Primary esophageal malignant melanoma without recurrence after surgery and adjuvant therapy with nivolumab.

Primary malignant melanoma of the esophagus is a rare disease with a severely poor prognosis. Here, we report a patient with primary malignant melanoma of the esophagus surviving without recurrence after surgery and adjuvant therapy with nivolumab. The patient was a 60-year-old female with dysphagia. Esophagogastroscopy showed an elevated dark brown tumor in the lower thoracic esophagus. A histological examination of the biopsy revealed human melanoma black 45 and melan-A positivity. The patient was diagnosed with primary malignant melanoma of the esophagus and was treated with radical esophagectomy. As postoperative treatment, the patient was given nivolumab (240 mg/body) every 2 weeks. Although bilateral pneumothorax occurred after 2 courses, she recovered after chest drainage. Nivolumab treatment is still ongoing over 1 year after the surgery, and the patient has survived without recurrence. We conclude that nivolumab is an optimal option as a postoperative adjuvant treatment for PMME.

A case of undifferentiated pleomorphic sarcoma in esophagus after multiple cancer treatments of surgery and chemoradiotherapy.

BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) in the esophagus is extremely rare. Therefore, there are few reports of UPS in the esophagus (UPSE). We present a case of UPSE after multiple cancer treatments. CASE PRESENTATION: A 73-year-old man with a history of cancer treatment, including distal gastrectomy, transverse colectomy, and chemoradiotherapy, was diagnosed with an elevated lesion such as a submucosal tumor in the lower esophagus by regular endoscopy. A boring biopsy was performed, and the specimen showed features of sarcoma. The patient underwent a partial esophagectomy without lymph node dissection. Histopathological findings confirmed an undifferentiated pleomorphic sarcoma. Adjuvant therapy was not administered, and the patient survived without recurrence 1 year after surgery. CONCLUSIONS: Currently, complete resection is the only treatment option for UPSE. An optimal treatment strategy using chemotherapy or radiotherapy should be established.

Association Between Anti-Helicobacter pylori Antibody Seropositive and De Novo Gallstone Formation After Laparoscopic Sleeve Gastrectomy for Japanese Patients with Severe Obesity.

PURPOSE: Patients who have undergone bariatric surgery are at risk for gallstone formation. However, the incidence of gallstone formation after bariatric surgery has not been adequately studied in the Japanese population. We aimed to elucidate the incidence and risk factors for gallstone formation after laparoscopic sleeve gastrectomy (LSG) for Japanese patients with severe obesity. METHODS: We conducted a retrospective cohort study among patients with severe obesity treated with LSG between April 2017 and June 2020 at two institutions. Patients who had received previous cholecystectomy, had preoperative gallstones, and had received postoperative prophylactic ursodeoxycholic acid were excluded. Body weight, body mass index, and blood data were collected at each follow-up visit before and after the surgery. Follow-up abdominal ultrasonography was performed 6-12 months after surgery, and the incidence of gallstones was calculated. The association between the data and gallstone formation was evaluated. RESULTS: During the study period, we performed LSG for 98 patients. Of these, 61 cases remained by above conditions and were examined using abdominal ultrasonography over 6 months after surgery. The incidence of gallstones was 23.0% and that of symptomatic gallstones was 3.3%. Anti-Helicobacter pylori antibody seropositive and titer were the only factors that showed significant association with de novo gallstone formation after LSG. CONCLUSIONS: Anti-Helicobacter pylori antibody seropositive may be associated with de novo gallstone formation after LSG for Japanese patients with severe obesity.

Prediction of hospital mortality after colorectal perforation surgery from inflammation-based prognostic scores.

