[Two Cases of the Significant Liver Damage by Regorafenib].

There is a liver damage in a serious side effect of regorafenib. Case 1 was a 54-year-old woman, and she had an operation of rectal cancer and metastasized to multiple organs afterwards and started regorafenib as third-line. Erythema exudativum multiform developed on the 8th day after a start and regorafenib was canceled once and reduced on the 21st day when a skin symptom was relieved and restarted. However, because a significant rise of AST, ALT, T -Bil was recognized afterwards, regorafenib was canceled on the 27th day and enforced steroid pulse therapy and was relieved afterwards. Case 2 was a 61-year-old woman, and she had an operation of ascending colon cancer, ovarian metastasis and peritoneum dissemination. Regorafenib was started by frequent occurrence lung metastasis, cancerous pleurisy afterwards as fifth-line. Dissemination erythema developed on the 16th day and a liver damage developed on the 22nd day. Because a rise of AST, ALT went and was prolonged, liver biopsy was enforced in a cause close inspection purpose on the 45th day. A medicamentosus liver damage was diagnosed. The liver enzyme decreased afterwards. It may be easy to make the liver damage by regorafenib serious, and attention is necessary.

Abdominal complications due to collapse of a large mesenteric hematoma after rupture of a right colic artery aneurysm: a case report.

BACKGROUND: Non-traumatic mesenteric hematomas are usually well controlled, with no resulting symptoms. Herein, we report a case in which collapse of a large mesenteric hematoma, after rupture of a right colic artery aneurysm, caused small bowel obstruction and rapid absorption of the hematoma contributed to cholestasis. CASE PRESENTATION: A-44-year-old man presented with a sudden onset of severe right lower abdominal pain. Computed tomography (CT) revealed rupture of a right colic artery aneurysm and intra-abdominal bleeding. After embolization of the right colic artery aneurysm, a large mesenteric hematoma remained. As the patient had no symptoms, we elected to pursue conservative treatment. However, on day 16 post-onset, he developed right lower abdominal pain. On CT imaging, partial collapse of the wall of the residual mesenteric hematoma was observed, with visible leakage from the hematoma into the abdominal cavity, resulting in small bowel obstruction and cholestasis. Symptoms did not improve with conservative treatment, and we proceeded to surgical treatment on day 32 after onset. Intra-operatively, adhesions between the small bowel and the abdominal wall were identified and caused the small bowel obstruction. We proceeded with removing these adhesions and as much of the hematoma as possible. Although the small bowel obstruction improved after surgery, cholecystitis developed, and percutaneous transhepatic gallbladder aspiration was performed on day 45. The patient was discharged on day 70. CONCLUSIONS: Collapse of a mesenteric hematoma can cause small bowel obstruction. Rapid absorption of the hematoma due to the collapse might contribute to cholestasis. A large abdominal hematoma might be a risk factor for failure of conservative treatment, and surgery might be required due to abdominal complications.

Perianal abscess due to a long fish bone: a case report.

Few articles have reported cases of perianal abscess due to ingested foreign bodies. Herein, we report a case of perianal abscess due to a long fish bone. A 72-year-old man who was toothless and wore a denture had a chief complaint of anal pain. His left-side buttock had swelling and redness. Computed tomography revealed a perianal abscess on his left-side buttock and high-intensity linear structure in the abscess cavity. We made a diagnosis of perianal abscess due to a fish bone and performed an emergency operation. We opened the abscess cavity and removed the 5 cm fish bone from the cavity. After drainage of the abscess cavity and antibiotic administration, he was discharged from our hospital on day 8. A long fish bone could cause perianal abscesses. Rapid diagnosis and ensuring fish bone removal are important to prevent sepsis.

A Simple and Reliable Method for Intracorporeal Circular-Stapled Esophagojejunostomy Using a Hand-Sewn Over-and-Over Suture Technique in Laparoscopic Total Gastrectomy.

BACKGROUND: The controversy regarding laparoscopic total gastrectomy (LTG) is mainly due to the difficulty associated with esophagojejunostomy during this procedure. Although several techniques have so far been reported to overcome this issue,1 (-) 4 a reliable technique has not yet been established. We developed intracorporeal esophagojejunostomy using a circular stapler in LTG with a hand-sewn over-and-over suture technique, and have shown its favorable outcomes compared with those of conventional open surgery.5 This technique is presented in the video. METHODS: After transection of the esophagus, an over-and-over suture with a 2-0 monofilament is placed counterclockwise from the right to the left side of the cut end in an outside-to-inside direction, and then from the left to the right side in an inside-to-outside direction. After insertion of the anvil head into the esophagus, it was fixed by ligation of the thread. Finally, intracorporeal esophagojejunal anastomosis was performed using a circular stapler. RESULTS: In LTG, reconstruction using this method was performed for 23 consecutive patients with gastric cancer. There were no serious intraoperative complications or need for conversion to open surgery. Anastomotic leakage and stenosis occurred in one case each, respectively. The mean time for fixation of the anvil to the esophagus was 15 min for the last 12 consecutive patients. CONCLUSIONS: This method is simple and feasible, and the advantage of this technique is the elimination of the backhand stroke throughout the suturing procedure.

