A new method using a vessel-sealing system provides coagulation effects to various types of bleeding with less thermal damage.

BACKGROUND: Hemostasis is very important for a safe surgery, particularly in endoscopic surgery. Accordingly, in the last decade, vessel-sealing systems became popular as hemostatic devices. However, their use is limited due to thermal damage to organs, such as intestines and nerves. We developed a new method for safe coagulation using a vessel-sealing system, termed flat coagulation (FC). This study aimed to evaluate the efficacy of this new FC method compared to conventional coagulation methods. METHODS: We evaluated the thermal damage caused by various energy devices, such as the vessel-sealing system (FC method using LigaSure™), ultrasonic scissors (Sonicision™), and monopolar electrosurgery (cut/coagulation/spray/soft coagulation (SC) mode), on porcine organs, including the small intestine and liver. Furthermore, we compared the hemostasis time between the FC method and conventional methods in the superficial bleeding model using porcine mesentery. RESULTS: FC caused less thermal damage than monopolar electrosurgery's SC mode in the porcine liver and small intestine (liver: mean depth of thermal damage, 1.91 ± 0.35 vs 3.37 ± 0.28 mm; p = 0.0015). In the superficial bleeding model, the hemostasis time of FC was significantly shorter than that of electrosurgery's SC mode (mean, 19.54 ± 22.51 s vs 44.99 ± 21.18 s; p = 0.0046). CONCLUSION: This study showed that the FC method caused less thermal damage to porcine small intestine and liver than conventional methods. This FC method could provide easier and faster coagulation of superficial bleeds compared to that achieved by electrosurgery's SC mode. Therefore, this study motivates for the use of this new method to achieve hemostasis with various types of bleeds involving internal organs during endoscopic surgeries.

Usefulness of evaluating hepatic elasticity using artificial acoustic radiation force ultrasonography before hepatectomy.

AIM: To evaluate hepatic fibrosis and tumor diagnosis preoperatively, we investigated the elasticity calculated by the new parameter of ultrasonography, acoustic radiation force impulse (ARFI). METHODS: We examined ARFI of the non-tumorous right and left lateral liver and in the tumor by push pulse of probe in 95 patients with hepatic malignancies undergoing hepatectomy. Measurement of ARFI as hepatic stiffness was indicated as the Vs (m/s). RESULTS: Measuring the Vs in the non-tumor region was achieved in the right liver in 99% and at the left lateral liver in 94%. The Vs in the right liver was significantly lower than in the left lateral liver, and the Vs of the liver tumor was significantly higher than in the non-tumorous liver. The Vs in the right and left lateral liver was correlated with the platelet count, aspartate aminotransferase, fibrotic indices and indocyanine green test. The Vs in the right liver was significantly correlated with the fibrotic marker or index. The Vs of liver cirrhosis and histological stage 4 in the right and left liver was significantly the highest compared to the others. The Vs in the right liver showed a high area under the receiver-operator curve value predicting histological fibrosis. The Vs in the right was significantly correlated with blood loss and postoperative complications, particularly uncontrolled ascites. CONCLUSION: Non-invasive ARFI imaging elastography is useful in evaluating impaired liver function or in the differential diagnosis of liver malignancies, highly hepatic fibrosis and in predicting posthepatectomy morbidity.

Predictive parameters of intraoperative blood loss in patients who underwent pancreatectomy.

BACKGROUND/AIMS: Despite recent advances in surgical techniques, blood loss is an important factor associated with postoperative outcomes in pancreatectomy. It is useful to identify risk factors of increased blood loss. METHODOLOGY: The clinical records of 161 patients who underwent an elective pancreatectomy for peripancreatic diseases between 1994 and March 2011 were retrospectively examined. Univariate and multivariate analysis of clinicopathological and surgical parameters influencing intraoperative blood loss were performed. We determined the cut-off value of the amount of blood loss based on the analyzed results. RESULTS: The mean and median blood loss was 1346±901 and 1070 mL, respectively. Red cell blood transfusion was performed in 72 patients (45%). Based on ROC analysis, the predictive value of blood loss in patients who received red cell blood transfusion was 880 mL (p <0.001); however, blood loss was not significantly associated with postoperative complications (p = 0.40). The cut-off level of estimated amount of blood loss in the present study was set at 880 mL. Male patients, fatty pancreas, higher serum alkaline phosphatase level, longer operating time, performance of pancreaticoduodenectomy (PD) and combined resections of adjacent major vessels were associated with significantly more increased blood loss (p <0.05). Based on multivariate analysis, longer operation time over 480 minutes and performance of PD were significantly associated with increased blood loss (p <0.05). CONCLUSIONS: Attempting to reduce operating time in cases of PD is necessary to reduce intraoperative blood loss.