Background: Inflammation-based prognostic scores have prognostic value in cancer or cardiovascular disease patients. This study evaluated the prognostic value of inflammation-based prognostic scores in colorectal perforation patients. Methods: Data of 97 patients who underwent surgery for colorectal perforation were reviewed. We calculated various inflammation-based prognostic scores and analyzed the relationship between inflammation-based prognostic score and hospital mortality due to colorectal perforation. Results: Multivariate analyses of hospital mortality revealed neutrophil-lymphocyte ratio (P = .0021), C-reactive protein/albumin ratio (P = .0224), and prognostic nutritional index (P = .0078) as independent predictive factors. The Kaplan-Meier analysis showed that patients who met all of the following parameters avoided hospital death: neutrophil-lymphocyte ratio < 30, prognostic nutritional index ≥ 27.2, age < 75 years, and perforation of the left colon. Conclusion: Neutrophil-lymphocyte ratio, C-reactive protein/albumin ratio, and prognostic nutritional index were superior to other inflammation-based prognostic scores in predicting mortality of colorectal perforation. Neutrophil-lymphocyte ratio, prognostic nutritional index, patient's age, and sidedness of the perforation site may be useful parameters to identify subgroups in which a favorable prognosis can be expected.

New index combining multiple inflammation-based prognostic scores for predicting the prognosis of gastric cancer patients.

Background and Aim: Several inflammation-based scores have prognostic value for patients diagnosed with various cancers. However, using only a single inflammation-based prognostic score may be unreliable, as the cut-off values and relative usefulness among various inflammation-based prognostic scores vary. We established a new combined index of four inflammation-based prognostic scores, namely the neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, prognostic index, and prognostic nutritional index, and assessed its usefulness to predict the prognosis of gastric cancer. Methods and Results: We reviewed the data of 635 patients who underwent surgical resection for gastric cancer. We calculated the combined index as the total value of each of the four included inflammation-based prognostic scores and analyzed the relationship between the combined index and postoperative prognosis of gastric cancer. The new combined index was represented as a value between 0 and 6 in each patient. The Kaplan-Meier survival curves showed that patients whose combined index was 0 had good long-term outcomes, while the prognosis of patients whose combined index ranged from 4 to 6 was poor. Conclusion: This new combined index was strongly associated with poor prognosis in patients who underwent surgery for gastric cancer. It is inferred that it can predict patient prognosis after surgical resection for gastric cancer with a stronger correlation and clearer stratification than a single inflammation-based prognostic score.

Combined laparoscopic and thoracoscopic surgical repair of Bochdalek hernia in an adult: a case report.

BACKGROUND: Bochdalek hernia is a rare disease in adults. Diaphragmatic hernia in adults has been repaired using minimally invasive surgery through laparoscopy or thoracoscopy. However, the literature regarding the combined use of laparoscopy and thoracoscopy for the repair of Bochdalek hernia is limited. CASE PRESENTATION: A 26-year-old man diagnosed with Bochdalek hernia was managed through combined abdominal and thoracic endoscopic surgery. On laparoscopy, the omentum prolapsed into the left thoracic cavity through the posterolateral area of the left diaphragm. On thoracoscopy, no adhesions of the omentum were seen in the thoracic cavity. The omentum was drawn back to the abdominal cavity, and a 4 × 3-cm hernial orifice was identified. The hernia orifice was repaired through simple closure with sutures laparoscopically. The patient's postoperative course was uneventful with no recurrences within the first year post-surgery. CONCLUSION: Combined laparoscopic and thoracoscopic surgery is a safe and effective method for Bochdalek hernial repair in adults.

Comparison of Inflammation-Based Prognostic Scores Associated with the Prognostic Impact of Adenocarcinoma of Esophagogastric Junction and Upper Gastric Cancer.

BACKGROUND: Several inflammation-based prognostic scores have a prognostic value in patients with various cancers. This study investigated the prognostic value of various inflammation-based prognostic scores in patients who underwent a surgery for adenocarcinoma of the esophagogastric junction (AEG) and upper gastric cancer (UGC). METHODS: We reviewed data of 206 patients who underwent surgery for AEG and UGC. We calculated neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), Glasgow Prognostic Score (GPS), modified GPS (mGPS), C-reactive protein (CRP)/albumin (Alb) ratio, prognostic index (PI), and prognostic nutritional index (PNI) and analyzed the relationship between these biomarkers and postoperative prognosis. RESULTS: In multivariate analyses for overall survival, mGPS (P = 0.0337, hazard ratio [HR] = 5.211), PI (P = 0.0002, HR = 21.20), and PNI (P < 0.0001, HR = 6.907) were identified as independent predictive factors. A multivariate analysis for recurrence-free survival showed that only PI (P = 0.0006, HR = 11.89) and PNI (P = 0.0002, HR = 4.972) were independent predictive factors among the above-mentioned inflammation-based prognostic scores. CONCLUSIONS: In various inflammation-based prognostic scores, PI and PNI were more strongly associated with poor prognosis in patients who underwent surgery for AEG and UGC.

