[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.

A case of intestinal intussusception with unique hemorrhagic polyps due to AL amyloidosis and excessive anticoagulation.

Most adult intussusceptions are secondary to various pathological conditions that serve as a lead point. Because of their serious nature, intussusceptions often require emergency surgery. We report a surgical case of amyloidosis associated with intussusception, probably due to polypoid protrusions and bleeding tendencies. An 80-year-old man with abdominal pain was suspected of having jejunal intussusception on computed tomography. He had been prescribed warfarin for atrial fibrillation, and excessive anticoagulation was observed with a prolonged prothrombin time/international normalized ratio of 5.44 at presentation. After the excessive anticoagulation was resolved, emergency surgery was performed. The intussuscepted jejunum was resected, and a 7 cm long dark-red pedunculated polyp was identified as the lead point, which was accompanied by multiple small pedunculated polyps. Histopathological examination showed that these were all hemorrhagic polyps. Amyloid depositions were observed in the muscularis mucosae, submucosa, and the walls of the blood vessels. Immunohistochemical analysis revealed immunoglobulin light chain amyloidosis. This case is informative to discuss the clinical sequelae of gastrointestinal amyloid deposition.

[A Case of Rectal Neuroendocrine Carcinoma with Iris Metastasis].

A 62-year-old man with anal pain was diagnosed with rectal neuroendocrine carcinoma. There were multiple metastases in the liver, lung, paraaortic lymph node, and bone of the patient. After performing a diverting colostomy, irinotecan and cisplatin were administered. Partial response was obtained after 2 courses, and anal pain improved. However, after 8 courses, multiple skin metastases were found on his back. At the same time, the patient also complained of redness, pain, and impaired vision in the right eye. Iris metastasis was diagnosed clinically by ophthalmologic examination and with contrast- enhanced MRI. Iris metastasis was treated with 5 doses of 4 Gy irradiation, ameliorating the eye symptoms. The patient died of the original disease 13 months after the initial diagnosis; however, multidisciplinary treatment appeared effective for palliating cancer symptoms.

[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.

Clinical Impact of Two-Week Placement of a Subcutaneous Suction Drain in Preventing Incisional Surgical Site Infection in Open Gastrointestinal Surgery with Class 4 Dirty Wound: A Retrospective Study.

Background: Two recent randomized controlled trials demonstrated the beneficial effects of subcutaneous drainage in preventing incisional surgical site infection (SSI) in colorectal surgery. This study aimed to evaluate the efficacy of subcutaneous suction drains (SSDs) compared with primary skin closure (PC) in class 4 dirty wound surgery. Patients and Methods: Eighty-one patients undergoing open gastrointestinal surgery with class 4 dirty wounds were enrolled in this study, 30 of whom underwent SSD insertion, whereas the other 51 were treated with PC. Because several studies have reported that the median onset of the development of incisional SSI was eight to 13 days after surgery, we used a two-week placement of an SSD. Comparison of patients treated with SSD and PC and multivariable analysis were performed to test the ability of SSD in decreasing the SSI rate. Results: No differences were observed between the two groups in terms of gender, body mass index, American Society of Anesthesiology score, steroid use, presence of diabetes mellitus, peri-operative transfusion, and surgery type. Surgical site infection incidence was lower in the SSD group (6.6%; 2/30) than that in the PC group (23.5%; 12/51; p = 0.069). Multivariable analysis revealed that the presence of diabetes mellitus was an important independent risk factor for incisional SSI, and the placement of an SSD has substantial preventive effects on incisional SSI (p = 0.018 and p = 0.014, respectively). Conclusions: This study suggested the potential importance of a two-week placement of an SSD for preventing incisional SSI in class 4 dirty wound surgery.

A successful operation for giant intra-abdominal desmoid tumors associated with familial adenomatous polyposis: A case report.