Surgical outcomes of intracorporeal circular-stapled esophagojejunostomy using modified over-and-over suture technique in laparoscopic total gastrectomy.

BACKGROUND: Esophagojejunostomy in laparoscopic total gastrectomy (LTG) is a technically demanding procedure. Although several methods have been reported to date, none is considered consistently reliable. We developed a simple method for intracorporeal circular-stapled esophagojejunostomy using a modified over-and-over suture technique. The surgical outcomes of our technique were evaluated in comparison with those of open total gastrectomy (OTG). METHODS: From April 2012 to August 2014, reconstruction using this method in LTG was performed for 21 consecutive patients with gastric cancer (LTG group). Their surgical outcomes were compared with those of 27 patients with gastric cancer who underwent OTG without splenectomy (OTG group) between January 2011 and April 2014. RESULTS: Estimated blood loss was significantly lower, and the postoperative hospital stay was significantly shorter in the LTG group than in the OTG group. The operating time and the number of harvested lymph nodes were similar between the two groups. The incidence of overall complications did not differ significantly between the two groups. Anastomotic leakage developed in one of the 21 patients in the LTG group and in two of the 27 patients in the OTG group. Anastomotic stenosis was observed in one patient in the LTG group. CONCLUSIONS: We consider this method as simple and feasible for most laparoscopic surgeons with basic laparoscopic suturing skills. This method might help LTG to become an accepted standard surgical option for treatment of patients with gastric cancer.

Cranially approached radical lymph node dissection around the middle colic vessels in laparoscopic colon cancer surgery.

PURPOSE: Laparoscopic lymph node (LN) dissection around the middle colic vessels is technically demanding, thus raising controversy regarding the role of laparoscopic surgery for transverse colon cancer. We herein describe a cranial approach method to perform radical LN dissection around the middle colic vessels. The key characteristic of this approach is early division of middle colic vessels prior to mobilization of the colon. METHODS: From April 2010 to September 2013, 27 patients with colon cancer received laparoscopic LN dissection around the middle colic vessels using this cranial approach. Their surgical and short-term outcomes were reviewed. RESULTS: The mean number of harvested LNs was 29 (range, 6-50). The mean operative time and intraoperative blood loss were 274 min (range, 160-362 min) and 42 mL (range, 3-247 mL), respectively. There were no serious intraoperative complications or conversions to open surgery. There were two patients with stage 0, 7 with stage I, 12 with stage II, and 6 with stage III. No recurrent case was observed with a median follow-up period of 30 months (range, 9-48 months). CONCLUSIONS: We consider this approach feasible and useful for radical LN dissection around the middle colic vessels during laparoscopic colon cancer surgery.

Cranial-to-caudal approach for radical lymph node dissection along the surgical trunk in laparoscopic right hemicolectomy.

Complete mesocolic excision with central vascular ligation is considered to contribute to superior oncological outcomes after colon cancer surgery [1]. For advanced right-sided colon cancer, this surgery sometimes requires lymph node (LN) dissection along the superior mesenteric vein (SMV), with division of the middle colic vessels, or their right branches, at origin [2]. Here, we present cranially approached radical LN dissection along the surgical trunk during laparoscopic right hemicolectomy. The omental bursa is first opened wide, and the gastrocolic trunk of Henle is exposed, using the right gastroepiploic vessels and the accessory right colic vein (ARCV) as landmarks. After division of ARCV, SMV and middle colic vein (MCV) are identified. After dividing MCV at its root, LN dissection along SMV is conducted in a cranial-to-caudal manner. Concurrently, the middle colic artery, or its right branch, is exposed and divided at origin. The transverse colon is then raised ventrally, and LN dissection along SMV using a cranial-to-caudal approach is again performed. The ileocolic and right colic vessels are divided at origin. The ascending and transverse mesocolon, including the pedicles, are then separated from the retroperitoneal tissues, pancreatic head, and duodenum, using a medial approach. The key characteristics in this procedure consist of easy access to pancreas, early division of ARCV and middle colic vessels at origin, and easy dissection along SMV. We performed a laparoscopic colectomy using this approach for 18 patients with right-sided colon cancer. The mean operative time and blood loss were 288 min and 83 ml, respectively. The mean number of harvested LNs was 24. There were 6 cases with positive LN metastasis. There were no recurrent cases at a median follow-up period of 24 months. We consider this approach to be safe and useful for radical LN dissection along SMV for right-sided colon cancers.