Laparoscopic sleeve gastrectomy performed in a morbidly obese patient with gastrointestinal stromal tumor: a case report and literature review.

BACKGROUND: Gastrointestinal stromal tumor (GIST) is the most frequent submucosal tumor, and with advancements of diagnostic modalities, the incidence of GIST cases diagnosed have increased. Similarly, prevalence of morbid obesity has also rapidly increased over the past decade. Notably, the incidence of GIST in obese patients was reported to be more frequent as compared to the general population. Despite local resection being the first choice for GIST treatment, extensive surgery should also be considered depending on the tumor size and location. Laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure, could also be a concomitant treatment option for both morbid obesity and GIST when the tumor is contained within LSG the excision range. There are, however, few reports about LSG planned for GIST preoperatively. CASE PRESENTATION: A morbidly obese 46-year-old Japanese male (body weight of 105.4 kg, body mass index (BMI) of 36.6 kg/m2) was diagnosed with an intramural GIST in the gastric fundus. Because of his extreme visceral fat dominated obesity (visceral fat area of 386 cm2), in addition to the size and location of the tumor, we determined that it would be difficult to perform local resection. We planned LSG as a concomitant treatment for both GIST and morbid obesity. After the preoperative examination and 6 months of weight control, the patient lost enough weight to undergo LSG safely. Keeping enough distance away from the tumor, which we observed with an endoscope, we performed LSG to successfully resect the tumor. The patient was discharged uneventfully. Weight loss was successful as his BMI was 21.0 kg/m2 at 3 months post-surgery. CONCLUSION: We successfully performed LSG in a morbidly obese patient with a large GIST. This is the largest GIST concomitantly resected with LSG reported within current literature.

A Novel Non-Gas Endospray for Applying Fibrin Glue in Laparoscopic Surgery.

Purpose: Fibrin glue and polyglycolic acid felt are used for tissue repair in various surgical procedures. However, using a spray device to apply fibrin sealant during laparoscopic surgery can increase the intraperitoneal pressure, which can cause complications such as air embolism. We developed a novel non-gas endospray for use in laparoscopic surgery. This study aimed to evaluate the sealing effect of this non-gas endospray in comparison with a conventional gas-spray device and to evaluate the safety of its application in the clinical setting. Materials and Methods: An ex vivo pressure test model was used to assess the sealing effect of the non-gas endospray (method 1) versus conventional gas-spray (method 2). A bottle was sealed with a rabbit skin sample that had been pierced nine times by a 19G needle. Each skin sample was sealed using either method 1 or method 2 (n = 10 for each method). The non-gas endospray was then used in two patients undergoing laparoscopic splenectomy with CO2 pneumoperitoneum. Intra-abdominal pressure was measured throughout the surgery. Results: Bursting pressures were similar in method 1 (246.9 ± 123.2 mmHg) and method 2 (265.5 ± 93.6 mmHg; P = 0.7082). During laparoscopic splenectomy, the non-gas endospray was successfully used to apply fibrin glue without any increase in intra-abdominal pressure. Conclusions: The novel non-gas endospray produced a strong sealing effect similar to that of a conventional gas-spray device and has thus far proved feasible in the clinical setting.

Analysis of Response Evaluation Criteria in Solid Tumors reduction ratio of primary chemotherapy in unresectable advanced or recurrent colorectal cancer.

