[A Case of Curative Resection of the Local Advanced Gastric Cancer after SOX plus Nivolumab Chemotherapy, and the Pathological Diagnosis Was Complete Response].

A-78-year-old woman presented with difficulty swallowing. She was diagnosed as having advanced upper gastric cancer with invasion to the esophagus and the diaphragm. Biopsy examination of the tumor showed MSI-high and HER2-negative. The patient received 4 courses of SOX plus nivolumab in combination. After the chemotherapy, the size of the tumor decreased remarkably. We performed total gastrectomy with D2 lymph node dissection. Pathological examination revealed no residual cancer at the primary tumor location and the regional lymph nodes. The patient has shown no recurrence for 9 months without adjuvant chemotherapy. We conclude that SOX plus nivolumab in combination as first-line chemotherapy is an effective strategy against advanced gastric cancer.

[Long-Term Relapse-Free Survival after Resection of Lung Metastasis in a Patient with Pancreatic Cancer-A Case Report].

The patient was a 71-year-old man with the pancreatic cancer. He underwent subtotal stomach-preserving pancreaticoduodenectomy and D2 lymphadenectomy. CT conducted 38 months after the surgery revealed the 10-mm mass at the lower lobe in the left lung. On PET-CT, the mass showed an abnormal uptake. We suspected that the mass was either a lung metastasis or a primary lung cancer. Partial resection of the left lung was performed, and pathological findings led to the diagnosis of lung metastasis originating from the primary pancreatic cancer. Currently at 9 years post-surgery, the patient has not had any recurrence of the metastasis. In this study, we report our case and discuss the literature.

[A Patient with Gastric Adenosquamous Cell Carcinoma].

A 73-year-old female was referred from a local clinic with abdominal pain. A diagnosis of gastric cancer(cT3, cN0, M0, cStage ⅡB)and acute cholecystitis was made. Distal gastrectomy, D2, and cholecystectomy were performed. Postoperative pathological examination led to a diagnosis of adenosquamous cell carcinoma(pT3, pN2, M0, pStage ⅢA). SOX therapy was administered as postoperative adjuvant chemotherapy. However, multiple liver metastases were detected. XP and DTX therapies were administered; however, there was a reduction in performance status. The patient died 10 months after surgery. Gastric adenosquamous cell carcinoma is classified as a specific type according to the Japanese Classification of Gastric Carcinoma(15th edition). This carcinoma accounts for 0.3 to 0.5% of patients undergoing gastric cancer surgery and is relatively rare. Its malignancy level is higher than that of gastric adenocarcinoma, and its prognosis is poorer.

[A Case of Malignant Lymphoma Incidentally Diagnosed by Lymph Node Dissection during Gastrectomy].

A 65‒year‒old man was diagnosed with gastric cancer during a detailed examination for anemia and hospitalized for surgery. Laparoscopy‒assisted distal gastrectomy, D1+ dissection, and Billroth Ⅰ reconstruction were performed. The postoperative course was favorable, and he was discharged on postoperative day 8. The histopathological stage of the cancer was pStage ⅠA(T1aN0M0). A malignant lymphoma was found in the dissected No. 3, No. 4d, and No. 8a lymph nodes. He was diagnosed with a large B‒cell lymphoma(Stage Ⅲ)by hematological examination and is currently being administered R‒ CHOP. No gastric cancer recurrence has occurred for 2 years since the surgery. There is no published report on the diagnosis of such a double cancer, ie, malignant lymphoma diagnosed by lymph node dissection during surgery for gastric cancer. We herein report this case with reference to the literature.

[A Case of Strangulation Ileus Caused by Pseudomyxoma Peritonei of Appendiceal Origin].

The patient was a 38-year-old woman who visited our hospital with a chief complaint of abdominal pain. She was diagnosed with strangulation ileus and was subsequently admitted to our hospital to undergo surgery. During the surgical procedure, we observed mucus adhesion accumulating within the peritoneal cavity and identified strangulation ileus resulting from a cord-like structure. We did not observe intestinal necrosis. Given that the appendix was swollen, we made the diagnosis of strangulation ileus caused by pseudomyxoma peritonei of appendiceal origin and performed ileocolic resection. The patient recovered well postoperatively and was discharged on postoperative day 9. Pseudomyxoma peritonei is often diagnosed in patients who present with ascites, abdominal swelling, or appendicitis. This is the first case report of pseudomyxoma peritonei diagnosed in a patient with strangulation ileus.

[A Case of Sigmoid Colon Cancer with Idiopathic Thrombocytopenic Purpura].

An 80-year-old man reported at our hospital with the chiefcomplaint ofconstipation. He was diagnosed with sigmoid colon cancer(T4aN0M0, Stage II). He also had steroid-resistant idiopathic thrombocytopenic purpura(ITP)since 2001. After a high dose g-globulin therapy, he underwent sigmoidectomy and splenectomy simultaneously because ofthe steroidresistant ITP. While some reports suggest that ITP is dominant when it occurs with blood cancer, others suggest that it can be immunologically dominant even when it occurs with solid tumors. ITP has a significant effect on solid tumors.

