis as pulmonary metastasis, FOLFIRI plus bevacizumab was performed. After 41 courses of FOLFIRI plus bevacizumab, the pulmonary nodule decreased in size, and no new lesions appeared. The chemotherapy was terminated at the patient's request. Six months later, the pulmonary nodule increased in size, and thoracoscopic partial pulmonary resection was performed. Hepatic and pulmonary resection specimens were histopathologically consistent as metastasis of colorectal cancer. The patient has been alive without recurrence for about 4 years after final surgery(pulmonary resection)without postoperative adjuvant chemotherapy. We report a case of long-term survival with metachronous hepatic and pulmonary metastases from transverse colon cancer by multidisciplinary treatment.

[A Case of the Rectal Cancer with Metastatic Skin Cancer after Inguinal Hernia Surgery].

A woman in her 90s underwent laparoscopic hernia repair for a recurrent left inguinal hernia with abdominal wall defect 2 years ago. She came to our department with a complaint of a mass in the hernia wound, which was suspected to be a skin cancer, and the pathology diagnosis was adenocarcinoma. A colonoscopy was performed and she was diagnosed with sigmoid rectal cancer with only skin metastasis and the operation was performed. Laparoscopic anterior resection of the rectum, excision of the skin tumor, mesh removal, and rectus abdominis skin grafting were performed, and these were radical surgery. Simultaneous cutaneous metastasis of rectal cancer is extremely rare, being part of the 2.0% of other sites, and is reported with some literature review.

[A Case of the Metastatic Colonic Carcinoma from an Endometrial Carcinoma].

A woman in her 80s, had undergone radical surgery for an endometrial carcinoma 9 years earlier, and her 5-year postoperative follow-up had been completed without recurrence. She consulted an orthopedic surgeon with a chief complaint of a mass in the left inguinal region, and was referred to surgery after MRI scan revealed lymph node metastases in the left inguinal and external iliac region and a sigmoid colon tumor. Due to postoperative adhesion of the uterine cancer, the colonoscope could not be inserted to the tumor, and no tissue diagnosis was made. CT and PET scans revealed a sigmoid colon tumor plus periungual lymph node metastasis, and it was determined that radical surgery was possible, and the patient underwent resection. Surgery was performed by laparoscopic resection of the sigmoid colon and lymphadenectomy, with R0 resection. The sigmoid colon tumor and lymph nodes were of the same histology as the 9-year-old endometrial carcinoma, leading to the diagnosis of colon and lymph node recurrence 9 years after endometrial carcinoma surgery.

[Two Cases of Trousseau Syndrome during Chemotherapy].

Case 1 is a 56-year-old man. During postoperative adjuvant chemotherapy for pancreatic cancer, weakness in the right upper and lower limbs appeared, and a head CT scan was performed, but no abnormal findings were noted. Diffusion- weighted MRI scan of the head showed multiple cerebral infarcts, and a diagnosis of Trousseau syndrome was made. Case 2 is an 86-year-old man. During chemotherapy for postoperative recurrence of distal bile duct carcinoma, he developed weakness in the right upper and lower limbs, and a head MRI scan was performed. Diffusion-weighted MRI showed scattered high-signal areas, and a diagnosis of Trousseau syndrome was made. Trousseau syndrome is a condition in which stroke is caused by hypercoagulability associated with malignant tumor. The initial symptoms of cerebral infarction in patients with cancer are similar to those of chemotherapy-induced adverse events and brain metastases, and therefore, a head MRI scan is recommended even if there is no obvious abnormality on head CT scan.

[A Case of Wernicke Encephalopathy with Ileus by Small Intestinal Cancer].

The patient was a 74 year-old woman. She came to the hospital with the chief complaint of vomiting, difficulty walking, and disorientation. The MRI study showed increased FLAIR and DWI signals in the bilateral medial thalamus. Abdominal enhanced CT scan showed a 2.4 cm tumor in the jejunum. And ileus due to small intestinal tumor was observed. She diagnosed Wernicke's encephalopathy associated with gastrointestinal transit disorder. Vitamin B1 300 mg/day for 3 days was started, and eye movements and disorientation improved on the day following the start of administration. On the 10th day after admission, partial resection of the small intestine was performed for a small intestinal tumor. She was diagnosed as small intestinal cancer. She was transferred to the hospital on the 20th postoperative day.