Response Evaluation Criteria in Solid Tumors (RECIST) is used to assess the objective response of solid tumors to treatment. However, it remains unclear to what extent the response rate assessed by RECIST reflects a reduction of tumor size in multiple organs in patients with unresectable advanced or recurrent colorectal cancer (CRC) with multiple organ metastases. It is also unclear whether the management of liver metastases with systemic chemotherapy in CRC patients with multiple organ metastases improves their prognosis, although surgical resection has been shown to be the most effective treatment approach to CRC cases with liver metastases. A total of 38 CRC patients who underwent systemic chemotherapy in Kyushu Medical Center Hospital between January 2013 and April 2016 were examined. The patients had measurable lesions in multiple organs, including the liver, and did not undergo curative surgery for metastatic lesions after initiation of chemotherapy. The association between the total reduction ratio (TRR) of all lesions and liver lesion reduction ratio (LRR) was retrospectively analyzed. A total of 18 patients (47%) had H3 liver metastases, and the median liver lesion occupancy rate in the sum of the measured lesions with RECIST was 76%. TRR and LRR were strongly correlated, regardless of the volume of the liver metastases. Although a TRR of >30% was significantly associated with improved overall survival (OS), this improvement was not observed in patients with H3 liver metastases. TRR was correlated with LRR and was associated with a better OS. CRC patients with both multiple organ and H3 liver metastases exhibited poor survival, even with a high reduction ratio by chemotherapy.

Validation of an assessment tool: Estimation of Postoperative Overall Survival for Gastric Cancer.

BACKGROUND: Benchmarking of long-term surgical outcomes has rarely been attempted. We previously devised a prediction model for assessing the outcome of late survival after surgery, termed the Estimation of Postoperative Overall Survival for Gastric Cancer (EPOS-GC). This study was undertaken to validate EPOS-GC in an external data set. METHODS: A retrospective cohort study was conducted in 11 cancer care hospitals in Japan, analyzing a consecutive series of patients who underwent elective gastric cancer resection between April 2007 and March 2009. EPOS-GC consists of three tumor-related variables and three physiological variables. The primary endpoint was postoperative overall survival. The observed-to-expected (O/E) ratio of 5-year survival rates was defined as a metric of quality of care. The sample size for O/E was determined as 42. RESULTS: We included 2045 patients for analysis. The median (95% confidence interval) follow-up time was 5.1 (1.2-6.8) years for censored patients. Although EPOS-GC demonstrated a good discriminative power (Harrell's C-index, 95% confidence interval: 0.80, 0.79-0.83), the calibration plot revealed that EPOS-GC underestimated 5-year survival rates in the high-risk group. Therefore, we recalibrated the model with Cox's regression analysis. The recalibrated EPOS-GC showed a good calibration, preserving the high discriminative power (C-index, 95% confidence interval: 0.80, 0.78-0.82). The O/E among hospitals according to the recalibrated EPOS-GC ranged between 0.87 and 1.27. The O/E correlated with hospital volumes (Spearman's correlation = 0.76, n = 11, p = .006). CONCLUSION: EPOS-GC with recalibration can convey risk-adjusted quality assurance regarding late survival following gastric cancer resection.

Phase II study of S-1 plus leucovorin in patients with metastatic colorectal cancer: Regimen of 1 week on, 1 week off.

A phase II study of S-1 plus leucovorin (LV) given in a 4-week schedule (2 weeks' administration followed by 2 weeks' rest) for patients with untreated metastatic colorectal cancer (mCRC) showed that the combination was effective, but grade 3 toxicities (diarrhea, stomatitis and anorexia) occurred at a relatively high rate. In this phase II study, we evaluated the efficacy and safety of a 2-week schedule of S-1 plus LV. Patients with mCRC received oral S-1 (40-60 mg) and LV (25 mg) twice daily for 1 week, followed by 1 week's rest. Treatment was repeated until disease progression or unacceptable toxicity. The primary endpoint was response rate. The pharmacokinetics of S-1 and LV in Chinese patients were evaluated on day 1 of the first cycle. Seventy-three patients were enrolled in Japan and China. Of 71 eligible patients, the response rate was 53.5%, and the disease control rate was 83.1%. Median progression-free survival and median overall survival were 6.5 and 24.3 months, respectively. The incidences of grade 3 toxicities were diarrhea 8.3%, stomatitis 8.3%, anorexia 2.8% and neutropenia 9.7%. There were no treatment-related deaths. The pharmacokinetics profiles of S-1 plus LV in Chinese patients were similar to those in Japanese patients. This 2-week schedule of S-1 plus LV showed good efficacy and better tolerability than the 4-week schedule. This therapy will be the base regimen for mCRC to be added by other cytotoxic or molecular-targeted drugs. The optimized treatment schedule for S-1 plus LV was 1 week on and 1 week off.

