[A Case of Sigmoid Colon Cancer with Horseshoe Kidney].

We reported a case of sigmoid colon cancer with horseshoe kidney. A 79-year-old man had lower abdominal pain and underwent colonoscopy. The results of colonoscopy revealed sigmoid cancer. Preoperative computed tomography revealed horseshoe kidney. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅱa(The 9th Edition). He has not recurred 22 months later after operation. Surgery for colorectal cancer with congenital anomalies of the urinary tract requires attention to intraoperative secondary injuries. Therefore, preoperative evaluation using 3D-CT is useful tool for safety. Operating the proper dissecting normal layer would make safe laparoscopic operation possible without unexpected injuries.

[A Case of Appendiceal Metastasis from Hilar Cholangiocarcinoma with Acute Perforated Appendicitis and Cholecystitis].

An 88-year-old woman had been diagnosed with hilar cholangiocarcinoma for 3 years since she received metallic stents for malignant biliary obstruction, and observed without any aggressive medical treatment. She was admitted to our hospital for further investigation of her abdominal pain. Abdominal CT showed an enlarged gallbladder, fluid collection in the right paracolic gutter, and swollen appendix. Laboratory tests showed high-grade inflammation. She was diagnosed with acute perforated appendicitis with acute cholecystitis. Laparoscopic cholecystectomy and appendectomy were performed. Perforation was confirmed intraoperatively in the appendix wall and accumulation of pus was found in the right paracolic gutter. There were no macroscopic findings of metastasis and peritoneal dissemination. Microscopic examination of the resected appendix showed adenocarcinoma cells positive for CK7 and negative for CK20 and CDX2, and were predominantly infiltrated from the muscular layer to the serosa of the appendix wall, with a diagnosis of appendiceal metastasis from hilar cholangiocarcinoma. Metastatic appendiceal carcinoma is rare, and appendiceal metastasis from hilar cholangiocarcinoma is extremely rare. Herein, we report a rare case of metastatic appendiceal carcinoma from hilar bile duct cancer with acute perforated appendicitis and cholecystitis along with findings of previous literature.

[A Case of Resected Type 4 Rectal Cancer with Difficulty in Preoperative Diagnosis].

We reported a case of Type 4 rectal cancer performed laparoscopic surgery. A 73-year-old man had diarrhea and constipation and underwent colonoscopy. From the first colonoscopy, histological findings of biopsy showed non-neoplastic cells. The results of colonoscopy strongly suggested the possibility of Type 4 rectal cancer. Therefore, we performed colonoscopy twice and he was diagnosed Type 4 rectal cancer. Computed tomography revealed no distant metastasis. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅲc(The 9th edition). He then received adjuvant chemotherapy but was relapsed at bones and lymph nodes. He died 18 months later after surgery.

[A Case of Rectal Cancer with Protein-Losing Gastroenteropathy].

We report a case receiving laparoscopic surgical resection of rectal cancer with protein-losing gastroenteropathy. A 58- year-old man was referred to our hospital because of melena, diarrhea, and anorexia. He showed septic shock, anemia, and hypoproteinemia. CT scan showed a rectal tumor with regional lymph node swelling and a cavernous lung lesion with a pulmonary embolus. Ninety-five days after admission to intensive care, he was introduced to our department because of the disappearance of a lung lesion indicating a lung abscess. Colonoscopy showed a cauliflower-like type 1 rectal cancer lesion. He experienced laparoscopic low anterior resection 121 days after admission. He was discharged without problems 66 days after the operation. After 8 months of surgery and no chemotherapy, he had no recurrence of rectal cancer. Colon cancer with protein-losing gastroenteropathy is rare and shows a typical cauliflower-like type 1 tumor appearance. Hypoproteinemia can be improved after resection of colon cancer.

[A Case of Rectal GIST Resected using the TAMIS Method].

We reported a case of rectal gastrointestinal stromal tumor(GIST)performed transanal surgery. A 46-year-old woman was pointed out uterinal cancer and lower rectal GIST. After operation for uterine cancer, GIST was treated. Because of the patent's opinion for anal preservation, chemotherapy with imatinib for 3 months was performed and local resection was done by transanal minimally invasive surgery(TAMIS). The histopathological diagnosis was low-grade GIST and immunostaining showed the tumor was positive for c-kit, CD34, DOG-1 and α-SMA. Because capsule of the GIST was damaged intraoperatively, imatinib therapy was started and she has no recurrence after 2 years.

