Positioning of Bristol Stool Form Scale type 3 in constipation treatment satisfaction: A multicenter study in Japan.

BACKGROUND AND AIM: Many patients are not satisfied with chronic constipation (CC) treatments. The aim of this study was to identify factors linked to CC treatment satisfaction or dissatisfaction. METHODS: Our study population included patients who received CC treatment at a clinic or hospital. CC was diagnosed by a physician based on the patient's complaint. Treatment satisfaction was evaluated using the 28th question of the Patient Assessment of Constipation Quality of Life questionnaire. RESULTS: We conducted this study at 28 facilities. We included 167 patients (mean age 66.7 ± 15.2 years, male:female ratio is 1:3.07). Sixty-eight (40.7%) of patients were satisfied with their constipation treatment. Treatment dissatisfaction of CC was significantly associated with frequency of bowel movement <3/week (odds ratio [OR] = 0.376, 95% confidence interval [CI]: 0.156-0.904, P = 0.029) or Bristol Stool Form Scale (BSFS) type 3 (OR = 0.401, 95% CI: 0.170-0.946, P = 0.037). CONCLUSIONS: Our study showed that CC patients with BSFS type3 were not satisfied with constipation treatment. In general, BSFS types 3-5 are defined as normal stools. Therefore, BSFS type 3 may be set as a treatment goal even though the patient is not satisfied. The pathophysiology of CC differs by region and patient background. Therefore, parameters used to define successful treatment will be different by patient or region. We should reconsider the positioning of BSFS type 3 to improve treatment satisfaction for CC.

Short-Term Outcomes from a Randomized Screening Phase II Non-inferiority Trial Comparing Omentectomy and Omentum Preservation for Locally Advanced Gastric Cancer: the TOP-G Trial.

BACKGROUND: Omentectomy is considered an essential part of curative gastrectomy for locally advanced gastric cancer (GC), albeit without solid evidence. We conducted a randomized phase II trial (the TOP-G trial) comparing omentectomy and omentum preservation for gastric cancer. This report describes the short-term findings regarding the trial's secondary endpoints. METHODS: The trial protocol was submitted to the University Hospital Medical Information Network Clinical Trials Registry ( http://www.umin.ac.jp/ctr/ : UMIN000005421). The key eligibility criteria were histologically confirmed cT2-4a and N0-2 gastric adenocarcinoma. Short-term surgical outcomes, including morbidity and mortality, were compared between the omentectomy group (group A, control arm) and the omentum-preserving surgery group (group B, test arm). All procedures were performed via an open approach. Based on a non-inferiority margin of 7%, statistical power of 0.7, and type I error of 0.2, the sample size was set to 250 patients. RESULTS: A total of 251 patients were eligible and randomized (group A: 125 patients, group B: 126 patients) between April 2011 and October 2018. After excluding patients who had peritoneal metastasis or laparotomy history, safety outcomes were analyzed for 247 patients. Group A had a significantly longer median operation time (225 min vs. 204 min, p = 0.022) and tended to have greater median blood loss (260 mL vs. 210 mL p = 0.073). The incidences of morbidity were similar and < 10% in both groups (8% vs. 9%, p = 1.000). There was no mortality in either group. CONCLUSIONS: Operative risk was generally similar between omentectomy and omentum-preserving surgery for locally advanced gastric cancer.

Changes in bone metabolism after gastric cancer surgery in male patients: a prospective observational study.

