[A Case of Submucosal Invasion(SM2)Gastric Cancer with Peritoneal Dissemination Three Years after Surgery].

The patient is a 90-year-old man. Three years and 3 months after laparoscopic distal gastrectomy for early gastric cancer, pT1b(SM2)pN1M0, Stage Ⅰ, the patient visited our hospital with abdominal pain, and a large amount of ascites and stenosis of transverse colon were pointed out. He underwent a right hemicolectomy under laparotomy. Histopathologically, it was diagnosed as peritoneal recurrence of previous gastric cancer. Postoperatively, he died of aspiration pneumonia. As for the cause of death after surgery of early gastric cancer, there are many causes of death from other diseases and few from primary malignancy. Furthermore, recurrence of peritoneal dissemination is extremely rare and considered to be a valuable case.

[A Case of Perforation at the Stump of Descending Colon after Hartmann's Operation Performed after Transverse Colostomy].

A 77-year-old man with complaining of anemia and abdominal pain was admitted to our hospital. An abdominal computed tomography showed the sigmoid colon tumor with bowel obstruction. Laparoscopic transverse colostomy was performed to release intestinal obstruction. After first operation, he was diagnosed the sigmoid colon cancer: cT4b(bladder), cN0, cM0, and cStage Ⅱc. Radical laparoscopic operation(Hartmann's operation)was performed. On the 4th postoperative day, fecal juice was discharged from the abdominal drain placed in the Douglas fossa, so emergency laparotomy was performed. The intraoperative findings showed perforation in the blind end of the descending colon. The descending colon was resected from a site approximately 5 cm anal side of the transverse colostomy to the blind end. It was thought that perforation occurred due to an increase in internal pressure in the residual intestinal tract after Hartmann's surgery without blood flow disorder. We believe that further attention is required to the management of residual intestinal tract at the blind end for the obstructive colorectal cancer.

[Association between the Preoperative Nutritional Index and Postoperative Complications/Prognosis in Older Adults with Gastric Cancer Who Have Undergone a Gastrectomy].

We analyzed the relationship between preoperative nutritional indices and postoperative complications/prognoses in patients with pStage Ⅰ and Ⅱ gastric cancer aged ≥75 years who had undergone gastrectomy in our hospital. Between January 2012 and March 2021, a total of 79 cases of pStage Ⅰ and Ⅱ gastric cancer were examined in individuals aged ≥75 years who had undergone gastrectomy. We investigated the correlation between short- and long-term outcomes and the nutritional index. CONUT, GPS, and GNRI were employed as indicators of nutritional status. CONUT and GPS showed associations with postoperative complications and an extended postoperative hospital stay, whereas GNRI did not exhibit such associations. Among the patients, 7 deaths were attributed to primary diseases, whereas 16 deaths were attributed to other diseases. No correlation was found between survival rate and preoperative nutritional status. Conclusions: There were minimal cancer recurrences among older adults with gastric cancer who had undergone gastrectomy. Although preoperative nutritional status was associated with postoperative complications, it did not show an association with prognosis.

[Surgical Outcomes of the Patients with Gastric Cancer in Aged 85 and Older at Our Hospital].

We investigated the surgical outcomes of the patients with gastric cancer in aged 85 and older. There were 9 males and 8 females, with a median age of 86 years. All had comorbidities and 7 had double cancers. Type of surgery was distal gastrectomy in 14 and total gastrectomy in 3, respectively. Postoperative complications occurred in 8 cases, and case with adhesion ileus or mesenteric bleeding performed reoperation. The postoperative hospital stay was 15 days. The cause of death was recurrent diseases in 2 cases and other diseases in 4. The overall survival rate was 63.9% for 3 years and 42.6% for 5 years, respectively. Elderly patients with gastric cancer may be increase in Japan, but they have large individual differences about tolerance of surgical intervention. Therefore, it is important to evaluate the detail of general condition in such patients.

[Small Bowel Obstruction Due to Internal Hernia Caused by the Vermiform Appendix, Mesentery of the Small Intestines, and Greater Omentum in a Patient with No History of Abdominal Surgery].