[A Case of Superior Mesenteric Artery Syndrome Following Transverse Colon Cancer Surgery].

We reported a case of superior mesenteric artery(SMA)syndrome after decreased body weight and unstable oral intakes due to anastomotic leakage of postoperative transverse colon cancer. A 63-year-old man underwent laparoscopic left hemicolectomy and D3 lymph node dissection with a diagnosis of transverse colon cancer. He had postoperative anastomotic leakage and was discharged after conservative treatment on postoperative day 35. However, he had visited our hospital by the symptom of bowel obstruction caused by anastomotic stenosis and had been admitted twice. After second colonoscopic balloon dilation on postoperative day 129, he was diagnosed as anastomotic perforation and emergency reoperation was performed. In the postoperative course, he repeated vomiting and his body weight decreased and superior mesenteric artery syndrome was diagnosed. He improved after conservative treatment by fasting, a nasogastric intubation and total parenteral nutrition and was discharged 22 days after the diagnosis.

[A Case of Laparoscopic Surgery for Sigmoid Lymph Node Metastases after Surgery for Rectal Cancer].

Herein, we report a case of laparoscopic surgery for sigmoid lymph node metastases after surgery for rectal cancer. A 58- year-old man underwent laparoscopic surgery for rectal cancer. He underwent D2 lymph node dissection, and he was undergoing dialysis for renal disease as a complication of diabetes. CT imaging performed 15 months after surgery revealed recurrence of tumors in the sigmoid lymph nodes. Subsequently, laparoscopic removal of the sigmoid lymph nodes was planned, as the patient had no tumor recurrence at any other location, and because his condition was not suitable for chemotherapy. The postoperative course was uneventful, and the patient was discharged a few days after surgery.

[A Case of Small Intestinal Cancer Resected by Laparoscopic Surgery].

We report a case of laparoscopic surgical resection of a small intestinal cancer. A woman in her 40s was referred to our department for prolonged abdominal problems(epigastralgia, nausea, diarrhea, and constipation). CT scan revealed a small intestinal tumor with dilatation of the oral side of the intestine. She was admitted to our hospital, and an ileus tube was introduced. One week after admission, she experienced laparoscopic partial resection of the small intestine. She was soon discharged without any problems and has had no recurrence of small intestinal cancer after 8 months of surgery without any adjuvant chemotherapy. Small intestinal cancer is frequently detected in an advanced stage, resulting in poor prognosis, but curative surgery can improve the prognosis. Optimal therapy for small intestinal cancer has not been established yet because it is rare. A multi-centered study of small intestinal cancer for the establishment of its diagnosis and therapy needs to be conducted.

The prevalence of calcification around odontoid process and the incidence of crowned dens syndrome in the neurosurgical ward: A single institution's analysis.

OBJECTIVE: The objective of this study is to assess the prevalence and natural history of odontoid calcification and to identify factors related to its progression to crowned dens syndrome (CDS). METHODS: We reviewed a consecutive series of patients who underwent head CT upon admission to the neurosurgical ward of Niigata Prefectural Shibata Hospital. We evaluated the relationship between the presence of odontoid calcification and the patient's age, sex, and primary disorder for admission. The incidence of CDS was also determined, and factors related to the progression of odontoid calcification to CDS were analyzed. RESULTS: Odontoid calcifications were found in 88 out of 554 patients (15.9%) undergoing CT scans. Age, female, and stroke were predictive of odontoid calcification. The odds ratios (95% CIs) for age, female, and stroke estimated from the logistic analysis were 1.084 (1.054-1.114; p < .0001), 1.746 (1.06-2.875; p = .029), and 1.909 (1.123-3.247; p = .017), respectively. Eleven (12.5%) of the 88 patients with odontoid calcification developed CDS. The age, sex, and primary disorder for admission were not associated with the onset of CDS. CONCLUSIONS: Odontoid calcification is observed incidentally on head CT. Clinicians should keep in mind that patients with odontoid calcification might develop CDS, even if they are asymptomatic at the time of CT examination.

[Long-term Results Regarding the Instability of Decompressive Surgery without Fusion for Degenerative Spondylolisthesis].

