[Synchronous Lung Metastasis and Hilar Lymph Node Metastasis from Rectal Cancer-A Case Report].

A 64-year-old male was referred to our hospital with both advanced rectal cancer and lung tumor with swollen lymph nodes in the lung hilum. The patient underwent laparoscopic low anterior resection followed by systematic lobectomy of the lung 2 months later. Postoperative pathological examination revealed a diagnosis of metastatic lung tumor and metastasis in the lung hilum. However, hilar lymph node metastasis is considered a poor prognostic factor for lung metastasis. Herein, we report a case of synchronous lung metastasis and hilar lymph node metastasis from colorectal cancer that achieved 20 months of recurrence free survival with surgical therapy alone.

Hemorrhagic shock successfully treated with emergency pancreaticoduodenectomy for pancreatic carcinoma in radiochemotherapy: A case report.

INTRODUCTION: Pancreatic cancer often invades the duodenum; however, it rarely causes duodenal bleeding. PRESENTATION OF CASE: We describe a case of a 77-year-old Japanese woman admitted to our hospital with hematemesis, who presented with pancreatic head cancer and received radiochemotherapy (radiotherapy + gemcitabine). The following day, she developed hemorrhagic shock, and an emergency endoscopy was performed, which revealed a bleeding ulcerative lesion in the second portion of the duodenum. We chose surgical treatment over other therapies (interventional radiology or endoscopy). Pancreaticoduodenectomy was successfully performed to control hemorrhage and the Child's method was used for reconstruction. The patient's postoperative course was uneventful. After her condition improved, she was treated for residual cancer 2 months after surgical treatment; therefore, complementary radiation with concurrent chemotherapy based on GEM was administrated. However, she died 12 months after the surgery. DISCUSSION AND CONCLUSION: During the treatment of pancreatic cancer, it is necessary to avoid bleeding as much as possible by considering prophylactic treatment, including periodic gastrointestinal scrutiny and resection or embolization, depending on the case.

Salvage PTBD With Chemotherapy Improves Survival in Patients With Unresectable Malignant Biliary Obstruction - A Single Center Retrospective Study.

BACKGROUND/AIM: Malignant biliary obstruction (MBO) is a life-threatening condition. We aimed to investigate the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in patients with unresectable MBO due to failure of management by endoscopic retrograde cholangiopancreatography (ERCP) and/or prior surgical bypass. PATIENTS AND METHODS: Fifty-two consecutive patients (mean age, 69 years; 44.2% women) underwent salvage PTBD between 2013 and 2020. RESULTS: The median overall survival rate was 4.2 months, with a 95% confidence interval (CI) of 1.9-5.7. The median overall survival (OS) were 11.1 months and 1.9 months for patients who underwent chemotherapy (n=17) and best supportive care (n=35), respectively (p=0.0005). Independent factors predicting poor outcome were best supportive care, with a hazard ratio (HR) of 3.3 (95%CI=1.3-8.5), American Society of Anesthesiologists physical status classification (ASA) with a HR of 13.5 (95%CI=1.3-136.0) and Eastern Cooperative Oncology Group (ECOG) performance status of 4, with a HR of 3.3 (95%CI=1.0-6.2). CONCLUSION: Salvage PTBD with chemotherapy has the potential to achieve prolonged survival in patients with unresectable MBO, including those with failure of ERCP and/or surgical bypass.

Pancreaticoenterostomy With Seromuscular-parenchymal Anastomosis for Prevention of Postoperative Pancreatic Fistula in Distal Pancreatectomy.

BACKGROUND/AIM: There have been several attempts to prevent the development of a postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP); however, there is no established method yet. In the present study, we investigated whether POPF can be prevented using pancreaticoenterostomy with seromuscular-parenchymal anastomosis. PATIENTS AND METHODS: We evaluated the incidence of POPF and complications in 20 patients who underwent DP since August 2014, wherein pancreaticoenterostomy with seromuscular-parenchymal anastomosis was performed. RESULTS: No patient developed POPF, and only 4 patients developed a biochemical leak. Postoperative complications (Clavien-Dindo classification: CD) occurred in 5 patients (Grade IIIa in 2 cases, Grade II in 2 cases, and Grade I in 1 case). In a case of CD Grade II, a gastric ulcer was formed at the pancreatico-gastric anastomosis. CONCLUSION: Although new complications, such as the formation of ulcers, consistent with pancreatic anastomosis, were noted, the present method was useful in preventing POPF.

