[A Case of Long-Term Survival in Gastric Cancer with Multiple Liver Metastases Successfully Treated by Conversion Surgery after S-1 plus Cisplatin Combination Therapy].

A 49-year-old man was diagnosed with advanced gastric cancer, with a chief complaint of epigastric discomfort. Computed tomography revealed multiple liver metastases. S-1 plus cisplatin therapy was administered as first-line chemotherapy, and after 4courses, the liver metastases markedly reduced. Total gastrectomy with D2 lymphadenectomy and a needle biopsy of segment 2 of the liver were performed. Histopathological examination revealed no viable cancer cells in the resected stomach, lymph nodes, or liver tissue. The primary tumor was defined as Grade 3 by histopathological examination. Adjuvant chemotherapy with S-1 was administered for 1 year. The patient is alive without recurrence more than 6 years after surgery.

Treatment outcomes of hepatectomy for liver metastases of gastric cancer diagnosed using contrast-enhanced magnetic resonance imaging.

BACKGROUND: Chemotherapy is the standard treatment for liver metastases of gastric cancer (LMGC). Hepatectomy for LMGC reportedly has a 5-year survival rate of 13-37 %; however, its significance has not been established. At our hospital, hepatectomy is performed for patients with three or fewer metastases diagnosed using contrast-enhanced magnetic resonance imaging (MRI). To identify the ideal patient subpopulation for resection, we retrospectively analyzed treatment outcomes in patients with LMGC who underwent hepatectomy. METHODS: Clinicopathological factors affecting survival were explored using univariate and multivariate analyses in 28 patients who underwent hepatectomy for LMGC diagnosed using contrast-enhanced MRI between December 2004 and October 2014. RESULTS: The study included 23 men and 5 women with a median age of 72 years. Metastases were synchronous in 15 patients and metachronous in 13 patients. The median overall survival time was 49 months, with a 5-year survival rate of 32 %. Univariate analysis revealed that overall survival time was shorter in the presence of the following factors: age ≥70 years (p = 0.030), synchronous liver metastases (p = 0.017), and presence of postoperative complications (p = 0.042). In patients with metachronous liver metastases, the post-resection 5-year survival rate was 59 %. CONCLUSIONS: The 5-year survival rate was 32 % in patients who underwent hepatectomy for LMGC according to our criteria, suggesting that hepatectomy is an important treatment if indications are on the basis of contrast-enhanced MRI. Therefore, active resection should be considered, particularly for patients with metachronous liver metastases.

[A Case with Solitary Brain Metastatic Tumor from Colon Cancer].

We report a rare long-surviving case of solitary brain metastasis from colon cancer. The patient was a 64-year-old female. She had undergone laparoscopic right hemicolectomy for ascending colon cancer in October 2012(pStage III b). She was discharged from the hospitalin a satisfactory state, but 26 days after the operation, she was transported to the emergency department for systemic tonic-clonic convulsions. Magnetic resonance imaging revealed solitary metastatic tumor in the brain, but there were no metastatic lesions in other organs. Metastatic lesion was small and complete removal was considered to be difficult. Thus, we planned stereotactic radiosurgery for the metastases, and then regimen of mFOLFOX6 plus Bmab, tegafur-uracil plus Leucovorin were administered. As a means of evaluating recurrence of brain metastasis, methionine positron emission tomography(methionine PET)was also performed, and the patient has survived for 54 months since the surgery, to date, without recurrence. Cases with brain metastasis of colorectal cancer often have metastases involving other organs and are considered to have a poor prognosis. For solitary brain metastasis, long-term survival can be obtained with multidisciplinary treatments, and methionine PET is considered to be usefulfor recurrence evaluation after radiation treatment.

Robotic surgery for gastric cancer.

Laparoscopic gastrectomy is a widely used minimally invasive surgery for gastric cancer. However, skillful techniques are required to perform lymph node dissection using straight shaped forceps, particularly for D2 dissection. Robotic surgery using the da Vinci surgical system is anticipated to be a powerful tool for performing difficult techniques using high-resolution three-dimensional (3D) images and the EndoWrist equipped with seven degrees of freedom. Attempts are being made to apply robotic surgery in gastrectomy procedures mainly in Japan, South Korea, and Europe. Although definite superiority to laparoscopic gastrectomy is yet to be proven, robotic surgery has been reported to have a shorter learning curve and offer more precise dissection for total gastrectomy. Hence, its oncological efficacy needs to be verified in a clinical trial.

Robotic radical distal gastrectomy for gastric cancer using the soft coagulation scissors technique.

We have developed a novel technique for safe and precise lymph-node dissection during robotic gastrectomy for gastric cancer using monopolar curved scissors with soft coagulation. This technique is called the soft coagulation scissors technique. The technical details of this technique are as follows: a long bipolar grasper in the first arm and monopolar curved scissors in the third arm are primarily used for lymph-node dissection, maximizing the use of the robotic arm articulation. The monopolar curved scissors were energized in the soft coagulation mode of the Valleylab™ FT10 energy platform or in the forced coagulation mode of the ERBE VIO®dV with an effect 1/power limit of 15 W. This limit was confirmed to be equivalent to the soft coagulation mode in preliminary experiments, and a long bipolar grasper applied adequate tension to the surgical site without strongly grasping the tissue or applying traction. The peak temperatures of our devices were more than 100 °C lower than those of the Harmonic ACE and the Maryland bipolar forceps with the forced coagulation mode. Overall, 80 patients with gastric cancer, including 36 (45.0%) with stage III or IV cancers, underwent robotic distal gastrectomy with this technique. The median estimated blood loss was 10 g. There were only four surgical complications (5.0%): two paralytic ileus, one intra-abdominal abscess, and one duodenal stump leakage. Robotic distal gastrectomy for gastric cancer is made possible by the soft coagulation scissors technique, which allows for safe and precise lymph-node dissection.

Modified side overlap esophagogastrostomy after laparoscopic proximal gastrectomy.

We report a new method of esophagogastrostomy after proximal gastrectomy, side overlap with fundoplication by Yamashita (SOFY) in 2017. Recently, even better treatment results can be obtained by modifying the SOFY method. We describe the technical details of the modified SOFY (mSOFY) after laparoscopic proximal gastrectomy. The stomach was dissected in the short axis direction and the esophagus was dissected in the left and right direction. After the proximal gastrectomy, the bilateral diaphragmatic crus were dissected to enhance gastric elevation. After confirming that the esophagus overlapped more than 5 cm at the center of the remnant stomach (we call it SOFY check), the remnant stomach was suture-fixed to the dissected diaphragmatic crus. The right wall of the esophageal stump and the remnant stomach were anastomosed using the full length of a 45 mm-linear stapler. The entry hole was closed in a direction that did not widen the anastomotic hole. Both sides of the esophagus, remnant stomach, and diaphragmatic crus were suture-fixed on the cranial side 1-2 cm away from the anastomosis. Moreover, the left wall and lower end of the esophagus was suture-fixed to the remnant stomach. The preserved dorsal esophageal wall is pressed and flattened by pressure from the pseudofornix, which is the reflux prevention mechanism. The mSOFY method had favorable treatment outcomes. In conclusion, mSOFY can be one of the safe and feasible reconstruction methods after laparoscopic proximal gastrectomy.