[Usefulness of an Epidural Catheter with a Subcutaneous Port for Locally Advanced Rectal Cancer Pain Which Was Difficult to Manage with Opioids-A Case Report].

A 56-year-old woman was diagnosed with advanced rectal cancer, with tumor invasion to the sacrum and levator muscle of the anus and multiple lymph node metastasis. After construction of an artificial anus, chemotherapy was started. However, tumor invasion and the cancer pain progressed. Finally, she was hospitalized for pain control; an anesthesiologist planned to insert an epidural catheter. The epidural catheter was placed at the L5-S1 interspace, and continuous administration of 0.2% ropivacaine was started. Cancer pain in the buttocks improved quickly. Therefore, an epidural catheter with a subcutaneous port was placed to prevent catheter-related infection after a long period. The postoperative course was uneventful, and she was discharged from the hospital on the 10th day postoperatively. She could receive home medical care and pain control treatment in an outpatient clinic. Finally, she died due to progression of the rectal cancer, 3 months after placement of the epidural catheter with the subcutaneous port. Some patients with advanced rectal cancer develop cancer pain even though they are sufficiently treated with opioids or palliative radiation therapy. Here, we describe the case of a patient with locally advanced rectal cancer, treated with an epidural catheter with a subcutaneous port for cancer pain that was difficult to manage with opioids alone.

[Low-Dose and Interval Administration of Imatinib in a Patient with Liver Metastasis of the Gastrointestinal Stromal Tumor of the Stomach - A Case Report].

A 69-year-old woman underwent proximal gastrectomy with distal pancreatectomy and splenectomy for a gastrointestinal stromal tumor of the stomach.Adjuvant imatinib was administered for a year.Two years after resection of the tumor, liver metastasis in S8 was detected.Therefore, imatinib was re-administered at 300mg/day.After a year of re-administration, the patient suffered muscle cramps in the hands, and therefore imatinib was administered with intervals, such as 4 weeks administration and 4 weeks rest.Re -administration of imatinib was effective and her liver metastasis decreased in size.It was not detected with CT after 1 year and 4 months and remained in complete response(CR)for 3 years and 8 months.After she suffered a brain infarction, imatinib administration was stopped for 4 months.Consequently, the liver metastasis was detectable in S8 again.This clinical course suggested that low-dose and interval administration of imatinib is effective in the treat- ment of GIST.

Description of pylorus-preserving pancreaticoduodenectomy in elderly patients.

BACKGROUND/AIMS: The aim of this paper is to examine the safety and feasibility of pylorus-preserving pancreaticoduodenectomy in elderly patients. METHODOLOGY: The study population consisted of 40 consecutive patients. They were divided into two groups: Group A (<75 years old) and Group B (=75 years old). Reconstruction with a vertical duodenojejunostomy and internal pancreatic drainage with an omental wrapping was performed on the patients in both the groups. RESULTS: Less time was required to complete the operations in Group B (280±20min) than in Group A (386±88min; p=0.0006). Intraoperative blood loss in Group B was significantly lesser (365±109g) than that in Group A (629±249g; p=0.0026). No statistically significant difference was observed between both groups, in terms of the length of time required until food intake resumed and length of hospital stay. Although the rate of postoperative complication was higher in Group B (10.0%), no statistically significant difference was observed. CONCLUSIONS: Pylorus-preserving pancreaticoduodenectomy with a vertical duodenojejunostomy and internal pancreatic drainage with an omental wrapping seems safe and can be performed on elderly patients without a significant risk of complications.

Laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy for superior mesenteric artery syndrome with dysphagia: a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome denotes a mechanical duodenal obstruction between the SMA and aorta. Total parenteral or enteral nutrition is the treatment of choice. However, surgical intervention is indicated if the patient's condition does not improve with conservative treatment. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy. CASE PRESENTATION: A 64-year-old man was admitted to another hospital because of appetite loss and vomiting. There, he was diagnosed as having superior mesenteric artery (SMA) syndrome after appropriate investigation. He had had a cerebral infarction at age 57 years, since which he had lived in social housing because of complications of that infarction. A nasogastric tube was inserted into the third portion of the duodenum beyond the constricted section. He was discharged 2 months after admission his condition having improved. He was subsequently referred to our hospital for gastrostomy because the nasogastric tube had been in place for a long time and his condition had not improved. Additionally, gastrostomy was needed as a route for enteral nutrition because he had dysphagia, which had persisted despite attempts at rehabilitation, restricting his food intake to small amounts. Computed tomography (CT) revealed compression of the third portion of the duodenum between the SMA and aorta. After obtaining informed consent, we planned an operative procedure. We performed laparoscopic gastrojejunostomy under general anesthesia, followed by laparoscopic-assisted percutaneous endoscopic gastrostomy. The operation time was 156 min and there was little blood loss. Contrast radiography on postoperative day 3 revealed no evidence of leakage or stenosis. Enteral nutrition via the gastrostomy was started. He was discharged from our hospital on the 27th postoperative day. The gastrostomy was well tolerated and there has been no evidence of recurrence of SMA syndrome during follow-up. CONCLUSION: Gastrostomy is often performed to provide a route for administering enteral nutrition in patients with dysphagia. Development of SMA syndrome in patients with dysphagia necessitates operative management of the obstruction. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.

Patient with gastric cancer who underwent distal gastrectomy after treatment of COVID-19 infection diagnosed by preoperative PCR screening.

BACKGROUND: Because of the coronavirus disease 2019 (COVID-19) pandemic, preoperative screenings for COVID-19 infection are often performed in many institutions. Some patients are diagnosed with COVID-19 infection by antigen tests or polymerase chain reaction (PCR) testing for COVID-19, even if they have no symptoms, such as fever or respiratory symptoms. We herein describe a patient with gastric cancer who underwent distal gastrectomy 6 weeks after recovering from COVID-19 infection diagnosed by preoperative PCR. CASE PRESENTATION: An 86-year-old man was transferred to our hospital because of hematemesis and melena. A hemorrhagic gastric ulcer was found in the lesser curvature of the antrum by emergency endoscopy. Endoscopic hemostasis was performed, and he was discharged after recovery. A tumor-like lesion in the lesser curvature of the antrum was found on repeat endoscopy and was diagnosed as well-differentiated adenocarcinoma by biopsy. There was no evidence of lymph node metastasis or distant metastasis; therefore, we planned radical surgery. However, he was diagnosed with COVID-19 infection by preoperative PCR screening. Although he had no symptoms, such as fever or respiratory symptoms, he was hospitalized because of his advanced age. He was discharged 10 days after admission, and repeat COVID-19 PCR was negative. We planned radical surgery for the stomach tumor 6 weeks after recovery from the COVID-19 infection. A PCR-negative COVID-19 status was confirmed again before hospitalization. Open distal gastrectomy with Billroth I reconstruction was performed. We avoided ultrasonic scalpels and used a Crystal Vision 450D surgical smoke evacuator (I.C. Medical, Inc., Phoenix, AZ, USA) to reduce intraoperative surgical smoke. The postoperative course was uneventful. CONCLUSION: Because of the COVID-19 pandemic, some patients are diagnosed with COVID-19 infection by preoperative antigen tests or PCR, even if they have no symptoms. If possible, elective surgery should be performed 4 to 6 weeks after recovery from COVID-19 infection to maximize safety. Moreover, surgeons must consider intraoperative surgical smoke.

Liver hemorrhage due to idiopathic peliosis hepatis successfully treated with hepatic artery embolization.

