Curative resection via right hemicolectomy and regional lymph node dissection for colonic adenomatous polyposis of unknown etiology with adenocarcinomas localized in the right side of the colon: a case report.

BACKGROUND: APC and MUTYH are both well-known colorectal polyposis causative genes. However, 30-50% of colorectal adenomatous polyposis cases are classified as colonic adenomatous polyposis of unknown etiology and lack identifiable pathogenic variants. Although guidelines recommend total proctocolectomy for colonic adenomatous polyposis of unknown etiology with over 100 adenomas, evidence is lacking. This study presents a unique case of localized colonic adenomatous polyposis of unknown etiology with multiple adenocarcinomas, treated with hemicolectomy and regional lymph node dissection. CASE PRESENTATION: The patient was a 72-year-old woman whose colonoscopy revealed numerous polyps and two adenocarcinomas localized in the right side of the colon, with no lesions in the left side. The patient had no family history of polyposis or colorectal cancer. No extracolonic lesions, enlarged lymph nodes, or distant metastases were found. Considering the patient's age and lesion localization, laparoscopic right hemicolectomy with regional lymph node dissection was performed. Histopathological diagnosis revealed three adenocarcinoma lesions with no lymph node metastasis. The most advanced pathological stage was T2N0M0 Stage I (UICC 8th edition). The patient was alive 5 years postoperatively, without recurrence of cancer or polyposis in the remaining colon and rectum. To diagnose hereditary colorectal cancer/polyposis, a germline multigene panel testing for APC, EPCAM, MBD4, MLH1, MLH3, MSH2, MSH3, MSH6, MUTYH, NTHL1, PMS2, POLD1, POLE, and TP53 was performed using DNA extracted from blood samples: however, no pathogenic variant was detected. Therefore, the patient was diagnosed with colonic adenomatous polyposis of unknown etiology. CONCLUSIONS: In this rare case, colonic adenomatous polyposis of unknown etiology, with numerous adenomatous polyps and multiple adenocarcinomas localized in the right side of the colon, was successfully treated with right hemicolectomy and regional lymph node dissection. Despite genetic analysis, no causative germline variants were identified. Segmental colectomy according to the distribution of polyps might be a curative approach.

Comparison of percutaneous ablation and hepatectomy for liver metastasis: A single center retrospective study.

AIM: To investigate the current treatment for liver metastasis and clarify the indications for percutaneous thermal ablation for liver metastasis. METHODS: Ninety-two patients were enrolled and retrospectively analyzed. The patients underwent hepatectomy and/or percutaneous thermal ablation for liver metastases between January 2012 and December 2018. Twenty-six patients who underwent ablation treatment and seven patients who underwent both ablation and hepatectomy were included in the ablation treatment group (group A). We compared these patients with 59 patients who underwent hepatectomy only (group H). Subgroup analyses were performed between ablation (group AC) for colorectal liver metastasis and hepatectomy (group HC) for colorectal liver metastasis in 17 and 53 patients, respectively. RESULTS: The percentage of liver metastases other than colorectal cancer in group A was higher than that in the group H. Maximum tumor size in group A was significantly smaller than that in group H. Similarly, the patients in group AC were significantly older and demonstrated higher total bilirubin, lower serum albumin, and lower platelet counts than those in group HC. Overall survival was poorer in the AC group than that in the HC group. However, no differences were observed at metastasis ≤2 cm in size. CONCLUSIONS: Percutaneous thermal ablation was performed for many cancer types than hepatectomy. It is performed in elderly patients. We suggested that ablation for colorectal liver metastasis sized ≤2 cm is a suitable indication.

Cardiac tamponade complicating esophagectomy and retrosternal gastric tube reconstitution in a patient with an abnormal ascending aorta position: a case report.