Our patient was a 69-year-old man being treated for hyperlipidemia. He was admitted to our hospital with the chief complaint of vomiting and abdominal pain. Abdominal computed tomography(CT)showed dilation of the distal small intestines, a small amount of ascites in the small intestines near the right pelvis, and a closed loop of the small intestine. Enhanced abdominal CT was performed to evaluate intestinal ischemia. Given the adequate blood flow to the wall, the small intestines forming the closed loop, and no increase in ascites, the patient was treated conservatively. Diagnostic laparoscopy was performed because of the narrowed lumen and incomplete obstruction observed on the abdominal CT and contrast- enhanced imaging of the ileal tube. The tip of the appendix adherent to the mesentery of the small intestines, approximately 80 cm from the ileum, and the omentum adherent to the bottom of the right pelvis caused the obstruction. A cord dissection and appendectomy were performed. Making the diagnosis was difficult because there was no history of appendicitis and the small intestinal obstruction was caused by adhesions in 2 places with no history of laparotomy.

[A Case of Multiple Small Bowel GIST Complicated with von Recklinghausen's Disease].

The case was a 55-year-old woman. She have been pointed out von Recklinghausen's disease for several years. She was referred to our hospital due to multiple abdominal tumor and severe anemia. Enhanced CT examination revealed multiple intraabdominal tumors with central necrosis. The tumors diagnosed mesenchymal tumors associated with von Recklinghausen's disease, and tumor resection was indicated under laparotomy. Tumors were resected together with small and large bowel. The tumor in the pelvic space was resected together with the uterus and right ureter. She was discharged without any postoperative complications at 15 days after the operation. Because immunostaining was positive for CD34, c-kit and DOG1 and Ki-67-positive cells were 18%, the tumors were diagnosed with high-risk GIST for small bowel.

[Outcomes of Salvage Thoracoscopic Esophagectomy after Definitive Radiochemotherapy for Clinical Stage â £a Esophageal Cancer].

We investigated the clinical outcomes of salvage thoracoscopic esophagectomy for residual or recurrent cases after radical radiochemotherapy for cStage Ⅳa esophageal cancer. Thoracic procedure was started thoracoscopically in all cases, but converted to thoracotomy in 2 cases. The operation time was 315 minutes and the blood loss was 300 mL. Lymph node metastasis was diagnosed in 5 cases, and 2 cases were finished in R1or 2. Nine cases died of recurrence and 1 case died of pneumonia. The 2-year and 5-year survival rates(OS)of all cases were 46.1% and 28.3%, respectively. R1,2 cases and pN+ cases had significantly poor prognosis. Surgical treatment after radical radiochemotherapy for cStage Ⅳa esophageal cancer can be safely performed thoracoscopically. If R0 is not obtained, the long-term prognosis cannot be expected, and selection of R0 resectable cases is important.

[Clinical Outcomes of Recurrent Diseases after Esophagectomy According to Time of Recurrence].

We analyzed retrospectively the difference in treatment selection and prognosis according to timing of recurrence after radical resection of esophageal cancer. Of 190 patients who underwent radical esophagectomy for esophageal cancer from April 2010 to December 2017, 56 patients(29.5%)had recurrent diseases during the postoperative periods. These cases were divided into 27 cases with recurrence diagnosed less than 180 days after initial surgery(Group A)and 29 cases with recurrence diagnosed more than 180 days(Group B). Although there was no difference in the pathological staging, preoperative treatment, and type of recurrence between the 2 groups, there were significantly more cases with symptomatic recurrence in Group A. Surgical intervention was possible in 1 case in Group A and 10 cases in Group B, respectively. There was significantly more in Group B. Second-line treatment was possible in only 5 cases in Group B. Survival after recurrence was tend to have better in Group B. There are few cases who indicated surgical intervention and second-line treatment in early recurrence cases after radical esophagectomy for esophageal cancer, and the prognosis is poor in such cases.

[A Case of Stage IV Gastric Cancer Which Showed Pathological Complete Response after Neo-Adjuvant Chemotherapy].

We report a case of Stage IV gastric cancer showing pathological complete response(pCR)after neo-adjuvant chemotherapy( NAC)using S-1 and oxaliplatin(SOX).A woman 73-year-old was diagnosed as harming type 3 Stage IV gastric cancer with para-aortic lymph node(PAN)metastasis.She underwent 4 courses of NAC with SOX regimen.After the treatment, both the primary tumor and the metastatic PAN decreased in size remarkably.She underwent distal gastrectomy with D2 plus PAN dissection with curative intent.Pathological diagnosis revealed complete disappearance of cancer cells in both the primary lesion of the stomach and all dissected lymph nodes, confirming pCR.She is alive without recurrence 4 months after surgery.