[A Case of Ischemic Colitis Four Months after Laparoscopic Left Hemicolectomy Preserving Superior Rectal Artery].

The case was for a male at the age of 80. We performed laparoscopic left hemicolectomy and D3 lymph node dissection for descending colon cancer. He had a good postoperative prognosis and was discharged on the 14th day after the operation. Later, he was receiving the treatment on an outpatient basis without postoperative adjuvant chemotherapy during the followup period. He visited the hospital for sudden abdominal pain and melena as chief complaint approximately 4 months after the operation. We found prominent edematous wall thickening and increased surrounding fat concentration in the anal side of colon from the anastomosis site with plain abdominal CT scan. We also found that the anal side of colon from the anastomosis site an edematous change broadly in the lower gastrointestinal endoscopy. We conducted conservative treatment with the diagnosis of ischemic colitis at the anal side of colon from the anastomosis site. He was discharged on the 11th day after the hospitalization. Later, we conducted a follow-up examination for him on an outpatient basis. We recognized the symptom improvement approximately 2 months after the onset of the ischemic colitis.

Risk factors to predict severe postoperative pancreatic fistula following gastrectomy for gastric cancer.

AIM: To allow the identification of high-risk postoperative pancreatic fistula (POPF) patients with special reference to the International Study Group on Pancreatic Fistula (ISGPF) classification. METHODS: Between 1997 and 2010, 1341 consecutive patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery, Kyoto Prefectural University of Medicine, Japan. Based on the preoperative diagnosis, total or distal gastrectomy and sufficient lymphadenectomy was performed, mainly according to the Japanese guidelines for the treatment of gastric cancer. Of these, 35 patients (2.6%) were diagnosed with Grade B or C POPF according to the ISGPF classification and were treated intensively. The hospital records of these patients were reviewed retrospectively. RESULTS: Of 35 patients with severe POPF, 17 (49%) and 18 (51%) patients were classified as Grade B and C POPF, respectively. From several clinical factors, the severity of POPF according to the ISGPF classification was significantly correlated with the duration of intensive POPF treatments (P = 0.035). Regarding the clinical factors to distinguish extremely severe POPF, older patients (P = 0.035, 65 years ≤ vs < 65 years old) and those with lower lymphocyte counts at the diagnosis of POPF (P = 0.007, < 1400/mm(3) vs 1400/mm(3) ≤) were significantly correlated with Grade C POPF, and a low lymphocyte count was an independent risk factor by multivariate analysis [P = 0.045, OR = 10.45 (95%CI: 1.050-104.1)]. CONCLUSION: Caution and intensive care are required for older POPF patients and those with lower lymphocyte counts at the diagnosis of POPF.

Overexpression of TRIM44 contributes to malignant outcome in gastric carcinoma.

Recent studies have shown that some members of the tripartite motif-containing protein (TRIM) family, which is characterized by a conserved RING finger, B-box, and coiled-coil domains, function as important regulators for carcinogenesis. In this study, we tested whether TRIM44 (11p13) acts as a cancer-promoting gene through overexpression in gastric cancer. We analyzed seven gastric cancer cell lines and 112 primary tumors, which were curatively resected in our hospital between 2001 and 2003. Expression of the TRIM44 protein was detected in gastric cancer cell lines (2/7 cell lines; 29%) and primary tumor samples of gastric cancer (29/112 cases; 25%). Knockdown of TRIM44 expression using several specific siRNAs inhibited the proliferation, migration, and invasion of TRIM44-overexpressing cells. Overexpression of the TRIM44 protein was significantly correlated with an advanced type of macroscopic appearance, lymphatic invasion, and higher recurrence rate. TRIM44-overexpressing tumors had a worse overall rate of survival than those with non-expressing tumors (P = 0.0038, log-rank test) in both intensity and proportion expression-dependent manner. TRIM44 positivity was independently associated with worse outcome in multivariate analysis (P = 0.0233, hazard ratio 3.37 [1.18-9.64]). These findings suggest that TRIM44 plays a crucial role in tumor cell proliferation through its overexpression, and highlight its usefulness as a predictor and potential therapeutic target in gastric cancer.

Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct.

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.

Port site herniation of the small bowel following laparoscopy-assisted distal gastrectomy: a case report.

INTRODUCTION: Port-site herniation is a rare but potentially dangerous complication after laparoscopic surgery. Closure of port sites, especially those measuring 10 mm or more, has been recommended to avoid such an event. CASE PRESENTATION: We herein report the only case of a port site hernia among a series 52 consecutive cases of laparoscopy-assisted distal gastrectomy (LADG) carried out by our unit between July 2002 and March 2007. In this case the small bowel herniated and incarcerated through the port site on day 4 after LADG despite closure of the fascia. Initial manifestations experienced by the patient, possibly due to obstruction, and including mild abdominal pain and nausea, occurred on the third day postoperatively. The definitive diagnosis was made on day 4 based on symptoms related to leakage from the duodenal stump, which was considered to have developed after severe obstruction of the bowel. Re-operation for reduction of the incarcerated bowel and tube duodenostomy with peritoneal drainage were required to manage this complication. CONCLUSION: We present this case report and review of literature to discuss further regarding methods of fascial closure after laparoscopic surgery.