BACKGROUND: Several retrospective studies have shown that bone disorders occur after gastric cancer surgery. This study was designed to prospectively evaluate the changes in bone metabolism after gastrectomy for gastric cancer. METHODS: We prospectively enrolled 39 men with early gastric cancer who underwent gastrectomy. We excluded women to avoid the effects of menopause. We employed dual energy X-ray absorptiometry (DEXA) to measure bone mineral density (BMD) of the lumbar spine. DEXA was performed before and 1 and 2 years after surgery. The serum levels of alkaline phosphatase (ALP), 1,25-dihydroxy vitamin D [1,25(OH)2VD], 25-hydroxy vitamin D [25(OH)VD], and estradiol were measured before surgery and every 3 months until 2 years after surgery. RESULTS: DEXA revealed that BMD significantly decreased by 0.036 ± 0.033 g/cm2 12 months after gastrectomy (P < 0.001) and by 0.046 ± 0.040 g/cm2 24 months after gastrectomy (P < 0.001). The serum ALP level significantly increased by 38.31 ± 103.8 IU/L 24 months after surgery (P = 0.013). The serum 25(OH)VD level significantly decreased by 4.88 ± 6.42 ng/ml 24 months after surgery (P < 0.001), whereas the serum 1,25(OH)2VD levels were consistently in the normal range. The serum estradiol level significantly increased by 2.94 ± 7.49 pg/ml 12 months after gastrectomy (P = 0.035). A lower preoperative body mass index (BMI) significantly correlated with the reduction in BMD 12 months after surgery; the correlation coefficient was 0.37 (P = 0.025). CONCLUSIONS: This study showed that a significant decrease in BMD was observed for up to 24 months after gastrectomy, not only 12 months.

[A Case of Undifferentiated Intestinal Carcinoma].

Undifferentiated cancer of the small intestine has a poor prognosis and has rarely been reported.We report a case of undifferentiated intestinal carcinoma.A 55-year-old man presented with epigastralgia in December 2018. Blood test results showed a high degree of anemia.Contrast -enhanced abdominal CT showed a small intestinal tumor with a diffuse thickened wall along with multiple liver metastases.Capsule endoscopy revealed a bleeding tumor.It was diagnosed as carcinoma by transhepatic-ultrasound-guided core needle biopsy.Given the preoperative diagnosis of intestinal carcinoma, we resected the tumor along with a part of the small intestine and the enlarged lymph nodes.The pathological diagnosis was undifferentiated intestinal carcinoma.The patient was discharged on the 6th postoperative day after surgery.He was scheduled to receive postoperative chemotherapy.There was no evidence of undifferentiated intestinal carcinoma.Herein, we review case reports from the literature.

[A Case of a Resected Giant Gastric Schwannoma by Laparoscopic Surgery].

This case involved a 42-year-old woman who had no remarkable findings in terms of case history and family history. Upper gastrointestinal series performed during a medical examination revealed ulcerative lesions in the anterior wall of the stomach body. Upper gastrointestinal endoscopy was performed, and a submucosal tumor with a maximum diameter of 50mm accompanied by an ulcerative lesion was found in the anterior wall of the lower part of the stomach. She was diagnosed with a schwannoma based on endoscopic ultrasonography-guided fine needle aspiration, and we received consultation for surgical purpose. Surgery was performed with laparoscopic partial resection of the stomach and lymph nodes in the lesser curvature of the stomach. She was discharged on the 7th day after the surgery. The postoperative pathologic findings showed no nuclear fissure or atypia with a diagnosis of a schwannoma and no lymph node metastasis. Gastric schwannoma is a rare disease that arises from Schwann cells of the Auerbach's plexus of the gastric wall muscularis and comprises 0.1-0.2% of all stomach tumors. Preoperative diagnosis is often extremely difficult, and there are reports of malignancy. Treatments and surgical methods should be carefully considered. Herein, we encountered a case of a resected giant gastric schwannoma by laparoscopic surgery, which is reported with a literature review.

[A Case of Early-Developing Rapidly Progressive Glomerulonephritis after Laparoscopic-Assisted Distal Gastrectomy for Gastric Cancer].

This is a case of a 76-year-old man who had no significant past medical or family history. In the current medical history, in November 2017, upper gastrointestinal endoscopy showed a semicircular protruding lesion in the posterior wall of the gastric antrum, and gastric cancer was diagnosed following biopsy. Endoscopic submucosal dissection(ESD)was performed in the same year for the treatment of gastric cancer(cT1aN0M0). Pathological findings after ESD treatment showed invasion into the submucosa requiring non-curative resection. For this reason, laparoscopic pylorus side gastrectomy(D1 dissection)and Billroth Ⅰ reconstruction were performed as additional procedures in March 2018. The patient was discharged on the 10th postoperative day and was followed-up on an outpatient basis. On the postoperative day 14, he was re-admitted with complaints of upper abdominal pain and exacerbation of inflammation. Medical treatment, such as antibiotic administration was followed, however, a high degree of inflammatory response, renal dysfunction, and occult blood in urine were observed. Because of suspicion of vasculitis-related nephritis, the case was diagnosed as anti-GBM antibody type rapid progressive nephritis. We came across a case of rapidly progressive glomerulonephritis after laparoscopic pylorus side gastrectomy performed for early gastric cancer, and hence, We will review the related literature.

