Assessment of Perioperative Symptoms of Patients with Gastric Cancer Using The Edmonton Symptom Assessment System Revised Japanese version (ESAS-r-J).

Purpose To evaluate the perioperative symptoms of gastric cancer patients undergoing gastrectomy using the Edmonton Symptom Assessment System Revised Japanese version (ESAS-r-J), which is a nine-item visual analogue scale to rate patient symptoms. Methods Between February 2015 and March 2017, 246 patients completed the ESAS-r-J before and after gastrectomy. We evaluated the changes in the prevalence and score of each ESAS-r-J item before and after gastrectomy. In addition, we compared them after gastrectomy between patients who underwent the different approaches. Results Before gastrectomy, anxiety and well-being were the most prevalent items (80%), followed by depression (45%). After gastrectomy, well-being was the most prevalent item (87%), followed by pain (68%). The prevalence of anxiety decreased from 80% to 59% (P = 0.002). The depression and anxiety scores decreased from 1.6 to 1.1 (P < 0.001) and from 2.6 to 1.7 (P = 0.002), respectively. The total score was higher in patients who underwent open surgery than in patients who underwent laparoscopic surgery (16.9 vs 12.9 ; P = 0.031). Conclusions After gastrectomy, psychological symptoms such as depression and anxiety improved despite more physical complaints than before gastrectomy. The laparoscopy was less invasive. It is very important to take care of psychological aspects before gastrectomy. J. Med. Invest. 68 : 90-95, February, 2021.

Short- and Long-Term Outcomes of Transabdominal Preperitoneal, Open Mesh Plug and Open Tissue Inguinal Hernia Repair.

BACKGROUND: There have been few comparisons of the postoperative outcomes of transabdominal preperitoneal (TAPP), open mesh plug (mesh plug) and open tissue (tissue) hernia repair. The objectives of this study were to compare these repair methods. METHODS: This was a retrospective study of 1813 inguinal hernia patients between January 2008 and December 2016. Of these patients, 474 underwent TAPP repair, 1293 underwent mesh plug repair, and 46 underwent tissue repair. The short-term and long-term outcomes determined by questionnaire were compared among the three groups. In addition, risk factors for patient dissatisfaction were assessed. RESULTS: In the TAPP group, the postoperative complications rate was the lowest at 4.6% (7.4% and 6.5% in the mesh plug and the tissue groups, respectively, P = 0.07), and recurrence rate was lower compared to the mesh plug group (0.8% vs. 3.3%, P = 0.002). As long-term outcomes, 92%, 88% and 75% of patients were satisfied in the TAPP, mesh plug and tissue groups, respectively (P = 0.03). The rate of patients with numbness was 3.1% in the TAPP group, 5.2% in the mesh plug group and 14% in the tissue group (P = 0.04). Predictive independent risk factors for patient dissatisfaction were complications (OR: 3.99, 95% CI: 1.35-11.8, P = 0.012) and infection (OR: 16.9, 95% CI: 1.25-229, P = 0.003). CONCLUSIONS: TAPP repair is superior to mesh plug and tissue repairs in terms of complications, satisfaction and numbness, as determined by questionnaire. Complications and infection were independently associated with the patient dissatisfaction.

Laparoscopic liver resection after laparoscopic pancreatoduodenectomy for liver metastases of ampulla of Vater adenocarcinoma.