Peliosis hepatis is an extremely rare condition that may cause fatal hepatic hemorrhage and liver failure. We report a case of liver hemorrhage due to idiopathic peliosis hepatis. A 60-year-old woman was admitted to our hospital with slight right hypochondriac pain. She went into hemorrhagic shock, and computed tomography (CT) showed multiple low-density areas in the right liver with massive subcapsular blood collection. Selective transfemoral arteriography of the celiac artery revealed no signs of vascular malformation or tumor stain, but showed signs of pooling in the right posterior segmental artery. The artery was embolized with particles of gelatin sponge, and hemostatic control was successful. Although peliosis hepatis is extremely rare, the diagnosis is significant because of its urgent clinical status, and transarterial embolization is a useful and minimally invasive procedure for liver hemorrhage due to peliosis hepatis.

Colon angiolipoma with intussusception resected by laparoscopy-assisted surgery: a case report.

Angiolipomas are benign mesenchymal tumors that often occur under the skin of the upper extremity or thoracic and abdominal walls. Angiolipomas of the digestive tract are rare. Here, we describe a case of transverse colon angiolipoma with intussusception resected by laparoscopy-assisted surgery. A 50-year-old woman visited a family hospital with complaints of left lower abdominal pain and bloody stool. Colonoscopy revealed a submucosal tumor in her left colon. She was referred to our hospital for further examination. Computed tomography revealed a low-density tumor with intussusception in the left transverse colon. Elective surgery was planned for this patient because there were no alarming symptoms such as ileus or obstruction. Laparoscopy-assisted surgery and partial resection of the left transverse colon were performed. The histopathological diagnosis was angiolipoma of the colon. Angiolipomas are benign mesenchymal tumors that rarely occur in the digestive tract. Thus, accurate preoperative diagnosis is difficult.

[A case of hepatocellular carcinoma complicated with Caroli's disease].

A 29-year-old man was admitted with right hypochondralgia and fever. Markedly dilated bile ducts were observed, mainly in the right lobe of the liver. Based on both the clinical findings and imaging, we diagnosed Caroli's disease and choledochal cyst complicated with cholangitis. Hepatocellular carcinoma (HCC) was also observed in segment 3, and the tumor measured 4cm in diameter. The patient was successfully treated with hepatectomy of the right lobe, partial hepatectomy of the left lateral lobe, and bile duct reconstruction. A histopathological examination revealed moderately differentiated HCC without any components of cholangiocellular carcinoma (CCC). Although Caroli's disease is complicated with CCC, a case of Caroli's disease complicated with HCC, as in the present case, is quite rare and therefore is considered to be worthy of reporting.

Gastric cancer with features of submucosal tumor: a case report.

A case of stomach carcinoma showing the features of a submucosal tumor (SMT) is reported. The patient was a 65-year-old woman admitted to the Internal Medicine Department with autoimmune hepatitis and complaining of anemia and tarry stools. Endoscopy revealed a submucosal tumor-like lesion with central ulceration. The lesion was the suspected cause of the anemia; therefore, a partial resection of the stomach was performed. The histopathologic examination revealed a mucinous adenocarcinoma (MUC). The tumor extended to the submucosa. Accordingly, a subtotal gastrectomy with regional lymph node dissection was performed. In stomach carcinoma simulating an SMT, generally preoperative diagnosis is important. However, in this patient, surgery was selected as the best treatment.

[A case of osteonecrosis of the lower jaw due to bisphosphonates in a breast cancer patient with bone metastasis].

Recently, osteonecrosis of the jaw (ONJ) with bisphosphonates is frequently reported. ONJ due to bisphosphonate is an adverse event in the treatment of breast cancer with bone metastasis. We report a case of ONJ due to bisphosphonates. A 66-year-old woman was admitted to our hospital due to right advanced breast cancer with bone metastasis. She received neo-adjuvant chemotherapy consisting of paclitaxel 70 mg/m2, qw, trastuzumab 2 mg/m2, qw. After chemotherapy, we performed modified mastectomy for local control. Postoperative adjuvant chemotherapy was added with bisphosphonate for bone metastasis of breast cancer. After bisphosphonate was used 14 times, she had a pain and pus-discharge in her lower jaw. The dentists' diagnosis was ONJ. We treated her with antibiotics and local minor curettage. The inflammatory symptoms almost disappeared. In this case, the administration of bisphosphonates was thought to be a major risk factor for ONJ. We think that special precautions for ONJ should be taken in patients administered bisphosphonates for bone metastasis of breast cancer.

