[A Case of Rectal Cancer That Could Be Safely Resected by Laparoscopic Surgery, after Capecitabine plus L-OHP plus Cetuximab as Pre-Operative Chemotherapy].

A 56-year-old woman. She was underwent a lower gastrointestinal endoscopy for bloody stool, and type 2 advanced rectal cancer was found. In CT scan, although distant metastasis is not found, the tumor has been expanded to the dorsal side. So, infiltration into the sacrum was suspected. For the risk of bleeding and residual tumor in circumferential resection surface, it was decided to perform pre-operative adjuvant chemotherapy. Because RAS gene has no mutation, the regimen chose CAPOX plus cetuximab. Although skin damage and cytopenia were observed, there was no appearance of adverse events that were intolerant, and 4 courses were performed. Although scar stenosis was observed in the endoscope after 4 courses, tumor size decreased. Even in CT, the wall thickening was significantly reduced, and progress to the tumor dorsal side was also reduced, so laparoscopic lower anterior resection was performed. During surgery, the tumor dorsal side sacral infiltration was suspected, although observed a sclerotic change, it is relatively easily peelable, it was possible to safely complete the laparoscopic operation. Even after the operation, the course was good, and it was discharged from the hospital lightly on the 12th day after the operation. In pathological diagnosis, medium-differentiated adenocarcinoma, T3, N0, histological therapeutic effect of chemotherapy was grade 2. Cetuximab combination regimen was considered to be an effective option.

[Goblet Cell Carcinoid of the Appendix with Complicated Appendicitis-A Case Report].

A 50-year-old male was referred to our hospital for the further evaluation and treatment of abdominal pain. He was diagnosed with complicated appendicitis using computed tomography. After conservative treatment, he underwent an interval appendectomy. A histopathological examination revealed a goblet cell carcinoid(GCC)of the appendix with subserosal invasion. He underwent laparoscopic ileocecal resection with D3 lymph node dissection. Histopathological findings showed neither residual tumor nor lymph node metastasis. The patients is currently followed as an outpatient without recurrence. Here we report our experience with GCC, a rare disease.

The Combined Use of Drainage Amylase Concentration and Serum C-reactive Protein as Predictors of Pancreas-Related Complications after Elective Gastrectomy.

INTRODUCTION: Postoperative pancreas-related complications (PPRC) can cause critical conditions, including sepsis and intra-abdominal bleeding. Thus, it is important to identify patients who are at risk of clinically significant PPRC as early as possible in the postoperative period. Some authors have reported the use of amylase concentration of the drainage fluid (dAmy) to predict PPRC. However, the positive predictive value of dAmy alone is not sufficient. OBJECTIVE: The aim of this study is to evaluate the predictive value of combined use of dAmy and serum C-reactive protein (sCRP) for PPRC. METHODS: The clinicopathological data of 327 patients who underwent elective gastrectomy for gastric cancer were reviewed. There were 18 patients who developed PPRC. Univariate and multivariate analyses were conducted to identify the risk factors of PPRC. Receiver operating characteristic curves were used to identify the cut-off values of dAmy and sCRP on postoperative day 3 (dAmy3 and sCRP3) to predict the risk of PPRC. RESULTS: In the multivariate analysis, splenectomy alone correlated with PPRC. The cut-off values of dAmy3 and sCRP3 were 761 IU/L and 15.15 mg/dL, respectively. Among the 17 patients with both dAmy3 and sCRP3 above the thresholds, 10 (58.8%) had PPRC with Clavien-Dindo classification (CD) ≥II and 7 (41.2%) had PPRC with CD ≥III. In contrast, among the 236 patients with both parameters below the thresholds, 233 (98.7%) did not develop PPRC, and only 1 (0.4%) had PPRC with CD ≥III. CONCLUSIONS: Splenectomy correlates with PPRC, which is consistent with results from large clinical trials. A combined use of dAmy3 and sCRP3 can be useful in predicting the risks of PPRC.

Validity of Laparoscopic Gastrectomy in the Elderly.