Predictors of intraoperative blood loss in patients undergoing hepatectomy.

PURPOSE: Despite recent advances in surgical techniques, blood loss can still determine the postoperative outcome of hepatectomy. Thus, the preoperative identification of risk factors predicting increased blood loss is important. METHODS: We studied retrospectively the clinical records of 482 patients who underwent elective hepatectomy for liver disease, and analyzed the clinicopathological and surgical parameters influencing intraoperative blood loss. RESULTS: Red cell transfusion was required for 165 patients (35 %). Based on blood transfusion requirement and hepatic failure, we estimated predictive cut-off values at 850 and 1500 ml. The factors found to be significantly associated with increased blood loss were as follows: male gender, obstructive jaundice, non-metastatic liver carcinoma, Child-Pugh B disease, decreased uptake ratio on liver scintigraphy, platelet count, or prothrombin activity, longer hepatic transection time, operating time, the surgeon's technique, J-shape or median incision, major hepatectomy, and not using hemostatic devices (p < 0.05). Multivariate analysis identified male gender, low prothrombin activity, longer transection time, longer operation time, and not using hemostatic devices as factors independently associated with increased blood loss (p < 0.05). CONCLUSIONS: Male gender and low prothrombin activity represent risk factors for increased blood loss during hepatectomy. Moreover, every effort should be made to reduce the transection and operating times using the latest hemostatic devices.

Short- and Long-term Outcome After Gastric Cancer Resection in Patients Aged 80 Years and Older.

Background/Aim: We aimed to assess the risk factors for postoperative complications and long-term outcome of patients aged ≥80 years after curative resection for gastric cancer (GC). Patients and Methods: Patients aged ≥80 years who underwent curative gastrectomy for stage I-III GC between 2013 and 2020 were included. Clinical factors were retrospectively analyzed. Results: Of all 109 patients, 29 (26.6%) had 33 postoperative complications (Clavien-Dindo grade ≥2). The rate of postoperative complications was higher in those with greater blood loss (≥170 ml, p<0.001). In multivariate analysis, greater blood loss was confirmed as an independent predictor of postoperative complications (p<0.001). The 30-day, 180-day, 1-year, and 3-year cumulative overall survival rates were 100%, 97.0%, 91.6%, and 74.7%, respectively. Multivariate analysis showed postoperative complications (p=0.014) and low prognostic nutritional index (PNI, p=0.044) were independent prognostic factors for poor overall survival. Conclusion: Performing operations with less bleeding is important to reduce postoperative complications. According to the analysis of long-term survival, patients who experience postoperative complications and patients with a low preoperative PNI require special attention in the follow-up period. Nutritional support should be considered in patients with malnutrition.

Short- and long-term survival after curative resection for colorectal cancer in nonagenarian patients.

BACKGROUND/OBJECTIVE: With increased life expectancy, the incidence of colorectal cancer in oldest-old patients has been rising. Advanced age is a risk factor for adverse outcomes after surgery. This study aimed to evaluate the short- and long-term outcomes of curative resection for colorectal cancer in nonagenarians. METHODS: Patients who had undergone curative resection for colorectal cancer (CRC) at Stage I to III from January 2010 to December 2019 were included. Cases of emergent surgery were excluded. The clinical characteristics were documented retrospectively, and factors affecting the long-term outcome were analyzed using multivariate analysis. RESULTS: Fifty patients met the selection criteria. Most of them were women (58.0%), and the median age was 92 years. Among these patients, 29 (58.0%) had a poor performance status (ASA-PS≥3). Laparoscopic surgery was performed in 42.0% of the patients, and 50% of the patients had postoperative complications classified as Clavien-Dindo grade 2 or severer, including 3 patients (6.0%) with grade 3 disease. No postoperative mortality occurred. The 30-day, 180-day, 1-year, 3-year and 5-year survival rates were 100%, 80.4%, 71.0%, 46.3%, and 33.8%, respectively. Multivariate analysis showed that a preoperative poor performance status (ASA-PS≥3) (HR: 3.067; 95% CI: 1.220-7.709; p = 0.017) was an independent prognostic factor for OS. CONCLUSION: Curative elective resections for CRC in nonagenarians were performed safely without postoperative mortality. The preoperative performance status was significantly associated with OS after curative elective resection of colorectal cancer in nonagenarians. Our results suggest that excellent long-term outcomes can be achieved in a selected group with a good performance status.