A case report of intracholecystic papillary neoplasm of the gallbladder resembling a submucosal tumor.

BACKGROUND: Intracholecystic papillary neoplasm (ICPN) is defined as papillary tumors detected macroscopically in the gallbladder. We report a case of ICPN which exhibited the atypical form like a submucosal tumor. CASE PRESENTATION: A 70-year-old man was admitted to our hospital because of hepatic disorder. Computed tomography and magnetic resonance imaging showed irregular thickening of the wall within the gallbladder fundus. Because the lesion might have been malignant, we performed laparoscopic cholecystectomy and liver bed resection. Macroscopic findings showed the mucosal surface of the tumor was smooth, and its form was similar to that of a submucosal tumor. Histopathological examination revealed papillary tumors within the mass with low-grade dysplasia; therefore, we diagnosed ICPN. CONCLUSION: In the present case, ICPN was resembling a submucosal tumor macroscopically because the tumors arose into the Rokitansky-Aschoff sinus and the adenomyomatous hyperplasia was merged with the ICPN. It is necessary to consider the possibility of tumor lesions within adenomyomatous hyperplasia.

Ten-Year Survival of a Patient Treated with Stereotactic Gamma Knife Radiosurgery for Brain Metastases from Colon Cancer with Ovarian and Lymph Node Metastases: A Case Report.

Brain metastasis from colorectal cancer is infrequent and carries a poor prognosis. Herein, we present a patient alive 10 years after the identification of a first brain metastasis from sigmoid colon cancer. A 39-year-old woman underwent sigmoidectomy for sigmoid colon cancer during an emergency operation for pelvic peritonitis. The pathological finding was moderately differentiated adenocarcinoma. Eleven months after the sigmoidectomy, a metastatic lesion was identified in the left ovary. Despite local radiotherapy followed by chemotherapy, the left ovarian lesion grew, so resection of the uterus and bilateral ovaries was performed. Adjuvant chemotherapy with tegafur-uracil (UFT)/calcium folinate (leucovorin, LV) was initiated. Seven months after resection of the ovarian lesion, brain metastases appeared in the bilateral frontal lobes and were treated with stereotactic Gamma Knife radiosurgery. Cervical and mediastinal lymph node metastases were also diagnosed, and irradiation of these lesions was performed. After radiotherapy, 10 courses of oxaliplatin and infused fluorouracil plus leucovorin (FOLFOX) were administered. During FOLFOX administration, recurrent left frontal lobe brain metastasis was diagnosed and treated with stereotactic Gamma Knife radiosurgery. In this case, the brain metastases were well treated with stereotactic Gamma Knife radiosurgery, and the systemic disease arising from sigmoid colon cancer has been kept under control with chemotherapies, surgical resection, and radiotherapy.

Vascular endothelial growth factor C (VEGF-C) expression in pT2 gastric cancer.

BACKGROUND/AIMS: The purpose of this study was to determine whether the vascular endothelial growth factor C (VEGF-C) protein expression was related to the clinicopathologic features of patients with pT2 (primary tumor invasion of muscularis propria or subserosa) gastric cancer. METHODOLOGY: The expression of VEGF-C protein was investigated retrospectively in 102 patients with pT2 gastric cancer. Immunohistochemical staining of the paraffin sections was performed using a polyclonal antibody to VEGF-C. RESULTS: Normal gastric mucosa was not immunoreactive with an anti-VEGF-C antibody. Among the 102 tumors examined, 27 (26.5%) showed high expression of VEGF-C protein. No staining was observed in the normal tissue surrounding the tumor. There were no significant differences in age, gender, or histological types. With regard to the clinicopathological characteristics, significant differences were observed in depth of tumor invasion (muscularis propria vs. subserosa; p<0.05), lymph node metastasis (p<0.001), and stage grouping (p<0.001). The prognosis for VEGF-C-positive patients was worse than that for VEGF-C-negative patients in terms of overall survival, and VEGF-C expression was an independent prognostic indicator (p=0.023) by multivariable analysis. CONCLUSIONS: Determination of VEGF-C expression is important in predicting nodal metastasis and poor clinical outcome in pT2 gastric cancer patients.

