[A Case of Late Recurrence of Gastric Cancer Over Ten Years Post Gastrectomy].

A 72-year-old woman underwent a low anterior resection of the rectum and a total hysterectomy with a bilateral salpingo- oophorectomy simultaneously for rectal and ovarian cancer, respectively. The pathological diagnosis was a moderately differentiated adenocarcinoma of the rectum with some poorly differentiated components signet-ring cell components. A mucinous adenocarcinoma, with similar characteristics as that in the rectum, was found in the ovary. Intraoperative findings revealed no direct invasion between the rectum and ovaries, with no peritoneal dissemination. She was, therefore, diagnosed with synchronous double cancer. The rectal cancer was pT3N0M0, Stage Ⅱ and the ovarian cancer pStage Ⅰ. Adjuvant chemotherapy with capecitabine was performed for high-risk Stage Ⅱ rectal cancer. At 3.5 years after surgery, her CA19-9 level was high and pleural dissemination and para-aortic lymph node metastasis were confirmed on thoracoabdominal CT. Twelve years after the gastrectomy for gastric cancer, a comparison of the pathological specimens of her stomach at that time with the current pathological specimens revealed that the rectal and ovarian tumors were metastases of gastric cancer and that the current recurrence was a late recurrence of this disease. Late recurrence after gastrectomy, especially 10 years or more after surgery, is extremely rare.

[Laparoscopic Distal Gastrectomy for Elderly Patients with Advanced Gastric Cancer and Gastric Outlet Obstruction - A Case Report].

A 90-year-old female patient was admitted to our hospital with a chief complaint of vomiting.Gastroscopy revealed type 3 gastric cancer and gastric outlet obstruction(GOO).Abdominal computed tomography revealed thickening of the antral wall and suggested the presence of 3 perigastric lymph node metastases, but there was no ascitic fluid or distant metastasis.The clinical diagnosis was T4a(SE)N2H0CYXP0M0, Stage III B, according to the Japanese Classification of Gastric Carcinoma.Her general conditions including kidney and cardiac function were good, we considered that she was able to tolerate radical distal gastrectomy.We planned laparoscopic distal gastrectomy(LDG)and D2 lymphadenectomy after getting sufficient informed consent.The patient experienced an uneventful post-operative recovery, and was discharged in good health 11 days after surgery.

[Sigmoid colon cancer with intussusception prolapsing through the anus treated by elective laparoscopic radical surgery].

An 86-year-old man was brought in ambulance to our hospital because of sudden hematochezia and abdominal pain during defecation. Intestinal prolapse approximately 80mm from the anus and a type 1 tumor 50mm in size on the mucosal surface were detected. The intestinal prolapse was manually repositioned, and the reduction of the intussusception was confirmed by computed tomography (CT). Following colonoscopy and abdominal-enhanced CT, a sigmoid colon cancer without distant metastases was detected. Elective laparoscopic radical surgery was performed. The present study described a rare case of sigmoid colon cancer with an intussusception prolapsing through the anus and highlighted the treatment strategy by reviewing 48 previous cases. The treatment strategy employed was as follows:first, manual repositioning of the intestinal prolapse was attempted;and second, the presence of intussusception was confirmed by CT. In cases when repositioning of the intussusception was not possible, even with the use of an endoscope or contrast enema, emergency surgery was required.

[A Case of Metastatic Carcinoma of Anal Fistula].

A 58-year-old man underwent rectal resection(D2 dissection)for rectal cancer and liver/lung metastases in August 2009. Histopathological findings were Ra, type 2, 70×80mm, tub1>tub2, int, pSI(peritoneum), INF b, ly1, v1, pN1(2/13), pPM0, pDM0, M1a(H1, PUL1), fStage IV . The lung metastasis had disappeared on chest CT after postoperative chemotherapy and we were able to perform radical resection of the liver metastasis by performing hepatectomy twice. In October 2013, anal pain appeared and a painful tumor approximately 2 cm in size was found in the 5 o'clock direction of the anus. Biopsy revealed a well-differentiated tubular adenocarcinoma similar to rectal cancer, and it was diagnosed as a fistula metastasis of rectal cancer.We performed chemoradiotherapy(S-1 120mg/day plus RT 60 Gy/30 Fr)as surgery was recommended but refused. As a result, the tumor reduced markedly in size. In December 2015, the tumor enlarged in size and the patient and family requested surgery. We, therefore, performed abdominoperineal resection. Currently, the patient is alive at 18 months after surgery with no recurrence.

[Early Liver Metastases after Curative Surgery for Stageâ Gastric Cancer with Neuroendocrine Differentiation-A Case Report].

