[Collision Tumor Involving Primary Ascending Colon Cancer and Malignant Lymphoma].

A 78-year-old male was diagnosed with a primary gastric B-cell malignant lymphoma and metastatic lung tumor 10 years ago. He underwent chemotherapy at another hospital, achieved complete remission, and was actively undergoing follow- up. He presented to our hospital with a 1-month history of a bulge in his right lower abdomen. CT revealed thickening of the ascending colon and dilatation of the oral intestine. He was diagnosed with ascending colon cancer and underwent right hemicolectomy. The subsequent pathological examination revealed a collision tumor involving diffuse, large B-cell lymphoma and well-differentiated adenocarcinoma. He was discharged from our hospital and received chemotherapy at another institution. Unfortunately, the patient died of interstitial pneumonia 31 months postoperatively. This report describes the resection of a collision tumor involving ascending colon cancer and malignant lymphoma. Surgical treatment combined with postoperative chemotherapy improved this patient's long-term survival.

Acceptability and feasibility of S-1 plus cisplatin adjuvant chemotherapy for completely resected non-small cell lung cancer: an open-label, single arm, multicenter, phase 2 trial.

BACKGROUND: Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC. METHODS: Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m2 on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS). RESULTS: A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m2; 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%. CONCLUSIONS: This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy. TRIAL REGISTRATION: This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

Impact of postoperative remote infection on length of stay and medical costs in hospitals in Japan.

PURPOSE: To analyze the impact of postoperative remote infections (PRIs) on medical expenditure. METHODS: The subjects of this retrospective study were 338 patients who had undergone gastroenterological surgery at one of the 20 Japanese institutions within the Japan Society for Surgical Infection (JSSI) and mainly authorized as educational institutions. The patients were allocated to 169 pairs of those with a PRI (PRI (+) group) matched with those without a PRI (PRI (-) group). PRIs included pneumonia, urinary tract infection (UTI), catheter-associated blood stream infection (CA-BSI), and antibiotic-associated enteritis. RESULTS: SSI developed in 74 of the 338 patients (22 without PRI and 52 with PRI). The SSI incidence was significantly higher in the PRI (+) group (p < 0.001). The difference in the median postoperative length of hospital stay was 15 days, indicating a significant prolongation in the PRI (+) group (p < 0.001). The PRI (+) group also had a higher rate of inter-hospital transfer (p < 0.01) and mortality (p < 0.001). Similarly, the difference in median postoperative medical fees was $6832.3, representing a significant increase in the PRI (+) group (p < 0.001). CONCLUSIONS: The postoperative length of hospital stay is longer and the postoperative medical expenditure is higher for patients with a PRI than for those without a PRI.

Successful perioperative infection control measures after gastroenterological surgery reduced the number of cases of methicillin-resistant Staphylococcus aureus or Clostridioides (Clostridium) difficile infection to almost zero over a 30-year period: a single-department experience.

PURPOSE: To investigate changes in the incidence of postoperative infections in the surgical department of a teaching hospital. METHODS: During the 30-year period from September 1987 to August 2017, 11,568 gastroenterological surgical procedures were performed in our surgical department. This 30-year period was divided into seven periods (A-G), ranging from 2 to 7 years each and based on the infection control methods used in each period. We then compared the rates of incisional surgical site infection (SSI) and organ/space SSI; remote infection (RI) including respiratory tract infection (RTI), intravascular catheter-related infection, and urinary tract infection (UTI); and antibiotic-associated colitis caused by methicillin-resistant Staphylococcus aureus (MRSA) enteritis or Clostridioides (Clostridium) difficile-associated disease (CDAD) among the seven periods. RESULTS: In periods B (September 1990-August 1997) and E (November 2004-July 2007), when a unique antibiotic therapy devised in our department was in use, MRSA was isolated from only 0.3% and 0.4% of surgical patients, respectively, and these rates were significantly lower than those in the other periods (p < 0.05). The rate of CDAD increased during period F (August 2007-July 2014), but in period G (August 2014-August 2017), restrictions were placed on the use of antibiotics with a strong anti-anaerobic action and, in this period, the rate of CDAD was only 0.04%, which was significantly lower than that in period F (p < 0.05). CONCLUSIONS: Limiting the use of antibiotics that tend to disrupt the intestinal flora may reduce the rates of MRSA infection and CDAD after gastroenterological surgery.

Adherence and feasibility of 2 treatment schedules of S-1 as adjuvant chemotherapy for patients with completely resected advanced lung cancer: a multicenter randomized controlled trial.