PURPOSE: The long-term results of decompressive surgery for degenerative spondylolisthesis (DS) were evaluated with reference to instability. MATERIALS AND METHODS: Patients (n=48) undergoing decompressive surgery without fusion were studied. The diagnosis of spondylolisthesis was made based on the presence of sagittal vertebral slippage greater than 3mm. Instability was defined as translation more than 2mm on lateral functional radiography. Surgical interventions were divided into two groups: bilateral laminotomy (n=25)and laminectomy (n=23). Clinical results were evaluated according to the McCulloch's classification and Japanese Orthopedic Association(JOA)score. RESULTS: Of 48 patients, 25 showed preoperative instability. Eleven patients showed both pre-and postoperative instability. The mean pre-and postoperative slippages were 7.5 and 7.6mm, respectively. Of 23 patients without preoperative instability, nine developed postoperative instability. In this group, slippage changed from 6.2 to 6.1mm. Instability was not related to slippage progression. Surgical results of patients undergoing laminotomy were superior to those undergoing laminectomy. The mean pre-and postoperative JOA scores and recovery rate were 14.5, 20.9, and 63.1 in instability group patients with laminotomy and 15.6, 23.2, and 59.0 in the non-instability group, respectively. Surgical results were similar and not related to preoperative instability. Low back pain (LBP) showed no correlation to the degree of slippage, instability, and surgery type. LBP improved in each group. CONCLUSIONS: Instability, defined by vertebral translation on lateral functional radiography, did not affect the surgical results of patients with DS treated with laminotomy.

[A Case of Small Bowel Cancer Treated with Laparoscopic Surgery].

We report a case of small intestinal adenocarcinoma treated with laparoscopic surgery. A 70-year-old woman had abdominal pain and epigastralgia. There were no abnormal findings on upper and lower endoscopy. The symptoms continued for 4 months after endoscopy, so she presented to our hospital. After CT examination, small bowel cancer with ileus was suspected. An ileus tube was inserted to relieve the bowel pressure and she was diagnosed with ileum cancer by enteroscopy. Laparoscopic surgery was performed and the pathological stage was determined as pStage Ⅲa. She was treated with oral chemotherapy (UFT plus LV) and had no recurrence 6 months after surgery.

[Usefulness of Metallic Stent for Left-Sided Obstructive Colon Cancer].

The aim of this study was to compare the efficacy of self-expandable metallic stent (SEMS) and transanal tube as preoperative treatments for left-sided obstructive colon cancer. Forty-three patients (the SEMS group: 28 cases, the tube group: 15 cases) were included in this study. Clinicopathological data (age, sex, tumor location, depth, histological type, stage) were comparable between the 2 groups. In addition, there was no difference in intestinal decompression rate between the SEMS group and the tube group (technical success rate: 100% vs 86.7%, clinical success rate: 92.8% vs 73.3%, complication rate: 7.1% vs 0%). A significantly higher number of patients in the SEMS group underwent laparoscopic surgery because of difference of historical background. However, no significant difference was observed between the 2 groups in postoperative outcome(complication rate, hospital stay duration). SEMS insertion had several benefits compared to transanal tube placement, such as the resumption of oral intake because of rapid resolution of obstruction and easier management because SEMSs do not require washing. SEMS insertion could be a safe and effective bridge to subsequent surgery in patients with left-sided obstructive colon cancer.

[A Case of Radical Resection of Rectal Cancer with Multiple Liver and Lung Metastases after Preoperative Chemotherapy].

We report a case of radical resection of rectal cancer with multiple liver and lung metastases after preoperative chemotherapy. A 54-year-old woman presented with abdominal pain and loss of body weight due to rectal cancer with multiple liver and lung metastases. Therefore, the patient received 14 courses of bevacizumab+mFOLFOX6, and 7 courses of panitumumab+FOLFIRI. After the chemotherapy, the size of the distant metastases reduced by 62% on computed tomography, according to RECIST. Due to the reduction in size, a conversion surgery was attempted. First, an abdominal operation with laparoscopy was performed, and 2 months later an operation to resect the lung metastases via thoracoscopy was performed. Currently, 3 months after surgery, the patient is alive, without recurrence.

[A Case of Locally Advanced Rectal Cancer Successfully Treated by Conversion Surgery after Multidisciplinary Treatment].

