[Ascending Colon Cancer with Radical Resection after Stent Reimplantation Due to Colonic Stent Obstruction for Palliation-A Case Report].

Since the insurance coverage of colorectal stents for bowel obstruction due to colorectal cancer in 2012, the use of colorectal stenting for palliation has rapidly spread. We report a case of ascending colon cancer in which a colorectal stent was placed for palliation, but the stent was reimplanted due to obstruction, followed by radical resection. The patient was a 92- year-old woman who was brought to the emergency room at the age of 90 years with repeated vomiting and abdominal pain, and was diagnosed as colorectal cancer ileus caused by ascending colon cancer, and a colorectal stent was inserted. She received palliative care and had been asymptomatic for 1 year and 3 months, but due to in-stent stenosis, she had bowel obstruction and sent to emergency room, and another stent was installed. The patient had a good course, but 4 months after the second stenting, she was concerned about restenosis and referred to the department of surgery, then performed a radical resection. The indication for colorectal stents for palliative purposes should be considered on a case-by- case basis, including ADL, stage of the disease, and prognosis.

Successful multimodal therapy for the metastasis of ascending colon after curative resection of esophageal cancer: a case report with long-term survival.

Solitary colonic metastasis from esophageal cancer is rare. The prognosis of patients with distant metastases from esophageal cancer is extremely poor. A case of long-term survival with colonic metastasis from esophageal cancer treated by multimodal therapy is reported. A 67-year-old man was diagnosed with middle thoracic esophageal squamous cell carcinoma. The patient received neoadjuvant chemotherapy and then underwent subtotal esophagectomy. Approximately 1 year after esophagectomy, an asymptomatic, solitary colonic mass was detected on the follow-up computed tomography for esophageal cancer. Preoperative colonoscopy showed a 5-cm type 3 tumor at the ascending colon, and histological findings of the biopsy specimen indicated possible metastasis from primary esophageal squamous cell carcinoma. The patient underwent laparoscopic ileocolic resection with D3 lymph noddle dissection. Histologically, the colonic tumor was confirmed to be a metastasis from the esophageal squamous cell carcinoma. To the best of our knowledge, only eight cases with resected solitary colonic metastasis, including the present case, have been reported, and the present patient achieved greater than 3-year survival after esophagectomy. Resection of an asymptomatic solitary organ metastasis from primary esophageal cancer appears to be a good therapeutic option, even following esophagectomy.

[A Case of Two-Stage Operation for Esophageal Cancer with Sarcoidosis].

A 69-year-old man with dysphagia was diagnosed with advanced esophageal cancer by upper gastrointestinal endoscopy. He had undergone pancreatic tail and partial transverse colon resection for pancreatic cancer, and right hilar lymph node biopsy and partial lower lobe resection for the diagnosis of pulmonary sarcoidosis. Contrast-enhanced computed tomography(CT)scan showed no change over time in lymph node enlargement in the mediastinum, so metastasis of esophageal cancer was considered to be negative. Therefore, the diagnosis of advanced esophageal cancer, Mt, type 2, T2N0M0, cStage Ⅱ, was made, and surgery was performed after 2 courses of DCF therapy. Because of the adhesions in the thoracic cavity and possible problems with elevation of the gastric tube and blood flow due to resection of the pancreatic tail, it was decided to perform two-stage operation. Although imaging studies over time, as in the present case, can help in the diagnosis, it is difficult to distinguish whether enlarged lymph nodes are reactive changes or metastases. In this study, we experienced a case of thoracic esophageal cancer complicated by sarcoidosis with enlarged mediastinal lymph nodes.

[A Case of Refractory Lymphorrhea after Laparoscopic Distal Gastrectomy].