Usefulness of 18F-fluorodeoxyglucose positron emission tomography for assessment of tumorviability after resection of granulocyte-colony-stimulating-factor -Producing cholangiocarcinoma-a case report.

INTRODUCTION AND IMPORTANCE: Granulocyte colony-stimulating factor (G-CSF)-producing intrahepatic cholangiocarcinoma is rare. Surgical cases with postoperative clinical course have rarely been reported. CASE PRESENTATION: A 63-year-old woman complained upper abdominal pain. Computed tomography (CT) showed intrahepatic mass measuring 9 × 9 × 9 cm in the left lateral segment. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed high uptake by the tumor, with diffuse uptake in the bone marrow. An extended left lobectomy was performed to achieve complete resection. Histopathological examination showed poorly differentiated adenocarcinoma with no lymph node metastasis. Immunohistochemical analysis revealed that tumor cells produced G-CSF. After chemotherapy with S-1 regimen at 10 months after the operation, CT and FDG-PET detected lymph node metastasis in the peri-duodenal area and left kidney metastasis, with no FDG uptake in the bone marrow. Serum G-CSF was normal. Combination chemotherapy with gemcitabine plus cisplatin was administered, and, 12 months after liver resection, metastases were enlarged and FDG uptake in the bone marrow was detected again. Serum G-CSF was elevated at 71.6 pg/mL. The patient was enrolled in a clinical trial of chemotherapy with another regimen and was alive at 19 months after liver resection. CLINICAL DISCUSSION: Because of rapid progression, rapid diagnosis and resection are important. FDG uptake in the bone marrow is characteristic in G-CSF producing tumor. In this case, FDG uptake in the bone marrow reappeared after the enlargement of recurrent lesions, followed by tumor enlargement. CONCLUSION: FDG-PET was useful for differential diagnosis and to assess tumor viability and determine the surgical indication.

Postoperative Complications Predict Long-term Outcome After Curative Resection for Perforated Colorectal Cancer.

BACKGROUND/AIM: Perforation and postoperative complications have a negative effect on long-term outcomes in patients with colorectal cancer (CRC). The aim of this study was to evaluate the clinical factors with special reference to postoperative complications predicting the long-term outcome in those for whom curative resection for perforated CRC was performed. PATIENTS AND METHODS: Patients who underwent curative resection for perforated CRC at stage II or III from April 2003 to March 2020 were included. Clinical factors were retrospectively analyzed. RESULTS: Forty-four patients met the selection criteria. The 30-day mortality rate was 4.5% and the complication rate was 47.7%. Excluding 30-day mortality, five-year recurrence-free survival (RFS) and overall survival (OS) were 62.3% and 73.6%, respectively. Multivariate analysis showed that postoperative complications (p=0.005) and pT4 pathological factor (p=0.009) were independent prognostic factors for RFS. Only postoperative complications (p=0.023) were an independent prognostic factor for OS. CONCLUSION: Postoperative complications were significantly associated with RFS and OS, and pT4 was associated with RFS. The prevention and management of postoperative adverse events may be important for perforated CRC.

Safe laparoscopic resection of a giant schwannoma in the retroperitoneum using a fluorescent ureteral stent: a case report.

Schwannomas that occur in the retroperitoneal cavity are rare. We herein report a patient who underwent safe laparoscopic resection by using a preoperative 3D computed tomography (CT) image and a fluorescent ureteral stent during the surgery. A 47-year-old man presented with left lower abdominal pain. CT showed a 10-cm continuous retroperitoneal tumor originating at the third lumbar nerve in the lower left abdomen. Schwannoma was suspected. We underwent laparoscopic resection of the tumor guided by 3D images obtained preoperatively. A fluorescent ureteral stent was implanted during the surgery to improve visibility and protect the left ureter. The resection was completed without injury of other organs and vessels. The patient was discharged on postoperative Day 5. By performing a preoperative simulation using 3D CT images, we could anticipate the anatomical findings and easily identify them intraoperatively. In addition, the fluorescent ureteral stent provided visual support, thereby contributing to safe surgery.