BACKGROUND: Cardiac tamponade is a rare postoperative complication of esophageal cancer surgery, which leads to rapid hemodynamic changes and can be fatal if not treated properly and promptly. Herein, we report a case of cardiac tamponade after thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution for esophageal cancer that was successfully treated with surgical drainage. CASE PRESENTATION: An 86-year-old man with lower thoracic esophageal cancer underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution. No intra-operative complications were observed. On the first postoperative day, tachycardia and hypotension were observed, and pericardial effusion was identified on computed tomography images. The patient was diagnosed with obstructive shock secondary to cardiac tamponade. As percutaneous puncture drainage was not possible due to the presence of a retrosternal gastric tube, pericardiotomy with a small left anterior thoracotomy was performed, and a large amount of hematogenous fluid was drained, which instantly improved circulation. On the second postoperative day, the patient showed decreased pulse pressure, and computed tomography revealed a residual and enlarged hematoma around the right ventricle. The patient underwent surgical drainage and another pericardiotomy with a small right anterior thoracotomy was performed to drain the hematoma. At this time, multiple injuries to the fatty tissue, epicardium, and myocardium with active bleeding were observed on the anterior surface of the right ventricle near the root of the pulmonary artery. In this patient, the ascending aorta ran further to the right and dorsal sides than usual, causing the anterior wall of the right ventricle near the root of the pulmonary artery to be closer to the back of the sternum. This abnormality may have contributed to injury during the creation of the retrosternal pathway, leading to cardiac tamponade. CONCLUSIONS: Cardiac tamponade after esophagectomy can occur because of manipulation during creation of the retrosternal route, with an anomaly in the aortic position being present in this case. Gentle manipulation and selection of the reconstruction route according to the patient's condition are necessary in cases with such anatomical abnormalities.

Impact of the perioperative assessment of deglutition on postoperative respiratory complications in elderly patients undergoing gastrectomy for gastric cancer.

PURPOSE: To investigate the association between perioperative deglutition screening and postoperative respiratory complications (PRCs) in elderly patients undergoing gastrectomy for gastric cancer. METHODS: We analyzed data from 86 patients with gastric cancer (aged ≥ 70 years) who underwent gastrectomy between October, 2016 and November, 2018. Videofluoroscopic swallowing examinations (VFSEs) were performed before and after surgery. We examined the association of these results with postoperative respiratory complications, as well as the relationships between demographic, operative, and swallowing function assessment data. RESULTS: PRCs were identified in 16 patients. The results of pre- and postoperative VFSE showed abnormalities in 28 and 32 patients, respectively. Multivariate analysis revealed that abnormalities in the postoperative VFSEs were strongly associated with the development of PRCs (P = 0.002). The findings of this analysis suggests that ventilatory impairment, a Charlson comorbidity index score ≥ 3, and an open surgical approach are independent risk factors for PRCs. CONCLUSION: This is the first study to demonstrate the efficacy of perioperative assessment of swallowing function using VFSE for predicting PRCs in elderly patients undergoing gastrectomy for gastric cancer.

Convergent genomic diversity and novel BCAA metabolism in intrahepatic cholangiocarcinoma.

BACKGROUND: Driver alterations may represent novel candidates for driver gene-guided therapy; however, intrahepatic cholangiocarcinoma (ICC) with multiple genomic aberrations makes them intractable. Therefore, the pathogenesis and metabolic changes of ICC need to be understood to develop new treatment strategies. We aimed to unravel the evolution of ICC and identify ICC-specific metabolic characteristics to investigate the metabolic pathway associated with ICC development using multiregional sampling to encompass the intra- and inter-tumoral heterogeneity. METHODS: We performed the genomic, transcriptomic, proteomic and metabolomic analysis of 39-77 ICC tumour samples and eleven normal samples. Further, we analysed their cell proliferation and viability. RESULTS: We demonstrated that intra-tumoral heterogeneity of ICCs with distinct driver genes per case exhibited neutral evolution, regardless of their tumour stage. Upregulation of BCAT1 and BCAT2 indicated the involvement of 'Val Leu Ile degradation pathway'. ICCs exhibit the accumulation of ubiquitous metabolites, such as branched-chain amino acids including valine, leucine, and isoleucine, to negatively affect cancer prognosis. We revealed that this metabolic pathway was almost ubiquitously altered in all cases with genomic diversity and might play important roles in tumour progression and overall survival. CONCLUSIONS: We propose a novel ICC onco-metabolic pathway that could enable the development of new therapeutic interventions.

[A Case of Rectal Cancer with Enlarged Lateral Lymph Nodes Treated with Total Neoadjuvant Therapy and Robotic Surgery].