An 84-year-old man with gastric cancer, cT2N0M0, cStage Ⅰ underwent laparoscopic distal gastrectomy, D1+dissection, and Roux-en-Y reconstruction. We started enteral nutrition on the second postoperative day, but milky drainage appeared from the drain on the fifth postoperative day. The triglyceride in the ascites was markedly elevated, and it was diagnosed as a lymphorrhea. Neither conservative treatment nor lymphangiography were successful. We decided to perform surgical intervention because the lymphorrhea did not improve for about 1 month after gastrectomy. At laparotomy, we detected the lymphatic ducts using enteral nutrition of fat formulas during surgery and successfully closed the lymphatic ducts by suturing and ligation on the 38th postoperative day. Prolonged lymphorrhea causes extreme deterioration of the patient's general condition. Prolonged total parenteral nutrition also increases the risk of infection. It is important to perform surgical treatment for intractable lymphorrhea that does not improve with conservative treatment without hesitation.

Evaluating Neoadjuvant Chemotherapy for Lower Esophageal Squamous Cell Carcinoma by Measuring Esophageal Wall Thickness.

BACKGROUND/AIM: The aim of this study was to evaluate the efficacy of preoperative chemotherapy for stage II-III esophageal squamous cell carcinoma based on an objective computed tomography method. PATIENTS AND METHODS: A total of 82 patients who underwent preoperative chemotherapy followed by surgery for advanced esophageal squamous cell carcinoma from January 2006 to June 2019 were included. Treatment effect was evaluated by measuring the esophageal wall thickness before and after neoadjuvant chemotherapy using contrast-enhanced thoracoabdominal computed tomography. The percentage decrease in esophageal wall thickness was calculated using the following formula: reduction (%)=(wall thickness before preoperative chemotherapy - wall thickness after preoperative chemotherapy)/(wall thickness before preoperative chemotherapy)×100. We demonstrated the efficacy of this measurement method and then analyzed which patient factors might affect the treatment effect. RESULTS: Receiver operating characteristic analysis showed the percentage tumor reduction to be a good predictor of histological therapeutic effect (grade ≥2) (area under the curve=0.727). In the multivariate analysis, tumor location (lower versus upper esophagus) was identified as an independent factor associated with tumor reduction (odds ratio=0.15; 95% confidence interval=0.03-0.79; p=0.025). CONCLUSION: We demonstrated an association between the reduction of esophageal wall thickness in the tumoral area and the histological therapeutic effect of chemotherapy. Secondary analysis showed poorer tumor reduction in patients with lower esophageal cancer than in those with upper esophageal cancer.

Postoperative pain management after concomitant sacrectomy for locally recurrent rectal cancer.

PURPOSE: To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain. METHODS: Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra. RESULTS: Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05). CONCLUSIONS: Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence.

[A Case of Palliative Abdominoperineal Resection and Perineal Reconstruction by Gluteus Maximus Flap following Regrowth of Primary Anal Canal Cancer with the Perianal Skin Infiltration after CRT].

An 85-year-old woman who visited the hospital with sores on the perianal skin was diagnosed with squamous cell carcinoma of the anal canal(cT3N1aM0, cStage ⅢC). She received chemoradiotherapy(radiation total 54 Gy/30 Fr, mitomycin C/capecitabine). The tumor initially shrank, but regrowth of the primary lesion, extensive perianal skin infiltration, and the appearance of para aortic lymph node metastases was observed 6 months later. Laparoscopic abdominoperineal resection was performed to mitigate strong local symptoms. The perineal defect was repaired with bilateral gluteus maximus flap(V- Y flap). The operation prevented anal pain and improved ADL. The patient is currently undergoing chemotherapy 7 months after surgery. We report the case with a review of the literature in which ADL was improved by salvage surgery for tumor regrowth with severe local symptoms and distant metastases after chemoradiotherapy for squamous cell carcinoma of the anal canal.

Coexistence of multiple liver metastases from sigmoid colon cancer and a gastrointestinal stromal tumor in the small intestine.