Long-Term Prognosis after Surgery for Locally Recurrent Rectal Cancer: A Retrospective Study.

OBJECTIVE: Resection is usually recommended for locally recurrent rectal cancer (LRRC) for which R0 resection is possible, but its suitability varies by individual patient risk. Here, we report outcomes of resected LRRC in our hospital. METHODS: We retrospectively evaluated short- and long-term results of 33 patients who underwent resections for LRRC from January 2003 to December 2019. RESULTS: At the initial surgeries for these 33 patients, their disease stages at that time were Stage I: n=2, Stage II: n=12, Stage III: n=11, Stage IV: n=6, and unknown: n=2. Patients with Stage IV disease at their initial surgeries underwent radical one-step or two-step procedures. Metastasis to other organs was observed in 5 patients at the their initial LRRC diagnoses. At the LRRC surgeries, 7 patients received palliative surgeries; 26 received intent-to-treat resections, of which 17 were R0 resections. All-grade postoperative complications were observed in 11 patients, including 1 surgery-related death. Five-year overall survival rates were all cases: 38.4%; R0 group: 52.3%, R1 or R2 group: 19.4%, and palliative surgery group: 0%. The R0 group thus had significantly better prognosis than other patients (P = 0.0012). Eleven patients in the R0 group (64.7%) suffered re-recurrences but some patients achieved long-term survival through chemotherapy, radiation therapy, and surgery for metastasis to other organs, even after re-recurrence. CONCLUSION: Long-term prognosis after surgery for LRRC was significantly better for patients with R0 margins. Multimodal treatments may greatly improve survival for patients who suffer re-recurrences after local recurrence resections.

[Radiofrequency (RF) ablation for liver metastases of colorectal cancer].

PURPOSE: To evaluate the effectiveness of radiofrequency ablation (RFA) for liver metastases of colorectal cancer. METHODS: RFA was used to treat 31 tumors (median diameter 1.5 cm, range 0.5-3.9 cm) in 13 patients of liver metastases of colorectal cancer. The median number of tumors treated per patient was 2. 9 (range, 1-10). RESULTS: Two patients had complications; bleeding and liver dysfunction. Four (12.9%) of 31 lesions developed a local recurrence after the treatment. We achieved a local control in 2 (92.6%) of 27 lesions <3.0 cm in diameter. In 4 (30.8%) of 13 patients, new metastases were observed at follow-up. One year survival rate from the initial ablation was 92.3% and 2-year was 46.2%. One year total local recurrence rate from the initial ablation was 55.6%. CONCLUSION: In the case of tumor greater than 3 cm, RF ablation is an effective method to treat hepatic metastases from colorectal carcinoma.

Acute perforating appendicitis caused by metastatic squamous cell carcinoma from the lung: A case report.

INTRODUCTION: Lung cancer is one of the most common cancers. On the other hand, lung cancer metastasis to the appendix is extremely rare, and in many cases it has been diagnosed with the onset of acute perforating appendicitis. PRESENTATION OF CASE: An 85-year-old man with fever and abdominal pain visited our hospital. He had a history of squamous cell carcinoma of the left upper and lower lobes, metastasis to the ipsilateral lung and femur. CT showed that a finding of acute perforating appendicitis, emergency cecal resection was performed. Examination of the resected specimen showed that the appendix was thickened overall, with a white nodular structure at the root and a perforation in the middle. The final diagnosis was acute perforating appendicitis caused by metastatic squamous cell carcinoma from the lung. The patient had no particular problems during the postoperative course. DISCUSSION: A PubMed search was performed, this appears to be the first reported case of appendiceal metastasis of squamous cell carcinoma of the lung. Since squamous cell carcinoma of the lung has a stronger tendency for local extension than other histological types, perforating appendicitis due to distant metastasis to the abdominal organs and metastasis to the appendix was reported as a very valuable case. CONCLUSION: Because the progression of concomitant or secondary appendicitis is rapid, we recommend frequent imaging modalities, prophylactic appendectomy be considered for patients who also have lung cancer and imaging findings show suspected metastasis to the appendix.