Randomized phase II study of gemcitabine and S-1 combination therapy versus gemcitabine and nanoparticle albumin-bound paclitaxel combination therapy as neoadjuvant chemotherapy for resectable/borderline resectable pancreatic ductal adenocarcinoma (PDAC-GS/GA-rP2, CSGO-HBP-015).

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease, and multimodal strategies, such as surgery plus neoadjuvant chemotherapy (NAC)/adjuvant chemotherapy, have been attempted to improve survival in patients with localized PDAC. To date, there is one prospective study providing evidence for the superiority of a neoadjuvant strategy over upfront surgery for localized PDAC. However, which NAC regimen is optimal remains unclear. METHODS: A randomized, exploratory trial is performed to examine the clinical benefits of two chemotherapy regimens, gemcitabine plus S-1 (GS) and gemcitabine plus nab-paclitaxel (GA), as NAC for patients with planned PDAC resection. Patients are enrolled after the diagnosis of resectable or borderline resectable PDAC. They are randomly assigned to either NAC regimen. Adjuvant chemotherapy after curative resection is highly recommended for 6 months in both arms. The primary endpoint is tumor progression-free survival time, and secondary endpoints include the rate of curative resection, the completion rate of protocol therapy, the recurrence type, the overall survival time, and safety. The target sample size is set as at least 100. DISCUSSION: This study is the first randomized phase II study comparing GS combination therapy with GA combination therapy as NAC for localized pancreatic cancer. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000021484 . This trial began in April 2016.

[A Successful Management of Thrombocytopenia Due to Multiple Lung Metastasis of Intrahepatic Cholangiocarcinoma Using Laparoscopic Splenectomy-A Case Report].

We report a case of multiple lung metastasis of intrahepatic cholangiocarcinoma treated with chemotherapy, in which laparoscopic splenectomy was effective for thrombocytopenia. A 74-year-old woman was diagnosed with multiple lung metastasis of intrahepatic cholangiocarcinoma 6 years after partial liver resection(S3). She was undergoing treatment for post-transfusion hepatitis C infection since the age of 46 years and developed thrombocytopenia due to splenomegaly. The previous hospital determined that there was no indication for chemotherapy due to thrombocytopenia. Elective laparoscopic splenectomy resulted in an increase in the platelet count and facilitated the initiation of gemcitabine(GEM)and cisplatin (CDDP)combination chemotherapy. The patient has maintained a good treatment course without interruption due to thrombocytopenia during chemotherapy. In advanced cancer patients with thrombocytopenia complication due to splenomegaly, laparoscopic splenectomy may offer an effective auxiliary means for the safe implementation of chemotherapy.

[A Case of Liver Metastasis of Distal Bile Duct Cancer].

A 60-year-old female visited our hospital due to anorexia and jaundice in March 2016. She underwent pancreatoduodenectomy( PD)and was diagnosed with distal bile duct cancer. The histopathological diagnosis was distal bile duct cancer, tub2, pT3aN1M0, pStage ⅡB. Postoperatively, she received S-1 therapy as adjuvant chemotherapy. One year after surgery, abdomi- nal enhanced CT and EOB-MRI revealed a liver metastasis(S3; 20mm). After 4courses of gemcitabine(GEM)/cisplatin(CDDP) combination therapy, there was no new lesion; thus, we performed partial hepatectomy(S3)in July 2017. The histopathology findings revealed well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as a recurrence of bile duct cancer. She remains alive without second recurrence for 2 years since the tumor resection(about 3 years since PD). Surgical intervention might be beneficial in selected patients with recurrent bile duct cancer.

[Analysis of Early Palliative Care for Patients with Gastric Cancer].

BACKGROUND: Palliative care delivered to cancer patients late in the course of disease are inadequate to improve advance care planning and quality of life; thus, early palliative care is recommended. We retrospectively analyzed early palliative care delivered to patients with gastric cancer. METHOD: Forty-nine gastric cancer patients who underwent surgery and had received interdisciplinary care from the first visit(early palliative care)were assessed for physical and psychosocial symptoms. RESULTS: All patients were followed up continuously by a nurse certified in palliative care support to provide quality patient-centered care from the beginning(advance care planning). Four patients had experienced relapse, and 3 older patients had decided not to receive chemotherapy following their advance care planning. However, all 4 patients were admitted to a palliative care unit without barriers. CONCLUSION: Early palliative care might lead patients to have advance care planning, and a better quality of life.

[A Case of Superficial-Type Gastric Cancer with Metastatic Ovarian Cancer Diagnosed by Exploratory Laparotomy].