A 60-year-old man was referred to our hospital for the evaluation and treatment of general malaise. Contrast-enhanced computed tomography detected sigmoid colon cancer that had invaded the bladder, multiple liver metastases, and a small intestinal tumor. Hartmann's procedure was performed, with partial bladder and small bowel resection. A pathological examination revealed that the patient had sigmoid colon cancer and a gastrointestinal stromal tumor. The biopsy findings of a tumor in segment 8 of the liver indicated the presence of adenocarcinoma, thereby indicating the origin of multiple liver metastases from sigmoid colon cancer. On chemotherapy, the tumors in liver segments 2/3 and 8 shrank. However, the tumor in segment 6 enlarged. Since radical resection of all metastatic liver tumors was possible, hepatectomy was performed 10 months after the initial surgery. A pathological examination revealed that the tumors in segments 2/3, 4, and 8 were adenocarcinomas and the tumors in segments 4, 6, and 7 had originated from the gastrointestinal stromal tumor. This suggested the coexistence of liver metastases from sigmoid colon cancer and the gastrointestinal stromal tumor. In cases involving multiple primary tumors, it is necessary to consider the possible coexistence of multiple metastases from different primary tumors.

A giant esophageal liposarcoma radically resected by the cervical approach: a case report.

Primary esophageal liposarcoma is an extremely rare malignancy, whereas liposarcoma is one of the most common soft tissue sarcomas, which develop mainly in the soft tissues of the extremities and retroperitoneum. A rare case of giant esophageal liposarcoma that originated from the cervical esophagus that was successfully excised by a cervical approach is reported. A 72-year-old woman presented with difficulty swallowing for 6 months. Esophagogastroduodenoscopy showed a pedunculated esophageal submucosal tumor arising just below the pyriform fossa in the esophagus. Contrast-enhanced computed tomography showed a giant, heterogeneous, intraluminal esophageal tumor from the cervical esophagus to the upper thoracic esophagus for approximately 17 cm. Based on the imaging findings, an esophageal liposarcoma was suspected. Since the symptom of dysphagia was gradually worsening, surgical treatment was planned. The giant esophageal tumor was successful resected through a cervical approach without either thoracotomy or laparotomy. The patient's postoperative course was uneventful, and she was discharged on day 15 after surgery. The histopathological and immunohistological findings showed well-differentiated esophageal liposarcoma, 15 × 7 × 5 cm in size. A cervical approach is an appropriate option for a tumor that developed at the cervical esophagus as a minimally invasive surgical technique.

[A Case of Long-Term Survival without Recurrence following Resection of Hepatic and Pulmonary Metastases of Gastric Cancer].

A 78-year-female underwent distal gastrectomy for gastric cancer. The final diagnosis was moderately differentiated tubular adenocarcinoma, T4a, N2, M0, Stage ⅢB. Four years later, S6 hepatic metastasis and S9 pulmonary metastasis were detected. After 10 courses of S-1 plus oxaliplatin therapy, she received partial hepatectomy(S6). One year after hepatectomy, she underwent partial pulmonary resection for lung metastasis in the left lung(S9). Histopathological findings revealed the lung tumor was a pulmonary metastasis from gastric cancer with a small primary lung adenocarcinoma. There has been no recurrence for 30 months since the last operation.

[A Case of Solitary Desmoid Tumor after Laparoscopic Sigmoid Colon Cancer Resection].

A 71-year-old man with pathological Stage Ⅰ(pT1bN0M0)underwent laparoscopic sigmoid colon cancer resection. After 18 months postoperatively, follow-up computed tomography(CT)showed a 30 mm enhanced soft tissue tumor near the anastomotic site. Considering the magnetic resonance imaging(MRI)and positron emission tomography(PET)results, we diagnosed sigmoid colon cancer with local recurrence. Laparoscopic radical resection of the colon and intestine, including the tumor, was performed. Pathologically, the tumor comprised spindle-shaped cells with collagen fibers and was diagnosed as a desmoid tumor by immunostaining(ß-catenin+, c-kit-, CD34-, α-SMA-, and DOG-1-). We report a case of intra-abdominal desmoid tumor near the anastomotic site after laparoscopic sigmoid colon cancer resection.

[A Case of Conversion Surgery after Chemotherapy for Advanced Gastric Cancer with Peritoneal Disseminations].