Clinical significance of the C-reactive protein-to-albumin ratio for the prognosis of patients with esophageal squamous cell carcinoma.

The aim of the present study was to investigate the prognostic value of the C-reactive protein-to-albumin ratio (CAR) and compare it with other inflammation-based prognostic scores (Glasgow prognostic score, modified Glasgow prognostic score, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutritional index and prognostic index) in patients with esophageal squamous cell cancer (ESCC). A database of 116 patients with primary ESCC who underwent treatment at the Division of Surgical Oncology at Nagasaki University Hospital between January 2007 and August 2014 was retrospectively reviewed and the correlations between CAR and overall survival (OS) were investigated. Kaplan-Meier and Cox regression analyses were used to assess independent prognostic factors. The area under the curve (AUC) was used to compare the prognostic value of different scores. According to the receiver operator characteristics analysis, the recommended cut-off value for CAR was 0.042, with an AUC of 0.678 (sensitivity 31.1%, specificity 66.7%). Thus, patients were dichotomized into low (<0.042) and high (≥0.042) CAR groups. On multivariate analysis, CAR was found to be significantly associated with OS in patients with ESCC [hazard ratio (HR)=2.350; 95% confidence interval (CI): 1.189-4.650; P=0.014], as was tumor-node-metastasis stage (HR=3.059; 95% CI: 1.422-6.582; P=0.004). In addition, CAR had a higher AUC value (0.678) compared with several other systemic inflammation-based prognostic scores (P<0.001). This study suggested that CAR is a novel and promising inflammation-based prognostic score in patients with ESCC. Due to its simplicity, affordability and availability, CAR may be important for improving clinical decision-making and may contribute to more rational study design and analyses.

Clinical Value of Serum p53 Antibody in the Diagnosis and Prognosis of Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: Identifying useful biomarkers is central to selecting optimal therapeutic strategies for esophageal squamous cell carcinoma (ESCC). Serum p53 antibody (S-p53Ab), squamous cell carcinoma antigen (SCC-Ag), and carcinoembryonic antigen (CEA) were investigated to evaluate the significance of single and combined tumor markers in determining the diagnosis and prognosis of ESCC. MATERIALS AND METHODS: Serum samples were obtained preoperatively from 133 patients with histologically-confirmed ESCC, including 32 patients with stage I (24.1%). Levels of S-p53Ab were assessed by enzyme-linked immunosorbent assay, using a new version of a highly specific, quantitative kit. The cut-off value for S-p53Ab was 1.3 U/ml. RESULTS: S-p53Ab was detected in 39.1% (52 out of 133) of patients with ESCC, including 40.0% (20 out of 50) of patients with early-stage ESCC. Positive rates for S-p53Ab, CEA, and SCC-Ag among patients with stage I ESCC (n=32) were 40.6%, 12.5%, and 31.3%, respectively. Positivity for S-p53Ab was not associated with positivity for CEA or SCC-Ag (p=0.249 and 0.747, respectively). The positive rate for diagnosis of ESCC increased from 39.1% to 65.4% when S-p53Ab was combined with SCC-Ag in this study. We found no significant correlation between the presence of S-p53Ab in ESCC and overall survival. Conversely, Cox regression analysis revealed that the International Union Against Cancer/TNM classification and systemic inflammation score were independent prognostic factors for ESCC in this series (hazard ratio(HR)=3.811, 95% confidence interval(CI)=1.548-9.378, p=0.004; and HR=2.218; 95% CI=1.087-4.523, p=0.029, respectively). Kaplan-Meier analysis revealed significant differences between patients with elevated S-p53Ab and SCC-Ag and patients with elevated levels of only one or neither of these factors (p=0.009). CONCLUSION: The diagnostic rate with S-p53Ab was better than that with SCC-Ag and CEA in patients with early-stage ESCC. Combined detection of S-p53Ab and SCC-Ag can markedly improve diagnostic sensitivity and may permit more accurate stratification of patients with ESCC.

Liver resection for metastases of tracheal adenoid cystic carcinoma: Report of two cases.

