[A Case of Synchronous-Metachronous Cancer of the Rectum, Stomach, Pharynx, Esophagus and Small Intestine].

A 71-year-old man presented with the chief complaint of fecal occult blood. Based on imaging studies, the patient was diagnosed advanced rectal cancer. He received laparoscopic low anterior resection. Three months after the rectal cancer operation, upper gastrointestinal endoscopy revealed gastric cancer. The patient had a diagnosis of synchronous cancer of the rectum and stomach, and received laparoscopic distal gastrectomy. Two years after the rectal cancer operation, liver metastasis(S4)was detected and resected. Three years after the rectal cancer operation, esophageal cancer and laryngeal cancer were detected synchronously and chemoradiotherapy was performed. Five years after the rectal cancer operation, small intestinal cancer with infiltration of descending colon and esophagus cancer were detected synchronously. Small intestinal resection and Hartmann procedure were performed for small intestinal cancer. ESD was performed for esophageal cancer. Six years after the rectal cancer operation, FDG-PET showed the peritracheal lymph node metastasis, lumbar spine metastasis and local recurrence in the pelvis. Currently, systemic chemotherapy is undergoing. We report a rare case of synchronous- metachronous cancer of the rectum, stomach, pharynx, esophagus and small intestine.

[A Case of Sigmoid Colon Cancer with Intussusception Prolapsing through the Anus].

A 76-year-old woman presented to the hospital with the colon prolapsing through the anus. The enhanced abdominal computed tomography(CT)showed intussusception of the sigmoid colon due to sigmoid colon cancer. It was difficult to reduce the intussusception, and we did not recognize the ileus and ischemic change of the colon. Therefore, we performed an elective surgery. Hartmann's procedure and lymph node dissection were performed 8 days after the hospitalization. The postoperative course was uneventful. We report a case of sigmoid colon cancer with intussusception prolapsing through the anus.

The Combined Use of Drainage Amylase Concentration and Serum C-reactive Protein as Predictors of Pancreas-Related Complications after Elective Gastrectomy.

INTRODUCTION: Postoperative pancreas-related complications (PPRC) can cause critical conditions, including sepsis and intra-abdominal bleeding. Thus, it is important to identify patients who are at risk of clinically significant PPRC as early as possible in the postoperative period. Some authors have reported the use of amylase concentration of the drainage fluid (dAmy) to predict PPRC. However, the positive predictive value of dAmy alone is not sufficient. OBJECTIVE: The aim of this study is to evaluate the predictive value of combined use of dAmy and serum C-reactive protein (sCRP) for PPRC. METHODS: The clinicopathological data of 327 patients who underwent elective gastrectomy for gastric cancer were reviewed. There were 18 patients who developed PPRC. Univariate and multivariate analyses were conducted to identify the risk factors of PPRC. Receiver operating characteristic curves were used to identify the cut-off values of dAmy and sCRP on postoperative day 3 (dAmy3 and sCRP3) to predict the risk of PPRC. RESULTS: In the multivariate analysis, splenectomy alone correlated with PPRC. The cut-off values of dAmy3 and sCRP3 were 761 IU/L and 15.15 mg/dL, respectively. Among the 17 patients with both dAmy3 and sCRP3 above the thresholds, 10 (58.8%) had PPRC with Clavien-Dindo classification (CD) ≥II and 7 (41.2%) had PPRC with CD ≥III. In contrast, among the 236 patients with both parameters below the thresholds, 233 (98.7%) did not develop PPRC, and only 1 (0.4%) had PPRC with CD ≥III. CONCLUSIONS: Splenectomy correlates with PPRC, which is consistent with results from large clinical trials. A combined use of dAmy3 and sCRP3 can be useful in predicting the risks of PPRC.

Validity of Laparoscopic Gastrectomy in the Elderly.