A 70s woman with advanced rectal cancer(AV 3 cm, type 2)was diagnosed as cT3N2M1a, Stage Ⅳ(UICC, TNM 8th) and underwent total neoadjuvant therapy(TNT)consisted of preoperative 5 Gy×5 short course RT followed by 5 courses of CAPOX plus BEV and CAPOX. Post-treatment endoscopy revealed nearCR, MRI failed to identify the primary tumor, and the mesenteric and lateral lymph node enlargement had disappeared. The patient underwent robot-assisted low anterior resection, bilateral lymph node dissection, and temporary ileal colostomy. Postoperative pathological findings were ypT0N0M0, Stage 0, and the efficacy evaluation was TRG 0(AJCC)with no residual tumor including lateral lymph nodes. The patient was discharged on the 16th day without any postoperative complications and is currently alive 6 months postoperatively without recurrence.

[A Case of Hepatic Encephalopathy Caused by Portal Vein Thrombosis after Surgery for Perihilar Cholangiocarcinoma].

A female in her 70s underwent right hepatectomy with resection of caudate lobe and extrahepatic bile duct for perihilar cholangiocarcinoma(T2aN0M0, Stage Ⅱ: Biliary Cancer Treatment Regulations, 7th edition). On the 4th postoperative day, the patient had impaired consciousness, which worsened to almost coma on the 5th postoperative day. On the same day, a blood test showed high ammonia level, thus the state was thought to be hepatic encephalopathy. Contrast -enhanced CT on the same day showed thrombus from the main trunk of the portal vein to the remnant left branch, narrowing of the lumen of the vessel. Simultaneously, enlarged portosystemic shunt in the pelvic floor due to portal hypertension induced by the thrombosis. Plasmapheresis was performed, and anticoagulation with sodium heparin and antithrombin Ⅲ were started. Then, the portal vein thrombus was reduced, and encephalopathy was improved. She was discharged from the hospital on postoperative day 48. She was treated with edoxaban as an outpatient, and anticoagulation therapy was terminated after a CT scan 6 months after surgery, which confirmed no recurrence of thrombus. She is now alive without recurrence of thrombus or tumor for about 2 years after the surgery.

[A Case of Single Hole Ileal Resection for Ascendiry Colon Cancer with Ureterocutaneous Fistula in the Right Lower Abdomen].

The patient is a 70s woman. She underwent cystectomy for bladder cancer 6 years ago and had a ureterocutaneous fistula in the right lower abdomen. After colonoscopy for positive fecal occult blood, a type 1 elevated lesion was found in the ascending colon, which was diagnosed as a well-differentiated adenocarcinoma on biopsy. Surgery was performed with a single hole. The approach from the right lower abdomen, where the ureterocutaneous fistula and ureter are located, was avoided, and the approach from the hepatic flexure of the transverse colon was used first. After the right colon was mobilized, the large mesh adhesions around the ureter were carefully dissected, and the right ureter was identified and preserved, extending from the lateral ascending colon to the abdominal wall. The ileal artery was dissected at the root and after dissection of the D3 lymph node, the intestine was dissected and anastomosed extracorporeally. The operative time was 246 minutes with small amount of blood loss. The patient was discharged on the 6th postoperative day without any postoperative complications. The pathology result was pT3N0M0, pStage Ⅱa, and radical resection had been performed. The patient is currently undergoing recurrence-free follow-up.

[A Case of Pathological Complete Response for MSI-High Locally Advanced Unresectable Transverse Colon Cancer Treated with Nivolumab plus Ipilimumab Combination Therapy].

74-year-old woman was diagnosed with locally advanced unresectable transverse colon cancer. She started CAPOX therapy as first-line therapy after ileostomy. After second course, MSI-high was detected, so nivolumab plus ipilimumab combination therapy was started as second-line therapy. After 4 courses of combination therapy, she was judged to be in partial response and surgery was performed. Histopathological diagnosis of the surgical specimen showed complete response, and she is still alive without recurrence 15 months after surgery.

[A Case of Conversion Surgery after Chemotherapy for Locally Advanced Unresectable Rectal Cancer].