BACKGROUND: We conducted a multicenter randomized study of adjuvant S-1 administration schedules for surgically treated pathological stage IB-IIIA non-small cell lung cancer patients. METHODS: Patients receiving curative surgical resection were centrally randomized to arm A (4 weeks of oral S-1 and a 2-week rest over 12 months) or arm B (2 weeks of S-1 and a 1-week rest over 12 months). The primary endpoints were completion of the scheduled adjuvant chemotherapy over 12 months, and the secondary endpoints were relative total administration dose, toxicity, and 3-year disease-free survival. RESULTS: From April 2005 to January 2012, 80 patients were enrolled, of whom 78 patients were eligible and assessable. The planned S-1 administration over 12 months was accomplished to 28 patients in 38 arm A patients (73.7%) and to 18 patients in 40 arm B patients (45.0%, p = 0.01). The average relative dose intensity was 77.2% for arm A and 58.4% for arm B (p = 0.01). Drug-related grade 3 adverse events were recorded for 11% of arm A and 5% of arm B (p = 0.43). Grade 1-3 elevation of bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine transaminase were more frequently recorded in arm A than in arm B. The 3-year disease-free survival rate was 79.0% for arm A and 79.3% for arm B (p = 0.94). CONCLUSIONS: The superiority of feasibility of the shorter schedule was not recognized in the present study. The conventional schedule showed higher completion rates over 12 months (p = 0.01) and relative dose intensity of S-1 (p = 0.01). Toxicity showed no significant difference among the shorter schedule and the conventional schedule, except for grade 1-3 elevation of bilirubin. TRIAL REGISTRATION: This randomized multicenter study was retrospectively registered with the UMIN-CTR (UMIN000016086, registration date December 30, 2014).

Neutrophil/lymphocyte ratio has a prognostic value for patients with terminal cancer.

BACKGROUND: Determining prognosis in advanced cancer is of key importance. Various prognostic scores have been developed. However, they are often very complex. In this study, we evaluated the feasibility of neutrophil/lymphocyte ratio (NLR) as an index to estimate survival in terminal cancer patients. METHODS: NLR was calculated retrospectively based on blood tests performed at 3 months, 2 months, 4 weeks, 3 weeks, 2 weeks, 1 week, and within 3 days before death in 160 cancer patients (82 men, 78 women; age range, 33-99 years; mean age, 69.8 years). RESULTS: NLR increased significantly with time (P < 0.0001). Mean NLR was significantly higher in patients who died within 4 weeks (29.82) than in those who lived more than 4 weeks (6.15). The NLR cutoff point was set at 9.21 according to receiver operating characteristic curve analysis (area under the curve, 0.82; 95% confidence interval, 0.79-0.85). We inferred that life expectancy would be <4 weeks when NLR >9.21. The sensitivity, specificity, positive predictive value, and negative predictive value were 65.6, 84.1, 90.6, and 51.1%, respectively. The positive and negative likelihood ratios were 4.125 and 0.409, respectively. CONCLUSIONS: NLR appears to be a useful and simple parameter to predict the clinical outcomes of patients with terminal cancer.

Risk factors for conversion of laparoscopic cholecystectomy to open surgery associated with the severity characteristics according to the Tokyo guidelines.

PURPOSE: The aim of this retrospective study was to identify the risk factors associated with the severity characteristics in the Tokyo guidelines for conversion to open surgery in patients with acute cholecystitis (AC) who underwent laparoscopic cholecystectomy. METHODS: A total of 225 patients were enrolled in the study. The patients were classified into two groups: a conversion group and a no-conversion group. The preoperative characteristics and therapeutic strategy were analyzed as risk factors for conversion to open surgery. The postoperative outcomes were also analyzed. RESULTS: Conversion to open surgery occurred in 29 patients (12.9%), including seven patients (6.7%) with mild AC and 22 patients (18.5%) with moderate AC. A univariate analysis showed that the risk factors for conversion to open surgery included a duration of symptoms longer than 72 h, an elevated C-reactive protein (CRP) value and the Tokyo guidelines 2013 (TG 13) severity classification. The multivariate analysis showed that the risk factors for conversion to open surgery included a duration of symptoms longer than 72 h and a CRP value >11.5 mg/dl. CONCLUSIONS: A duration of symptoms longer than 72 h, which is included in the criterion for moderate AC severity in the TG 13, was an independent risk factor for conversion to open surgery. In addition, adoption of a high CRP value as an additional criterion for moderate AC may increase the utility of the TG 13.

Video-assisted thoracoscopic surgery for ectopic middle mediastinal thymoma in a patient with myasthenia gravis.

We present a rare case of middle mediastinal thymoma with myasthenia gravis. A 51-year-old man presented with right ptosis and muscle weakness, and received a diagnosis of generalized myasthenia gravis. Computed tomography of the chest showed a 20-mm nodule in the middle mediastinum, suggesting a possible ectopic thymoma. He underwent video-assisted thoracoscopic extended thymectomy and resection of the tumor. Histologic examination revealed an ectopic thymoma and ectopic thymic tissue around the tumor. One year after the operation, his condition remains well controlled solely with tacrolimus. Careful preoperative radiologic examination concerning possible ectopic thymoma outside the dissection area of the extended thymectomy is recommended.