OBJECTIVES: This study aimed to investigate the validity of laparoscopic gastric cancer surgery in elderly patients. METHODS: A total of 202 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and December 2016 were divided into an elderly group (age ≥75 years, n = 36) and a control group (age < 75 years, n = 166). The patients' clinicopathological data were reviewed. RESULTS: The overall morbidity rate was relatively higher in the elderly group (16.7 vs. 11.4%, p = 0.389), whereas the incidence of serious complications ≥grade III according to the Clavien-Dindo classification did not increase significantly in the elderly group (8.3 vs. 7.8%, p = 0.920). Univariate and multivariate analyses revealed that age ≥75 years was not a significant predictive factor of postoperative morbidity (p = 0.568). There was no significant difference in the 5-year overall survival rate of patients with pathological stage I gastric cancer between the groups (97.1 vs. 96.1%, p = 0.704; hazard ratio, 0.669; 95% confidence interval, 0.036-3.692). CONCLUSIONS: Laparoscopic gastrectomy has an acceptable morbidity rate in elderly patients, and the long-term outcome of patients with stage I gastric cancer was similar to that of the control group.

Impact of Gastric Cancer Surgery in Elderly Patients.

OBJECTIVES: This study aimed to investigate the validity of gastric cancer surgery in elderly patients. METHODS: A total of 544 patients who underwent elective gastrectomy for gastric cancer were divided into an elderly group (age ≥75 years, n = 171) and a control group (age <75 years, n = 373). The clinicopathological data of the patients were reviewed. RESULTS: The overall morbidity rate (26.3 vs. 16.1%, p = 0.005) and the incidence rate of anastomotic leakage (6.4 vs. 1.6%, p = 0.003) were significantly higher in the elderly group. The proportion of patients who had severe complications (≥grade IIIa) was relatively higher in the elderly group (10.5 vs. 5.7%); however, the difference was not significant (p = 0.074). A stage-matched survival analysis revealed no significant differences between the groups (stage I: p = 0.978; stage II: p = 0.964; stage III: p = 0.199). For the pathological stages II and III, the overall survival of the patients in the elderly group who received adjuvant chemotherapy for >3 months was significantly better than that of the patients who received it for ≤3 months or did not receive it (p = 0.023). CONCLUSIONS: An aggressive treatment strategy should be adopted in selected elderly patients with gastric cancer.

[Early Surgery for Acute Cholecystitis Complicated with Gallbladder Cancer].

The present study involved 6 patients who had urgent surgery for acute cholecystitis(AC)complicated with gallbladder cancer(GBC)in our hospital from January 2014 to December 2016. We analyzed the clinical outcome of early surgery for AC complicated with GBC. According to Tokyo Guidelines 2013, the AC severity was classified as Mild 1 case, Moderate 5 cases. Only one patient was diagnosed with GBC before the operation for AC. The others were during or after the laparoscopic cholecystectomy. Histopathologically, all patients had Stage II disease or greater. Two patients had adjunctive radical operation with the wedge resection of the gallbladder bed, lymphadenectomy and bile duct resection, and they survived without recurrence for 28 months and 12 months, respectively. Of the 3 patients without any additional surgery, 2 patients died in several months after the operation. In consideration of the concurrence of GBC, early surgery for AC must be decided carefully.

Outcome of Gastric Cancer Surgery in Patients with Chronic Kidney Disease.

BACKGROUND: The influence of chronic kidney disease (CKD) on the outcome of gastric cancer surgery has rarely been reported. METHODS: Retrospectively collected clinicopathological data on patients who underwent elective gastrectomy between January 2007 and December 2014 were analyzed (n = 500). The patients were divided into 2 groups based on the preoperative estimated glomerular filtration rate (eGFR): a non-CKD group (eGFR ≥60 ml/min/1.73 m2, n = 392) and a CKD group (eGFR <60 ml/min/1.73 m2, n = 108). Short- and long-term results of the surgery were compared. RESULTS: There was no significant difference between the 2 groups in terms of the overall morbidity rate (p = 0.215), and in any kind of postoperative complication, including infectious and cardiovascular complications. Additionally, there was no significant difference in the morbidity rate irrespective of the type of gastrectomy and the extent of lymph node dissection. The 3-year relapse-free survival rates in the non-CKD and CKD groups were 92.1 and 92.0%, respectively, in stage I disease (p = 0.640), 81.4 and 73.7%, respectively, in stage II disease (p = 0.825), and 35.9 and 31.9%, respectively, in stage III disease (p = 0.784). CONCLUSION: CKD did not affect the short- and long-term outcomes in patients after gastric cancer surgery.