[A Case of Malignant Peritoneal Mesothelioma Resected Four Times in Five Years].

We report a long-surviving case of malignant peritoneal mesothelioma requiring 4 operations in 5 years. A 63-year-old man was diagnosed with gastrointestinal stromal tumor(GIST)that was excised for the first time in June 2011. The pathological diagnosis was malignant peritoneal mesothelioma. Thereafter, we excised recurrences of the tumor in the hepatic hilum in December 2011. Similar operations were performed in March 2012 and August 2015 because of tumors in the small bowel mesentery and the segment 8 of the liver. The pathological diagnosis was malignant peritoneal mesothelioma. It is an extremely rare variant of malignant peritoneal mesothelioma. There is no record of multiple excision of malignant peritoneal mesothelioma for recurrences. In this case, the cause of long survival was considered to be the excision of recurrent tumors.

[A Case of Long-Term Survival in a Patient with Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis Who Responded to Combined Modality Therapy].

A 59-year-old woman was diagnosed with advanced gastric cancer with para-aortic and Virchow's lymph node metastases (L, Less, type 2, tub1, cT3N2H0P0M1[LYM: #16, Virchow's]). Four courses of S-1(80mg/m / 2, days 1-21)and CDDP(60mg/ m2, day 8)were administered. After the chemotherapy, CT showed that the primary tumor and para-aortic and Virchow's lymph nodes had reduced in size. The clinical stage was ycT3N1H0P0M0, stage III A. The patient underwent distalgastrectomy, D2 dissection, and sampling of the para-aortic lymph nodes(#16b1lat, #16a2int). The pathological diagnosis was L, less, type 1, por1/2, pT2N2H0P0M0CY0, pStage III B. The patient was treated with S-1(80mg/m2, days 1-28)as adjuvant chemotherapy. After 3 courses had been administered(6 months after the resection), swelling of a para-aortic lymph node (#16b1int)was detected using CT. Based on the diagnosis of recurrence in the lymph node, weekly paclitaxel(80mg/m2, days 1, 8, and 15)was administered. After receiving 9 courses of weekly paclitaxel, the swelling of the lymph node disappeared, and the response evaluation was complete response. She discontinued the chemotherapy 5 years and 9 months after the surgery. To date, she has survived more than 6 years after surgery without recurrence. We report a long-surviving patient with advanced gastric cancer with para-aortic lymph node metastasis who received combined modality therapy.

[A Case of Advanced Gastric Cancer with Long-Term Survival Due to Successful Ramucirumab and Paclitaxel Therapy].

This is a case of a 70-year-old man. Two courses of docetaxel/cisplatin/S-1 combination therapy were administered after clinical trial registration with diagnosis of Stage Ⅳ gastric cancer(ypT3N3aM1). In June 2014, gastrectomy and splenectomy were performed. Postoperative S-1 adjuvant chemotherapy was administered; however, in September 2014, aorticl ymph node metastasis was diagnosed as recurrent. After recurrence, irinotecan/cisplatin therapy was administered. In February 2015, recurrent lymph node metastasis increased, and chemotherapy was changed to paclitaxel. In May 2015, numbness (Grade 2)of the fingers was observed, and treatment was changed to oxaliplatin/S-1. In February 2016, storage of ascites became remarkable; therefore, chemotherapy was discontinued as per policy. After that, we continued outpatient visit and observed increased recurrent lymph node metastasis on image evaluation; however, as the patient's general condition was good, chemotherapy was restarted. Ramucirumab/paclitaxel therapy started in February 2017. During the course of treatment, neutropenia(Grade 2)was observed as an adverse event, but therapy continuation was possible without loss of ramucirumab only with loss of paclitaxel. Thereafter, the recurrence of lymph node metastasis was reduced, and the ascites accumulation decreased. Until now, 1 year after the start of ramucirumab/paclitaxel therapy, the patient still visits the outpa- tient clinic.

