[A Case of Inverted LECS for GIST Near the Pylorus Ring].

Laparoscopy and endoscopy cooperative surgery(LECS)is a surgical procedure to avoid excessive resection of the gastrointestinal wall and preserve its function. For gastrointestinal stromal tumors(GIST)near the cardia and pylorus ring, the function of the cardia and pylorus can be preserved by minimum excision and hand-sewn suture closures. Here, we report a case successfully treated with inverted LECS for GIST near the pylorus ring. The patient was a 58-year-old male. Upper gastrointestinal endoscopy had revealed a 45 mm sized SMT near the pylorus ring. Biopsy by EUS-FNA indicated gastric GIST. The tumor was separated from the pylorus ring and inverted LECS was performed. The defect was closed with hand-sewn sutures, forming an L-shape. The postoperative course was good and he was discharged from hospital 10 days after surgery. It is considered that devising the direction of closure by means of the LECS procedure can preserve the pyloric function without passage obstruction or stasis, even for gastric GIST near the pylorus ring.

[Unresectable Advanced HER2-Positive Gastric Cancer Leading to a Perforation during Chemotherapy with Trastuzumab plus Paclitaxel].

The patient was a 70s female with gastric cancer. CT and PET scans revealed metastases of para-aortic lymph nodes, hepatoduodenal ligament lymph nodes, and left supraclavicular lymph nodes. She was diagnosed with T4a, N2, M1(LYM), and cStage ⅣB and was given chemotherapy with paclitaxel due to chronic kidney disease and trastuzumab treatment. We planned to perform radical gastrectomy with lymph node dissection due to the disappearance of FDG uptake except for primary gastric cancer on PET scans 5 months after chemotherapy. However, the patient developed pan-peritonitis due to gastric cancer perforation; therefore, emergency distal gastrectomy with Billroth Ⅱ reconstruction was performed. She received chemotherapy(only trastuzumab)after getting discharged. Reports about gastric cancer perforation during chemotherapy using trastuzumab are rare. We should consider the possibility of perforated gastric cancer during chemotherapy and optimal surgical procedures, including the extent of lymph node dissection in the case of Stage Ⅳ gastric cancer.

[A Case of Colon Cancer with Suspected DPD Deficiency Causing Severe Adverse Effects following Adjuvant Chemotherapy with Capecitabine].

The present study reports a case of colon cancer in a 76-year-old female who underwent laparoscopic right colectomy. Pathological findings revealed pT3(SS), pN2a, cM0, and pStage Ⅲb. Hence, we administered adjuvant chemotherapy with capecitabine. On day 18, she was urgently hospitalized because of severe oral mucositis(grade 3), diarrhea(grade 3), and leukocytopenia(grade 4). Furthermore, the patient experienced DIC, which gradually improved through intensive conservative treatment. From the clinical course, we suspected that the severe adverse effects were caused due to a deficiency of DPD. We were able to save the patient through early treatment.

[A Case of Laparoscopic Subtotal Gastrectomy with a Very Small Remnant Stomach in an Elderly Patient with Multiple Malignant Gastric Tumors].

An 85-year-old man was referred to our hospital for anemia. Upper gastrointestinal endoscopy showed 6 malignant gastric lesions. Abdominal CT showed a primary tumor. We treated early gastric cancer at the upper stomach with endoscopic submucosal dissection(ESD)to avoid total gastrectomy. We then performed laparoscopic subtotal gastrectomy with a very small remnant stomach. In elderly patients with multiple gastric cancer, it is useful to combine ESD with laparoscopic subtotal gastrectomy with a very small remnant stomach.

[A Case of Laparoscopic Distal Gastrectomy for Gastric Cancer with Common Hepatic Artery Anomaly].

A 67-year-old woman with upper abdominal pain was referred to our hospital. Upper gastrointestinal endoscopy revealed a type 3 gastric cancer at the greater curvature of the angular notch. Abdominal CT helped detect the primary tumor. Multi-detector-row computed tomography(MDCT)and 3D-CT angiography revealed a vascular anomaly in which the left gastric and splenic arteries formed the common trunk. The common hepatic and superior mesenteric arteries formed the common trunk. We performed a laparoscopic distal gastrectomy with D2 lymph node dissection. During suprapancreatic lymph node dissection, the surface of the portal vein was difficult to expose toward the left side because the portal vein joined the splenic and superior mesenteric veins on the caudal side. Therefore, the No. 8a lymph nodes were dissected along the anterior hepatic plexus. In cases of common hepatic artery anomaly, identifying the anterior hepatic plexus is useful for the dissection of the suprapancreatic lymph nodes.

[A Case of Surgery for Transversal Colon Cancer with Intestinal Malrotation -Visualizing Method of Blood Flow in the Fluorescence Navigation Period].

BACKGROUND: Anastomotic blood flow evaluation using the fluorescence method with indocyanine green(ICG)is expected to decrease the risk of anastomotic leakage in colorectal cancer surgery. The fluorescence method is considered to be also useful for assessing arterial divergence patterns in patients with special anatomical features. We report a case of transverse colon cancer with intestinal malrotation treated with laparoscopic surgery using the ICG fluorescence method. CASE: A 62- year-old woman who was diagnosed as having transverse colon cancer with intestinal malrotation underwent a laparoscopic transverse colon resection with D3 lymph node dissection. We identified the ileocolic artery and middle colic artery (MCA)after the ICG injection and the severed MCA during lymphadenectomy. We made a final diagnosis of pT2N0M0, pStage Ⅰ. CONCLUSION: The fluorescence method was useful for assessing the arterial divergence pattern in a patient with a special anatomical feature. However, the ICG fluorescence method had some problems, including visualizing blood flow for only a short time and poorly transmitting the dye through thick fat.