[Azygos Arch Preserving Thoracoscopic Esophagectomy for Less Invasiveness].

We reported the technique ofthoracoscopic esophagectomy with preservation ofazygos arch for less invasivenesss. Among thoracoscopic esophagectomy, this retchnique indicated for the patients with the tumor located at middle or lower thoracic and don't reach adventitia. Twenty-eight patients was performed this procedure and azygos arch were preserved in all cases. None the cases were converted conventional thoracotomy. The operation time was 133.5 minutes(median), and estimated blood loss was 30 mL(median)in thoracic procedure. As for thoracoscopic esophagectomy, could preserved respiratory function, further less surgical stress can obtain this technique.

[Treatment Outcomes and Prognosis of Patients with Recurrent Diseases after Esophagectomy for Esophageal Cancer].

We retrospectively analyzed the treatment outcomes of 52 patients with recurrent diseases after radical esophagectomy for esophagealcancer. Median time of diagnosis of recurrent diseases was 180 days after surgery, and 90.4%of allpatients were diagnosed with recurrent diseases within 2 years. Twenty-seven patients were diagnosed with single area recurrence, and the remaining 25 were diagnosed with complex recurrence. Among patients with single area recurrence, surgical intervention was indicated in 9, and chemoradiotherapy(CRT)was indicated in 14. Meanwhile, among patients with complex recurrence, surgicaltreatment was indicated in only 2 patients. Median survivaltime was 293 days in allpatients, 611 days in single area recurrence, and 148 days in complex recurrence. Among patients with single area recurrence, those treated with surgical intervention or CRT had significantly better survival than those who underwent other treatment modalities. Although the prognosis of the patients with recurrent diseases after esophagectomy was poor, the patients with single area recurrence or treated with local therapy were expected to survive longer than patients with complex recurrence or those treated with other modalities.

[Two Resected Cases with Superficial Basaloid Squamous Carcinoma of the Esophagus].

We report 2 resected cases of superficial type basaloid squamous cell carcinoma of the esophagus. Case 1 is a 67-year-old man who underwent endoscopic submucosalresection for superficialel evated type esophagealcancer of the middle thoracic esophagus. Because the pathological diagnosis of the resected specimen was basaloid squamous cell carcinoma invading to the submucosal layer with lymphatic vessel invasion, esophagectomy was indicated. The resected specimens showed no tumor in the esophagus. However, metastasis was diagnosed in the dissected mediastinall ymph nodes. Left cervicall ymph node recurrence was detected 1 years 10 months after surgery, and lymphadenectomy was performed after irradiation therapy. He survived 4 years after the first operation. Case 2 is a 60-year-old man who underwent esophagectomy for superficial elevated type adenosquamous cell carcinoma with submucosal invasion. The pathological diagnosis revealed basaloid squamous cell carcinoma with submucosal invasion. The pathological diagnosis revealed basaloid squamous cell carcinoma invading the submucosal layer with lymphatic and blood vessel invasion. The patient died of recurrent disease in the lungs and liver 3 months after surgery. Although these 2 cases were superficial type esophageal basaloid squamous cell carcinoma, both had severe vessel invasion and lymph node metastasis. In basaloid squamous cell carcinoma, adjuvant therapies are needed after surgery, even if the lesion is diagnosed as superficial type. Multimodality treatment is needed for greater survival benefit.

[Clinical Outcomes of Local Therapy for Lymph Node Recurrence after Radical Esophagectomy for Esophageal Cancer].