Association between endoscopic findings related to colonic diverticula and bowel habits: A multicenter study in Japan.

BACKGROUND AND AIM: Few studies have shown the associations between colonic diverticula and endoscopic findings such as location, inflammation, number of diverticula, sigmoid colon rigidity, and bowel habits. METHODS: Japanese subjects who underwent total colonoscopies at six centers in Japan from November 2015 to October 2016 were analyzed. Bowel habits were evaluated using the Gastrointestinal Symptom Rating Scale. Location and number of diverticula, inflammation, and sigmoid colon rigidity were evaluated from endoscopy results. RESULTS: A total of 762 subjects (486 men and 276 women [ratio, 1.76:1]) whose mean age was 65.5 ± 11.4 years were evaluated. In multivariate analysis, presence of constipation was associated with a significantly lower likelihood of left-sided colonic diverticula (odds ratio = 0.40, 95% confidence interval 0.20-0.82, P = 0.012), whereas right-sided and bilateral-sided colonic diverticula, multiple colonic diverticula, inflammation findings, and sigmoid colon rigidity were not related to bowel habits. CONCLUSIONS: Among endoscopic findings related to colonic diverticula and bowel habits, only left-sided colonic diverticula were inversely associated with constipation, whereas inflammation findings, multiple diverticula, and sigmoid colon rigidity were not related to bowel habits. However, the association of inflammation findings with colonic diverticula and bowel habits should be further studied. Investigation of changes in left-sided colonic diverticula may lead to new treatments for constipation.

[Evaluation of Postoperative Complications after Gastrectomy in Elderly Patients Aged Over 80 Years].

PURPOSE: The aim of this study was to evaluate the safety and feasibility of gastrectomy in elderly patients aged over 80 years. PATIENTS AND METHODS: A total of 393 patients who underwent gastrectomy for gastric cancer were assigned to 2 groups: those aged over 80 years(n=48; elderly group)and those less than 80 years(n=345).Clinicopathological features, operative factors, post-operative complications(Clavien-Dindo Grade II or higher), and mortality were retrospectively analyzed. RESULTS: Rates of distal gastrectomy(73% vs 59%, p=0.043)and D1 or D1+dissection(73% vs 58%, p=0.046)were significantly higher in the elderly group.There were no significant differences in post-operative complication rates(23% vs 20.3%, p=0.255)or mortality rates(2.1% vs 0.6%). CONCLUSION: Our results indicate that gastrectomy in elderly patients aged over 80 years may be safe and feasible.

[Safety Evaluation of Laparoscopic-Assisted Colorectomy for Colorectal Carcinoma in Patients Older than 70 Years].

BACKGROUND: The aim of this study was to evaluate the safety of laparoscopic-assisted colorectomy(LAC)for elderly patients more than 70 years old. METHODS: The outcomes of 131 patients more than 70 years old who underwent LAC between April 2013 and March 2014 were retrospectively analyzed.Morbidity and mortality were evaluated using the Clavien-Dindo classification. RESULTS: Postoperative complications exceeding Grade II in the Clavien-Dindo classification were found in 20 patients(15.3%).No mortalities were observed in this study. CONCLUSIONS: LAC can be performed safely for elderly patients older than 70 years.

[A case of gastric cancer with liver metastases achieving a clinical complete response after S-1 plus CDDP therapy].

We report a case of gastric carcinoma with metastasis to the liver responding to surgery and chemotherapy.The patient was a 74-year-old man with gastric cancer, clinically diagnosed as P0H0M0T3N0.We initially planned to perform an open distal gastrectomy.However, intraoperative findings revealed metastatic tumors in the liver.Therefore, the patient underwent a D1 distal gastrectomy.After surgery, the patient received the following chemotherapy regimens: 1 course of S-1 and 8 courses of a S-1 and cisplatin (CDDP) combination.After 8 courses of S-1 plus CDDP treatment, liver metastases could not be detected by computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET). The patient was assessed to have a clinical complete response.Fifty months after surgery, the patient is alive without recurrence.