INTRODUCTION: Tracheal adenoid cystic carcinoma (ACC) is rare and accounts for <1% of all lung cancers. Although ACC is classified as a low-grade tumor, metastases are frequently identified in the late period. Extrapulmonary metastases are rare, and their resection has rarely been reported. PRESENTATION OF CASE: Case 1: A 77-year-old man underwent tracheal resection for ACC with postoperative radiation (60 Gy) 14 years before　(at the age of 63). He underwent two subsequent pulmonary resections for metastases. Fourteen years after the first operation, he underwent extended right posterior segmentectomy with resection of segment IV and radiofrequency ablation for metastases of ACC to the liver. He was diagnosed with metastases to the kidney with peritoneal dissemination 4 years after the liver resection and died of pneumonia 2 years later. Case 2: A 53-year-old woman underwent a two-stage operation involving tracheal resection for ACC and partial resection of liver segments II and V for metastases of ACC to the liver. The tracheal margin was histopathologically positive. Postoperative radiation was performed, and she was tumor-free for 10 months after the liver resection. DISCUSSION: Complete resection of tracheal ACC provides better survival. Radiotherapy is also recommended. However, the optimal treatment for metastases of ACC is unclear, especially because liver resection for metastases of tracheal ACC is rarely reported. Our two cases of metastases of tracheal ACC were surgically managed with good outcomes. CONCLUSION: Liver resection for metastases of tracheal ACC may contribute to long survival.

Unusually high levels of serum p53 antibody in recurrent gastric cancer.

Serum tumor markers in patients with cancer assist with establishing diagnosis, estimating prognosis, monitoring treatment, and detecting tumor recurrence. Changes in the p53 tumor suppressor gene are the most common genetic abnormalities in many different human malignancies. Several studies have demonstrated that serum p53 antibodies (S-p53Ab) comprise an early marker of malignant disease, a marker for treatment effects and a prognostic factor for patients with several types of tumors. We recently reported that S-p53Ab is useful for patients with gastric cancer. We describe a rare situation in which unusually high serum p53 antibodies helped to detect recurrent gastric cancer in the small intestine after gastrectomy. Further studies are required to gain a more precise understanding of the clinical impact of S-p53Ab titer monitoring in gastric cancer.

Single-incision laparoscopic ileocecal resection using an organ retractor.

INTRODUCTION: Single-incision laparoscopic surgery has been reported to be a safe and feasible technique for colorectal cancer. However, the technique needs skill due to the limitations of the device. An organ retractor is a new grasp device that has the potential to overcome these limitations. PRESENTATION OF CASE: A 63-year-old woman with a tumor palpated in the right lower quadrant of the abdomen presented to hospital. Colonoscopy showed a type 2 mass with nearly complete stenosis, and a biopsy specimen showed well-differentiated adenocarcinoma. Single-incision laparoscopic surgery ileocecal resection was performed using an organ retractor. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted. An organ retractor was used for hepatocolic ligament resection, resection of the ileocolic vessels, and resection of the insertion of the mesentery proper. For each resection, the trailer line's tension was adjusted to provide a good operative view. The patient's postoperative course was good, and she was discharged 7days after surgery. DISCUSSION: An organ retractor was effective for single-incision laparoscopic surgery technique not only to maintain a good operative view, but also to change trailer line tension, which enabled safe dissection. CONCLUSION: An organ retractor could facilitate single-incision laparoscopic surgery.

Clinical Significance of Serum p53 Antibody in the Early Detection and Poor Prognosis of Gastric Cancer.

