[A Case of Goblet Cell Adenocarcinoma Incidentally Diagnosed after Appendectomy That Required Additional Bowel Resection with Lymph Nodes Dissection].

A 54-year-old male presented to the clinic, complaining of dull lower abdominal pain that started a day ago. There was a tenderness on right lower quadrant on palpation and abdominal computed tomography(CT)showed that dilated appendix with a diameter of 12 mm. The patient was diagnosed with acute appendicitis and laparoscopic appendectomy was performed on the same day. The tip of the appendix was swollen and looked purple, gangrenous appendicitis findings were identified. However, histopathology detected GCA on resected appendix with positive surgical margin and additional tumor resection was indicated. Laparoscopic ileocecal resection with D3 lymph nodes dissection was performed 24 days after the first surgery. Resected specimen showed that the stump of the appendix was palpable as a mass in the orifice of the appendix and histopathology revealed the remnant of the appendiceal GCA. No lymph nodes tumor metastasis was identified. Chromogranin A and synaptophysin were positive and Ki-67 was approximately 50%. According to the guideline of neoadjuvant chemotherapy for colon cancer, oral 5-fluorouracil therapy was performed for half a year after the second surgery and the patient remains still healthy without recurrence 1 year after the surgery. Here, we experienced a rare case of GCA of the appendix that was detected incidentally after appendectomy for acute appendicitis.

[A Case of Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma Causing Perforation of the Small Intestine].

Monomorphic epitheliotropic intestinal T-cell lymphoma(MEITL)is very rare and aggressive subtype of lymphoma with poor prognosis. A 60-year-old man complaining of abdominal pain was underwent partial resection of the jejunum for panperitonitis with a small intestinal perforation. The histopathological and immunohistochemical findings led to the diagnosis of MEITL. Postoperative course was uneventful. One month after the operation, the patient was scheduled for 6 courses of CHOP regimens. He presented with bowel obstruction twice during the 3 courses of CHOP. As the recurrence of MEITL could not be ruled out, diagnostic laparoscopy was performed. Laparoscopic findings revealed no recurrence and adhesive small bowel obstruction. The patient was followed closely without treatment after 6 courses of CHOP. The patient has been alive without recurrence 18 months after the resection. We reported a case of monomorphic epithelial intestinal T- cell lymphoma causing jejunal perforation.

[A Case of Type 4 Gastric Cancer with Peritoneal Dissemination Successfully Treated with Conversion Surgery after Intensive S-1 plus Oxaliplatin Chemotherapy].

S-1 plus oxaliplatin(SOX)chemotherapy is now widely used for the treatment of unresectable gastric cancer but there are few case reports about conversion surgery following SOX. Hereby, we report a case of type 4 gastric cancer with peritoneal dissemination successfully treated with conversion surgery after intensive SOX chemotherapy. A 69-year-old female was diagnosed of type 4 gastric cancer by upper endoscopy(por1, HER2 negative)and peritoneal disseminations were identified on left diaphragm and mesentery under direct vision. After 11 courses of SOX chemotherapy, CT revealed that primary tumor markedly decreased in size. Therefore, staging laparoscopy was performed and peritoneal disseminated lesions disappeared. Peritoneal cytology also turned negative. Subsequently, total gastrectomy and splenectomy were performed. Histology revealed that tumor was categorized as por2, ypT2N3M0, ypStage ⅢA, and Grade 2 in histological evaluation criteria. SOX was continued as an adjuvant chemotherapy for another 6 months and the patients remain healthy without recurrence. Unresectable gastric cancer with peritoneal dissemination can be successfully treated with conversion surgery following SOX chemotherapy and staging laparoscopy was useful to evaluate peritoneal dissemination. When conversion surgery is indicated for gastric cancer with peritoneal dissemination, downstaging should be confirmed by staging laparoscopy.

[A Case of Multiple Metachronous Metastases from Hepatocellular Carcinoma to Thoracic Spine and Right Adrenal Invading Right Kidney with Tumor Thrombus in the Inferior Vena Cava That Was Treated with Chemotherapy, Radiotherapy, Intravascular Therapy, and Surgery].

For extrahepatic recurrence after primary hepatocellular carcinoma resection, molecular targeted therapy is the first- choice and no consensus is reached on the indication of surgical resection of extrahepatic metastasis. However, when the extrahepatic lesion extends to vena cava, tumor thrombus can cause acute pulmonary embolism that can lead to fatal consequences. Here, we experienced a case of multiple metachronous metastases from hepatocellular carcinoma to thoracic spine and right adrenal invading right kidney with tumor thrombus in the inferior vena cava. Local radiation therapy to thoracic vertebra, molecular targeted therapy, and transcatheter arterial chemoembolization were performed but tumor thrombus still occluded vena cava. Therefore, to prevent pulmonary embolism and to bridge to immunotherapy, right adrenalectomy, right nephrectomy, thrombectomy and replacement of inferior vena cava were performed. The patient remains healthy 6 months after the surgery and still receiving immunochemotherapy.