[Safety and feasibility of gastrectomy after neoadjuvant chemotherapy for gastric cancer].

PURPOSE: The aim of this study was to evaluate the safety and feasibility of gastrectomy after neoadjuvant chemotherapy in patients with gastric cancer. PATIENTS AND METHODS: Forty-five patients received neoadjuvant chemotherapy and curative gastrectomy between December 2002 and May 2011. Surgical complications were evaluated according to the Clavien- Dindo classification. RESULT: The median age of the patients was 63 years. Twenty-three patients received a PTX and CDDP regimen, 20 received an S-1 and CDDP regimen, 1 received an S-1 regimen, and 1 received an CPT-11 and CDDP regimen as neoadjuvant chemotherapy. Distal gastrectomy was performed in 6 patients, and total gastrectomy was performed in 39 patients. The median operation time was 268 minutes, and the median blood loss was 249.5 mL. Complications more severe than grade 2 were observed in 10 patients: anatomic bleeding( grade 3a) was observed in 2 patients; abdominal abscess( grade 2), in 1 patient; and pancreatic fistula( grade 2), in 7 patients. No surgical mortality was observed. DISCUSSION: The results of our study suggest that gastrectomy after neoadjuvant chemotherapy for the treatment of patients with gastric cancer is safe and feasible.

[Clinical significance of the human epidermal growth factor receptor 2( HER2) in patients with recurrent gastric cancer who received S-1 adjuvant chemotherapy].

PURPOSE: The aim of this study was to clarify the human epidermal growth factor receptor 2( HER2) positivity, clinicopathological characteristics, and survival of patients with recurrent HER2-positive gastric cancer who received S-1 adjuvant chemotherapy. METHODS: Thirty-eight patients with recurrent gastric cancer who underwent curative D2 surgery and received S-1 adjuvant chemotherapy between June 2002 and December 2011 were examined. HER2 positivity was determined as defined in the ToGA study. RESULTS: The positivity score was assessed by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) as follows: IHC 0 in 27 patients, IHC 1+in 4, IHC 2+/FISH-in 3, IHC 2+/FISH+in 1, and IHC 3+in 3. The HER2 positivity rate was 10.5% (4/38). HER2-positive recurrent gastric cancer was characterized by a differentiated histological feature and frequent blood vessel invasion. However, the recurrence and survival rates were not significantly different between the HER2-negative and HER2-positive tumors. CONCLUSIONS: The HER2 positivity rate after S-1 adjuvant chemotherapy did not differ significantly between patients with recurrent gastric cancer and those with primary Stage II/III gastric cancer, suggesting that S-1 adjuvant chemotherapy was equally effective, regardless of HER2 status.

[Effect of enteral nutrition enriched with eicosapentaenoic acid on body weight loss and compliance with S-1 adjuvant chemotherapy after gastric cancer surgery].

BACKGROUND: Eicosapentaenoic acid-enriched oral nutritional supplements (Prosure®; Abbott Japan, Tokyo, Japan) may attenuate surgical stress and catabolism after gastric cancer surgery. The present study aimed to evaluate the effects of Prosure® on body weight loss( BWL) and compliance with S-1 adjuvant chemotherapy after gastrectomy. PATIENTS AND METHODS: Patients who underwent curative total gastrectomy for gastric cancer were selected to undergo adjuvant S-1 chemotherapy at Kanagawa Cancer Center between December 2010 and October 2011. The patients received a normal postgastrectomy diet and two 240 mL packs of Prosure® for 21 postoperative days. BWL was defined as %BWL and calculated as %BWL=(preoperative body weight-1-month postoperative body weight)×100/preoperative body weight. Time to S-1 treatment failure was calculated. RESULTS: Five patients were enrolled in this study. The median age was 62.0 years. One patient was male, and 4 were female. The 1-month postoperative BWL was 92.1%. Compared to our previous report, a 20% risk reduction was observed in this study (Prosure® group vs control group, 92.1% vs 89.7%). Moreover, all the patients continued with the S-1 adjuvant chemotherapy for longer than 6 months. CONCLUSION: Prosure® may inhibit BWL at 1 month after gastrectomy. Moreover, Prosure® improved the patients' compliance with the adjuvant chemotherapy after gastrectomy.