OBJECTIVES: This study aimed to investigate the validity of laparoscopic gastric cancer surgery in elderly patients. METHODS: A total of 202 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and December 2016 were divided into an elderly group (age ≥75 years, n = 36) and a control group (age < 75 years, n = 166). The patients' clinicopathological data were reviewed. RESULTS: The overall morbidity rate was relatively higher in the elderly group (16.7 vs. 11.4%, p = 0.389), whereas the incidence of serious complications ≥grade III according to the Clavien-Dindo classification did not increase significantly in the elderly group (8.3 vs. 7.8%, p = 0.920). Univariate and multivariate analyses revealed that age ≥75 years was not a significant predictive factor of postoperative morbidity (p = 0.568). There was no significant difference in the 5-year overall survival rate of patients with pathological stage I gastric cancer between the groups (97.1 vs. 96.1%, p = 0.704; hazard ratio, 0.669; 95% confidence interval, 0.036-3.692). CONCLUSIONS: Laparoscopic gastrectomy has an acceptable morbidity rate in elderly patients, and the long-term outcome of patients with stage I gastric cancer was similar to that of the control group.

[A Case of Advanced Gastric Cancer with Multiple Bone Metastases, Virchow Lymph Node and Para-Aortic Lymph Node Metastases That Responded to Combined Modality Therapy and Underwent Conversion Surgery].

A 41-year-old woman with type 3 advanced gastric cancer and Virchow lymph node, para-aortic lymph node, and multiple bone metastases was diagnosed with U-less cType 3 cT4aN3M1, cStage IV. We administered docetaxel, cisplatin, and S-1 (DCS)therapy for unresectable gastric cancer. After 11 courses of DCS, we confirmed that the distant lymph node metasta- ses were significantly reduced. We performed radiotherapy(30 Gy/10 Fr)on the thoracic lumber vertebrae. Because the patient was successfully downstaged, we performed total gastrectomy with Roux-en-Y reconstruction. The histopathological diagnosis was ypT3N2M0, ypStage III A. In this case, DCS therapy successfully treated gastric cancer with distant metastases, including multiple bone metastases.

Postoperative morbidity in elderly patients after gastric cancer surgery.

BACKGROUND: Elderly patients have a high risk of adverse outcomes after surgery. Therefore, it is essential to determine the predictive factors for postoperative morbidity in elderly patients undergoing gastric cancer surgery. METHODS: A total of 544 patients who underwent elective gastrectomy for gastric cancer at Yodogawa Christian Hospital between January 2007 and December 2015 were divided into the elderly group (age ≥70 years, n=282) and a control group (age <70 years, n=262). Clinicopathological data from all patients were reviewed. RESULTS: The overall morbidity rates were 24.8% in the elderly group and 13.4% in the control group, indicating a significant difference (P<0.001). The incidence rates of anastomotic leakage (4.6% vs. 1.5%, P=0.039) and cardiovascular complications (2.5% vs. 0%, P=0.01) were significantly higher in the elderly group. A multivariate analysis revealed that a blood loss of ≥320 mL was an independent predictive factor of overall morbidity (P=0.004). A blood loss of ≥219 mL (P=0.025) and American Society of Anesthesiologists (ASA) physical status of 3/4 (P=0.006) were associated with anastomotic leakage and postoperative cardiovascular complications, respectively. CONCLUSIONS: The overall morbidity rate was significantly higher among elderly patients and an intraoperative blood loss of ≥320 mL was a significant predictive factor. In particular, anastomotic leakage and cardiovascular complications were seen with greater frequency among those with a higher blood loss volume and ASA physical status, respectively.

[Early Surgery for Acute Cholecystitis Complicated with Gallbladder Cancer].

The present study involved 6 patients who had urgent surgery for acute cholecystitis(AC)complicated with gallbladder cancer(GBC)in our hospital from January 2014 to December 2016. We analyzed the clinical outcome of early surgery for AC complicated with GBC. According to Tokyo Guidelines 2013, the AC severity was classified as Mild 1 case, Moderate 5 cases. Only one patient was diagnosed with GBC before the operation for AC. The others were during or after the laparoscopic cholecystectomy. Histopathologically, all patients had Stage II disease or greater. Two patients had adjunctive radical operation with the wedge resection of the gallbladder bed, lymphadenectomy and bile duct resection, and they survived without recurrence for 28 months and 12 months, respectively. Of the 3 patients without any additional surgery, 2 patients died in several months after the operation. In consideration of the concurrence of GBC, early surgery for AC must be decided carefully.