Desmoid tumors are benign proliferations of spindle cells originating in fibro-aponeurotic tissue. Many patients with familial adenomatous polyposis (FAP) die from desmoid tumors, which can arise spontaneously but often appear to be surgically induced by prophylactic colectomy. Desmoid tumors are the second most common cause of death in patients with FAP, second to colorectal cancer. Many patients can live a long life with desmoid tumors without symptoms, but when symptoms (ranging from bowel or ureteric obstruction to bowel perforation with abscess and fistula) appear or there is a risk of functional impairment, a wide spectrum of therapies (local and systemic) are valuable in improving the symptoms and controlling the disease. A half-Japanese, half-Caucasian male, who had been diagnosed with intra-abdominal desmoid tumors associated with FAP at age 13, was treated using abdominal wall incision for decompression and chemotherapy from the age of 38. The therapeutic outcome was progressive disease, based on the modified response evaluation criteria in solid tumors (mRECIST), and when he visited our hospital at age 41 the desmoid tumor had invaded the small bowel with a fistula to the abdominal wall. We performed a palliative operation to improve his symptoms, which were fever, abdominal pain, vomiting, and difficulty eating. As the tumor was extremely large and had invaded the small intestine, massive resection including the small intestine was required. To prepare for anticipated massive bleeding, a balloon catheter was placed in the superior mesenteric artery just prior to surgery. Although the operation was extremely difficult, following surgery the patient regained his ability to eat and when discharged was ambulatory and without short-bowel syndrome. We report our experience treating one of the largest reported intraperitoneal desmoid tumors. Resection resulted in a good postoperative course, with improved quality of life and prognosis.

Low G9a expression is a tumor progression factor of colorectal cancer via IL-8 promotion.

The histone methyltransferase G9a is expressed in various types of cancer cells, including colorectal cancer (CRC) cells. Interleukin 8 (IL)-8, also known as C-X-C motif chemokine ligand 8 (CXCL8), is a chemokine that plays a pleiotropic function in the regulation of inflammatory responses and cancer development. Here, we examined the relationship between G9a and IL-8 and the clinical relevance of this association. We immunohistochemically analyzed 235 resected CRC samples to correlate clinical features. Samples with high G9a expression had better overall survival and relapse-free survival than those with low G9a expression. Univariate and multivariate analyses demonstrated that low G9a expression remained a significant independent prognostic factor for increased disease recurrence and decreased survival (P < 0.05). G9a was expressed at high levels in commercially available CRC cell lines HCT116 and HT29. Knockdown of G9a by siRNA, shRNA or the G9a-specific inhibitor BIX01294 upregulated IL-8 expression. The number of spheroids was significantly increased in HCT116 cells with stably suppressed G9a expression, and the number of spheroids was significantly decreased in HCT116 cells with stably suppressed IL-8 expression. Thus, the suppression of IL-8 by G9a may result in a better prognosis in CRC cases with high G9a expression. Furthermore, G9a may suppress cancer stemness and increase chemosensitivity by controlling IL-8. Therefore, G9a is a potential novel marker for predicting CRC prognosis, and therapeutic targeting of G9a in CRC should be controversial.

[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.

[A Case of Jejunal Cancer Treated by Laparoscopic Partial Jejunectomy].

The patient was a 30s male visited our hospital with the complaints of abdominal pain and melena. The internal medicine physician could not detect the cause of the melena by upper and lower gastrointestinal endoscopy. Although the patient resolved with a fast as conservative management so he left our hospital once, he relapsed nausea and abdominal pain. He visited our department. We performed surgery under a preoperative diagnosis of intestinal obstruction. The histopathological diagnosis was moderate differentiated jejunal adenocarcinoma(Stage ⅡA). At present, 1 year 7 months since surgery, the patient survives although with lymphnode recurrence.

Radical lymphadenectomy of a para-aorta lymph node metastasis in colorectal cancer prolongs relapse-free survival.

BACKGROUND: It is highly controversial whether a lymphadenectomy for treating distant lymph nodes, such as the para-aortic lymph node, provides clinical benefit in colorectal cancer (CRC). This study aimed to investigate the benefit of a lymphadenectomy for para-aortic lymph node metastasis (PALM) in CRC, by evaluating the extent of dissection. METHODS: This retrospective cohort study included 28 consecutive patients with pathologically positive PALMs in CRC that underwent lymphadenectomies from October 2001 to March 2018 at our institute. We analyzed the rates of 3-year recurrence-free survival (RFS), postoperative complications, and peri-operative death. We examined RFS in two groups with different operation types. One group received radical resections (radical group), defined as a systematic dissection of para-aortic lymph nodes, which removed the area under the renal vein and above the aortic bifurcation. The other group (targeted group) received targeted dissections, which removed specific swollen para-aortic lymph nodes. RESULTS: The radical group had a significantly better RFS than the targeted group. In addition, females had significantly better RFS prognoses than males. Univariate and multivariate Cox regression analyses identified two clinical factors significantly associated with RFS: sex (P = 0.0100) and surgical procedure (P = 0.0033). Postoperative complications after PALM resections occurred in 35.7% of patients. There was no postoperative mortality. CONCLUSION: Our study suggested that a radical lymphadenectomy for treating PALMs in CRC could be performed safely and could prolong the RFS. More studies are necessary to strengthen the evidence in support of this conclusion.