Adenosquamous carcinoma of the bile duct treated with pancreaticoduodenectomy in a patient presenting situs inversus totalis: A case report.

INTRODUCTION: Situs inversus totalis represents an unusual anomaly characterized by a mirror-image transposition of the abdominal and thoracic viscera. It often occurs concomitantly with other disorders, hindering the diagnosis and management of abdominal pathology. The relationship between situs inversus totalis and cancer remains unclear. PRESENTATION OF CASE: We describe a 79-year old Japanese female with situs inversus totalis who presented with obstructive jaundice. Imaging and endoscopic examinations showed a mass in the distal common bile duct, which was identified as an adenocarcinoma on biopsy. The patient was successfully treated by cephalic pancreaticoduodenectomy and the histological diagnosis was adenosquamous cell carcinoma. Ten months following surgery, the patient received chemotherapy and radiotherapy due to the presence of liver metastasis. DISCUSSION AND CONCLUSION: The occurrence of an adenosquamous carcinoma of the bile duct in a patient with situs inversus totalis is an extremely rare coincidence. In this setting, when the tumor is resectable, surgical management should be considered without contraindication and must be preceded by careful preoperative staging.

[Small Bore Chest Tube Management for Traumatic Hemothorax Patients More than 24 Hours after Injury].

Thoracic drainage with a 28 Fr or 32 Fr chest tube is recommended as an initial treatment for traumatic hemothorax, however the recommended drainage tube size is unknown when thoracic drainage becomes necessary more than 24 hours after injury. In this report, the experience with the application of a small bore tube (16 Fr or less) for 18 cases of hemothorax requiring thoracic drainage more than 24 hours after injury is presented. The complications observed in 2 of 8 patients with 8 Fr size and none of 10 patients with 16 Fr size. It was considered that 16 Fr size tube is enough to manage the hemothorax developed more than 24 hours after injury.

[A Case of Subphrenic Lymph Node Metastasis from Gastric Cancer in Which FDG-PET/CT Was Useful for Diagnosis].

A 70-year-old man was admitted for lymph node metastasis detected by FDG-PET/CT showing a mass 10mm in diameter. He had a history of a distal gastrectomy for advanced gastric cancer and was administered postoperative adjuvant chemotherapy consisting of 2 courses of TS-1 with CDDP and TS-1 only for 1 year. Lymph node recurrence was diagnosed and resected 4 years after the initial surgery. Histological examination revealed lymph node metastasis of the gastric cancer. He was administered adjuvant chemotherapy using TS-1 and has been followed-up without recurrences for 17 months after the second operation. We reported a case in which FDG-PET/CT was potentially beneficial for the diagnosis of the postoperative small lymph node metastasis.

[A Case Report of Neuroendocrine Carcinoma in the Gall Bladder Showing Recurrence Shortly after Surgery].

A55 -year-old woman with a 10×8mm protuberant gallbladder lesion visited our hospital. To determine possible malignancy, she underwent laparoscopic excision biopsy of the gallbladder, and pathological findings revealed an endocrine carcinoma in the gallbladder. Surgery involved extrahepatic bile duct resection, gallbladder bed resection, and hepatic portal lymph node resection. Recurrence in the peritoneal lymph node was observed in the early postoperative period. Chemotherapy was initiated with cisplatin and irinotecan, and continues 18 months post-operatively. Neuroendocrine carcinoma of the gallbladder is rare and is known to have a poor prognosis, with few confirmed treatments reported for this disease due to its rarity. Therefore, we report this case along with a review of the literature.

Improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation.