An 87-year-old male patient was admitted to our hospital with a chief complaint of vomiting. Gastroscopy revealed Type 0-Ⅱc+Ⅱa tumor at the posterior wall in the middle third of the stomach. A biopsy indicated moderately differentiated adenocarcinoma. Abdominal CT revealed no lymph node or distant metastases. The clinical diagnosis was cT2(MP), N0, M0, cStage Ⅰ. Laparoscopic distal gastrectomy with D2 lymphadenectomy was performed. The pathological findings revealed moderately differentiated adenocarcinoma containing synaptophysin, chromogranin A, and CD56-positive tumor cells. He was then diagnosed with adenocarcinoma with neuroendocrine differentiation. The pathological diagnosis was pT2(MP), pN0, M0, pStage ⅠB. MRI revealed multiple liver metastases 5 months postoperatively. S-1 alone chemotherapy was started, and the patient showed partial response(PR)after 3 courses, according to the Response Evaluation Criteria in Solid Tumor (RECIST).

[Invasive Micropapillary Carcinoma of the Colon That Was Difficult to Diagnose Preoperatively].

A 73-year-old man was admitted with sigmoid colon diverticulitis. Although a biopsy did not indicate malignancy, the sigmoid colon was completely obstructed following conservative treatment. After sigmoidectomy, the histopathological findings revealed a well-differentiated adenocarcinoma localized to the mucosal surface; invasive micropapillary carcinoma (IMPC)accounting for>95% of the tumor volume spread extensively below the submucosal layer. IMPC is highly malignant and difficult to diagnose preoperatively, possibly due to the presence of poorly differentiated histological sub-types in the deepest portions of the tumor.

Non-traumatic bladder rupture showing less than 10 Hounsfield units of ascites.

Aim: Bladder ruptures are commonly misdiagnosed as gastrointestinal perforations or intestinal ischemia. If a diagnosis is made preoperatively, conservative treatment is a safe and effective option. We evaluated the validity of using the attenuation value of ascites, measured by non-contrast computed tomography (CT), to identify patients with bladder ruptures. Methods: A retrospective search of our hospital database identified 7 patients with confirmed bladder ruptures between 2007 and 2013. We also enrolled 18 patients with gastrointestinal perforations and 10 patients with intestinal ischemia with detectable ascites on abdominal CT that had undergone emergency exploratory laparotomy between 2007 and 2013. Between-group comparisons of attenuation values of ascites as obtained by non-contrast CT were evaluated. Results: All attenuation values were less than 10 Hounsfield units (HU) in bladder rupture patients. Moreover, the attenuation value of ascites in cases of bladder rupture (median, 5.7; range, 3.1-6.1) was significantly lower than in cases of gastrointestinal perforation (median, 14.7; range, 4.7-25.4) and intestinal ischemia (median, 13.3; range, 6.0-18.1) (P = 0.004 for both comparisons). Conclusion: Bladder rupture mimics gastrointestinal perforation and intestinal ischemia with acute kidney injury. Therefore, the diagnosis of bladder rupture using the attenuation value of ascites on non-contrast CT is both useful and highly significant. We suggest that bladder rupture be considered in the differential diagnosis of patients presenting with acute abdominal pain and attenuation values of ascites of less than 10 Hounsfield units.

Prediction of difficult laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: No report has described the predictive factor of surgical difficulty for laparoscopic cholecystectomy (LC) by preoperative computed tomography (CT) findings. This study aimed to investigate whether dynamic CT findings can predict the difficulty of LC for acute cholecystitis. MATERIALS AND METHODS: Fifty-seven patients who underwent emergency LC and dynamic CT preoperatively were enrolled. Difficult LC (DLC) was defined as any patient with an operative time ≥3 h, bleeding volume ≥300 mL, common bile duct injury, partial cholecystectomy, the need for a second surgeon, and/or conversion to open surgery. Patients were assigned to either the DLC (+) or DLC (-) group. We determined the CT attenuation ratio of the arterial phase (ARAP) to represent the degree of transient focal enhancement of the liver adjacent to the gallbladder. The ARAP cutoff value for a DLC predictor was determined using receiver operating characteristic curve analysis. Patients' characteristics and CT findings, including the ARAP, were compared between the groups. The Fisher exact test for categorical variables and the Mann-Whitney U test for continuous variables with Bonferroni correction were used to evaluate the significance of differences. RESULTS: Fifteen patients were assigned to the DLC (+) group. The ARAP was significantly higher in the DLC (+) group than in the DLC (-) group (P = 0.006). The ARAP cutoff value was 1.55. Regarding the CT findings, an ARAP ≥1.55 (P = 0.005) was significantly correlated with DLC. CONCLUSIONS: Among dynamic CT findings, an increased ARAP is a predictive factor for DLC.

[A Case of Rectal Cancer Presenting with Schistosomiasis Japonica Eggs].

A 87-year-old man had used to live in Shizuoka Prefecture. He got colonoscopy due to melena, and a type 1 tumor about 3 cm was detected in the rectum. He was diagnosed with rectal cancer. We performed a laparoscopic low anterior resection with lymphadenectomy. Histopathological findings shows tub1, pSM(7mm), med, INF a, ly1, v0, pPM0, pDM0, pN0(0/7), T1bN0M0, Stage I . Schistosoma japonica eggs were seen in submucosal of the rectum not around the tumor but also normal tissue. The eggs embolized microvessels. It has been 5 year since the operation, the patient has survived without recurrence.

