[A Case Report of Esophageal Cancer Accompanied with Esophago-Bronchial Fistula Which Treated Using Multimodal Therapy Including Esophageal Bypass Surgery].

We report the case of a patient with esophageal cancer accompanied by esophago-bronchial fistula and pneumonia, who experienced improved quality of life following multimodal therapy that included esophageal bypass surgery. A 56-year-old man was diagnosed with advanced esophageal cancer with an esophago-bronchial fistula on computed tomography scan. He underwent esophageal bypass surgery followed by definitive chemoradiotherapy. He started eating 12 days after the surgery and was discharged home after the completion of chemoradiotherapy. On follow-up, the primary lesion was found to be significantly decreased in size and the esophago-bronchial fistula was closed. Although the patient ultimately died owing to distant metastases, he enjoyed a prolonged period of survival following surgery. Multimodal therapy including esophageal bypass surgery is an useful strategy for treating patients with critical conditions such as esophago-bronchial fistula induced by esophageal cancer.

[A Case of Laparoscopic Ileocecal Resection for Ascending Colon Cancer with Portosystemic Shunt].

A 72-year-old woman who underwent colorectal endoscopy because of positive fecal occult blood test results was diagnosed with ascending colon cancer.Preoperative CT revealed advanced ascending colon cancer and portosystemic shunt between the ileocecal vein and inferior vena cava.It was necessary to cut the shunt when ileocecal resection was performed. The patient had no symptoms caused by the shunt, and blood examination results showed no liver enzyme abnormalities. Abdominal ultrasound examination revealed no liver cirrhosis and normal blood flow in the portal vein and shunt flow from the ileocecal vein to the inferior vena cava.We assessed that surgery could be safely performed without increasing portal vein pressure.Laparoscopic ileocecal resection was performed by cutting the shunt.Partial jejunum resection was also performed for a mesenteric tumor observed intraoperatively, and pathological findings revealed a lymphangioma.The patient was discharged home on postoperative day 7 without any symptoms, liver enzyme abnormalities, or ascites suggestive of increased portal vein pressure on abdominal ultrasound examination.Colorectal cancer surgery with simultaneous cutting of a portosystemic shunt has rarely been reported.It is necessary to consider the causes of portosystemic shunt and then cut the shunt during surgery when needed.

[18F]FMISO PET/CT as a preoperative prognostic factor in patients with pancreatic cancer.

BACKGROUND: While [18F]fluoromisonidazole (FMISO), a representative PET tracer to detect hypoxia, is reported to be able to prospect the prognosis after treatment for various types of cancers, the relation is unclear for pancreatic cancer. The aim of this study is to assess the feasibility of [18F]FMISO PET/CT as a preoperative prognostic factor in patients with pancreatic cancer. METHODS: Patients with pancreatic cancer who had been initially planned for surgery received [18F]FMISO PET/CT. Peak standardized uptake value (SUV) of the pancreatic tumor was divided by SUVpeak of the aorta, and tumor blood ratio using SUVpeak (TBRpeak) was calculated. After preoperative examination, surgeons finally decided the operability of the patients. TBRpeak was compared with hypoxia-inducible factor (HIF)-1α immunohistochemistry when the tissues were available. Furthermore, correlation of TBRpeak with the recurrence-free survival and the overall survival were evaluated by Kaplan-Meyer methods. RESULTS: We analyzed 25 patients with pancreatic adenocarcinoma (11 women and 14 men, median age, 73 years; range, 58-81 years), and observed for 39-1101 days (median, 369 days). Nine cases (36.0%) were identified as visually positive of pancreatic cancer on [18F]FMISO PET/CT images. TBRpeak of the negative cases was significantly lower than that of the positive cases (median 1.08, interquartile range (IQR) 1.02-1.15 vs median 1.50, IQR 1.25-1.73, p < 0.001), and the cutoff TBRpeak was calculated as 1.24. Five patients were finally considered inoperable. There was no significant difference in TBRpeak of inoperable and operable patients (median 1.48, IQR 1.06-1.98 vs median 1.12, IQR 1.05-1.21, p = 0.10). There was no significant difference between TBRpeak and HIF-1α expression (p = 0.22). The patients were dichotomized by the TBRpeak cutoff, and the higher group showed significantly shorter recurrence-free survival than the other (median 218 vs 441 days, p = 0.002). As for overall survival of 20 cases of operated patients, the higher TBRpeak group showed significantly shorter overall survival than the other (median survival, 415 vs > 1000 days, p = 0.04). CONCLUSIONS: [18F]FMISO PET/CT has the possibility to be a preoperative prognostic factor in patients with pancreatic cancer.