Loss of KAI1 expression in gastric cancer.

BACKGROUND/AIMS: The purpose of this study was to determine whether the loss of KAI1 expression was related to the clinicopathologic features of patients with gastric cancer. METHODOLOGY: The expression of KAI1 protein was investigated retrospectively in 174 patients with gastric cancer. Immunohistochemical staining of the paraffin sections was performed using polyclonal antibody to KAI1. RESULTS: KAI1 was consistently and highly expressed in normal gastric epithelium, while 47 (27%) of 174 patient samples had KAI1-positive expression in the primary gastric carcinoma. There were no significant differences of age, gender, and tumor location. With regard to the clinicopathological characteristics, significant differences were observed in histological types (p<0.001), increased tumor stage (p<0.001), lymph node (p<0.001) and distant metastasis (p<0.001). KAI1-negative patients had a worse prognosis than that of positive patients in overall survival, but loss of KAI1 expression was not an independent prognostic indicator (p=0.779) by multivariable analysis. CONCLUSIONS: Loss of KAI1 of expression is likely to predict metastasis and poor clinical outcome in gastric cancer patients. For the purpose of predicting the prognosis of gastric cancer patients, it is important to discriminate whether the carcinoma cells have loss of KAI1 expression.

Increased thermosensitivity of mouse colorectal carcinoma cells transfected with human FUT1 gene.

The thermal responses of mouse colorectal carcinoma cells were investigated in the wild type cells and the transfected cells with human FUT1 gene which encodes alpha 1,2fucosyltransferase. The heat sensitivity was observed to increase in the FUT1 gene transfected cells and the effect of hyperthermia at 44 degrees C on these cells was demonstrated to be significant (P<0.001) to the wild type cells even though no remarkable difference in the expression of the heat shock protein, Hsp70 was found in these cells. Thus the expression of alpha 1,2fucosylated antigens seemed to increase the heat sensitivity in mouse colorectal carcinoma cells.

Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy.

BACKGROUND: Postoperative ileus limits early hospital discharge for patients who have undergone laparoscopic procedures. Sham feeding has been reported to enhance bowel motility. Here, the effect of gum chewing is evaluated as a convenient method to enhance postoperative recovery from ileus after laparoscopic colectomy. STUDY DESIGN: A total of 19 patients who underwent elective laparoscopic colectomy for colorectal cancer participated in the study. Each patient was randomly assigned to one of two groups: a gum-chewing group (n = 10, mean age 58.6 years, range 50 to 71 years) or a control group (n = 9, mean age 60.6 years, range 45 to 80 years). The patients in the gum-chewing group chewed gum three times a day from the first postoperative AM until oral intake. The times of the first passage of flatus and defecation were recorded precisely. RESULTS: The first passage of flatus was seen, on average, on postoperative day 2.1 in the gum-chewing group and on day 3.2 in the control group (p < 0.01). The first defecation was 2.7 days sooner in the gum-chewing group (postoperative day 3.1) than in the control group (5.8 days; p< 0.01). All patients tolerated gum chewing on the first operative AM. The postoperative hospital stays for the gum-chewing and control groups were 13.5+/-3.0 days and 14.5+/-6.1 days, respectively. CONCLUSIONS: Gum chewing aids early recovery from postoperative ileus and is an inexpensive and physiologic method for stimulating bowel motility. Gum chewing should be added as an adjunct treatment in postoperative care because it might contribute to shorter hospital stays.

Laparoscopic transgastric tumor-everting resection of the gastric submucosal tumor located near the esophagogastric junction.