Weight Loss During Initial Chemotherapy Predicts Survival in Patients With Advanced Gastric Cancer.

BACKGROUND: Patients with advanced gastric cancer (AGC) often suffer weight loss, which can be used to predict prognosis. Few reports have assessed the correlation between weight loss during chemotherapy and survival in patients with AGC. METHODS: Fifty-three patients with histologically proven AGC, who started systemic chemotherapy from September 2010 to March 2014, were retrospectively examined for body weight, inflammatory status, and survival. Correlation analyses were performed between weight change and survival. Correlations between weight loss and the patient characteristics were analyzed by stepwise multiple regression analyses. RESULTS: The mean age of the patients was 64.4 years; 64% of the patients were males. Initial chemotherapy included fluoropyrimidine plus cisplatin (62%), fluoropyrimidine alone (26%), and other medications (12%); 72% of the patients exhibited weight loss during the initial therapy. Poorer mean overall survival and mean progression-free survival were observed in patients with weight loss of higher-than-average values than in those with weight loss of lower-than-average values. Serum C-reactive protein levels were significantly correlated with weight loss. CONCLUSIONS: Weight loss during initial chemotherapy for AGC may predict survival. Systemic inflammation is suggested to be associated with weight loss.

Pancreatic fistula after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis: effect of fibrin glue and polyglycolic acid felt on prophylaxis of postoperative complications.

BACKGROUND: This study aimed to determine the effect of fibrin glue and polyglycolic acid (PGA) felt on prevention of pancreatic fistula (PF) after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis. METHODS: Fifty consecutive patients were enrolled in this prospective study. Twenty-three patients underwent laparoscopic splenectomy with a fibrin sheet (fibrin sheet group). The sealing ability of each treatment was evaluated by an ex vivo pressure test model. Based on the results from ex vivo experiments, 27 patients received prophylaxis using fibrin glue and PGA felt (PGA with fibrin group). The primary endpoint was the incidence of PF. RESULTS: Significantly more (5, 22%) patients developed PF in the fibrin sheet group than in the PGA with fibrin group (0%, P = .037). CONCLUSIONS: Our new application of fibrin glue and PGA felt is an effective prophylactic procedure for preventing development of PF after laparoscopic splenectomy.

[Comorbid Meckel's diverticulum and omphalomesenteric cyst evaluated by small bowel series under double-balloon enteroscopy: a case report].

A 59-year-old man was referred to our hospital for examination of intermittent abdominal pain. Computed tomography scan showed a cystic lesion adjoining the ileum, and small bowel series demonstrated a small bowel diverticulum. Double-balloon enteroscopy (DBE) revealed a diverticulum in the ileum and a soft and smooth elevated lesion with a small hole at the base of the diverticulum. Small bowel series under DBE demonstrated that the cystic lesion communicated with the diverticulum through the small hole. The diagnosis was Meckel's diverticulum and an omphalomesenteric cyst. This is the first reported case of a Meckel's diverticulum and omphalomesenteric cyst communicating through a small hole without a fibrous ligament. In addition, precise evaluation was possible by small bowel series and DBE.

Induction of potentially lethal hypermagnesemia, ischemic colitis, and toxic megacolon by a preoperative mechanical bowel preparation: report of a case.