[Esophagogastric Junction Cancer Resection with Bilateral Adrenal Metastasis - A Case Report].

The patient was a 64-year-old man with esophagogastric junction cancer. We performed right thoracotomy-laparotomy for lower esophageal and cardiac gastric resection, D2 lymphadenectomy, and reconstruction of a gastric tube in October 2011. Histopathology confirmed T4aN1M1(LYM), Stage IV cancer(Japanese Classification of Gastric Carcinoma, 14th edition) with R0 resection. Because of preexisting alcoholic cirrhosis, postoperative chemotherapy was not an option. In March 2014, we performed left adrenalectomy for left adrenal metastasis, and in December 2014, we performed right adrenalectomy for metastasis to the right adrenal gland. The patient was prescribed 20mg/day of hydrocortisone postoperatively. Survival from the right adrenalectomy was 2 years and 2 months, and survival from the first operation was 5 years and 4 months, without recurrence. This case of esophagogastric junction cancer resection with bilateral adrenal metastasis is rare, with only one previously reported case in Japan.

Perforated Carcinoma in the Gastric Remnant: A Case of Conservative Treatment Prior to Successful Curative R0 Resection.

An 80-year-old man who had undergone distal gastrectomy and Billroth-II gastrojejunostomy 38 years previously, for a benign gastric ulcer, was diagnosed with remnant gastric cancer based on upper gastrointestinal endoscopy findings. He presented at our emergency department with acute-onset epigastric pain due to perforated remnant gastric cancer. Conservative medical management was selected, including nasogastric tube insertion, antibiotics, and proton pump inhibitors, because his peritonitis was limited to his epigastrium and his general condition was stable. Twenty-one days after the perforation occurred, curative total remnant gastrectomy and D2 lymphadenectomy were performed. Adhesion between the lateral segment of the liver and the dissected lesser curvature of the gastric remnant may have contributed to the peritonitis in this case, which was limited to the epigastrium. This is the first report of perforated remnant gastric cancer in which conservative treatment was effective prior to curative resection. The protocol reported here may be of use to other clinicians who may encounter this clinical entity in their practices.

Ascitic fluid with ammonia odor as a symptom of bladder rupture.

Case: An 88-year-old woman presented with abdominal pain, massive ascites, and acute kidney injury. She was clinically hypervolemic and the computed tomography attenuation value of the ascites was near that of water. Subsequent abdominocentesis revealed ammonia-smelling ascites fluid, leading to a suspicion of urinary tract injury, and a conclusive diagnosis of spontaneous bladder rupture was achieved using cystography. Outcome: The patient was managed conservatively with antibiotics, percutaneous drainage, and bladder catheter. As a result, she was discharged with normal renal function. Conclusion: The diagnosis of bladder rupture is difficult, and is rarely confirmed in the absence of a diagnostic suspicion. This case indicates that ascitic fluid odor, patient volume status, and the computed tomography attenuation value of ascites are potential indicators of bladder rupture.

[A Case of a Large Gastric Gastrointestinal Stromal Tumor with a PDGFRA Exon 18 Mutation].

A 49-year-old man visited our hospital with a chief complaint of abdominal pain that began 1 day before his visit.An approximately 30 cm tumor that was extensively in contact with the gastric wall in the abdominal cavity was detected on computed tomography(CT).An elevated lesion covered with normal mucosa on the posterior wall of the greater curvature was detected on upper endoscopy.He was diagnosed with a submucosal tumor of the stomach, and he underwent surgery. Surgical findings revealed an elastic soft tumor with a maximal dimension of 38 cm that projected from the posterior wall of the stomach beyond the gastric wall.No invasion and metastasis to other organs were detected.Partial gastrectomy was performed.On histopathological examination, proliferation of atypical round and spindle cells was found, and immunostaining was negative for KIT but positive for CD34.In the gene search, an Asp842Val mutation was detected in exon 18 of the PDGFRA gene.Currently, the patient has survived for 7 months after surgery without recurrence.

Continuous Administration of Vancomycin through a Long Intestinal Tube for Clostridium difficile Infection.

A 76-year-old previously healthy Japanese man experienced severe diarrhea (8,000 mL per day) after undergoing laparotomy for small bowel obstruction and was diagnosed with Clostridium difficile infection. Although he developed a maculopapular rash secondary to the systemic absorption of enteral vancomycin (VCM), the patient was successfully treated with the continuous administration of VCM through a long intestinal tube placed in the terminal ileum. This method ensured the reliable delivery of VCM to the colon, while the continuous administration maintained high fecal levels of the drug. This treatment approach is an effective minimally invasive option for patients with severe diarrhea.