BACKGROUND: Advanced gastric cancer with peritoneal dissemination is difficult to treat, although prognosis has improved with chemotherapy and the introduction of molecular targeted drugs. CASE: A 65-year-old male was diagnosed as type 3 advanced gastric cancer on the posterior wall of antrum by esophagogastroduodenoscopy for anemia screening. When the patient underwent radical surgery, multiple disseminated nodules(P1c)were detected. After chemotherapy(SOX, PTX plus RAM)was administered, the tumor shrank, and staging laparoscopy was performed. Since disseminated nodules have disappeared, distal gastrectomy(R0)was performed as conversion surgery. As postoperative adjuvant chemotherapy, S-1 was administered for about 1 year and 6 months. During repair of incisional hernia at 1 year postoperatively, the patient was confirmed to have no disseminated recurrence. The patient is currently alive with no sign of recurrence for 4 years.

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.

Hybrid approach with laparoscopic wall-inversion surgery and single-incision intragastric surgery for intraluminal gastrointestinal stromal tumor: A case report.

Laparoscopic wedge resection (LWR) for intraluminal gastrointestinal stromal tumor (GIST) leads to excessive resection of normal gastric wall. We report a case of GIST around the cardia successfully treated with full-thickness partial resection using a hybrid approach of laparoscopic surgery and single-incision intragastric surgery (SIIGS). A 69-year-old woman had a 5 cm intraluminal GIST at the posterior wall around the cardia. Submucosal injection of glycerin and indigo carmine was performed with transoral endoscopy. Circumferential seromuscular incision followed by placement of seromuscular sutures to invert the lesion into the stomach was performed under laparoscopy. By SIIGS, resection of the inverted mucosa and retrieval of the tumor were completed. A hybrid approach consisting of laparoscopic wall-inversion surgery and SIIGS was useful for intraluminal GIST and may expand the indications for laparoscopic wall-inversion surgery by removing size limitations.

Distal gastrectomy for early gastric conduit carcinoma after Ivor-Lewis esophagectomy.

A metachronous neoplasm can develop in a gastric conduit used for reconstruction after esophagectomy for thoracic esophageal cancer. Surgical resection is sometimes necessary to treat this neoplasm. We report a method for performing minimally invasive gastrectomy with preservation of the proximal residual stomach through laparotomy for cancer in the distal side of gastric conduit after Ivor-Lewis esophagectomy. Furthermore, Roux-en-Y reconstruction was performed after gastrectomy. This minimally invasive partial gastrectomy for early gastric conduit cancer and followed Roux-en-Y reconstruction may lead to a favorable clinical outcome.

Short-term and long-term outcomes of laparoscopic colectomy with multivisceral resection for surgical T4b colon cancer: Comparison with open colectomy.

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 Case of Advanced Gastric Cancer with Umbilical Metastasis, Pyloric Stenosis, and Peritoneal Dissemination Underwent Palliative Surgery after Chemotherapy].

A 62-year-old woman was diagnosed with gastric cancer, Type 4, cT4b(LN, mesentery of transverse colon), N1 M1H0P1CY1, cStage ⅣB. S-1 and L-OHP(SOX)were administered for 4 courses and clinical response was SD. She interrupted the treatment because of practicing folk therapy. She had an emergency hospitalization due to pyloric stenosis, vomiting, and an umbilical tumor with pain. She was treated with 1 course of mFOLFOX6(5-FU, L-OHP, l-LV)followed by palliative surgery(laparoscopy assisted distal gastrectomy, Roux-en-Y reconstruction, resection of umbilical tumor, and bypass for transverse colon stenosis due to dissemination). The pathological diagnosis was L, Circ, Type 4, 126×89 mm, por> sig, pT4b(SI, mesentery of transverse colon), pN3a(12/13), H0P1CY1, pStageⅣ, and metastatic umbilical tumor. Following surgery, oral administration of mFOLFOX6 is continued. Umbilical metastasis(Sister Mary Joseph's nodule)is associated with poor prognosis, however, appropriate management including symptom control by palliative surgery and continuation of chemotherapy may lead a better prognosis.

Feasibility and safety of laparoscopic lateral pelvic lymph node dissection for locally recurrent rectal cancer and risk factors for re-recurrence.

