Laparoscopic-Assisted Resection for an Extra-gastrointestinal Stromal Tumor Arising From the Mesentery of the Small Intestine: A Case Report.

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that arise in the muscular or submucosal layers of the gastrointestinal tract. Extra-gastrointestinal stromal tumors (EGISTs) are rare primary entities that develop outside the digestive tract which are histologically and immunologically similar to GISTs. We present the case of a 52-year-old female diagnosed with a primary EGIST arising in the small bowel mesentery four months after undergoing hormone therapy for multiple uterine myomas. Transvaginal ultrasonography and MRI revealed a pelvic mass suspected to be a GIST. The patient was treated with laparoscopic-assisted partial resection of the small bowel. Histopathological examination of the surgical specimen confirmed the diagnosis of an EGIST. Imatinib treatment was initiated, and no clinical evidence of recurrence or metastasis was detected postoperatively. Because EGISTs are extremely rare, the differences between EGISTs and GISTs, the degree of malignancy, and prognosis have not been fully investigated. Further studies are needed to accumulate additional cases. The present case shows that laparoscopic-assisted excision can be successfully used to manage EGISTs.

Risk factors for remnant gastric cancer after distal gastrectomy for gastric cancer: a retrospective database review.

Background: The number of patients with remnant gastric cancer (RGC) following gastrectomy for gastric cancer (GC) is increasing due to the increasing number of patients undergoing function-preserving gastrectomy and improved outcomes for patients with GC. A few studies involving a small number of cases reported male sex, old age, differentiated type, tumor depth and synchronous multiple GC were associated with RGC development. However, the risk factors for RGC development had not been fully understood. This study aimed to examine the clinicopathological features, followed up patients with GC after they underwent distal gastrectomy (DG), and evaluated the potential risk factors for RGC development. Methods: A retrospective database review of 438 patients who underwent DG for GC at a single institution, from 2006 to 2017, was conducted. We investigated the relationship of clinicopathological features, operative findings, and postoperative course with RGC development was estimated using Cox proportional hazard analysis. The cumulative incidences of RGC were calculated using the Kaplan-Meier method. Results: We retrospectively analyzed 405 cases. The median patient age was 69 years, and the patient cohort consisted of 263 men and 142 women. The Billroth-I reconstruction method was used in 204 cases, Billroth-II method was used in 3 cases, and Roux-en Y method was used in 198 cases. RGC was diagnosed in 11 of the 405 patients. The median follow-up period was 5 years. The cumulative incidences of RGC calculated by the Kaplan-Meier method were 3.0%, 4.1%, and 10.5% at 5, 10, and 15 years after DG, respectively. During the initial surgery, differentiated type was significantly associated with RGC development [hazard ratio (HR): 4.71, 95% confidence interval (CI): 1.02-21.80, P=0.05]. Male sex (HR: 2.97, 95% CI: 0.64-13.75, P=0.16), old age (≥70 years) (HR: 2.72, 95% CI: 0.78-9.47, P=0.11), and synchronous multiple GC (HR: 1.31, 95% CI: 0.28-6.08, P=0.73) were not associated with RGC development. Conclusions: Patients who have undergone DG for differentiated type GC were statistically significantly associated with developing RGC. Intensive endoscopic surveillance would be needed for the patients who underwent DG for differentiated type GC.

Cecal cancer with essential thrombocythemia treated by laparoscopic ileocecal resection: a case report.

BACKGROUND: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by thrombocytosis and a propensity for both thrombotic and hemorrhagic events. ET rarely occurs simultaneously with colorectal cancer. Here, we report a case of colorectal cancer in an ET patient treated using laparoscopic ileocecal resection. CASE PRESENTATION: A 40-year-old woman was admitted to our hospital after presenting with liver dysfunction. She had been previously diagnosed with ET; aspirin and anagrelide had been prescribed. Subsequent examination at our hospital revealed cecal cancer. Distant metastasis was absent; laparoscopic ileocecal resection was performed. Anagrelide was discontinued only on the surgery day. She was discharged on the seventh postoperative day without thrombosis or hemorrhage. However, when capecitabine and oxaliplatin were administered as adjuvant chemotherapy with continued anagrelide administration, she experienced hepatic dysfunction and thrombocytopenia; thus, anagrelide was discontinued. Five days later, her platelet count recovered. Subsequently, anagrelide and aspirin administration was resumed, without any adjuvant chemotherapy. Her liver function normalized gradually in 4 months. One-year post operation, she is well without tumor recurrence or new metastasis. CONCLUSIONS: To our knowledge, this is the first report of laparoscopic colectomy performed on an ET patient receiving anagrelide. Our report shows that complications such as bleeding or thrombosis can be avoided by anagrelide administration. Contrastingly, thrombocytopenia due to anagrelide intake should be considered when chemotherapy that could cause bone marrow suppression is administered.