[A case of undifferentiated gastric cancer that recurred with portal vein tumor thrombus].

A 69-year-old man with a malignant tumor of the stomach underwent distal gastrectomy with partial resection of the abdominal wall, transverse colon, and lateral segment of the liver. Based on a detailed pathological examination of the resected specimen, a diagnosis of undifferentiated gastric cancer was established. Six months after the operation, during postoperative adjuvant chemotherapy with S-1, diagnostic imaging, including CT and positron emission tomography (PET), revealed a portal vein tumor thrombus and diffusely spreading metastases in the posterior segment of the liver. Despite chemotherapy with S-1/CDDP, the metastatic tumors continued to grow rapidly. The patient died 10 months after the operation. On autopsy, the portal vein tumor thrombus was observed to be composed of undifferentiated cancer cells invading into the liver parenchyma through hepatic sinusoids, with the metastatic tumors replacing 60% or more of the entire liver.

Hemobilia associated with a giant thrombosed aneurysm of the hepatic artery requiring hepatectomy.

Hemobilia is an unusual and potentially catastrophic cause of gastrointestinal bleeding. Although hepatic artery aneurysm is a cause of hemobilia, nontraumatic cases are infrequently reported. Herein, we describe the case of a giant hepatic artery aneurysm requiring hepatectomy because of repeated hemobilia in a patient with Marfan syndrome. A 53-year-old man presented to our hospital with sudden epigastric pain and jaundice. Abdominal computed tomography showed a giant hepatic arterial aneurysm in the porta hepatis, and emergency endoscopic retrograde cholangiography revealed hemobilia. Assuming that the aneurysm caused the hemobilia, we performed an abdominal angiogram for treatment. The study revealed a thrombosed aneurysm along with tortuous abnormal vessels in the periphery of the left hepatic artery, which appeared to surround the aneurysm. Therefore, we embolized the left hepatic artery, and immediate hemostasis was achieved. Rebleeding occurred 3 times thereafter, and each time, transarterial embolization was performed, resulting in prompt but only temporary hemostasis. Then, emergency left hemihepatectomy and resection of the aneurysm were performed. Pathologic examination of the resected specimen revealed that the aneurysm was completely thrombosed and organized; however, abnormal arterioles proliferated between the aneurysmal wall and the bile duct. The unique feature of this case was that the abnormal arterioles induced by the organized hepatic artery aneurysm, not the aneurysm itself, caused the hemobilia.

[Case with gradually enlarging lymphoepithelial cyst of the pancreas that necessitated enucleation].

A 54-year-old man exhibited a pancreatic mass on abdominal ultrasonography. Diagnostic imaging with endoscopic ultrasonography, computed tomography, and magnetic resonance imaging revealed that the mass comprised various internal structures and was not connected to the pancreatic duct. Over a period of 4 years and 2 months, the mass increased from 22mm to 32mm in diameter. Laparoscopic enucleation was performed, and a histopathological diagnosis of a lymphoepithelial cyst (LEC) of the pancreas was obtained. LEC is rare and seldom reported in the literature. Although it is considered to be benign, most case reports indicate that they tend to increase in size. This indicates that LEC should be carefully monitored if surgery is not performed after diagnosis.

[A surgically resected case of AFP and PIVKA-II producing gastric cancer with hepatic metastasis].

A 78-year-old man was admitted for workup for a liver tumor. Both serum AFP and PIVKA-II levels were high (2260ng/ml and 806mAU/ml, respectively). Contrast-enhanced CT scan and MRI using Gd-EOB-DTPA demonstrated a liver tumor in segment 6 resembling the imaging patterns of hepatocellular carcinoma (HCC), while the upper gastrointestinal endoscopy revealed a type 2 gastric cancer in the gastric antrum. Although the liver metastasis of the gastric cancer was undeniable, we performed partial resection of segment 6 of the liver and distal gastrectomy under a preoperative diagnosis of double cancer. Histopathologically, gastric tumor consisted of two components, such as well differentiated adenocarcinoma and hepatoid adenocarcinoma. The histology of the liver tumor was similar to that of the hepatoid component in the stomach lesion. Immunohistochemical staining revealed both the gastric and the liver tumors to be positive for AFP and PIVKA-II, yielding a definite diagnosis of AFP and PIVKA-II producing gastric cancer with liver metastasis. Because many cases of this disease have liver metastases at presentation with confusing images with HCC, the diagnosis of liver tumors should be carefully differentiated in the gastric cancer patients with liver tumors, high serum AFP and PIVKA-II levels.