Clinicopathological study of a dimorphic variant of breast carcinoma.

BACKGROUND: Dimorphic cells have abundant clear cytoplasm similar to myoepithelial cells, and the nuclei are identical to those in adjacent malignant columnar epithelial cells. A dimorphic variant of a breast carcinoma involves a neoplastic proliferation of epithelial cells including dimorphic cells. METHODS: The subjects were patients with primary breast carcinoma, who underwent surgical resection at the Hospital of Dokkyo Medical University between 2000 and 2016, and were reviewed and diagnosed with a dimorphic variant of breast carcinoma. RESULTS: Dimorphic ICs typically showed a low-grade tumor and Hormonal receptor (HR) (estrogen and/or progesterone)+/HER2- subtype. Age, mean tumor size, status of nodal metastasis, stage and disease-free survival and overall survival did not differ between dimorphic and non-dimorphic ICs. The dimorphic cells were negative for p63 and cytokeratin 5/6 and 14 in most cases. In contrast, dimorphic cells were positive for HR, androgen receptor, and showed marked membrane-associated staining for E-cadherin and cytoplasmic staining for gross cystic disease fluid protein 15. CONCLUSIONS: The morphological features of dimorphic cells may be confused with cells of other origins if the features of the dimorphic cells are not recognized. However, the typical morphological architecture of this carcinoma and expression of immunohistochemical markers support the diagnosis.

Impact of Gastric Cancer Surgery in Elderly Patients.

OBJECTIVES: This study aimed to investigate the validity of gastric cancer surgery in elderly patients. METHODS: A total of 544 patients who underwent elective gastrectomy for gastric cancer were divided into an elderly group (age ≥75 years, n = 171) and a control group (age <75 years, n = 373). The clinicopathological data of the patients were reviewed. RESULTS: The overall morbidity rate (26.3 vs. 16.1%, p = 0.005) and the incidence rate of anastomotic leakage (6.4 vs. 1.6%, p = 0.003) were significantly higher in the elderly group. The proportion of patients who had severe complications (≥grade IIIa) was relatively higher in the elderly group (10.5 vs. 5.7%); however, the difference was not significant (p = 0.074). A stage-matched survival analysis revealed no significant differences between the groups (stage I: p = 0.978; stage II: p = 0.964; stage III: p = 0.199). For the pathological stages II and III, the overall survival of the patients in the elderly group who received adjuvant chemotherapy for >3 months was significantly better than that of the patients who received it for ≤3 months or did not receive it (p = 0.023). CONCLUSIONS: An aggressive treatment strategy should be adopted in selected elderly patients with gastric cancer.

Proper training in laparoscopic hernia repair is necessary to minimize the rising recurrence rate in Japan.

INTRODUCTION: The Japan Society for Endoscopic Surgery reported that the recurrence rate for inguinal hernia repair in Japan was less than 1% in 2010. However, its 2012 survey found that the recurrence rate had increased to 4% for the transabdominal preperitoneal procedure and 5% for the totally extraperitoneal procedure. We held 14 hernia repair training courses from 2011 to 2016 with help from Covidien. This study aimed to determine the effect of this training on the recurrence rate. METHODS: Training was composed of a theoretical revision of inguinal anatomy, dry laboratory suturing, a video lecture, and practice on an animal model. We made inquiries about the length of each surgeon's career, post-training changes in surgical methods, and recurrence rates before and after training. RESULTS: We received responses from 159 of 300 trainees (53%). The mean career length was 12.7 ± 8.2 years. The annual number of transabdominal preperitoneal procedures performed increased from 20.9 ± 29.9 to 32.4 ± 56.1 after training (P < 0.001), and the number of totally extraperitoneal procedures increased from 9.5 ± 13.9 to 13.9 ± 16.9 (P = 0.0218). The annual number of procedures performed via the anterior approach decreased from 153.1 ± 28.4 to 28.4 ± 52.2 after training (P < 0.001). The pre-training transabdominal preperitoneal procedure recurrence rate was 0.9%, and this decreased to 0.4% after training. There was no pre-training recurrence rate for the totally extraperitoneal procedure, but this was 0.4% after training. CONCLUSION: The high recurrence rate after inguinal hernia repair in Japan was mainly due to inadequate training in the laparoscopic method. Our laparoscopic hernia repair training course achieved low recurrence rates.