BACKGROUND: Repeat laparoscopic surgery has become increasingly common. However, reports of liver resection after pancreatoduodenectomy are scarce, and we report the first successful case of a patient who underwent laparoscopic liver resection after laparoscopic pancreatoduodenectomy. CASE PRESENTATION: A 65-year-old man underwent laparoscopic pancreatoduodenectomy for ampulla of Vater adenocarcinoma. According to the American Joint Committee on Cancer (8th edition) staging guidelines, the tumour was labelled as stage IIIB (fT2N2M0). Twelve months later, a computed tomography (CT) scan revealed liver masses (in segments 3 and 5) and swollen para-aortic lymph nodes. After six chemotherapy courses of gemcitabine with cisplatin, the CT scan showed the disappearance of the para-aortic lymph nodes and progression of liver metastases. Nineteen months after the initial surgery, the patient underwent laparoscopic partial liver resection of segment 5 and left lateral sectionectomy. First, we performed the operation in the left half lateral decubitus position. In this position, the portal vein was isolated safely without hindering the hepato-jejunal anastomosis, although the adhesions around the hepato-jejunal anastomosis were dense. Therefore, we were able to perform liver transection safely with vascular inflow control. The operation duration was 235 min, and the volume of blood loss was 100 g. Macroscopically, the resected margins were negative. The patient was uneventfully discharged 12 days after the second operation. Afterwards, drainage was needed because of an intra-abdominal abscess. Currently, he has been alive for 8 months postoperatively, receives chemotherapy to suppress para-aortic lymph node metastases, and has not had another recurrence. CONCLUSIONS: Liver resection after pancreatoduodenectomy can be performed safely with an innovative body position to isolate the portal vein, which is a key point of the surgery. A laparoscopic approach for liver resection after pancreatoduodenectomy is a feasible option.

[Effective Neo-Adjuvant Chemotherapy and Hormonal Therapy for Invasive Micro-Papillary Carcinoma of the Breast-Two Case Reports].

Case 1 involved a 54-year-old woman with a complaint of a lump in the left breast since October. A diagnosis of invasive micropapillary carcinoma(IMPC)was made by core needle biopsy. The profile of the carcinoma was as follows: ER(Allred 8=5+3), PgR(Allred 8=5+3), HER2(1+), Ki-67 index 30%. The patient underwent 4 courses of EC(epirubicin 90mg/ m2, cyclophosphamide 600 mg/m2), followed by 4 courses of triweekly docetaxel and nab-paclitaxel chemotherapy. Bp+Ax was underwent in May 2013. Pathologically, no residual tumor was observed. Case 2 involved a 61-year-old woman with the chief complaint of a lump in the right breast, diagnosed as IMPC by core needle biopsy. The profile of the carcinoma was as follows: ER(Allred 8=5+3), PgR(Allred 0=0+0), HER2(1+), Ki-67 index 30%. Pre-operative treatment consisted of letrozole(2.5mg/day)from May 2013 and hormone therapy for 6 months. Bp+SNB was performed in November 2013. Histopathologically, no remnant of IMPC component was observed apart from an 11mm papillo-tubular carcinoma. In spite of the fact that IMPC is considered highly malignant, pre-operative chemotherapy and hormonal therapy may be effective.

[Severe Liver Injury Due to Sinusoidal Obstruction Syndrome Induced by Oxaliplatin in a Patient with Resectable Colorectal Liver Metastases].

A 62-year-old man was diagnosed with liver metastasis of sigmoid colon cancer, which resulted in bowel obstruction. SOX plus bevacizumab therapy was administered to perform hepatectomy, after the artificial anus construction; however, substantial liver dysfunction occurred. Therefore, we only performed primary tumor resection and waited for improvement in liver function. After 2 months, liver function improved and liver metastasis increased. However, another metastasis was not recognized, so hepatectomy was carried out, and R0 resection was performed. The oxaliplatin-induced liver function disorder was reversible; however, preoperative chemotherapy for resectable colorectal liver metastases increases the risk of missing the resection window. It is necessary to carefully examine the tumor type and preoperative liver function.

[A Case of Intrathecal Infusion of Methotrexate and Ara-C for a Patient with Meningitis Due to Recurrent Gastric Cancer].

A 69-year-old woman underwent total gastrectomy for advanced gastric cancer with pyloric stenosis. She had a good postoperative course and was discharged 2 weeks after surgery. She received adjuvant chemotherapy with S-1 after discharge. One month after the initiation of the adjuvant chemotherapy, she complained of wobbling and weakness of her limbs. She stopped intake of S-1, but the symptoms did not improve. She was admitted to the hospital, but she became unconscious and had headache and blurred vision. We conducted a cerebrospinal fluid examination and made a diagnosis of meningeal carcinomatosis. After we started intrathecal infusion of methotrexate and Ara-C, referring to case reports clinical symptoms, including unconsciousness, headache, and left upper limb paralysis, improved and the CEA level in cerebrospinal fluid decreased.