Eosinophilic gastroenteritis associated with multiple gastric cancer.

Eosinophilic gastroenteritis (EG) is an inflammation of the digestive tract that is characterized by eosinophilic infiltration. There are no specific symptoms, and are related to the layer in which eosinophilic infiltration is observed. A 69-year-old Japanese man presented to our hospital with a history of general malaise, diarrhea, and dysgeusia. Esophagogastroduodenoscopy showed reddish elevated lesions that were edematous all over the gastric mucosa. In addition, three tumors were also observed. The biopsies of the reddish elevated mucosa revealed eosinophilic infiltration and tubular adenocarcinoma from the tumors. Colonoscopy showed abnormal reddish elevated mucosa. The biopsies from the reddish elevated mucosa showed eosinophilic infiltration. From the abdominal contrast computed tomography scan, tumor stain was seen in the anterior wall of the gastric body. No ascites, intestinal wall thickening, or lymph node swelling were found. A slight elevation in the serum immunoglobulin E (IgE), 480 IU/ml, was found from the laboratory test results; other laboratory results were within normal limits including the number of peripheral eosinophils. No specific allergen was found from the multiple antigen simultaneous test and from the skin patch test. The parasitic immunodiagnosis was negative. He was diagnosed with EG associated with gastric cancer and underwent total gastrectomy, regional lymph node dissection with reconstruction by a Roux-en-Y method. He was prescribed prednisolone after the operation and showed a good clinical response. There are many case reports on EG, but none of them were associated with cancer. We encountered a case of EG associated with multiple gastric cancer; the patient underwent total gastrectomy.

[A resected case of metachronous liver metastasis from mixed adenoneuroendocrine carcinoma of the stomach].

A 71-year-old woman was found in gastroendoscopic examination to have a type 2 tumor at the posterior wall of the stomach with two type 0-IIa early adenocarcinomas at the lesser curvature and anterior wall. She underwent distal gastrectomy. Pathological evaluation of the type 2 tumor was mixed adenoneuroendocrine carcinoma and that of two type 0-IIa tumors were well differentiated tubular adenocarcinomas. The solitary metastasis was found in liver S8 on 15th month though S-1 was taken after the operation. Partial resection of the liver was performed, and its histological findings were similar to the mixed adenoneuroendocrine carcinoma of the stomach. After adjuvant chemotherapy with S-1+CPT-11 during half a year, S-1 single therapy was done for 16 months, and there is no evidence of recurrence for 28 months after liver resection.

[Risk factors for recurrence of stage II colon cancer].

PURPOSES: This study was designed to clarify risk factors for the recurrence of stage II colon cancer in patients and to determine possible treatment options for postoperative adjuvant chemotherapy. SUBJECTS AND METHODS: The subjects were 132 patients with stage II colon cancer who underwent surgery in this department from January 1998 to December 2007. Various high risk factors for recurrence and factors indicative of poor prognosis were examined (age, gender, site of tumor, maximum tumor diameter, invasion depth, histopathological classification, D number, ly, v, number of biopsied lymph nodes, preoperative tumor marker values and presence of postoperative adjuvant therapy). RESULTS: The group with postoperative adjuvant therapy had a better prognosis than the others (p=0. 0168). Groups with an absence of postoperative adjuvant therapy (p=0. 041), presence of vessel involvement (p=0. 0127), and poorly-differentiated types (p=0. 027)were extracted in a multivariate analysis of risk factors for recurrence. CONCLUSIONS: Postoperative adjuvant therapy was effective for stage II colon cancer. Vessel involvement and poorly-differentiated types were risk factors for recurrence of stage II colon cancer.

Intra-abdominal plexiform neurofibromatosis including periportal, mesentery, and gastrointestinal tract involvement in neurofibromatosis type 1: case report and review of the literature.