BACKGROUND: Few studies have investigated the burst pressure of side-to-side anastomoses comparing different stapling devices that are commercially available. OBJECTIVES: We conducted side-to-side anastomoses with a variety of staplers and compared burst pressure in the crotch of the anastomoses. SETTING: Nagoya City East Medical Center. METHODS: We conducted side-to-side anastomoses with 9 staplers with different shapes and forms. Fresh pig small intestines were used. A side-to-side anastomosis was performed between 2 intestine specimens using a linear stapler. The burst pressure of the anastomosis was recorded. RESULTS: In total, 45 staplers were used for this experiment. The site of leakage in all cases was the crotch. Regarding the influence of the number of staple rows, the burst pressure in 3-row staplers was significantly higher than in 2-row staplers. With regard to the relationship between staple height and burst pressure, staples with a height slightly shorter than the intestinal thickness showed the highest burst pressure. In a comparison of staplers with uniform staple heights and stamplers with staples of 3 different heights, the latter had significantly lower burst pressures. Neoveil significantly increased the burst pressure in the crotch and contributed to the highest burst pressure of all the staplers used in this experiment. CONCLUSIONS: In this experiment, we defined the important factors that influence burst pressure at the crotch of a stapled, side-to-side anastomosis. These factors include the number of staple rows, the height of the staple compared with the thickness of the tissue, uniformity of staple height, and reinforcement of the staple line. In any surgical case requiring intestinal anastomosis, selection of a stapler is a critical step.

Eversion stripping of the esophagus with intraesophageal insufflation-A case report.

INTRODUCTION: Patients with esophageal cancer frequently cannot tolerate thoracotomy due to their overall debilitated condition. Moreover, some patients have severe adhesions in the thoracic cavity. Eversion stripping of the esophagus is an option for resection in these patients. PRESENTATION OF CASE: A 64-year-old man was admitted to our institution with the chief complaint of epigastric pain. Endoscopic examination showed a protruding lesion 22cm from the incisors, with a superficial and circumferential mucosal irregularity on the distal side of the lesion. Biopsy revealed squamous cell carcinoma. Clinical stage was T1b(sm)N0M0, cStage I. In addition to the poor pulmonary status of the patient, adhesions in the intrathoracic cavity were predicted. The decision was made to perform esophageal resection without a thoracotomy. In order to ensure complete invagination of the esophagus, the esophagus was insufflated prior to stripping. The stripping process was observed with a gastroscope. During the stripping, the esophagus did not bunch up, and stripping was smooth and with minimal resistance. DISCUSSION: The stripping resection of the esophagus is an important option for the esophageal surgeon. In this case report, we describe a new eversion stripping method of the esophagus. This easy and reliable stripping method incorporates intraesophageal insufflation. CONCLUSION: The indications for blunt esophageal dissection without thoracotomy have been decreasing. On the other hand, our method seems to be useful in optimal case of stripping of esophagus.

Resection of the Gastric Tube Reconstructed through the Retrosternal Route without Sternotomy.

With advances of combined modality therapy, prognoses in esophageal cancer have been improving. After resection of esophageal cancer, the development of gastric tube cancer is a risk. While such cancer in an early stage can be cured endoscopically, total gastric tube resection is indicated in advanced stages. A 68-year-old man underwent subtotal esophagectomy reconstructed with a gastric tube through the retrosternal route. Gastric cancer was found one and a half years postoperatively. The gastric tube was resected without sternotomy. This is the first report of a patient undergoing resection of the gastric tube reconstructed through the retrosternal route without sternotomy.

[Cisplatin and S-1 combination therapy after reduction surgery for stage IV gastric cancer].

To evaluate the efficacy of cisplatin and S-1 combination therapy after reduction surgery for Stage IV gastric cancer, we retrospectively examined 73 patients with Stage IV gastric cancer who underwent gastrectomy. We classified the patients into the following four groups according to their postoperative therapies and analyzed their outcomes: A) S-1 +CDDP therapy (n=22); B) oral 5-FU therapy (n=30); C) 5-FU+CDDP therapy (n=14); and D) S-1 therapy (n= 7). The median survival time was 465 days in the S-1+CDDP therapy group, 158 days in the oral 5-FU therapy group, 332 days in the 5-FU+CDDP therapy group, and 374 days in the S-1 therapy group. The respective 2-year and 3-year survival rate was 37.8% and 20.2% in the S-1+CDDP therapy group, 3.4% and 3.4% in the oral 5-FU therapy group, 7.1% and 0% in the 5-FU+CDDP therapy group, and 0% and 0% in the S-1 therapy group, respectively. We consider that S-1+CDDP therapy after reduction surgery improves survival in patients with Stage IV gastric cancer and should be further investigated.