We analyzed the prognostic factors related to long-term survival in 31 patients, 27 men and 4 women, median age 67 years, who had lymph node recurrence after radical esophagectomy for esophageal cancer. The pathological Stage was Stage I in 2 patients, Stage II in 9 patients, Stage III in 18 patients, and Stage IV a in 2 patients. Seventeen patients were diagnosed with lymph node recurrence in a single area and the other 14 patients were diagnosed with lymph node recurrence in multiple areas(n=3)or lymph node recurrence complicated by hematogenous or disseminated metastases(n=11). Eighteen patients were treated with chemoradiotherapy(CRT), and surgical intervention after CRT was indicated in 5 of them. One patient had surgery alone, 7 were treated with chemotherapy, and 5 were administered best palliative care. The median survival after recurrence was 357 days. The patients with lymph node recurrence in a single area and those treated by CRT or surgery had significantly better prognosis than the others. Although the overall prognosis for patients with tumor recurrence after esophagectomy is poor, lymph node recurrence in a single area or treated with local therapy was associated with better long-term survival.

[Clinical Outcomes and Prognosis of Salvage Thoracoscopic Esophagectomy after Definitive Chemoradiotherapy].

We examined the treatment outcomes and survival rate of patients treated with salvage thoracoscopic esophagectomy after definitive chemoradiotherapy (dCRT). Twenty-seven patients who were indicated for salvage thoracoscopic esophagectomy after dCRT in our department were enrolled through April 2014. Eight patients had tumor regrowth after a complete response, and 19 had residual tumors. Two patients needed conversion to conventional thoracotomy. The operation time was 340 minutes (thoracic procedure: 125 minutes), and the estimated blood loss was 330 mL (thoracic procedure: 100 mL). The mean number of dissected nodes was 18. None of the patients experienced serious perioperative complications, and R0 surgery was performed in 24 patients. Postoperative complications developed in 15 patients (56%), and anastomotic leakage occurred in 11. Pneumonia developed in 3 patients, but none of the patients had tracheal necrosis or hospital mortality. The 5-year survival rate of all the patients was 40.4%, and the patient who underwent R0 surgery had a significantly better outcome than a patient with R1 or R2. Thoracoscopic esophagectomy is a safe option for salvage treatment of patients in an institution that has physicians experienced and skilled in thoracoscopic esophagectomy. However, it is always necessary to prepare for conversion to conventional thoracotomy.

[Treatment outcomes of patients with cervical lymph node recurrence after esophagectomy for esophageal cancer].

Herein, we report the treatment outcomes of patients with limited cervical lymph node recurrence after esophagectomy for esophageal cancer. Between April 2010 and December 2013, 8 patients with cervical lymph nodes recurrence were diagnosed and treated in our department. All patients were detected with recurrent disease by using positron emission tomography computed tomography(PET-CT), and among these, 5 patients had solitary node recurrence. Initial treatments were irradiation therapy in 5 patients and lymphadenectomy in 3 patients. Four of 5 patients underwent irradiation therapy and lymphadenectomy. Four of 5 patients with solitary node recurrence are still alive without relapse of disease. In conclusion, PET-CT can be useful for early detection of recurrent disease after esophagectomy. Appropriate therapy for patients with solitary cervical lymph node recurrence is associated with long-term survival after recurrence.

Laparoscopic splenectomy for histiocytic sarcoma of the spleen.

Primary histiocytic sarcoma of the spleen is a rare but potentially lethal condition. It can remain asymptomatic or only mildly symptomatic for a long time. An 81-year-old woman presented with an extremely enlarged spleen. She suffered from progressive anemia and required a red blood cell transfusion once a month. Although computed tomography, ultrasonography, and magnetic resonance imaging were performed for diagnosis, a confirmed diagnosis was not obtained. Her enlarged spleen compressed her stomach, and she suffered from gastritis and a sense of gastric fullness just after meals. She underwent laparoscopic splenectomy for therapeutic and diagnostic purposes. Her post-operative course was uneventful. After surgery, her red blood cell and platelet counts increased markedly. The tumor was diagnosed as splenic histiocytic sarcoma. Post-surgical chemotherapy was not performed, and the patient died of liver failure due to liver metastasis 5 mo after surgery. Laparoscopic splenectomy is minimally invasive and useful for the relief of symptoms related to hematological disorders. However, in cases of an enlarged spleen, optimal views and working space are limited. In such cases, splenic artery ligation can markedly reduce the size of the spleen, thus facilitating the procedure. The case reported herein suggests that laparoscopic splenectomy may be useful for the treatment of splenic malignancy.

[Significance of preoperative neutrophil-to-lymphocyte ratio as a predictor of prognosis in patients with stage IV colorectal cancer].