Combined hepatic resection with the inferior vena cava and diaphragm and reconstruction using an equine pericardial patch: report of a case.

We herein report a case of combined hepatic resection with inferior vena cava (IVC) and diaphragm resection, and reconstruction using an equine pericardial patch. A 54-year-old woman showed hepatic cancer recurrence on radiological imaging, with invasion to the caudate lobe of the liver, IVC, diaphragm, and adrenal gland. We resected 10 × 5 cm of the diaphragm. After dissecting the hepatic parenchyma, the caudate lobe was connected only to the IVC. Clamping of the IVC was performed between the IVC below the confluence of the hepatic vein and the suprarenal IVC. A 6 × 3-cm segment of the IVC was then resected. The IVC and diaphragm were reconstructed using an equine pericardial patch, as both defects were too large to repair without a patch. The equine pericardium represents a suitable graft material for repairing both the IVC and diaphragm. Further investigation is needed to determine the durability and anti-infection properties of equine pericardial grafts.

Twenty years of countermeasures against postoperative methicillin-resistant Staphylococcus aureus infections.

PURPOSE: A total of 7345 cases of digestive organ surgery were investigated over the course of 20 years. METHODS: Owing to the increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections, we classified our countermeasures into periods A (September 1987 to February 1990), B (March 1990 to February 1997), C (March 1997 to February 1999), D (March 1999 to October 2004), and E (November 2004 to August 2007), and compared the number of infections during these periods. In period B, cefazolin and cefotiam were administered as prophylaxis. The treatment continued for 4 days, including the day of surgery. The patients undergoing endotracheal intubation or tracheotomy were managed with nonscreening pre-emptive isolation and cohorting (NSPEI&C), regardless of whether MRSA was present. However, NSPEI&C was halted in period C, but it was thereafter implemented again, and prophylactic antibiotics were administered only on the day of surgery during period D. In period E, prophylactic antibiotics were administered for 3 days. RESULTS: In period A, MRSA was contracted in 4.1% (34/833) of patients. In period B, the MRSA isolation rate decreased to 0.3% (8/2722). In period C, the MRSA isolation rate increased to 3.4% (23/681). In period D, the MRSA isolation rate fell to 2.2% (40/1807). In period E, MRSA isolation cases significantly decreased to 0.4% (5/1302; P < 0.002 vs period D). CONCLUSION: The comprehensive management, selection of prophylactic antibiotics, and NSPEI&C were all considered to be effective.

Antibiotic time-lag combination therapy with fosfomycin for postoperative intra-abdominal abscesses.

The first-line treatment for intra-abdominal abscess is source control. Sometimes, however, source control is too invasive for relatively small abscesses and is not feasible due to the risk of injury to some organs. Based on reports that fosfomycin (FOM) can break up biofilms to enhance the permeability of other antibiotics, we investigated the FOM time-lag combination therapy (FOM-TLCT). We enrolled 114 patients who had intra-abdominal abscess after gastrointestinal surgery and examined the efficacy of FOM-TLCT using the same therapeutic antibiotic (TA) as that which had been used previously, but had proven ineffective, at the same dose schedule. The efficacy endpoint determination was carried out as follows: among the systemic inflammatory response syndrome (SIRS)-positive cases, even after administration of TA, excellent outcome was defined as SIRS negative within 7 days of FOM-TLCT with TA without the need for other treatment, including other antibiotics or drainage. Of the 114 patients enrolled, 104 cases (SIRS positive 73; SIRS negative 31) were assessed. Ten patients were excluded; four had received TA at higher doses, three had received different TAs, and three were considered to have bacteria resistant to TAs. Among these patients, 86.3% (63/73) of the SIRS-positive cases were classified as excellent, and 90.3% (28/31) of the SIRS-negative cases were classified as effective. In total, the efficacy rate was 87.5% (91/104). The total no-response rates were 12.5% (13/104). FOM-TLCT seems to be effective for treating refractory intra-abdominal abscess.

[A case of locally recurrent breast cancer in which phlebothrombosis of the right leg after hormonal therapy using a high dose of toremifene citrate].

A 72-year-old female had undergone mastectomy at the age of 67 for right breast cancer (T2a, n1 alpha, positive for ER). In the surgery the pectoralis muscle was preserved. For adjuvant therapy, 20 mg/day of tamoxifen was orally administered for 5 years. Six years after surgery, relapse was detected in the right major pectoralis muscle. Irradiation at this site and oral administration of 120 mg/day of toremifene citrate were started. The patient had a medical history of diabetes, and the control of her blood sugar was poor. About 2 months after oral administration of toremifene citrate was started, flares with blebs and swelling were observed in the right lower leg, suggesting acute phlebothrombosis of the right lower limb. The symptoms were ameliorated by intravenous administration of heparin and an antibiotic. In administering a high dose of toremifene citrate to patients with complications, careful follow-up is needed.