We report a case of intra-abdominal plexiform neurofibromatosis, including periportal, mesenteric, and gastrointestinal tract involvement, in a patient with von Recklinghausen's disease/neurofibromatosis type 1 (NF-1). A 26-year-old man with familial NF-1 was admitted to hospital for further examination of an abnormal hepatic mass along the portal vein. Esophagogastroduodenoscopy revealed antral wall thickening and swelling of the papilla of Vater. Mucosal biopsies taken from the duodenum revealed possible ganglioneuromatosis. Abdominal ultrasonography, contrast-enhanced computed tomography, and magnetic resonance imaging revealed an abnormal periportal mass with serpiginous extension into the liver along the portal vein and the mesentery, which is the typical spread pattern of plexiform neurofibromatosis. A laparotomy and cholecystectomy for gallstones were performed, and this patient was diagnosed as having intra-abdominal plexiform neurofibromatosis. This is the 15th case of intrahepatic periportal plexiform neurofibromatosis and the 16th case of diffuse ganglioneuromatosis associated with NF-1 in the English literature. The imaging findings of the lesion have been followed for 10 years; there has been slight growth of the mass, but no malignant transformation has been found. The previously reported cases are reviewed.

[A case of AFP-producing gastric carcinoma, in which liver metastases were eliminated successfully underwent total gastrectomy after chemotherapy].

A 64-year-old man was admitted to our hospital for severe anemia, and a thorough examination revealed an AFP-producing gastric cancer with multiple liver metastases. He was treated with S-1, and liver metastases were reduced. However, the originalgastric tumor did not disappeare. We administered paclitaxelas second-line treatment, and CDDP/CPT-11 as thirdline treatment, intravenously. In August 2006, liver metastases were not detected, so he underwent total gastrectomy and lymph node dissection. The final stage was StageIB(mp, n0). He has had no recurrence as of 36 months postoperatively.

An experimental study on the pharmacokinetics of 5-fluorouracil regional chemotherapy for pancreatic cancer.

BACKGROUND: Recently a few centers reported promising results of regional intra-arterial chemotherapy for pancreatic cancer. However, the detailed pharmacokinetics and the side effects of anticancer agents remain unclear. METHODS: Catheters were introduced into the gastroduodenal artery and the splenic artery of dogs. In group I, arterial infusion of 5-fluorouracil (5-FU) was performed over 10 minutes. In group II, 5-FU was infused systemically. In group III, an intra-arterial infusion was repeated weekly three times. Blood samples and liver and pancreas tissue samples were obtained to determine 5-FU levels. In a subset of each group, the pancreas, duodenum, and liver were excised for histological analyses. RESULTS: Immediately after the infusion of 5-FU, the portal level in group I was higher than that in group II. However, the mean systemic level in group I was lower than in group II. The mean tissue concentration in the pancreas in group I was significantly higher than that of group II. Histological examination revealed no microscopic alterations after treatment in all groups, including group III. CONCLUSIONS: This fundamental study suggested that intra-arterial chemotherapy of 5-FU for pancreatic cancer allows higher regional drug delivery without adverse effects on normal regions of the pancreas, the duodenum, and the liver.

Ultrastructural analyses of pancreatic grafts preserved by the two-layer cold-storage method and by simple cold storage in University of Wisconsin solution.

The two-layer cold storage method (TLM) using University of Wisconsin (UW) solution supplies sufficient oxygen to pancreatic grafts during preservation and extends pancreas preservation time to up to 96 h in the canine model. Simple cold storage in UW (UWM) on the other hand, preserves canine pancreas grafts for up to 72 h by preventing cell swelling, mainly because of its high osmotic pressure. The aim of this study is to analyze morphologically dog pancreatic grafts preserved by these two methods with their different mechanisms. Immediately after preservation of canine pancreata by TLM for 72 h and 96 h (group 1 and group 3, respectively), and by UWM for 72 h and 96 h (group 2 and group 4, respectively), tissue ATP levels were determined using high-performance liquid chromatography (HPLC), and detailed morphological analyses of intragraft components were performed using light- and electron microscopy. The mean areas of one mitochondrion and rough endoplasmic reticulum (RER) vacuolization were calculated by computer-graphic analyses using NIH image 1.62 f soft. The tissue ATP levels were significantly higher in groups 1 and 3 than groups 2 and 4 ( P < 0.05). Light microscopy demonstrated no marked difference among the 4 groups. By electron microscopy however, mitochondrial swelling and RER vacuolization were observed in acinar cells to various extents in the 4 groups. They were significantly more evident in group 2 than group 1 ( P < 0.05), and in group 4 than group 3 ( P < 0.05). In conclusion, TLM demonstrated excellent protection of intracellular organelles, mitochondria, and RER, up to 72-96 h. Well-maintained graft ATP levels in TLM groups may result in maintaining the integrity of intracellular organelle membranes as well as cellular membranes.