We report a case of locally advanced rectal cancer that could not be curatively resected, in which the patient underwent conversion surgery after chemotherapy. The patient is a 70-year-old woman. She came to our hospital with a chief complaint of lower abdominal pain, and a close examination revealed rectal cancer with invasion of the external iliac artery and pelvic wall. She was treated with mFOLFOX6 plus cetuximab for locally advanced rectal cancer that was not amenable to surgical resection. After 11 courses of chemotherapy, significant shrinkage of the tumor was observed, and robot assisted laparoscopic high-anterior resection was performed. The patient didn't relapse at 12 months after surgery without adjuvant chemotherapy.

[A Case of Metastatic Liver Tumor from Colon Cancer with Preoperative Diagnosis Obtained by Immunohistochemical Analysis of Cytologic Specimen].

CASE: A woman in her 50s underwent sigmoid colectomy and D3 lymph node dissection for sigmoid cancer(pT3, N0, M0, Stage Ⅱ: Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma 9th). She received adjuvant chemotherapy with capecitabine. Seven months after surgery, contrast-enhanced computed tomography( CECT) scan revealed a small mass in the segment 2 (S2) of the liver with dilation of peripheral intrahepatic bile duct, and the size of this mass and the bile duct dilatation were gradually increased. FDG positron emission tomography(FDG-PET)/CT showed abnormal FDG uptakes in the lesion of S2, and EOB-MRI detected other small lesions in the S6 and S7. Considering the results of image examinations, multiple lesions intrahepatic cholangiocarcinoma was firstly assumed. However, immunohistochemistry of the tumor obtained by endoscopic retrograde cholangiopancreatography (ERCP) showed cytokeratin 7-negative. Based on preoperative diagnosis of liver metastasis from colon cancer rather than intrahepatic cholangiocarcinoma, we performed left lobectomy, partial hepatectomy of S6 and S7 and cholecystectomy. In the resected specimen, the tumor was macroscopically located in the intrahepatic bile ducts. Microscopically, there existed atypical epithelial cells with glandular duct-like structure, and the lesions was histopathologically diagnosed as metastasis from colon cancer. She was discharged on the 10th postoperative day, and she is alive without recurrence one year after surgery.

[A Case of Signet-Ring Cell Carcinoma of the Ampulla of Vater in a Young Male].

A male in his twentieth was referred to our hospital for jaundice. Computed tomography(CT)showed dilation of the intrahepatic and extrahepatic bile ducts and showed a lesion at the ampulla of Vater, which caused obstructive jaundice. Upper gastrointestinal endoscopy revealed a tumor of protruded-predominant type with raised margins at the ampulla of Vater, and biopsy from the lesion indicated malignancy. With no apparent distant metastasis, radical resection was assumed to be possible, thus we performed subtotal stomach preserved pancreatoduodenectomy. Before the operation, endoscopic retrograde biliary drainage(ERBD)was unsuccessful because of the existence of the tumor, so percutaneous transhepatic cholangio drainage(PTCD)was conducted. After the operation, although pancreatic fistula(ISGPF Grade B)occurred, it improved with conservative treatment, and he discharged at 30 postoperative days. Histopathological examination revealed signet-ring cell carcinoma among the tumor at the ampulla of Vater, which was infiltrating into the pancreas. Final diagnosis was pT3, pN0, M0, pStage ⅡA. Now he is alive without recurrence for 3 and a half years.

Intra-abdominal desmoid-type fibromatosis successfully resected using laparoscopic fluorescence imaging with indocyanine green after intersphincteric resection for rectal cancer.

Successful resection of intra-abdominal tumors using indocyanine green (ICG) fluorescence imaging has not been reported. Here, we report a rare case of an intra-abdominal desmoid-type fibromatosis successfully resected using this technique after intersphincteric resection (ISR) for rectal cancer. One year after ISR for rectal cancer in a 47-year-old man, computed tomography showed a 50-mm intra-abdominal tumor near the left common iliac vein. Surgical resection was performed. The tumor was located in the mesentery of the remnant rectum after ISR. ICG fluorescence imaging confirmed the blood supply to the mesentery of the distal remnant rectum after tumor excision. The anal canal was successfully preserved without creating a permanent colostomy. The tumor was safely resected with resection margins, diagnosed as desmoid-type fibromatosis. No tumor recurrence was observed 6 months post-resection. This was the first case report to demonstrate the utility of this technique for an intra-abdominal tumor resection.

[Investigation of the Short-Term Outcome of Perioperative Heparinization in Laparoscopic Surgery for Colorectal Cancer].