Hooking intestine sign: a typical diagnostic CT finding of Petersen's hernia.

PURPOSE: To clarify typical diagnostic computed tomography (CT) findings of Petersen's hernia for differentiation from other causes of internal hernia observed in patients having undergone gastrectomy with Roux-en-Y gastric bypass. METHODS: We retrospectively reviewed CT findings of internal hernia in patients who had undergone both gastrectomy and Roux-en-Y reconstruction and a second surgery for bowel obstruction. Thirteen patients with Petersen's hernia and 6 with internal hernia other than Petersen's hernia were investigated. Six CT findings, viz. whirl sign, mesenteric fat haziness, intestinal distension in the upper abdomen, herniated intestinal loop above the gastric level, middle/distal ileum courses downwards from the left hypochondrium, and hooking intestine sign, which means two or more intestines pass through the inner side of J-shaped vessels consisting of mesenteric vessels of the elevated jejunum, were scored and evaluated regarding their diagnostic performance. RESULTS: The hooking intestine sign showed the highest sensitivity, specificity and accuracy (100%, 100% and 100%). We could detect J-shaped vessels in all Petersen's hernia patients. Inside the J-shaped vessels there were two or more intestinal tracts passing through in the Petersen's hernia group. There was only transverse colon inside the J-shaped vessels in the control group. CONCLUSION: The hooking intestine sign may be useful for diagnosing Petersen's hernia on CT.

[Surgical Treatment for Synchronous Double Cancer of the Thoracic Esophagus and Lung].

We herein report 2 cases of radical operation for synchronous double cancer of the thoracic esophagus and each side of the lung. Case 1:A 71-year-old woman with synchronous double cancer of the thoracic esophagus (Mt, T3N2M0, Stage III) and right lung (M, T2aN0M0, Stage I B) underwent esophagectomy concomitantly with right middle lobectomy through right thoracotomy (single-stage operation) after 2 courses of systemic chemotherapy with docetaxel, cisplatin and 5-fluorouracil( DCF regimen). Case 2:A 72-year-old man with synchronous double cancer of the thoracic esophagus( MtLt, T3N2M0, Stage III) and left lung( U, T1aN0M0, Stage I A) underwent 2-stage operation after 2 courses of the DCF therapy. Esophagectomy through right thoracotomy was performed followed by left upper lobectomy through left thoracotomy 3 months later. Treatment strategy for synchronous double cancer of the thoracic esophagus and lung is discussed based on our experiences and previous reports.

Transcatheter arterial embolization for intercostal arterio-esophageal fistula in esophageal cancer.

BACKGROUND: While esophageal fistula formation in the adjacent organs is associated with high rates of morbidity and mortality, the management of non-aortic arterio-esophageal fistula has not been frequently reported. CASE PRESENTATION: A 69-year-old Japanese man who had undergone definitive chemoradiotherapy for esophageal cancer was admitted to our hospital with hematemesis. He was diagnosed with mediastinal abscess caused by esophageal perforation, and esophageal bypass surgery was performed. After 3 days, he presented with fatal hemoptysis. As angiography revealed an intercostal artery pseudoaneurysm, transcatheter arterial embolization was performed. CONCLUSIONS: When patients with esophageal cancer, especially those with a history of radiotherapy and/or mediastinitis, present with hematemesis and/or hemoptysis, the possibility of non-aortic arterio-esophageal fistula should be considered. Transcatheter arterial embolization is an effective treatment for non-aortic arterio-esophageal fistula.

[Long-Term Survivor of a Barrett's Esophageal Adenocarcinoma, Who Underwent Three Times Surgical Resection and MultidisciplinaryTherapyfor Lymph Node Recurrences - Report of a Case].

We report a case of a 42-year-old man who underwent 3 times surgical resection for lymph nodes recurrence and multidisciplinary therapy for Stage IV b Barrett's esophageal adenocarcinoma, and was well 6 years and 3 months after the first resection. The prognosis of the recurrence cases after radical recection of the esophageal cancer is extremely poor. Long-term prognosis may be obtained in few patients, but the cases are squamous cell carcinoma in most of the reported cases. The number of Barrett's esophageal adenocarcinoma patients is increasing, but it is not many. There is little reports, and there is no fixed treatment policy.