This study aimed to investigate the clinical significance of preoperative neutrophil-to-lymphocyte ratio(NLR)as a predictor of prognosis in patients with Stage IV colorectal cancer. A total of 130 patients who underwent operation for Stage IV colorectal cancer were enrolled in the study. Of the patients, 69 had an NLR of ≥ 3.0 and were defined as the high-NLR group. Patients who received preoperative therapy and underwent emergency operation for perforation were excluded from the analysis. The 2-year survival rate was 58.1% in the high-NLR group and 43.5% in the low-NLR group. The median survival time was 38.0 months in the high-NLR group and 22.3 months in the low-NLR group. The patient prognosis in the high-NLR group was significantly worse than that in the low-NLR group. A univariate analysis indicated that high NLR, peritoneal dissemination, curability C, histological type( non-differentiated), and number of organs involved in metastasis (more than 1 organ) were the risk factors of poor survival. All of these factors, except peritoneal dissemination, were independent risk factors for poor survival on multivariate analysis. A high preoperative NLR may be considered as a convenient biomarker to identify patients with a poor prognosis after operation for stage IV colorectal cancer.

[Clinical outcomes of thoracoscopic esophagectomy after neoadjuvant chemotherapy].

AIM: With recent advances in multimodal therapy for esophageal cancer, neoadjuvant chemotherapy (NAC) followed by surgery has become the standard treatment for advanced resectable esophageal cancer. This study analyzed the feasibility and clinical outcomes of thoracoscopic esophagectomy (TE) after NAC. PATIENTS AND METHODS: We retrospectively analyzed 129 patients who underwent TE with radical mediastinal lymph node dissection between January 2005 and December 2012. Of these patients, 54 received NAC( NAC+group) and 75 did not( NAC-group).The perioperative clinical outcomes, number of dissected nodes, and postoperative mortality were compared between the 2 groups. RESULTS: The operation time in the NAC+group was significantly longer than that in the NAC-group( p<0.01).However, the estimated blood loss was significantly less in the NAC+group( p<0.01).There was no significant difference in the number of dissected nodes and the frequency of postoperative complications between the 2 groups. CONCLUSION: TE can be safely adopted for the treatment of patients with advanced esophageal cancer after NAC.

[A case of familial adenomatous polyposis presenting with thyroid cancer].

We report a case of familial adenomatous polyposis( FAP) presenting with thyroid cancer. A 24-year-old woman, on histological examination, was diagnosed as having the cribriform-morular variant of papillary thyroid carcinoma, which is known to be associated with FAP. Therefore, she underwent colonoscopy, and FAP was diagnosed. In addition, abdominal computed tomography( CT) scans revealed a tumor, approximately 12 cm in diameter, in the right lower abdomen. After total thyroidectomy, total proctocolectomy and excision of the tumor arising from the mesentery of the small intestines were performed. The histological diagnosis was FAP with a desmoid tumor arising from the mesentery.

[Utility and drawbacks of fludeoxyglucose-positron emission tomography in locally advanced esophageal cancer treated by neoadjuvant chemotherapy followed by esophagectomy].

In Japan, neoadjuvant chemotherapy followed by esophagectomy has become the standard treatment for resectable advanced esophageal cancer. However, there are few reports on the utility of fludeoxyglucose( FDG)-positron emission tomography (PET) in such cases so far. In this study, we analyzed the utility and drawbacks of FDG-PET in patients who underwent neoadjuvant chemotherapy followed by surgery. Thirty-seven patients with cStage II or III thoracic esophageal cancer who received 2 courses of combination chemotherapy with 5-fluorouracil and cisplatin followed by surgery were enrolled this study. The maximum standardized uptake value (SUVmax) in the main lesion significantly decreased after chemotherapy (38.6%), and there was a greater decrease in SUVmax in patients with downstaging. Following chemotherapy, the esophageal lesions were not detected by FDG-PET in 6 patients. However, in these patients, the histopathological diagnosis of the resected specimens revealed that the cancer cells persisted. The SUVmax increased after chemotherapy in 5 patients, and in 4 of 5 patients recurrent disease was observed. In conclusion, we should understand the characteristics of FDG-PET in esophageal cancer after neoadjuvant chemotherapy and use it precisely.