A 67-year-old man was diagnosed with rectal cancer. The tumor invaded the subserosal layer, but it was not large, and there was no sign of obstruction. Neo-adjuvant chemotherapy reduced the size of the tumor. The patient was admitted to our hospital for surgery. For mechanical bowel preparation, he ingested 34 g of magnesium citrate (Magcorol P®), but then developed severe shock, a disturbance of consciousness, and acidemia, and he required catecholamines and mechanical ventilation. X-ray, CT, and laboratory tests revealed ischemic colitis, toxic megacolon, and hypermagnesemia (16.3 mg/dL). After 2 days of temporary hemodialysis and an enema to reduce his blood magnesium concentration, he recovered and left the intensive care unit. However, the left side of his colon had suffered ischemic damage and become irreversibly atrophied. One month later, he underwent laparoscopic abdominoperineal resection and left-side colectomy for the rectal cancer and severe ischemic colitis of the left side of the colon. Histopathology confirmed the rectal cancer with a grade 2 chemotherapeutic effect and severe ischemic colitis of the left side of the colon. Hence, the present case suggests that severe ischemic colitis, toxic megacolon, and hypermagnesemia can occur after taking a magnesium laxative without obstruction of the intestine.

Clinical Significance of Closure of Mesenteric Defects in Laparoscopic Colectomy: A Single-Institutional Cohort Study.

BACKGROUND: The effect of closure of mesenteric defects to prevent complications, such as internal hernia, during laparoscopic colectomy remains controversial and is a subject of debate. PURPOSE: This retrospective single-institution study aimed to clarify the clinical significance of mesenteric defect closure during a laparoscopic colectomy. METHODS: We evaluated 58 patients who underwent laparoscopic right-side colectomy or transverse colectomy. The statistical relevance of complications, surgical maneuvers, and clinical factors was examined. RESULTS: The mesenteric defects were closed in 30 patients and not closed in 28 patients. Two patients with ileus and 1 with a deep incisional surgical site infection required a second surgery. The reoperation rate was significantly higher in the nonclosure group than in the closure group (11% vs. 0%, respectively; P=0.033). CONSIDERATION: Serious complications requiring reoperation occurred only in the nonclosure group. The procedure for closing the defect did not extend the operation time or increase the bleeding.

Survival with Collateral Circulation after Gastrointestinal Ischemia Caused by Aortic Dissection: A Case Report.

We report a case of a 43-year-old man who presented with gradually intensifying abdominal pain of acute onset and was shown by contrast-enhanced computed tomography (CT) examination to have acute aortic dissection (Stanford type B). A diagnosis of gastrointestinal necrosis was made and he underwent emergency surgery. At laparoscopy, he was found to have no superior mesenteric arterial pulse and intestinal necrosis from the upper jejunum to the right transverse colon. Resection of the superior mesenteric artery (SMA) perfusion area was performed. Postoperatively, ischemia in the perfusion area of the celiac artery was also diagnosed, manifesting as gallbladder necrosis, portal vein gas accompanying gastric wall necrosis, perforation of the remaining upper jejunum, and hepatic and splenic infarction. However, development of a collateral circulation originating in the left colic branch of the inferior mesenteric artery (IMA) enabled retrograde provision of blood to the celiac artery through the SMA pancreaticoduodenal arcade. Thus, in this case, spontaneous development of a natural bypass created a new route for arterial perfusion, contributing to the patient's survival. When ischemia of the celiac artery and SMA perfusion areas occur, collateral circulation can develop from the IMA.

Huge epithelioid malignant peripheral nerve sheath tumor in the left axilla: a case report.

This report describes a patient with a rare huge epithelioid malignant peripheral nerve sheath tumor (MPNST) in the left axilla. A male in his 70s was admitted to our hospital for evaluation of a growing tumor in his left axilla. The tumor was solid and immovable. Examination of a biopsy specimen resulted in a diagnosis of epithelioid MPNST. Two weeks after the biopsy was performed, the tumor grew to 20 cm and became painful, and the patient was unable to feel pressure on his upper arm. Immediately before surgery to remove the tumor, computed tomography suggested the presence of lung metastases. The patient and his family were informed of his disease state, and they elected surgical treatment to ease the symptoms associated with tumor enlargement. Systemic metastases appeared soon after the surgery, and the patient died within 11 weeks. Comparative genomic hybridization (CGH) analysis showed that this tumor was chromosomally unstable, with impairments in gene expression.