Novel non-trocar technique for laparoscopic radiofrequency ablation.

We have developed a novel insertion method, a non-trocar technique (NTT), for laparoscopic radiofrequency ablation, whereby an ablation needle, guided by a 14.8-mm echo probe (PVM-787LA; Toshiba, Tokyo, Japan), accurately and easily punctures the target tumor in the liver. By existing methods, an ablation needle is inserted into the abdominal cavity through a puncture hole away from the echo probe because of the presence of a 15-mm trocar. Under such circumstances, fitting and sliding an ablation needle along the groove of the probe into the abdominal cavity is difficult because of the longitudinal dissociation between the needle and the probe. To avoid this dissociation, an echo probe is inserted directly through the small incision from which the 12-mm trocar is withdrawn and an ablation needle is introduced directly into the abdominal cavity through a puncture hole adjacent to and slid along the groove of the probe.

[A case of gastric carcinoma with peritoneal metastasis successfully treated by combination chemotherapy of S-1 and cisplatin].

This case is a 69-year-old woman. We diagnosed gastric cancer and cholecystolithiasis by close inspection of abdominal pain. Because preoperative diagnosis was T2N0M0, Stage I B, we performed an operation. Many lesser tubercles were shown, and were diagnosed as peritoneal metastases pathologically. The tumor in corpus ventriculi infiltrated out of gastric serosa. We judged that curative resection was impossible and finished the operation after giving an intra-abdominal dosage of cisplatin(CDDP)at 85mg. After operation, 3 courses of performed S-1/CDDP combination chemotherapy were performed. Because we observed contraction of the main lesion and could not point out the peritoneal metastases and ascitis, we performed a second look operation. All the nodules found with peritoneal and rectouterine excavation had disappeared and we performed distal gastrectomy. The postoperative diagnosis was pT2(MP), pN0CY0, Stage I B, Cur A, therapy grade 1a. Chemotherapy does succeed, and this is a valuable case in which a radical operation could be performed.

[A case of cystic duct metastasis from rectal cancer].

A 67-year-old man underwent laparoscopic low anterior resection and open medial segmentectomy of the liver for rectal cancer and liver metastasis. During the operation, a cystic duct mass, 1cm in diameter, was found. Therefore cholecystectomy with partial resection of the common bile duct was also performed. The rectal tumor and liver tumor were diagnosed pathologically as moderately differentiated adenocarcinoma. The cystic duct mass was mainly located in the lamina propria and its histological aspects were similar to the rectal cancer. Immunohistochemical staining revealed that rectal, hepatic, and cystic duct lesions were all negative for CK7 but were all positive for CK20. These findings confirmed the diagnosis of rectal cancer with metastases to the liver and the cystic duct. Metastatic cystic duct tumor is extremely rare and has never been reported in the Japanese literature.

[A case of accessory papilla of duodenum causing intestinal bleeding].

A 50-year-old man was admitted to our hospital with a chief complaint of melena. An emergency upper gastrointestinal endoscopic study revealed arterial bleeding from a duodenal submucosal tumor, 1.5cm in diameter and about 2cm in an oral direction from the papilla of Vater. Because it was not possible to stop the bleeding, an emergency resection of the tumor was performed. Macroscopically, the ulcerated tumor was approximately 1.5cm in diameter. Histopathologically, the tumor was determined to be located in the accessory papilla of the duodenum. We report here a rare case of bleeding from the accessory duodenal papilla and discuss the literature.

[A case of Cronkhite-Canada syndrome with multiple colon adenomas and early colon cancers].

A 60-year-old man presented with diarrhea and weight loss. Colonoscopy revealed multiple reddish polypoid lesions throughout the gastrointestinal tract and was diagnosed as Cronkhite-Canada syndrome (CCS). Prednisolone therapy caused regression of polyps. Some of them were suspected to be early colon cancers and adenomas. We endoscopically performed mucosal resection for 15 polyps after prednisolone therapy. Histological examination of one of polyps showed invasion of the submucosal layer and colon resection was performed. This case suggests that diagnosis and treatment are important in polyps of CCS.