Here, we report a case of superficial-type gastric cancer with metastatic ovarian cancer(Krukenberg tumor)diagnosed by exploratory laparotomy. Chemotherapy was initiated at an early stage in this patient. A 43-year-old woman with superficialtype gastric cancer(0-Ⅱb plusⅡa), an ovarian tumor, and a solitary sclerotic bone lesion underwent exploratory laparotomy and bilateral salpingo-oophorectomy. Pathological findings showed that the resected ovarian tumor specimen contained the same type of signet ring cell carcinoma as the biopsy gastric cancer specimen; hence, the patient was diagnosed with superficial- type gastric cancer with metastatic ovarian cancer. She was treated with first-line chemotherapy(capecitabine plus oxaliplatin)15 days after exploratory laparotomy, followed by second-line chemotherapy(ramucirumab plus paclitaxel), thirdline chemotherapy(nivolumab), and fourth-line chemotherapy(irinotecan). Twenty-two months after the start of first-line chemotherapy, she finally died due to bone metastasis.

[Long-Term Survival of a Patient with Metastatic Ovarian Cancer and Local Recurrence of Rectal Cancer].

A 60s woman with upper rectal cancer underwent low anterior resection; the patient was diagnosed with pSSN1, Stage Ⅲa cancer. She received adjuvant therapy with UFT. Three years after the primary resection, metastasis to the right ovary and local recurrence were diagnosed. She was treated with CAPOX plus bevacizumab(Bev), capecitabine, FOLFIRI, and irinotecan plus S-1. Because only the ovarian metastasis increased rapidly, we were able to perform surgery and R0 resection. Two years after resection, local recurrence became apparent, and chemotherapy was reinitiated. After treating the patient with chemotherapy and chemo-radiation therapy for 2 years, R0 resection was performed. Twelve years after primary tumor resection and 9 years after primary resection, we observed recurrence-free survival.

The Risk Factor of Anastomotic Hypoperfusion in Colorectal Surgery.

BACKGROUND: Inadequate blood flow is an important risk factor for anastomotic leakage. Indocyanine green (ICG) fluorescence imaging allows intraoperative assessment of intestinal blood flow. This study determined the risk factor of anastomotic hypoperfusion in colorectal surgery using ICG fluorescence imaging. METHODS: This study included 74 consecutive patients who underwent colorectal surgery between April 2017 and March 2018. ICG was injected intravenously after dividing the mesentery and central vessels along the planned transection line, but before completing the anastomosis. Intraoperative blood flow was evaluated using ICG fluorescence imaging. With regard to the patient-, tumor-, and surgery-related factors, anastomotic perfusion was evaluated based on the changed transection line and prolonged (more than 60 s) perfusion time. RESULTS: Intraoperative ICG fluorescence imaging was performed in all patients, and no adverse events were associated with ICG injection. Based on the perfusion assessment, we changed the transection line in six patients (8.1%). The prolonged perfusion time was observed in nine patients (12.2%). The postoperative course was uneventful in 63 (85.1%) patients, but one patient (1.4%) had postoperative anastomotic leakage. The changed transection line was significantly associated with anticoagulation therapy (P = 0.029). Well-known risk factors, including surgical site, sex, smoking, blood loss, operative time, and preoperative chemoradiotherapy, were not related to the changed transection line. Prolonged ICG perfusion time was not associated with any patient-, tumor-, or surgery-related factors. CONCLUSIONS: The evaluation of intraoperative blood flow using ICG fluorescence imaging may be able to detect anastomotic hypoperfusion, and anticoagulation therapy is a risk factor of anastomotic hypoperfusion in colorectal surgery.

[A Case of Recurrent Gastric Cancer Successfully Treated by S-1 Chemotherapy].

We report a case of recurrent gastric cancer that was successfully treated by S-1 chemotherapy.An 81-year-old woman with advanced gastric cancer[L Less, Type 2, cT4a(SE), cN0H0P0M0, cStageⅡB]underwent distal gastrectomy.Abdominal CT performed 6 months after surgery revealed a low-density area in the liver.She was diagnosed with liver metastasis and started receiving S-1 chemotherapy.The liver metastasis achieved complete response, so S-1 chemotherapy was discontinued 12 months after recurrence.Abdominal CT performed 9 months after the discontinuation of S-1 chemotherapy revealed multiple low-density areas in the liver.She started receiving S-1 chemotherapy again, but S-1 chemotherapy was discontinued because of side effects after 2 courses.The patient died 24 months after receiving S-1 chemotherapy.