Safety of laparoscopic colorectal surgery in patients with ventriculoperitoneal shunt.

INTRODUCTION: This study retrospectively investigated the safety of laparoscopic colorectal surgery in patients with ventriculoperitoneal shunt (VPS) based on the experiences within our department. METHODS: A total of 866 patients underwent laparoscopic colorectal surgery for colorectal cancer, ulcerative colitis, Crohn's disease, and acute appendicitis at Osaka University during the study period. Laparoscopic colorectal surgery cases were collected from the Osaka University database. Among them, four (0.5%) had VPS when they underwent surgery. In these four cases, we consulted a neurosurgeon and checked the route of the VPS catheter to determine whether it had a unidirectional valve to prevent backflow and whether it was working normally. We retrospectively investigated the clinical characteristics of these four cases. RESULTS: All cases were safely treated, with the pneumoperitoneum pressure set at 10 mmHg under routine anesthetic monitoring and without any manipulations such as clamping or externalization of the VPS catheter. The four patients were discharged without any VPS-related complications such as increased intracranial pressure, shunt failure, or infection. CONCLUSIONS: Our study suggests that laparoscopic colorectal surgeries in patients with VPS without any manipulations may be safe. Future studies should aim to better standardize the perioperative management of VPS during laparoscopic colorectal surgery.

A mesenteric solid tumor with unusual features in a young male: A case report.

The current study presents a mesenteric mesenchymal tumor case, with unusual features in diagnostic imaging and histology. A 16-year-old male was admitted to the hospital with abdominal pain. Computed tomography (CT) revealed an abdominal mass, 2 cm in diameter. The results of contrast-enhanced CT, magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography indicated no specific features suggestive of its histology. Two arteries branching from the superior mesenteric artery were observed feeding the hypervascular tumor. After endoscopic and other laboratory findings revealed no additional lesions, the lesion was diagnosed as a primary mesenteric tumor. As the possibility of malignancy and future bleeding from this tumor could not be ruled out, a resection of the tumor was performed. During the surgery, the tumor, which was well circumscribed and hypervascular, was located in the mesentery of the jejunum. The resected tumor did not exhibit typical histological characteristics, and was labeled as 'myxoid smooth muscle neoplasm of uncertain biologic potential'. At 2 years after surgery, the patient remained well without evidence of recurrence. As primary mesenteric tumors are rare, particularly in young patients, it is considered important that this type of unusual tumor be included in the differential diagnosis for mesenteric tumors.

Case of ileal herniation through the foramen of Winslow diagnosed preoperatively by CT and treated with laparoscopic surgery.

A previously healthy 35-year-old man visited the emergency room complaining of epigastric pain and vomiting. The pain was sudden in onset. His blood tests were within normal limits except for a mild neutrophilia of 14 300/µL. Enhanced abdominal CT scan showed the small intestine dilated into the space between the portal vein and inferior vena cava from the foramen of Winslow. Under the diagnosis of herniation through the foramen of Winslow (HFW), we performed emergency laparoscopic surgery. Laparoscopy revealed an internal herniation of the dilated small intestine through the foramen of Winslow. Because the herniated small intestine was viable, intestinal resection was unnecessary. We released the incarceration under laparoscopy. HFW is very rare and often overlooked, but abdominal CT examination enabled a precise preoperative diagnosis because of characteristic findings. We should consider the possibility of HFW in patients with internal herniation of unknown origin. Laparoscopic surgery for HFW is effective.

[A Case Report of Curative Surgery for Pancreatic Ductal Adenocarcinoma with Peritoneal Dissemination after Gemcitabine Chemotherapy].