[Comparison of body weight loss in gastrectomy patients who underwent only surgery and those who underwent surgery followed up with S-1 adjuvant chemotherapy].

BACKGROUND: Body weight loss is a common outcome in patients with gastric cancer who have undergone gastrectomy. However, the rate of body weight loss after surgery is unknown. METHODS: In this retrospective study, we selected patients who underwent radical gastrectomy for gastric cancer and were diagnosed with Stage II or III disease. Further, we compared the body weight loss after surgery between patients in the surgery alone group and the S-1 adjuvant chemotherapy group. RESULTS: We evaluated 163 patients, of which 81 underwent only surgery, and 82 underwent surgery followed up with S-1 adjuvant chemotherapy. The body weight loss rate at 1, 3, and 6 months in the surgery alone group were 93.1%, 92.9%, and 94.9%, while those in the S-1 adjuvant group were 92.9%, 90.4%,and 91.9%, which was a significant difference. CONCLUSIONS: Body weight loss after gastrectomy was higher in the S-1 adjuvant group than in the surgery alone group. Further, nutritional support is required for these patients to maintain body weight after surgery.

[A case of gastric small cell carcinoma with metastatic liver tumors responding to surgery and chemotherapy].

We report a case of gastric small cell carcinoma with metastatic liver tumors responding to surgery and chemotherapy. The patient was a 67-year-old man with advanced gastric cancer, clinically diagnosed as P0H1M0CY0T3N1. He was registered in a phase III trial, and was scheduled to undergo gastrectomy and S-1 plus CDDP chemotherapy after surgery. He underwent D1 total gastrectomy and Roux-en-Y reconstruction. Small cell carcinoma of the stomach was diagnosed from the histopathological findings. After surgery, he received the following chemotherapy: 13 courses of CPT-11 plus CDDP chemotherapy, 2 courses of S-1, 5 courses of paclitaxel, and 6 courses of CPT-11. The patient is alive 22 months after his operation. We conclude that the combination of surgery and chemotherapy was effective for small cell carcinoma of the stomach, which was considered to have a poor prognosis.

[Case of stage IIB gastric cancer with positive margin treated with sequential therapy consisting of S-1, chemoradiation therapy with paclitaxel and CDDP, and S-1 after surgery].

The patient was a 31-year-old man with advanced gastric cancer, clinically diagnosed as ML, Less, Type 3, sig, cT3, cN0, cH0, cP0, cM0, cCY0, cStage IIA. He underwent D2 distal gastrectomy. On microscopic examination, tumor cells were detected in the distal margin of the resected stomach. After surgery, he received 1 course of S-1 followed by chemoradiation therapy(1.8 Gy×25, a total of 45 Gy) with 90 mg/m2 of paclitaxel and 40 mg/m2 of CDDP on days 1, 15, and 29 over 5 weeks. Subsequently, he received 5 cycles of S-1 chemotherapy. To date, no recurrence has been observed 5 years after surgery. This sequential therapy is an option to consider for enabling local and systemic control after gastric cancer surgery.

[Postoperative anastomotic hemorrhage after gastrectomy].

BACKGROUND: Postoperative anastomotic hemorrhage is a relatively rare complication. However, when it does occur, immediate treatment is needed. METHODS: In all, 1,700 patients underwent curative gastrectomy between 2000 and 2010. Anastomotic hemorrhage was observed in 9 patients after surgery. The clinical course of these 9 patients was analyzed. RESULTS: The median age of the patients was 62 years, and all patients were men. Two patients underwent distal gastrectomy, 1 underwent laparoscopic distal gastrectomy, and 6 underwent total gastrectomy. Bleeding occurred as follows: 5 were at gastro- or esophagojejunostomic site, 2 were at gastroduodenostomic site, and 2 were at jejunojejunostomic site. Five patients received conservative treatment and 2 underwent re-operation. Two additional patients achieved complete hemostasis with endoscopic treatment. The patients who received endoscopic treatment were discharged earlier than those who received other treatments. CONCLUSIONS: Endoscopic intervention was useful for the diagnosis and treatment of postoperative anastomotic hemorrhage.