Modified enhanced recovery after surgery (ERAS) protocols for patients with obstructive colorectal cancer.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are now well-known to be useful for elective colorectal surgery, as they result in shorter hospital stays without adversely affecting morbidity. However, the efficacy and safety of ERAS protocols for patients with obstructive colorectal cancer have yet to be clarified. METHODS: We evaluated 122 consecutive resections for obstructive colorectal cancer performed between July 2008 and November 2012 at Tokyo Metropolitan Bokutoh Hospital. Patients with rupture or impending rupture and those who received simple colostomy were excluded. The first set of 42 patients was treated based on traditional protocols, and the latter 80 according to modified ERAS protocols. The main endpoints were length of postoperative hospital stay, postoperative short-term morbidity, rate of readmission within 30 days, and mortality. Differences in modified ERAS protocols relative to traditional care include intensive preoperative counseling (by both surgeons and anesthesiologists), perioperative fluid management (avoidance of sodium/fluid overload), shortening of postoperative fasting period and early provision of oral nutrition, intraoperative warm air body heating, enforced postoperative mobilization, stimulation of gut motility, early removal of urinary catheter, and a multidisciplinary team approach to care. RESULTS: Median (interquartile range) postoperative hospital stay was 10 (10-14.25) days in the traditional group, and seven (7-8.75) days in the ERAS group, showing a 3-day reduction in hospital stay (p < 0.01). According to the Clavien-Dindo classification, overall incidences of grade 2 or higher postoperative complications for the traditional and ERAS groups were 15 and 10% (p = 0.48), and 30-day readmission rates were 0 and 1.3% (p = 1.00), respectively. As for mortality, one patient in the traditional group died and none in the ERAS group (p = 0.34). CONCLUSION: Modified ERAS protocols for obstructive colorectal cancer reduced hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible for patients with obstructive colorectal cancer.

[A Case of Solitary Metastasis to the Small Intestine from Sigmoid Colon Cancer after Treatment of Seven Multiple Cancers].

A 75-year-old woman who had undergone a Hartmann's operation for sigmoid colon cancer 2 years ago was hospitalized because she experienced small bowel obstruction several times. She had a treatment history of 6 other cancers, including 5 gastrointestinal tract cancers. However, the obstruction was relieved by conservative therapy each time. In September 2015, she was hospitalized for ileus. Abdominal computed tomography revealed that the lumen of intestine was partially dilated. Subsequently, a long tube was inserted, but the dilatation of the small intestine was not fully recovered. She was diagnosed with small intestinal obstruction due to adhesion, and she underwent an operation in October 2015. During the laparotomy, she was diagnosed with adhesion due to an intestinal tumor, and a partial intestinal resection, including the entire tumor, was performed. Because the tumor appearance and histological findings were very similar to those of sigmoid colon cancer, the tumor was diagnosed as a solitary metastasis of sigmoid colon cancer to the small intestine. Generally, peritoneal dissemination causes metastasis of colon cancer to the small intestine. However, this is a rare case because the lymphatic system or extra-wall invasion was the most likely cause of metastasis. Ileus repeating the improvement exacerbation, an examination must be performed while considering possible intestinal tumors, especially for a patient previously treated for multiple gastrointestinal cancers.

Enhanced recovery after surgery (ERAS) protocols for colorectal cancer in Japan.