A 70-year-old man was diagnosed with pancreatic ductal adenocarcinoma(PDAC)with peritoneal dissemination and received systemic chemotherapy of gemcitabine(GEM)plus nab-paclitaxel. Since the patient could not continue the regimen due to an adverse event of liver dysfunction, he was administered GEM alone except for the first administration. GEM monotherapy resulted in remarkable anti-tumor effects with a distinct decrease of both tumor markers and size. Peritoneal metastases were not detected in images after 12 courses of the GEM regimen, and the vanished tumor metastasis in images was maintained until 16 courses were administered. After the laparoscopic examination proved no peritoneal metastasis, we performed curative surgery. The presence of peritoneal metastasis of PDAC indicated that it was at a lethal stage; however, a few cases were reported as receiving curative surgery after chemotherapy with modest long-term survival. We herein report a rare case of curative surgery following chemotherapy with GEM alone for unresectable PDAC accompanied with peritoneal dissemination.

[A case of synchronous cancer of the gall bladder, common bile duct, and the papilla of vater].

A 58-year-old man was diagnosed with liver dysfunction during a health exam and subsequently visited a doctor. Abdominal ultrasonography revealed space-occupying lesions in the gall bladder and bile duct, and he was hospitalized for further examination and treatment. Computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography (MRCP) revealed double cancer of the gall bladder and bile duct with pancreaticobiliary maljunction (PBM), and we performed a pancreatoduodenectomy. Pathological examination revealed gall bladder and bile duct cancer, and severe dysplasia of the papilla of Vater. We diagnosed synchronous triple cancer because none of the cancers had continuity or vascular invasion. Each cancer was at Stage I, and the patient has survived for 2 years and 6 months without recurrence and no additional treatment. PBM is a mutation of the junction of the pancreatic and bile ducts outside of the duodenal wall, and is a known complication of biliary tract cancer due to the reflux of pancreatic juice and bile. Because K-ras and p53 gene mutations occur in the biliary tract mucosal epithelium, PBM increases the risk of developing multicentric cancer. It is important to consider the existence of double cancer when biliary tract cancer is detected in a PBM patient.

[A case of postpancreaticoduodenectomy local recurrence successfully treated with extended resection].

A 68 -year-old man underwent a pancreaticoduodenectomy after being diagnosed with primary duodenal cancer. The postoperative pathological diagnosis was tub2, SE, ly1, v1, panc3, pn+, N0. Although adjuvant chemotherapy was administered, local recurrence in the portal region was detected 18 months later. The recurrent tumor pressed against the region of the bile duct anastomosis, which caused obstructive jaundice. After serum bilirubin levels were reduced, resection of the recurrent tumors was performed. This required resection of the transverse colon, parts of the portal vein, and the inferior vena cava. The bile duct anastomotic region, which had been infiltrated by the tumor, was excised and rebuilt. The postoperative pathological diagnosis was tub2. The patient continued to receive adjuvant chemotherapy and showed no signs of recurrence 9 months after surgery. Extended resection for local recurrences of primary duodenal cancer may be an effective means of disease control.

[A case of extragastrointestinal stromal tumor with peritoneal dissemination].

Here, we present the case of a 60-year-old man in whom abdominal computed tomography showed a solid abdominal tumor (11 cm in diameter) in the pelvic space, with widely disseminated nodular lesions. Emergency surgery was performed following the rapid onset of intense abdominal pain. Peritoneal disseminations were widespread and the tumor was confirmed to be in the pelvic space. The tumor was not connected to any segment of the intestinal tract but rather to the retroperitoneum. Immunohistochemical staining was positive for c-kit (exon 11 mutation) and CD34 but negative for S-100 protein. Careful postoperative examination did not reveal any lesions in the upper or lower alimentary tract. On the basis of these findings we diagnosed the tumor as an extragastrointestinal stromal tumor (EGIST) originating from the retroperitoneum. After surgery, intravenous infusion of imatinib was started at a full dose of 400mg/day; however, owing to strong adverse effects, the dose was reduced to 200mg/day. Despite halving the dose, the patient has remained lesion-free according to computed tomography for 36 months after the operation. Low-dose imatinib chemotherapy remained efficacious in controlling progression in this case.