Successful treatment of refractory complete separation of an esophagojejunal anastomosis after laparoscopic total gastrectomy: a case report.

BACKGROUND: Anastomotic leakage after total gastrectomy occurs despite improvements in surgical techniques and patient management. Although many cases of dehiscence can be managed non-operatively, major leakage requires a second surgery and can potentially lead to death. Therefore, accurate and immediate diagnosis and treatment are essential. CASE PRESENTATION: In this report, we describe a 66-year-old Japanese man who was diagnosed with a complete separation of an esophagojejunal anastomosis after laparoscopic total gastrectomy with oral contrast radiography using Gastrografin®. The severe complication was successfully treated by re-anastomosis after two emergency drainage surgeries. After the second surgery, the esophageal end formed a fistula with the jejunum, but balloon dilation failed to open the fistula. Therefore, oral ingestion and conservative treatment were considered unsuitable, and we performed esophagojejunal re-anastomosis 7 months after the first surgery. At a follow-up examination 2 years after re-anastomosis, the patient weighed 47 kg, and his ingestion had recovered to 80% of that before surgery. CONCLUSIONS: Complete separation of an esophagojejunal anastomosis is a rare but severe complication of total gastrectomy. Therefore, we consider that once separation is diagnosed, aggressive and urgent re-operation and effective drainage are useful. Moreover, it is necessary to take great care to minimize the operative morbidity associated with esophagojejunal anastomosis.

[The Clinical Outcome of Conversion Surgery for Unresectable Gastric Cancers in Our Institution].

BACKGROUND: In recent years, the development of chemotherapy has been remarkable. Some cases of conversion surgery for unresectable gastric cancer have been reported. METHODS: The clinical outcome of 11 patients with far advanced gastric cancer who underwent conversion surgery in our hospital from January 2013 to May 2017 were analyzed retrospectively. RESULTS: The median survival time was 592 days(355-1,460). Four patients died of recurrent gastric cancer. Patients with undifferentiated carcinoma dominant had significantly poor survival rather than with differentiated carcinoma dominant(p= 0.039). Meanwhile, the pathological responders for chemotherapy did not have significantly better survival rather than nonresponders. CONCLUSIONS: Although the short term outcome of conversion surgery was acceptable, recurrent rate was still high. To improve the prognosis, clarifying the optimal timing of operation and more effective adjuvant chemotherapy are mandatory.

[Surgical Therapy for Locally Recurrent Rectal Cancer].

We examined 40 cases of locally recurrent rectal cancer surgically treated at our hospital. The sites of recurrence were the anastomosis site(16 cases), pelvic lymph nodes(10 cases), pelvis(10 cases), and perineum(5 cases). Intraoperative complications were confirmed in 5% and postoperative complications in 45% of cases. The R0 resection rate was 60.0%, and positive radial margins were confirmed in 35.0% of cases. Second recurrences were confirmed in 60.0% of cases. The 3-year overall survival rate was 68.7%, and the 3-year relapse-free survival rate was 20.3%. Surgery for locally recurrent rectal cancer was performed relatively safely; however, the R1 resection rate and recurrence rate after surgery were high. R0 resection significantly improved the overall survival rate, and it seems that a treatment strategy to raise R0 resection rate is necessary.

[A Case of Laparoscopic Remnant Gastrojejunal Bypass Surgery for Postoperative Peritoneal Recurrence of Gastric Cancer].

A 77-year-old female case who underwent laparoscopic distal gastrectomy with D2 dissection, Billroth I reconstruction for gastric cancer. Since the stage was III A, she received an adjuvant chemotherapy with S-1 after surgery. However, about 2 years after surgery, she was referred to our hospital for anorexia and vomiting. As a result of the examination, we diagnosed stenosis due to peritoneal recurrence near the anastomotic site. We performed laparoscopic remnant gastrojejunal bypass (Billroth II method, with Braun anastomosis). A camera port was inserted into a median umbilical incision. Following this, 4 additional ports(1 ports of 12mm in diameter and 3 ports of 5mm in diameter)were inserted under laparoscopic imaging into the right lower, right upper, left upper, and left lower quadrants. We first detached the adhesion considered as the influence of the previous surgery, and the anastomosis of remnant stomach and jejunum and the Braun anastomosis were performed by the linear stapler. The postoperative course was good. She started oral intake from the day after surgery, was discharged on the 6 days after operation, and received chemotherapy promptly. This procedure was effective for recurrent gastric cancer with stenosis which is difficult to resect and it was considered to be a minimally invasive method with a view to initiating chemotherapy early after operation.