BACKGROUND: Japan has one of the highest five-year relative survival rates for colorectal cancer in the world, with its own traditions of perioperative care and a unique insurance system. The benefits of enhanced recovery after surgery (ERAS) protocols in the Japanese population have yet to be clarified. METHODS: We evaluated 352 consecutive cases of colorectal cancer resection at Tokyo Metropolitan Bokutoh Hospital between July 2009 and November 2012. Of these, 95 cases were performed according to traditional protocols (traditional group), and 257 according to ERAS protocols (ERAS group), which were introduced to the hospital in July 2010. Primary endpoints included length of postoperative hospital stay, postoperative short-term morbidity, and rate of readmission within 30 days. Intensive pre-admission counselling, no pre- and postoperative fasting (provision of oral nutrition), avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of ERAS protocols. RESULTS: The median (interquartile range) length of postoperative hospital stay was 10 (10-12.75) days in the traditional group and seven (6-8) days in the ERAS group, i.e., a three-day reduction (p < 0.05) in the ERAS group. Moreover, the proportion of patients discharged within one week dramatically increased from 1 % to 77 % in the ERAS group. The overall incidence of grade 2 and 3 postoperative complications according to the Clavien-Dindo classification was 9.5 % in the traditional group and 9.3 % in the ERAS group, and 30-day readmission rates were 8.3 % and 6.6 % in the traditional and ERAS groups, respectively. There were no significant differences between the two groups. Although operative time and blood loss did not differ significantly between the two groups, the volume of intraoperative infusion was significantly decreased in the ERAS group (p < 0.05), possibly due to ERAS recommendations to avoid dehydration (i.e., avoidance of sodium/fluid overload, no preoperative fasting). CONCLUSION: ERAS protocols for colorectal surgery helped reduce the length of postoperative hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible and effective in Japanese settings as well.

[Mixed adenoneuroendocrine carcinoma with multiple liver metastases successfully treated by cetuximab/CPT-11 chemotherapy followed by curative resection - a case report].

A 73-year-old man underwent laparoscopy-assisted partial resection of the rectum to treat rectal cancer diagnosed in September 2011 at a previous hospital. Lymph node dissection was not performed and the vertical margin was positive. When multiple liver tumors were detected 10 months later, the patient was referred to our hospital. A computed tomography (CT) scan revealed local recurrence of the rectal cancer, lymph node metastasis, and 9 liver metastases, which had a maximum diameter of 10 cm, and where curative resection would have been difficult. The rectal cancer expressed epidermal growth factor receptor (EGFR) and wild type K-ras gene, and we initiated cetuximab/irinotecan (CPT-11) chemotherapy. After 2 courses of chemotherapy, the liver tumors had markedly decreased in size and anterior resection of the rectum with regional lymph node dissection was performed. The pathological diagnosis of the rectal tumor was mixed adenoneuroendocrine carcinoma ( MANEC). Extended right hepatectomy was performed four months later. The liver tumors were also diagnosed as metastases of MANEC of the rectum. The therapeutic efficacy of chemotherapy was assessed as Grade 1b. The patient is alive without recurrence 34 months since the initial rectal surgery and 15 months after the liver resection. Thus, an anti-EGFR antibody agent might be effective against MANEC of the colon and rectum.

[Third-line therapy in a patient with recurrent colon cancer undergoing hemodialysis].

A 68-year-old man undergoing hemodialysis (HD) was diagnosed with recurrence of colon cancer and liver metastasis. He was treated with oxaliplatin, folinic acid and 5-fluorouracil (FOLFOX4), folinic acid, 5-fluorouracil and irinotecan (FOLFIRI), FOLFIRI+bevacizumab (BV), and cetuximab+irinotecan (CPT-11) as third-line therapy. Each drug was adequately reduced over time, but cetuximab was administered at the standard dose. The patient died of methicillin-resistant Staphylococcus aureus (MRSA) meningitis during the course of cetuximab+CPT-11 therapy, but there was no relation between the meningitis and the therapy. Therefore, each regimen can be safely performed, and cetuximab+CPT-11 therapy showed a significant anti-tumor effect and hence may be an effective regimen.

Metachronous colonic metastasis from pancreatic cancer seven years post-pancreatoduodenectomy.