A 70-year-old woman who complained of abdominal pain and a prolapsed tumor from the anus was diagnosed with an intestinal obstruction resulting from anal canal cancer. Computed tomography (CT) and magnetic resonance imaging revealed a huge tumor (11×5×12 cm) invading the vagina and levator ani muscle. Enlarged inguinal lymph nodes on both sides indicated metastasis. The clinical stage was T4b (vagina, levator ani muscle, and pudenda) N0H0M1a (LYM), stage IV (Japanese Classification of Colorectal Carcinoma: 8th edition). As curative resection was not possible, a transvers colostomy was performed to relieve the intestinal obstruction. This was followed by chemoradiotherapy (45 Gy/1.8 Gy×25; TS-1, 80 mg/body for 2 weeks and a 1-week interval, for 2 courses) and up to 10 courses of Bev+mFOLFOX6 continuously. After this regimen, there was a remarkable reduction in tumor size. Positron emission tomography-CT revealed no FDG uptake in the primary rectal site or inguinal lymph nodes, but a maximum standardized uptake value (SUVmax) of 6.3 was detected in the vagina. Six weeks after chemotherapy, the patient underwent a pelvic exenteration including resection of the vagina, bladder, and pudenda. The pathological stage was yp T4b (vagina) N0H0M0, stageⅡ. Curative resection was performed, and the patient had a Grade 2 pathological response after chemoradiotherapy.

[Long-term results of decompressive surgery without fusion for degenerative spondylolisthesis].

PURPOSE: The long-term results of decompressive surgery for degenerative spondylolisthesis with symptomatic lumbar spinal stenosis were evaluated retrospectively with regard to the postoperative progression of slippage and clinical symptoms. MATERIALS AND METHODS: The study included 53 patients who underwent surgery, and for whom follow-up of at least 5 years was conducted. Spondylolisthesis was diagnosed based on the presence of sagittal vertebral translation greater than 3mm on lateral radiographs. The patients were divided into two groups:Group I:37 patients undergoing bilateral laminotomy, and Group II:16 patients undergoing laminectomy. The clinical results were evaluated according to McCulloch's classification and the Japanese Orthopaedic Association(JOA)score. RESULTS: The mean pre-and postoperative JOA scores were 14.6 and 22.9 in Group I and 14.7 and 21.0 in Group II, respectively. The JOA scores improved soon after surgery, after which the scores declined gradually in both groups. The recovery rate was 63.0% in Group I and 43.7% in Group II. The average amount of pre- and postoperative slippage was 7.3mm and 6.9mm in Group I and 6.2mm and 6.9mm in Group II, respectively. In Group I, the slippage progressed within the first year, after which the degree of slippage slowly decreased to lower values than those observed preoperatively, whereas slippage progressed for 5 years before declining in Group II. No correlations were observed between progression of slippage and clinical outcomes in either group. CONCLUSIONS: Laminotomy produces satisfactory long-term results both clinically and radiographically in patients with degenerative spondylolisthesis.

[A case of advanced gastric cancer with liver metastasis involving curative surgery after neoadjuvant chemotherapy].

A 77-year-old-woman, whose chief complaint was anemia, was referred to our hospital and diagnosed with advanced gastric cancer with liver metastasis and lymph node metastasis.Gastrointestinal endoscopy showed a tumor on the lesser curvature of the gastric corpus.Histologically, biopsy specimens indicated adenocarcinoma with genetic amplification of human epidermal growth factor receptor type 2.Computed tomography and magnetic resonance imaging showed lymph node metastasis and liver metastasis.The patient received a total gastrectomy and a partial liver resection after combination chemotherapy consisting of capecitabine, cisplatin, and trastuzumab.Histopathological examination of a resected specimen showed a minute residual cancer nest at the subserosa of the stomach and lymph node metastasis, but no liver metastasis. This combined modality therapy can be considered an effective treatment for gastric cancer with liver metastasis, and we hope that it will be established as a standard therapy.

[Transcranial motor evoked potentials monitoring for cerebral aneurysm surgery].

OBJECTIVE: To evaluate the usefulness of transcranial motor evoked potential(MEP)monitoring for aneurysm surgery. METHODS: Sixty-four patients undergoing aneurysm surgery were included in the study. We recorded MEP responses at craniotomy, when dissecting the aneurysm and surrounding tissue, after clipping, and during temporary clipping of the parent artery. We examined the relations between MEP wave pattern change and postoperative motor function. RESULTS: In all of the patients MEPs were recordable for continuous neurophysiological monitoring of the vascular territory of interest throughout the surgery. In 16 patients, significant intraoperative MEP changes occurred. Of these patients, three patients presented with postoperative transient motor deficit. From the changes in MEP wave recording after aneurismal clipping and temporary occlusion of the parent artery. We speculated that the maximal time allowed for occlusion of the perforating arteries without ischemic damage is five minutes. Intraoperative MEP changes had a sensitivity of 100%(3/3)and specificity of 78.7%(48/61). The positive predictive value of postoperative motor deficit was 18.8%(3/16), and the negative predictive value was 100%(48/48). It was important to carry out MEP monitoring, so as not to produce false-negatives. CONCLUSIONS: Intraoperative transcranial MEP monitoring is useful for predicting motor function after aneurysm surgery.