[A Patient with Stage IV Gastric Cancer Who Survived More Than Five Years after Gastrectomy].

The prognosis of patients with Stage IV gastric cancer is generally poor. The 5-year overall survival rate is less than 10%. The patient was a 73-year-old man with Stage IV gastric cancer. Before chemotherapy, peritoneal dissemination was observed using staging laparoscopy. The patient received first-line chemotherapy with TS-1 plus CDDP. Renal function worsened and consequently the therapy was stopped. He received 3 courses of chemotherapy with weekly PTX. The peritoneal dissemination had disappeared by the second staging laparoscopy and he underwent distal gastrectomy. The final diagnosis was pT4a, ly2, v1, pN2(4/16),M0, fStage III B. The patient received adjuvant chemotherapy of TS-1 for 4 years and 8months after gastrectomy. More than 5 year after gastrectomy, the patient is alive without recurrence.

Spleen preservation versus splenectomy in laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer: A comparison of short-term outcomes.

INTRODUCTION: Splenic hilar lymph node dissection via a splenectomy for advanced proximal gastric cancer remains controversial. Recently, a laparoscopic spleen-preserving hilar lymph node dissection procedure was described in several publications. To assess the feasibility and safety of spleen-preserving laparoscopic total gastrectomy with D2 lymphadenectomy (LTG-D2), the present retrospective study compared the short-term surgical outcomes between spleen preservation and splenectomy during laparoscopic D2 total gastrectomy (LTG-D2S). METHOD: This study included 59 patients who underwent LTG-D2 and 19 patients who underwent LTG-D2S. RESULTS: The mean operation time did not significantly differ between the LTG-D2 and LTG-D2S groups (339.4 ± 56.8 vs 356.8 ± 46.0 min). The mean blood loss tended to be smaller in the LTG-D2 group than in the LTG-D2S group (105.9 ± 89.7 vs 210.0 ± 149.5 mL). The mean number of retrieved lymph nodes did not significantly differ between the LTG-D2 and LTG-D2S groups (39.9 ± 17.0 vs 40.6 ± 14.9), and the mean number of retrieved lymph nodes at the splenic hilum also did not significantly differ between the LTG-D2 and LTG-D2S groups (1.3 ± 1.7 vs 2.4 ± 2.6). Mild pancreatic fistula occurred in three cases (5%) in the LTG-D2 group and in three cases (15.8%) in the LTG-D2S group. CONCLUSION: A LTG-D2 is feasible in terms of the short-term outcomes. However, the indications for this complicated procedure should be considered carefully.

Triple-incision laparoscopic distal gastrectomy for the resection of gastric cancer: comparison with conventional laparoscopy-assisted distal gastrectomy.

INTRODUCTION: Reduced port surgery and single-port surgery are currently in the spotlight as next-generation, minimally invasive surgical techniques. We performed a triple-incision laparoscopic distal gastrectomy (TIL-DG) for gastric cancer as a reduced port surgery. METHOD: A total of 76 patients underwent a TIL-DG. A D1+ or D2 lymph node dissection was performed, and the Roux-en-Y method was used for reconstruction. The short-term patient outcomes of the TIL-DG group were compared with those of the conventional laparoscopy-assisted distal gastrectomy group (59 cases) to evaluate the feasibility of TIL-DG. RESULTS: No significant differences were observed between the TIL-DG group and the laparoscopy-assisted distal gastrectomy group in terms of mean operative time, blood loss, and the length of the postoperative hospital stay. The mean number of retrieved regional lymph nodes in the TIL-DG group was slightly higher than that in the laparoscopy-assisted distal gastrectomy group. CONCLUSION: A triple-incision laparoscopic distal gastrectomy is a feasible and safe procedure.

[A case of advanced esophagogastric junction cancer responding to pre-operative combination chemotherapy of docetaxel, cisplatin, S-1, and trastuzumab].

We have no consensus on surgical treatment and chemotherapy for esophagogastric junction cancer in Japan. A 51-yearold man reporting dysphagia was examined, and through upper gastrointestinal endoscopy was found to have a tumor at the esophagogastric junction. Histologically, biopsy specimens indicated adenocarcinoma with genetic amplification of human epidermal growth factor receptor type 2(HER2). Positron emission tomography showed swelling of several abdominal lymph nodes with accumulation of fluorodeoxyglucose. He was treated with esophagogastorectomy with left thoracotomy after combination chemotherapy of docetaxel, cisplatin, S-1, and trastuzumab. He had no complication from the operation and had no adverse effect from the combination chemotherapy. Histopathological examination of the resected specimen showed a minute residual cancer nest at the muscularis propria of the esophagus, but no lymph node metastasis. This regimen could be useful for advanced junctional cancer with HER2 amplification as preoperative chemotherapy.