[A Case of Liver Metastasis of Intrahepatic Cholangiocarcinoma That Achieved Clinical Complete Response after Gemcitabine and Cisplatin Combination Chemotherapy].

We report a case of liver metastasis of intrahepatic cholangiocarcinoma that achieved clinical complete response after gemcitabine(GEM)and cisplatin(CDDP)combination chemotherapy. The patient was a 69-year-old man who was diagnosed with intrahepatic cholangiocarcinoma with hilar invasion and intrahepatic metastasis(cT4N0M0, Stage ⅣA)and was initially treated with right trisegmentectomy with left portal vein resection, lymph node dissection, and reconstruction of the left portal vein and biliary tract after transhepatic portal vein embolization(PTPE). S-1 was administered continuously as postoperative adjuvant chemotherapy, and the patient showed no signs of recurrence. Three years after the surgery, a CT scan showed LDA 10mm in diameter in the middle area of the remnant liver. We suspected liver metastasis when both serum CA19-9 and DUPAN-2 levels were elevated with the increasing size of LDA; liver biopsy was then performed, and he was diagnosed with liver metastasis of intrahepatic cholangiocarcinoma. After 3 courses of combination chemotherapy containing GEM and CDDP, a CT scan revealed that the liver metastasis reduced in size, and PR was achieved based on the RECIST standard. After 12 courses, the liver metastasis disappeared, and the patient had achieved CR based on the RECIST standard. The patient has received S-1 following the combination chemotherapy and survived for 6 years since initial treatment without any other metastatic lesions.

[A Case of Esophageal Cancer with Aortic Thrombosis That Was Successfully Treated by Aortic Thrombectomy and Video-Assisted Thoracoscopic Esophagectomy].

We report a case of esophageal cancer with aortic thrombosis that occurred during chemotherapy and was successfully treated by aortic thrombectomy and video-assisted thoracoscopic esophagectomy. A 70-year-old man with esophageal cancer( Mt, Type 1c, cT2cN0cM0, cStage Ⅱ)was administered 5-FU plus cisplatin chemotherapy. On day 7 in the first course of the chemotherapy, he experienced abdominal pain. Abdominal CT revealed endo-aortic thrombotic deposits in the aortic arch about 3 cm in diameter. He immediately received heparin at a dose of 20,000 U/day administered intravenously, but the thrombus had not resolved by the next day. He underwent aortic thrombectomy, and warfarin was administered orally after the thrombectomy. He did not experience any difficulties or discomfort related to the thrombus after the thrombectomy. He then underwent video-assisted thoracoscopic esophagectomy and was discharged uneventfully on the 18th postoperative day. Currently, he is under follow-up with no recurrence.

[Analysis of Patients Who Received Nutritional Support and the Enhanced Recovery after Surgery(ERAS)Protocol after Esophagectomy].

BACKGROUND: Malnutrition is a frequently observed phenomenon in patients with esophageal cancer after esophagectomy. Nutritional support and the enhanced recovery after surgery(ERAS)protocol may prevent malnutrition. METHOD: Nine patients who underwent esophagectomy for esophageal cancer received perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®). We retrospectively evaluated the efficacy and safety of our perioperative management. RESULTS: The median day of first oral intake(water)was the second postoperative day. The median day of first oral intake(food)was the seventh postoperative day. The patients could consume more than one and a half bottle of enteral nutrition for a year after surgery. The prognostic nutritional index(PNI)was higher than 40, and the neutrophil-to-lymphocyte ratio(NLR)was lower than 3 for a year after surgery. CONCLUSIONS: Perioperative management according to the ERAS protocol and enteral nutrition support(ELENTAL®or ENEVO®)might be feasible and prevent malnutrition in patients after esophagectomy.

Evaluation of blood flow on the remnant distal bowel during left-sided colectomy.

Adequate blood flow in anastomosis is of paramount importance to prevent anastomotic leakage. However, it is sometimes difficult to predict the viability of the intestine during surgery. During left-sided colectomy, blood flow on the remnant distal bowel is supplied only from the middle and inferior rectal arteries. The blood backflow after the root ligation of the inferior mesenteric artery is often said to be kept up to promontorium levels; however, this premise is actually based on experience, without reliable evidence. Here, we introduce the intraoperative evaluation of blood flow on the remnant distal bowel during left-sided colectomy using an indocyanine green fluorescence technique.