[Case of advanced colon cancer after colostomy closure].

We report a case of advanced colon cancer after closure of a colostomy. A 77-year-old man suddenly began experiencing abdominal pain and pan-peritonitis due to perforate diverticulum of the sigmoid colon. A Hartmann operation was urgently performed, and closure of the colostomy was performed 6 months later. The patient had no history of colonoscopy. Colonoscopy was performed 45 months after the closure of the colostomy to examine the colon. Advanced colon cancer was detected near the anastomotic region. In conclusion, older patients, including those with numerous disease complications such as diabetes and hypertension, should undergo early colonoscopy as a preventative measure.

A study of patients whose mode of food intake changed during long-term bedside care.

Hatakeyama M, Shirahase M, Suzuki S, Morita K, Yamashita S. A study of patients whose mode of food intake changed during long-term bedside care. Jpn J Compr Rehabil Sci 2023; 14: 60-68. Objective: The objective of this study was to determine the characteristics of patients who exhibited changes in their food intake level (as determined by the Food Intake Level Scale [FILS] score) while hospitalized for long-term bedside care. Methods: The subjects were 264 patients hospitalized for long-term bedside care. The FILS was used to assess the subjects' mode of food intake on the admission and survey dates. The FILS score was used to divide the patients into three stages: no oral intake, combined oral intake and alternative nutrition, and exclusively oral intake; the patients whose FILS stage on the survey date was different from that on the admission date were examined to determine whether there were any characteristic tendencies with regard to their age, sex, length of hospital stay, level of long-term care needed, primary illness, and dysphagia rehabilitation. Results: Overall, 6.8%, 9.8%, and 4.5% of the subjects showed improvement in the FILS stage, experienced deterioration of the FILS stage, and transitioned to exclusively oral intake, respectively. Further, 33.3% of the improved-FILS stage group were in their ≥90s. The results of the exact binomial test with the entire study cohort as the population proportion showed that there were significantly more females in the improved-FILS group. In addition, 83.3% of those who improved from no oral intake to exclusively oral intake had cerebrovascular disease. No difference in the length of hospital stay and level of long-term care needed was observed in either the improved-FILS or deteriorated-FILS group in comparison to their proportions in the entire study cohort. In the entire study cohort, a greater proportion of the subjects in the improved-FILS group underwent indirect or direct swallowing training than those in the deteriorated-FILS group; the improved-FILS group had no subjects who were assigned to watchful waiting. Conclusion: Most patients who exhibited marked positive changes in their mode of food intake were females or patients with cerebrovascular disease. However, no characteristic attributes were observed among those whose FILS stage deteriorated.

School-Based Stroke Education Through On-Demand E-learning During Coronavirus Disease 2019 Pandemic: Itoigawa Stroke Awareness Campaign.

Introduction Raising stroke awareness is important to shorten the interval from onset to consultation. We performed a school-based stroke education by on-demand e-learning during the coronavirus disease 2019 pandemic. Methods We performed on-demand e-learning and distributed the online- and paper-based manga about stroke for students and parental guardians in August 2021. We carried out this in a manner similar to the prior effective online stroke awareness initiatives in Japan. An online post-educational survey in October 2021 was conducted to evaluate the awareness effects by asking participants about their knowledge. We also investigated the modified Rankin Scale (mRS) at the discharge of stroke patients who were treated in our hospital during the before- and after-campaign periods, respectively. Results We distributed the paper-based manga and asked to work on this campaign to all 2,429 students (1,545 elementary school and 884 junior high school students) who lived in Itoigawa. We acquired 261 (10.7%) online responses from the students and 211 (8.7%) responses from their parental guardians. The number of students who chose all correct answers in the survey significantly increased after the campaign (205/261, 78.5%) compared to that before the campaign (135/261, 51.7%) and those of parental guardians showed similar trends (before campaign 93/211, 44.1%; after campaign 198/211, 93.8%). We investigated 282 stroke patients (90 patients before and 192 patients after-campaign period), and their mRS at discharge after-campaign seemed to be improved. Conclusion Only 10.7% of students and 8.7% of the parental guardians worked on the online survey. However, the number of those who chose correct answers about stroke increased after the campaign. After this campaign, the mRS of stroke patients at discharge improved although it was unclear if this is a direct result of this activity.