INTRODUCTION: Lateral pelvic lymph node (LPLN) metastasis is considered a distant metastasis. It is often treated by systemic chemotherapy and/or radiation therapy, but complete radical resection of LPLN metastasis can sometimes achieve cure. However, the safety and efficacy of radical resection for recurrent LPLN after curative rectal surgery have not been well elucidated. Therefore, we evaluated the feasibility of laparoscopic radical surgery for recurrent LPLN compared with the conventional open approach and assessed oncological outcomes between patients with and without re-recurrence. METHODS: We retrospectively reviewed 17 cases (4 open, 13 laparoscopic) who underwent radical resection for LPLN metastasis after curative rectal surgery between July 2012 and August 2016 at the National Hospital Organization Osaka National Hospital. Operative factors and short-term outcomes were compared. Oncological outcome was evaluated based on the pathologic response to preoperative adjuvant therapy. RESULTS: The laparoscopic group's median blood loss and C-reactive protein elevation were lower than that of the open group on postoperative day 3. The laparoscopic group also had a shorter postoperative hospital stay. The median operative time, R0 resection rate, and morbidity rate were similar between the two groups. Local re-recurrence after LPLN resection occurred more frequently in pathologic non-responders than responders. CONCLUSION: Laparoscopic surgery for LPLN metastasis is feasible and less invasive than open surgery. Laparoscopic radical resection of LPLN may be justified for curative intent. Patients with incomplete pathologic response to neoadjuvant therapy have a greater risk of re-recurrence.

Breast metastasis from rectal cancer with BRAF V600E mutation: a case report with a review of the literature.

Metastasis of rectal cancer to the breast is an extremely rare clinical event. We report the case of a 67-year-old woman with a metastatic breast tumor derived from a BRAF V600E mutant rectal carcinoma that was diagnosed and resected curatively 1 year previously. Computed tomography showed a left breast mass and multiple lung nodules suspected to be indicative of recurrent rectal cancer. The ultrasonography examination demonstrated a 10 × 10-mm hypoechoic solid lesion in the left breast with an elevation in the serum carcinoembryonic antigen level and serum carbohydrate antigen 19-9 level. Core needle biopsy was performed, and histopathologic examination showed Cytokeratin 20 and CDX-2 positivity, compatible with rectal cancer. To our knowledge, this is the first case of a metastatic breast tumor arising from rectal carcinoma with BRAF mutation. Although breast metastasis is very rare event, the possibility of breast metastasis from extra mammary sites should be considered when the breast tumor is found in cancer treatment.

Efficacy and safety of anticoagulant prophylaxis for prevention of postoperative venous thromboembolism in Japanese patients undergoing laparoscopic colorectal cancer surgery.

AIM: To investigate the efficacy and safety of anticoagulant prophylaxis to prevent postoperative venous thromboembolism (VTE) during laparoscopic colorectal cancer (CRC) surgery, which is unknown in Japanese patients. METHODS: We conducted this randomized controlled trial at nine institutions in Japan from 2011 to 2015. It included 302 eligible patients aged 20 years or older who underwent elective laparoscopic surgery for CRC. Patients were randomly assigned to an intermittent pneumatic compression (IPC) therapy group or to an IPC + anticoagulation therapy group. Anticoagulation therapy comprised fondaparinux or enoxaparin for postoperative VTE prophylaxis. Postoperative VTE was diagnosed based on enhanced multi-detector helical computed tomography. The primary endpoint was VTE incidence, including asymptomatic cases, the secondary endpoint was incidence of major bleeding, and we conducted an intention-to-treat analysis. This study is registered in UMINCTR (UMIN000008435). RESULTS: Postoperative VTE incidence was 5.10% with IPC therapy (n = 157) and 2.76% with IPC + anticoagulant therapy (n = 145; P = .293). We identified no symptomatic VTE cases. The major bleeding rates were 1.27% with IPC alone and 1.38% with the combination (P = .936). The overall bleeding rates were 7.69% for enoxaparin and 13.6% for fondaparinux (P = .500), and there were no bleeding-related deaths. CONCLUSION: Anticoagulant prophylaxis did not reduce the incidence of VTE and the incidence of major bleeding was comparable between the two groups. Usefulness of perioperative anticoagulation was not demonstrated in this study. Pharmacological prophylaxis must be restricted in Japanese patients with higher risk of VTE.