In aging society, the number of colorectal cancer patients who take antithrombotic drugs is increasing. However, there are not established guidelines for perioperative management for antithrombotic drugs in laparoscopic surgery. Here, we investigated the clinical outcomes of antithrombotic drugs withdrawal and perioperative heparinization in laparoscopic surgery for colorectal cancer patients taking antithrombotic drugs. From January 2015 to December 2017 in our center, patients who took antithrombotic drugs and underwent laparoscopic surgery for colorectal cancer were reviewed retrospectively. The association between postoperative complications and heparinizations was analyzed. Among 79 patients taking antithrombotic drugs, heparinization was performed in 40 patients(50.6%). The total length of hospital stay in heparinization group was 21 days and significantly longer than 13 days in the non-heparinization group. There were no significant differences in the operation time, intraoperative blood loss, and postoperative complications between the 2 groups. The antithrombotic drugs withdrawal and perioperative heparinization were suggested to be safe and feasible in laparoscopic surgery for patients with colorectal cancer.

Successful treatment of remnant gastric cancer with afferent loop syndrome managed by percutaneous transhepatic cholangial drainage followed by elective gastrectomy: a case report.

BACKGROUND: There are only few reported cases of remnant gastric cancer with concomitant afferent loop syndrome. Emergency surgery is the standard treatment strategy for this disease. However, some afferent loop syndrome cases, especially those with complete obstruction, can lead to a septic state, which makes performing emergency surgery risky. We describe a case of remnant gastric cancer with complete afferent loop obstruction, which was successfully managed by radical surgery following percutaneous transhepatic cholangial drainage of the afferent loop. CASE PRESENTATION: A 71-year-old man presented with nausea and abdominal discomfort. When he was 27 years old, he had undergone distal gastrectomy for a benign gastric ulcer, with gastrojejunostomy (Billroth II reconstruction). Abdominal computed tomography revealed thickening of the anastomosis site and significant dilation of the afferent loop. Gastrointestinal fiberscopy revealed advanced remnant gastric cancer at the anastomosis site, and the stoma of the afferent loop was completely obstructed. We diagnosed the patient with remnant gastric cancer with afferent loop syndrome. Percutaneous transhepatic cholangial drainage was performed twice before surgery to decompress the afferent loop. This provided more time for the patient to recover. Radical surgery of total remnant gastrectomy and Roux-en-Y reconstruction were performed electively. There were no severe postoperative complications. The patient died 8 months following the operation owing to peritoneal dissemination recurrence. CONCLUSION: We encountered a case of remnant gastric cancer with afferent loop obstruction, which was successfully managed by radical surgery following decompression of the afferent loop by percutaneous transhepatic cholangial drainage. Percutaneous transhepatic cholangial drainage effectively managed the afferent loop syndrome, resulting in the safe performance of elective surgery.

[Risk Factors for Recurrence in Patients with Pathological Stage â ¡ Colorectal Cancer].

BACKGROUND: The risk factors for recurrence in patients with pStage Ⅱ colorectal cancer still remains controversial. The aim of this study was to investigate the risk factors for recurrence after surgery in patients with pStage Ⅱ colorectal cancer. METHOD: We retrospectively reviewed 311 patients with primary pStage Ⅱ colorectal cancer who underwent radical resection without neoadjuvant therapy at our institute between January 2014 and December 2019. RESULTS: Of 311 patients, 32 patients(10.3%)developed recurrences after surgery at a median follow-up of 32.9(0.23-74.2)months. The 3-year and 5-year recurrence-free survival(RFS)rate was 88.4% and 87.6%, respectively. A multivariate analysis for RFS showed that only pT4 (HR: 4.06, 95%CI: 1.60-10.29, p=0.003) was an independent risk factor. CONCLUSION: This study revealed that pT4 was an independent risk factor for recurrence after surgery in patients with pStage Ⅱ colorectal cancer.

[A Case of Undifferentiated Carcinoma of Gallbladder with Five Year Recurrence-Free Survival after Radical Resection].