[Granulomatosis with Polyangiitis Complicated with Gastrointestinal Perforation: A Case Report and Review of Literature].

  A 51-year-old man was detected nasal bleeding, multiple pulmonary nodule and mass, urinalysis abnormality, renal involvement and high titer of proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), and was suspected of granulomatosis with polyangiitis and initiated with steroid pulse therapy. On the day after the start of steroid pulse therapy, generalized peritonitis due to ileal perforation occurred, and emergency ileectomy and peritonitis surgery were performed. Induction therapy with steroid pulse therapy, plasma exchange and intravenous cyclophosphamide therapy (IVCY) and maintenance therapy with glucocorticoid and azathioprine led to good therapeutic outcomes. Gastrointestinal perforation in GPA is a rare complication, and we examined the clinical features, treatment contents, and prognosis of GPA with gastrointestinal perforation from this case and previous reports. Lung involvements were complicated in all reported cases. Gastrointestinal perforations in GPA were frequent in the small intestine, occurred just before and immediately after the start of treatment, and were severe involvement with poor prognosis because of the high mortality rate (46.7%). The frequency of ear, nose and upper respiratory tract lesions in the surviving group was significantly higher than in the dead group (survival 87.5%, death 28.3%, P = 0.041). IVCY were more frequently used in the surviving group (62.5%) than the death group (16.7%), but it was not significantly. GPA complicated with gastrointestinal perforation is a severe condition with poor prognosis, but there is a possibility to improve prognosis by early diagnosis and early initiation of strong treatment.

[A Case of Locally Advanced Breast Cancer Successfully Treated with Local Control That Achieved a Pathological Complete Response after Bevacizumab and Paclitaxel Combination Chemotherapy].

A 68-year-old woman with a 5-year history of an untreated left breast tumor presented to our hospital. She was admitted for untreated diabetes and severe anemia. The cause of the anemia was bleeding from the tumor, and she was referred to our department. She was diagnosed with T4bN0M0, stage IIIb breast cancer. First, we initiated hormonal therapy. However, the tumor did not decrease in size. We then administered chemotherapy. The tumor markedly decreased in size, and mastectomy and axillary lymph node dissection were performed. The response was a pathological complete response. She is currently undergoing hormonal therapy at the time of this writing.

Outcomes of Consistent Conservative Management for Acute Cholecystitis Followed by Delayed Cholecystectomy.

OBJECTIVE: This study's objective was to assess outcomes of a totally conservative strategy for acute cholecystitis (AC) followed by delayed elective cholecystectomy. PATIENTS AND METHODS: Consecutive patients who underwent cholecystectomy for AC were divided into the Emergent and Elective cholecystectomy groups. Patients in the elective cholecystectomy group were divided into early, medium, and late groups according to time from symptoms onset. RESULTS: The success rate for conservative management reached 97.2%. Increased blood loss and a higher conversion rate were significantly associated with the emergent group. Patients in the late group had significantly lower operative time and tended to have lower blood loss and less frequent conversion to open surgery than those in the early and medium groups. CONCLUSIONS: Most AC cases could be managed conservatively, and elective cholecystectomy was performed safely regardless of the time. Elective cholecystectomy carried out in late phase was likely to be associated with decreased surgical difficulty.

Is the Glasgow Prognostic Score Applicable to Both Early- and Advanced-Stage Gastric Cancers?