BACKGROUND: The aim of this retrospective study was to evaluate the clinical relevance of serum p53 antibody (S-p53Ab) as a biomarker and to investigate whether its diagnostic value could be improved when combined with other biomarkers of gastric cancer (GC). PATIENTS AND METHODS: Serum samples were obtained preoperatively from 208 patients with histologically-confirmed GC, including 126 stage I patients (60.6%). Levels of S-p53Ab were assessed by a commercial laboratory using an anti-p53 detection kit. The cut-off value for S-p53Ab was 1.3 U/ml. RESULTS: S-p53Ab was detected in 16.3% (34 of 208) of patients with GC, including 13.6% (22 of 162) of patients with early-stage GC. The positive rates for S-p53Ab, carbohydrate antigen 19-9 (CA19-9), and carcinoembryonic antigen (CEA) of patients with stage I GC were 10.3% (13/126), 2.4% (3/126), and 8.7% (11/126), respectively. Positivity for S-p53Ab was not associated with CA19-9 or CEA positivity (p=0.098 and 0.053, respectively). The positive rate for a diagnosis of GC increased from 16.3% to 29.3% when S-p53-Ab was combined with CEA in this study. We found no significant correlation between the presence of S-p53Ab in GC and overall survival. Conversely, Cox regression analysis revealed that a high level of CA19-9 was an independent prognostic factor for GC in this series (hazard ratio(HR)=3.864; 95% confidence interval(CI)= 1.248-11.959; p=0.019). Kaplan-Meier analyses demonstrated significant differences in survival between patients with elevated levels of both S-p53Ab and CEA and those with elevated levels of only one or neither. CONCLUSION: The diagnostic rate of S-p53Ab was better than that of CA19-9 and CEA in patients with stage I GC. Combined detection of S-p53Ab and CEA may improve the diagnostic sensitivity and may permit more accurate stratification of GC patients.

A case of multiple synchronous quadruple cancers of the stomach, sigmoid colon, rectum, and pancreas.

INTRODUCTION: Multiple primary neoplasms are relatively rare, but their incidence has increased because of aging and improvements in diagnostic imaging. PRESENTATION OF CASE: A 67-year-old man presented with epigastric pain. On upper gastrointestinal endoscopy, an ulcer was seen at the gastric angle, and biopsy showed moderately differentiated adenocarcinoma (AC). Colonoscopy demonstrated a 15-mm lesion in the sigmoid colon and a submucosal lesion in the lower rectum. The biopsy showed well differentiated AC and neuroendocrine tumor (NET). In addition, abdominal CT and MRI showed a 14-mm nodular lesion in the pancreatic body suggesting pancreatic duct cancer. Based on the above findings, four synchronous cancers, including the pancreas, stomach, sigmoid colon and rectum, were diagnosed, and surgery was performed. A midline incision was made in the upper abdomen, and a distal gastrectomy, pancreatic body and tail resection, and sigmoidectomy were performed. Trans-anal tumor resection was performed for the rectal lesion. Histopathology showed invasive pancreatic duct cancer, moderately differentiated AC of the stomach, moderately differentiated AC of the sigmoid colon, and NET G1 of the rectum. The patient had no postoperative complications, 4 years 3 months after resection, and he was disease-free from all of the cancers. DISCUSSION: The strategy of perioperative diagnosis and treatment for multiple primary tumors is usually difficult. This process was performed by consulting a cancer board, which could be useful as a practice guideline. CONCLUSION: This patient in whom four tumors were completely resected at the same time and who has had a good clinical course was reported.

A case of single-incision laparoscopic surgery for a bleeding Meckel's diverticulum diagnosed pre-operatively by double-balloon endoscopy.

INTRODUCTION: 　Meckel's diverticulum (MD) is a congenital true diverticulum that is residual yolk duct tissue, and some cases with complications require surgery. It has been reported that laparoscopic surgery is effective for patients with an MD. PRESENTATION OF CASE: A 79-year-old man with melena visited our hospital. Upper gastrointestinal series and colonoscopy showed no bleeding lesion. Double-balloon endoscopy was then performed to examine the small intestine. The examination showed a large diverticulum 80cm proximal to the ileocecal valve and a circular ulcer. MD resection was performed using single-incision laparoscopic surgery (SILS) technique through a 3-cm zig-zag incision in the umbilicus. Three ports were inserted for the scope and forceps devices. The MD was located 80cm proximal to the ileocecal valve. There were no other intestinal lesions. From the wound, the lesion could be easily moved outside the body. The MD including the ulcer lesion was then resected. The patient's postoperative course was good, and he rarely felt wound pain. He started dietary intake three days after surgery and was discharged from hospital eight days after surgery. DISCUSSION: SILS technique has attracted attention in the field of laparoscopic surgery. Using a single port with multiple working channels, SILS can reduce the number of incisions and the rates of incisional hernia port site-related complications, as well as improve cosmesis. CONCLUSION: A definite diagnosis of an MD was made by double-balloon endoscopy preoperatively. The SILS approach was effective for cosmesis, postoperative pain, and a shortened hospital stay.