Colonic metastasis from other organs is very rare. Here we report the case of a 62-year-old man with a history of pancreatoduodenectomy for stage IIB pancreatic head cancer performed seven years back. He presented with abdominal distension and pain. Under the preoperative diagnosis of bowel obstruction, surgical treatment was performed, and a circumferential lesion causing bowel obstruction of the ascending colon was detected. A right hemicolectomy with lymph node dissection was performed. The specimen showed a 5-cm wall thickening with a cobble-stone like appearance of the ascending colon, which morphologically appeared scirrhous. Histological examination revealed cancer nests invading from the subserosa to the muscular and submucosal layers of the colon. Immunohistochemical analysis of the tumor cells demonstrated positive staining for cytokeratin 7, but negative for cytokeratin 20, which was the same as the previous pancreatic cancer specimen. These pathological and immunohistochemical features strongly supported the diagnosis of colonic metastasis from the pancreas. Thereafter, the patient received systemic chemotherapy, but unfortunately, he died 14 mo after the surgery.

Anastomotic Recurrence of Sigmoid Colon Cancer over Five Years after Surgery.

The incidence of anastomotic recurrence after curative resection of colorectal cancer is relatively low compared to that of other types of recurrence, such as hepatic, lung and local recurrence. However, almost all cases of anastomotic recurrence of colorectal cancer occur within 3 years after surgery. We experienced a rare case of anastomotic recurrence in whom colonoscopy revealed no signs of recurrence 3 years after surgery; however, anastomotic recurrence was detected over 5 years after surgery. A 60-year-old female with a history of surgery for cancer of the cecum in her forties underwent sigmoidectomy and right colectomy with D3 lymph node dissection for both stage IIA sigmoid colon cancer and stage IIA transverse colon cancer. Computed tomography and colonoscopy revealed no signs of recurrence 3 years after surgery; however, 5 years and 4 months after surgery, colonoscopy demonstrated surrounding flaring and swelling in the anastomotic area of the sigmoid colon, and a biopsy revealed an adenocarcinoma. Under the diagnosis of anastomotic recurrence over 5 years after surgery, lower anterior resection was performed. The patient has exhibited no other signs of recurrence in the 2 years since the last operation.

[Treatment strategy for patients with multiple liver metastases of colorectal origin in the era of adjuvant chemotherapy].

A treatment strategy that includes adjuvant chemotherapy needs to be developed for the treatment of patients with multiple liver metastases of colorectal origin. Of the 91 patients who underwent initial hepatic resection for colorectal liver metastases, we reviewed the clinical courses of 10 patients who had 7 or more metastatic liver nodules. Twenty-one, 19, 17, and 9 metastases were initially resected in each of the 4 patients, and 7 metastases were resected in each of the remaining 6 patients. Portal vein embolization was performed in 3 patients, 2 of whom underwent two-stage hepatectomy. Adjuvant chemotherapy was administered to all the 10 patients. Recurrence was detected in all the 10 patients; however, in 6 of these patients, liver was the only site of recurrence. Repeated hepatic resection was performed in 5 of the 6 patients. As of the mean follow-up period of 25 months, 4 patients were alive and cancer-free, 4 were undergoing chemotherapy, and 2 had died of their cancer. Improvement in the survival outcome of patients with 7 or more colorectal liver metastases can be expected by treating them with adjuvant chemotherapy in addition to aggressive surgical procedures, including extended hemihepatectomy, portal venous embolization, two-stage hepatectomy, and repeated resection.

[A case of small intestinal cancer with peritoneal metastases treated with FOLFOX regimen].

A38 -year-old man complaining of abdominal pain was diagnosed with small intestinal cancer. Small intestinal endoscopy and PET-CT showed a primary jejunal cancer and five peritoneal metastases. Partial resection of the jejunum with three metastases was performed, but the others were unresectable. After surgery, FOLFOX chemotherapy was adapted. Follow-up pelvic CT showed a remarkable reduction of tumor size during FOLFOX chemotherapy after 4 courses, and follow-up PET-CT showed no tumor intake FDG after 10 courses. We judged him to be a complete response and stopped chemotherapy. After 7 months, the patient's level of tumor markers elevated, and there was recurrence. We resumed FOLFOX, and the chemotherapy for this patient is still being continued.