BACKGROUND: The Glasgow prognostic score (GPS) has been reported as a sensitive prognostic marker for gastric cancer. This study aimed to investigate whether the GPS is equally applicable to patients with early-stage and advanced-stage gastric cancers. METHODS: Patients (n = 544) who underwent elective gastrectomy for gastric cancer between 2007 and 2015 were retrospectively studied. GPSs of 2, 1, and 0 were allocated to patients with both an elevated C-reactive protein level (> 1.0 mg/dL) and hypoalbuminemia (< 3.5 mg/dL), patients with only one of these abnormalities, and patients with neither abnormality, respectively. The prognostic factors relevant to patients with early-stage (pStage I, n = 304) and advanced-stage (pStage II, III, and IV, n = 240) gastric cancer were analyzed through univariate and multivariate analyses. RESULTS: In the early-stage group, only the serum carbohydrate antigen (CA) 19-9 level (P = 0.037) was a significant prognostic factor in the multivariate analysis; the GPS was not significant (P = 0.095). In the advanced-stage group, an American Society of Anesthesiologists physical status of 3 or 4 (P = 0.032), elevated carcinoembryonic antigen (CEA) (P = 0.043) and CA19-9 (P = 0.045) levels, a GPS 1 - 2 (P = 0.017), and type 4 tumor (P = 0.020) correlated significantly with worse overall survival. CONCLUSIONS: GPS is a simple and useful prognostic score for patients with advanced-stage, but is not applicable to early-stage patients.

Outcome of Gastric Cancer Surgery in Patients with Chronic Kidney Disease.

BACKGROUND: The influence of chronic kidney disease (CKD) on the outcome of gastric cancer surgery has rarely been reported. METHODS: Retrospectively collected clinicopathological data on patients who underwent elective gastrectomy between January 2007 and December 2014 were analyzed (n = 500). The patients were divided into 2 groups based on the preoperative estimated glomerular filtration rate (eGFR): a non-CKD group (eGFR ≥60 ml/min/1.73 m2, n = 392) and a CKD group (eGFR <60 ml/min/1.73 m2, n = 108). Short- and long-term results of the surgery were compared. RESULTS: There was no significant difference between the 2 groups in terms of the overall morbidity rate (p = 0.215), and in any kind of postoperative complication, including infectious and cardiovascular complications. Additionally, there was no significant difference in the morbidity rate irrespective of the type of gastrectomy and the extent of lymph node dissection. The 3-year relapse-free survival rates in the non-CKD and CKD groups were 92.1 and 92.0%, respectively, in stage I disease (p = 0.640), 81.4 and 73.7%, respectively, in stage II disease (p = 0.825), and 35.9 and 31.9%, respectively, in stage III disease (p = 0.784). CONCLUSION: CKD did not affect the short- and long-term outcomes in patients after gastric cancer surgery.

Current role of percutaneous transhepatic gallbladder aspiration: from palliative to curative management for acute cholecystitis.

BACKGROUND: The present study assessed conservative management of acute cholecystitis (AC) with a focus on percutaneous transhepatic gallbladder aspiration (PTGBA). METHODS: Consecutive 275 patients with AC who underwent PTGBA were reviewed. Patients aged ≥80 years and/or with American Society of Anesthesiologists score III to IV and/or performance status 3 to 4 were defined as high risk. Patients were classified according to duration from symptom onset to first PTGBA: within 3 days (early PTGBA) or over 3 days (late PTGBA). They were also classified according to duration from first PTGBA to surgery: within 30 days (early surgery) or over 30 days (late surgery). RESULTS: A total of 263 patients (95.6%) showed recovery after PTGBA. There were no significant differences in operating time, blood loss, operating procedure, conversion rate to open surgery, postoperative complications, or postoperative hospital stay between the early and late PTGBA groups or between the early and late surgery groups. No significant complications associated with PTGBA or surgery were observed, including in those at high risk. CONCLUSIONS: Percutaneous transhepatic gallbladder aspiration can be a useful alternative for most patients with AC, including those at high risk. Elective cholecystectomy can be performed safely regardless of the timing of PTGBA or surgery.