A woman in her 60s realized heart palpitations and was pointed out anemia. CT revealed a tumor measuring 7 cm, with internal necrosis, originating from the gallbladder and invading the liver, and diagnosed as gallbladder cancer. There existed no distant metastasis and we performed cholecystectomy with partial resection of segment 4a+5 of the liver and lymph node resection. Histopathological examination revealed highly atypical cells with large nuclei and polynuclear cells and poor cell junctions in the specimen, and the tumor was histologically diagnosed as an undifferentiated carcinoma. Metastases were not detected in dissected lymph nodes, and this case was diagnosed as undifferentiated carcinoma of gallbladder, T3a, N0, M0, Stage ⅢA(JSHBPS 6th). She was discharged at 13 days after the operation with no apparent postoperative complications. Postoperative adjuvant chemotherapy with administration of TS-1 was conducted for half a year. Now over 5 years have passed since the operation, and she is alive without recurrence.

[A Case of Squamous Cell Cancer of the Anus Treated with Chemoradiotherapy].

BACKGROUND: In Japan, the standard treatment for squamous cell anal cancer(SCAC)has not been established. Herein, we report a case of SCAC that completely responded to chemoradiotherapy(CRT). CASE: A woman in her 80s presented with anal pain and bleeding. Computed tomography revealed bilateral inguinal adenopathy and a tumor in the anal canal. Histopathological examination of endoscopic biopsies showed adenocarcinoma. Thus, she was diagnosed with anal canal adenocarcinoma and lymph node metastases:cT3, cN1a(No. 292), cM0, cStage Ⅲc(Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma, 9th edition). Owing to her advanced age and refusal of a stoma, CRT(S-1, mitomycin C, and radiotherapy)was administered with the expectation that salvage surgery in the form of rectal amputation would eventually be necessary. The tumor noticeably shrank after CRT. The patient is alive to this date,14 months after the final round of CRT.

[Robotic Surgery Can Complete Radical Surgery and Urinary Tract Reconstruction for Locally Advanced Rectal Cancer with Ureteral Invasion-A Case Report].

A 82-year-old man presented with diarrhea and fatigue. He had no past medical or surgical history except chronic renal failure. Locally advanced rectal cancer with invasion to left ureter was detected in computed tomography. Colonoscopy revealed a circular lesion 12 cm from the anal verge. Biopsy showed moderately differentiated adenocarcinoma. There was no sign of distal metastasis and we decided to conduct radical surgery. Robot-assisted laparoscopic lower anterior resection with partial resection of left ureter, and diverting ileostomy were carried out. Besides, urinary tract reconstruction of ureterocystoneostomy using Lich-Gregoir technique was conducted by urologists also with robot assistance. The pathological stage of the disease was pT4b(left ureter)N1bM0, pStage Ⅲc. The resection margin was secured and radical surgery was achieved. The patient was discharged on postoperative day 22nd without postoperative complication. He is alive without recurrence at 6 months after the operation.

[A Case of Metastasis to the Pancreas from Colorectal Cancer Which Was Difficult to Distinguish from Primary Pancreatic Cancer].

A man in his 50s underwent laparoscopic sigmoid colectomy for sigmoid colon cancer with liver metastasis(cT4aN1M1a, cStage Ⅳa), followed by partial liver resection(S4, S6). One and a half years after the initial surgery, CEA and CA19-9 increased, and contrast-enhanced CT and MRI showed a hypovascular lesion with dilation of the distal pancreatic duct in the pancreatic body. Adenocarcinoma was detected by brushing cytology of the lesion and pancreatic juice cytology by ERCP. From the results of various examinations, the lesion was diagnosed as pancreatic ductal adenocarcinoma. We performed distal pancreatectomy, and initially the histopathological diagnosis was pancreatic body cancer(pT3N1aM0, pStage ⅡB). In a follow-up CT after surgery, a suspected metastatic lymph node was pointed out in the mediastinum, but it was difficult to distinguish between metastasis from colorectal cancer and one from pancreatic cancer. Immunostaining of the tumor tissue and comparative study of the excised specimens of colon and pancreas was performed in order to assume the primary lesion of the lymph node. As a result, both tissues were CK7(-)/CK20(+), and the lesion at first considered to be primary pancreatic cancer was originally the pancreatic metastasis from colon cancer. Bone metastases were also found on FDG-PET/CT around the same time, and then systemic chemotherapy for colorectal cancer was introduced. Four and a half years have passed since the first surgery, and he is still alive and undergoing treatment.