[A Case Report on a Successful Resection after FOLFIRI plus Cetuximab Therapy for Unresectable Colorectal Cancer with Multiple Liver Metastases].

The patient was a 66-year-old woman with a history of right breast cancer 20 years prior. Her chief complaint was hematochezia, and she was diagnosed as having rectal cancer. She underwent laparoscopic high anterior resection. We made a diagnosis of moderately differentiated adenocarcinoma, type 2, 25×20 mm, pMP, pN0, Stage I, KRAS being wild-type. Multiple liver metastases were detected 6 months after the surgery. Tumor contacted with grison. The tumor was not completely resected as evidenced by the small liver remnant volume. Conversion therapy was administered, and the patient received 6 courses of FOLFIRI plus cetuximab therapy. Alopecia and grade 1 eruption were observed as adverse effects of the chemotherapy. The tumor size was reduced, and we resected the tumor by performing right lobectomy and partial hepatectomy. At 1 year 3 months after surgery, no recurrence was observed.

Occult mucin-producing cholangiocarcinoma in situ: a rare clinical case with difficult tumour staging.

BACKGROUND: Mucin-producing cholangiocarcinoma (MPCC) is an uncommon tumour that is clinically characterized by mucin-hypersecretion. Because the initial symptoms of MPCC may be attributed to the viscus mucobilia, the primary tumour mass may potentially be unrecognizable. We report an interesting case of curatively resected occult MPCC in situ. CASE PRESENTATION: A 70-year-old man was referred to our hospital with increased levels of biliary enzymes. Multidetector row computed tomography (MDCT) demonstrated a diffuse dilatation of the entire biliary system without evidence of tumour mass. Additionally, there were numerous variably sized cysts throughout the liver. The cyst of S4 was the largest, followed by that of S1, which connected with the right hepatic duct. Endoscopic retrograde cholangiography showed intrabiliary mucus, predominantly in the left hepatic duct, but failed to show a communication of both cysts with the bile duct. We clinically suspected that minute MPCC was present within the S1 cyst and performed left hepatectomy, caudate lobectomy, and resection of the extrahepatic bile duct. Macroscopically, papillary adenocarcinoma in situ was present in the S1 cyst, and a final diagnosis of MPCC originating from the bile duct of the caudate lobe was made. CONCLUSIONS: For MPCC, in practice, we should consider the possibility that this tumour can be occult. In this complicated setting, demonstrating the communication to the responsible dilated duct is a clue to the diagnosis. Multidirectional MDCT images succeeded in specifically demonstrating this communication, which is insensitive to the presence of excessive mucobilia.

[Two Cases of ER-Positive Postmenopausal Breast Cancer That Increased in Size during Neoadjuvant Hormone Therapy].

The first patient was a 62-year-old woman who was referred to our hospital with the complaint of a left breast tumor. She was diagnosed with invasive ductal carcinoma(T1N0M0, stage I). The tumor was ER-positive, PgR-negative, and HER2- negative. She was treated with toremifene, letrozole, and anastrozole as neoadjuvant hormone therapy for 4 months, but the tumor increased in size. The clinical response was judged as progressive disease, and a left partial mastectomy and axillary lymph node dissection were performed. Chemotherapy and radiotherapy were performed after surgery. The second patient was a 68-year-old woman who was referred to our hospital with the complaint of a right breast tumor. She was diagnosed as invasive ductal carcinoma(T1N0M0, stage I). The tumor was ER-positive, PgR-negative, and HER2-negative. She was treated with letrozole as neoadjuvant hormone therapy for 4 months, but the tumor increased in size. The clinical response was judged as progressive disease, and a right partial mastectomy and axillary lymph node dissection were performed. Chemotherapy and radiotherapy were performed after surgery. Although the evidence is still insufficient, with neoadjuvant hormone therapy for hormone-sensitive breast cancer, improved tumor shrinkage and breast conservation have been reported. We experienced two cases in which the tumor increased in size during neoadjuvant hormone therapy; however, even though these cases showed no apparent effect, chemotherapy may be effective in future cases.