Local resection of the stomach is suitable for the treatment of submucosal tumors (SMT). However, it cannot be easily performed laparoscopically on tumors located near the esophagogastric junction. We have developed a new technique, which is called transgastric tumor-everting resection. To identify the location of the SMT laparoscopically without an oral endoscope, an Indiana ink mark was made prior to the operation. The SMT was everted from the gastrotomy and held by the Mini Loop Retractor II. The gastric mucosa could be observed from gastrotomy, allowing us to confirm that the staple line would not cause deformity of the esophagogastric junction. The lesion was then resected, and the gastrotomy was closed simultaneously using the Endo-GIA Universal. This technique is easy, safe, and useful for the laparoscopic resection of gastric SMTs located on the greater curvature or anterior wall of the fornix, near the esophagogastric junction.

Successful surgical treatment of a spontaneous rupture of the esophagus diagnosed two days after onset.

Esophageal perforation is a relatively uncommon disease with a high rate of mortality and morbidity. Delay in the diagnosis and treatment occurs in more than 50% of cases, leading to a mortality rate of 40-60%. Primary repair is generally considered the gold standard for patients who present within the first 24 h following perforation of the esophagus. In this paper, we present a case of successful surgical treatment of spontaneous rupture of the esophagus that was diagnosed 2 days after onset. The patient was a 42-year-old man admitted to internal medicine with a diagnosis of pleuritis and complaining of chest and back pain. The next day, computed tomography revealed left-sided pleural effusion and mediastinal emphysema. An esophagogram revealed extravasation of the contrast medium from the lower left esophagus to the mediastinal cavity. These results confirmed a rupture of the esophagus, and an emergency left thoracotomy was performed. The perforation was repaired with a single-layered closure and was covered with elevated great omentum obtained by laparotomy. The patient was discharged 23 days after the first surgery. In conclusion, primary repair surgery must be selected as the best treatment beyond 24 h if the patient's general state was stable and there was no evidence of clinical sepsis.

Rosai-Dorfman disease of the colon presented as small solitary polypoid lesion.

Rosai-Dorfman disease (RDD) was formerly known as "sinus histiocytosis with massive lymphadenopathy", and cases involving the gastrointestinal tract are rare. We present a case of pure extranodal RDD, resected as a polypoid lesion in colonoscopic study. The patient was a 62-year old woman with a history of sigmoidectomy for unexplained peritonitis. Microscopic study of the polypoid lesion showed the submucosal mass with histological and immunological features of RDD. The whole body computed tomography revealed neither lymphadenopathy nor tumor-like mass.

Soluble Human Leukocyte Antigen class I antigen and interleukin-12 in hepatectomized patients.

BACKGROUND: Interleukin-12 (IL-12) has been shown to enhance the cytotoxic activity of NK cells and CTL. IL-12 also acts as a growth factor for activated NK, T and NKT cells. The soluble HLA class I (sHLA-I) has been reported to bind a killer-cell inhibitory receptor, which is expressed on the NK cell, and its signals inhibit NK cell-mediated cytotoxicity. Effects of fresh frozen plasma (FFP) on post-operative immune status have not yet been completely examined. METHODS: Thirty consecutive patients taking a hepatectomy were enrolled. The levels of IL-12 and sHLA-I were examined by enzyme-linked immunosorbent assay. RESULTS: The rate of complication after hepatectomy in the FFP-administered patients was higher than that in patients without FFP administration (P = 0.0358). Decreased IL-12 levels after surgery in patients without FFP administration recovered to the preoperative state earlier than those in patients with FFP administration (P < 0.05). The levels of sHLA-I in the FFP-administered patients were higher than those in the patients without FFP administration (P < 0.05). CONCLUSIONS: Administration of FFP, which contains sHLA-I, affected the levels of sHLA-I after hepatectomy. Both high levels of sHLA-I and low levels of IL-12 could attenuate NK activities after hepatectomy, especially when FFP would be administered.