[A case of gastric carcinoma with lung and liver metastasis successfully treated by mFOLFOX6].

The case is a 66-year-old woman. CT showed multiple metastasis of the liver and lung after operation by colectomy for ascending colon carcinoma. A close inspection showed progressive stomach cancer with lymph node metastasis. Metastasis was considered an effect when it was of colon cancer origin, and treatment by mFOLFOX6 was started. In the results, we confirmed contraction of the liver and lung metastasis and contraction of the regional lymph node metastasis of the stomach by CT. The gastric cancer lesion became only a cicatrix with endoscopic examination. For gastric cancer, the availability of mFOLFOX6 was suggested.

[S-1-based chemotherapy for recurrent gastric cancer with peritoneal dissemination resulting in long-term survival--report of a case].

A 52-year-old man underwent distal gastrectomy for gastric cancer in July 2000. In July 2005, abdominal CT and barium study of the colon revealed peritoneal recurrence, and chemotherapy of S-1 was started. Within 2 courses, the serum CEA level increased, so combination chemotherapy of S-1 and cisplatin (CDDP) was begun. After 7 courses, the regimen was switched to S-1+paclitaxel (PTX). However, the patient developed digital numbness within 8 courses and single-agent chemotherapy with S-1 was restarted. In July 2007, he developed abdominal distension, and abdominal CT showed a large amount of ascites. S-1+CDDP was administered again, however, and we had to change the regimen within 3 courses due to fatigue and appetite loss. S-1 was restarted, but soon severe fatigue and appetite loss restricted the use of chemotherapeutic agents, and he died in December. This patient had been alive for 2 years and 5 months since peritoneal recurrence was diagnosed. We concluded that S-1-based sequential chemotherapy was effective for recurrent gastric cancer.

A new monitoring tool CLIP test for progression of oxaliplatin-induced peripheral neuropathy: A multicenter prospective study.

INTRODUCTION: Oxaliplatin-induced peripheral neuropathy (OIPN) is a common adverse events that can limit a patient's quality of life during/after chemotherapy. However, no appropriate methods have been established yet for monitoring the risk of progression of OIPN. METHODS: A simple assessment tool using gem clips, the CLIP test, was established and its performance in predicting the risk of progression to ≥grade 2 peripheral sensory neuropathy (CTCAE ver. 4.0) was investigated in patients receiving chemotherapy with oxaliplatin. RESULTS: Among 101 patients included in this study, 71 patients developed CTCAE ≥grade 1 peripheral neuropathy (grade 1, n = 67; grade 2, n = 4) at a median of 63 (range, 14-259) days after the start of treatment. Of the 67 patients with grade 1 peripheral neuropathy, 17 showed progression to ≥grade 2 neuropathy after a median interval of 84 (range, 21-246) days. Of these patients, 27 showed a positive result of the CLIP test at a median of 91 (range, 14-224) days, excluding one patient who already showed a positive result of the test at the baseline. Therefore, the risk ratio for the development of CTCAE ≥grade 2 peripheral neuropathy was 8.3 in the patients who showed a positive result on the CLIP test. Multivariate analysis confirmed that a positive results on the CLIP test was significantly correlated with the risk of future development of CTCAE ≥grade 2 peripheral neuropathy (odds ratio, 9.37; P = 0.002). CONCLUSION: A positive result on the CLIP test predict is predictive of the risk of progression of OIPN during chemotherapy with oxaliplatin.

[A case of hyperammonemia with encephalopathy related to FOLFIRI chemotherapy for advanced colon cancer].

A 50-year-old man undergoing operations for sigmoid colon cancer, small intestine invasion, and liver metastasis was given adjuvant chemotherapy postoperatively. During the course, lung, brain and bone metastasis were found, FOLFIRI therapy was started. Fifth FOLFIRI therapy was performed, but on the night of the next day, he was transported on an emergency basis to our hospital because of a coma. Laboratory examination revealed hyperammonemia, so aminoleban was started for its treatment. After 3 days in the hospital, consciousness and serum ammonia were improved. Cases of hyperammonemia caused by 5-FU have been reported in the literature, and this case was diagnosed with the same. Hyperammonemia should be taken into account as a differential diagnosis in the disturbance of consciousness in chemotherapy.