[A case of multiple distant lymph node metastases from advanced gastric cancer treated with adjuvant chemotherapy after total gastrectomy].

A 70-year-old woman with advanced gastric cancer (U, type 3, por, pT3, ly3, v2, pN3a [10/92, No. 1, 3], Stage IIIB) underwent total gastrectomy and D2 dissection followed by adjuvant chemotherapy with S-1. Eight months later, computed tomography (CT) showed multiple distant lymph node metastases, including metastases in the para-aortic and supraclavicular( Virchow's nodes) lymph nodes. Chemotherapy with cisplatin( CDDP) and irinotecan( CPT-11) was administered with concurrent radiation therapy for the para-aortic nodes. After 2 courses, the para-aortic lymph nodes showed complete response( CR), but Virchow's nodes showed partial response( PR). Dissection of Virchow's nodes was performed. Histopathological examination revealed a chemotherapeutic effect on the dissected node, and therefore, 2 more courses of chemotherapy were administered after the operation. Adverse events such as grade 3 neutropenia and grade 4 hyponatremia were observed. At present, the patient is well without recurrence, and chemotherapy is not being administered. Local therapy for distant metastasis followed by systemic chemotherapy may have been effective in this case.

Laparoscopic introduction of a center rod using a Nelaton catheter during laparoscopic esophagogastrostomy.

During laparoscopic proximal gasterctomy, the difficulty associated with the use of a circular stapler for esophagogastrectomy is not only the fixation of the anvil, but also the laparoscopic manipulation of the body of the circular stapler. We have developed a new approach to the laparoscopic introduction of the center rod using a Nelaton catheter. After transection of the esophagus, the stomach is pulled out through an umbilical minilaparotomy. The proximal gastrectomy is performed extracorporeally, and a Nelaton catheter is passed through a small incision at the lower body of the stomach and a small penetrating wound at the point of the esophagogastrostomy. The Nelaton catheter is attached to the center rod of the circular stapler. The center rod can be guided to the appropriate point laparoscopically by the Nelaton catheter. Between January 2009 and May 2010, 11 patients underwent this procedure, successfully. This technique was useful for laparoscopic proximal gastrectomy.

Laparoscopic-assisted low and ultralow anterior resection for lower rectal cancer using the simple "Rectum Catcher" device and an intra-operative colonoscopy.

PURPOSE: We report the feasible technique in lower rectal surgery. MATERIALS AND METHODS: The Rectum Catcher (Matsumoto et al. in Surg Endosc 22:1905-1909, 2008) is made of stainless steel, with a circle of diameter 6 mm punched out at a distance of 5 mm from the top and covered with a short-cut T-tube. A vessel tape is inserted into the stainless steel and the short-cut T-tube. The rectum is grasped using the Rectum Catcher at a proximal rectum of the cancer, and the location of the cancer is confirmed using an intra-operative colonoscopy. In the next step, the Rectum Catcher is applied at the distal rectum of the cancer, and which easily occludes the rectum, and we confirm that the cancer is not at the distal rectum from the Rectum Catcher, using an intra-operative colonoscopy. The rectal lumen is irrigated. Then, the linear cutter is positioned just distal rectum to the Rectum Catcher, and the rectum is transected adequately. RESULTS: From January 2009 to the present, this study included 18 patients undergoing laparoscopic-assisted low and ultralow anterior resection for lower rectal cancer, using the Rectum Catcher and an intra-operative colonoscopy. Using the Rectum Catcher and an intra-operative colonoscopy, we can easily make a decision of the location of rectal cancer in lower rectum and irrigation of rectal lumen can be easily performed to safely cut the bowel being occluded, in the narrow laparoscopic view of the pelvic cavity. CONCLUSION: The combination between the Rectum Catcher and an intra-operative colonoscopy is useful for performing laparoscopic rectal surgery.

[A case of recurrent breast carcinoma metastasis successfully treated with S-1 and zoledronic acid therapy].

We experienced a case of triple-negative recurrent breast carcinoma achieving a significant improvement by oral S- 1, a fluoropyrimidine-class anticancer drug and zoledronic acid(ZOL), a third generation bisphosphonate(BP). / Against metastases to orbital foramen, chest wall and bone, the oral treatment with S-1 was started at 80 mg/day everyday for 4 weeks, followed by a 2-week rest interval as 1 cycle, and ZOL was injected at 4 mg every 4 weeks. After 2 cycles of treatment, the level of tumor markers and tumor sizes became reduced. Twelve cycles after the initiation of the therapy, recrudescence of the metastatic lesions was not recognized, and no other metastases were recognized in any organ. In the course of the treatment, no adverse drug reactions to S-1 occurred in the patient. For treatment of recurrent breast carcinoma, S-1 is considered to be a useful and tolerable anticancer drug, and combination treatment of S-1 and ZOL is thought to be effective.

The simple "Rectum Catcher" device is a useful tool for laparoscopic-assisted high and lower rectal surgery.

BACKGROUND: This report describes our experience in 13 patients with rectal cancer along with a general overview of the use of the simple "Rectum Catcher" device in high and lower rectal surgery. MATERIALS AND METHODS: The Rectum Catcher is made of stainless steel (length 40 cm, caliber 7 mm), with a circle of diameter 6 mm punched out at a distance of 5 mm from the top and covered with a short-cut T-tube (length 1 cm, caliber 6 mm) (SILKOLATEX T-tube, 8 mm; Willy Rusch AG, Germany). A vessel tape (width 9 mm, length 120 cm; Kawano Seisakusho, Chiba, Japan) is inserted into the stainless steel and the short-cut T-tube. The Rectum Catcher is inserted into the abdominal cavity through the 12-mm trocar (Ethicon Endo Surgery) and a vessel tape is circled the rectum and pulled to catch it. Thirteen patients with rectal cancer were operated laparoscopically using the Rectum Catcher at our hospital. RESULTS: From January 2007 to the present, this study included 13 patients (5 men and 8 women) undergoing laparoscopic-assisted high anterior resection (Lap-HAR, five patients), low anterior resection (Lap-LAR: six patients), and abdominoperineal resection (Lap-APR: two patients) for rectal cancer, using the Rectum Catcher. Using the Rectum Catcher, easy maneuverability of the rectum and irrigation of rectal lumen can be easily performed to safely cut the bowel being occluded, in the narrow laparoscopic view of the pelvic cavity. CONCLUSION: In our experience, the simple Rectum Catcher device is safe and useful for performing laparoscopic assisted high and lower rectal surgery.

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument "Endo-PSI (II)" and circular stapler.

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the "Endo-PSI (II)", and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.

Prognostic significance of gastric cancer metastasis in second-tier lymph nodes detected on reverse transcriptase-polymerase chain reaction and immunohistochemistry.

To determine the prognostic significance of the methods used to determine the presence of metastasis in second-tier lymph nodes of patients with gastric cancer, the authors studied lymph nodes surgically removed from 100 patients with gastric cancer (55 with early cancer, 45 with progressive). The results of HE staining were compared with those of immunohistochemistry using the anticytokeratin (CK) antibody and reverse transcriptase-polymerase chain reaction (RT-PCR) assays. Lymph node 7 or 8a was obtained intraoperatively, then mRNA was extracted using an immunobeads method, and RT-PCR with CK19 mRNA was performed. The P for Cox regression analysis for metastasis detected by HE staining, CK staining, and RT-PCR of all 100 cases was 0.312, 0.426, and 0.021, respectively, while for second-tier lymph nodes it was 0.154, 0.013, and 0.006, respectively. In conclusion, RT-PCR and CK staining for detection of metastasis in second-tier lymph nodes were more reliable prognostic indicators than conventional HE staining.

Hand-assisted laparoscopic esophagojejunostomy using newly developed purse-string suture instrument "Endo-PSI".

Although there are several reports on the esophagojejunostomy during laparoscopy-assisted total gastrectomy, the procedures still remain to be established. We report hand-assisted laparoscopic esophagojejunostomy using circular stapler and newly developed instrument "Endo-PSI." Between April 2005 and April 2006, 13 patients received these products during laparoscopy-assisted total gastrectomy. The Endo-PSI was attached to the abdominal esophagus using hand-assisted laparoscopic surgery. The insertion of the straight needle with 2-0 polypropylene into the device and the cutting of the esophagus were also performed using hand-assisted laparoscopic surgery. The insertion of the anvil head into the esophagus and the ligation of the purse-string suture were performed laparoscopically. After the jejuno-jejunal anastomosis was performed extracorporeally, the combination of the circular stapler for esophagojejunostomy and the closure of the stump of the jejunum were performed laparoscopically. There were no complications attributable to this procedure and there were no cases that required conversion to conventional open procedure or required extension of median incision. This newly developed Endo-PSI was useful for laparoscopic purse-string suture.