Rapid Onset of De Novo Rectal Prolapse Following Colpocleisis.

INTRODUCTION: The aim of this video case series is to demonstrate our experience of the clinical findings and the surgical management of the rapid onset de novo rectal prolapse (RP) following colpocleisis METHODS: This is a case series of three patients who developed de novo RP within 1 month after colpocleisis, which was repaired by laparoscopic ventral mesh rectopexy (LVMR). The video shows the physical, radiological, and intraoperative findings of these patients. A retrospective review of our surgical cases of RP was also performed to analyze the onset timing of de novo RP after various pelvic organ prolapse (POP) procedures. RESULTS: The pathological condition of all three patients' RP was evacuation enterocele, and LVMR was feasible without postoperative complications or recurrences. In the retrospective case review of 158 RP surgeries in our institution (June 2015 to September 2023), 18 cases (11.4%) occurred following POP surgery. De novo RP following colpocleisis developed significantly earlier than those following other procedures (average: 6.1 vs 66.4 months, p = 0.010). CONCLUSIONS: Although de novo RP following colpocleisis is relatively rare, this complication could have a detrimental effect on patients' quality of life. Preoperative informed consent may be advisable before planning colpocleisis.

Tranexamic acid and blood loss in pancreaticoduodenectomy: TAC-PD randomized clinical trial.

BACKGROUND: Tranexamic acid (TXA) may reduce intraoperative blood loss, but it has not been investigated in pancreaticoduodenectomy (PD). METHODS: A pragmatic, multicentre, randomized, blinded, placebo-controlled trial was conducted. Adult patients undergoing planned PD for biliary, duodenal, or pancreatic diseases were randomly assigned to TXA or placebo groups. Patients in the TXA group were administered 1 g TXA before incision, followed by a maintenance infusion of 125 mg/h TXA. Patients in the placebo group were administered the same volume of saline as those in the placebo group. The primary outcome was blood loss during PD. The secondary outcomes included perioperative blood transfusions, operating time, morbidity, and mortality. RESULTS: Between September 2019 and May 2021, 218 patients were randomly assigned and underwent surgery (108 in the TXA group and 110 in the placebo group). Mean intraoperative blood loss was 659 ml in the TXA group and 701 ml in the placebo group (mean difference -42 ml, 95 per cent c.i. -191 to 106). Of the 218 patients, 202 received the intervention and underwent PD, and the mean blood loss during PD was 667 ml in the TXA group and 744 ml in the placebo group (mean difference -77 ml, 95 per cent c.i. -226 to 72). The secondary outcomes were comparable between the two groups. CONCLUSION: Perioperative TXA use did not reduce blood loss during PD. REGISTRATION NUMBER: jRCTs041190062 (https://jrct.niph.go.jp).

Removing part of the pancreas is an operation with a risk of major blood loss. Tranexamic acid is a drug thought to reduce blood loss. This study asked the question, 'Does tranexamic acid reduce blood loss during surgery on the pancreas?' Half of patients received tranexamic acid during surgery. The other half received only standard care. This study showed that tranexamic acid did not decrease the blood loss during the surgery and may have little effect in patients having a pancreaticoduodenectomy.

Phase 2 Trial of Adjuvant Chemotherapy With S - 1 for Node-Positive Biliary Tract Cancer (N-SOG 09).

BACKGROUND: Nodal metastasis is a leading attributable factor of poor survival in biliary tract cancer (BTC), and adjuvant chemotherapy targeting this high-risk feature has not been attempted to date. This study aimed to test the efficacy of adjuvant S - 1 for patients with node-positive BTC. METHODS: This single-arm multicenter phase 2 trial enrolled patients who underwent resection for histologically proven node-positive BTC. In this trial, S - 1 was administered at a dose of 80-120 mg/day on 14 days of a tri-weekly cycle for 6 months. The primary end point of the trial was 3-year overall survival (OS), in which the result would be promising if the 90% confidence interval (CI) surpassed a threshold of 30% (alpha error, 0.1; beta error, 0.2). The secondary end points were relapse-free survival (RFS), feasibility, and toxicity. RESULTS: The trial included 50 patients with perihilar (n = 23) or distal (n = 20) cholangiocarcinoma, or gallbladder cancer (n = 7). The median numbers of positive lymph nodes and examined lymph nodes were respectively 2 and 15. The 3-year OS and RFS were respectively 50% (90% CI, 40.9-59.1%) and 32.0% (95% CI, 19.1-44.9%), with median survival times of 34.6 months (95% CI, 19.3-49.8 months) and 18.4 months (95% CI, 11.9-24.9 months). Although hematologic toxicity often occurred, grades 3 and 4 toxicity were rare. The completion rate of the test therapy was 64%, and the median relative dose intensity was 87.5% (interquartile range, 50-100%). CONCLUSION: Adjuvant chemotherapy with S - 1 may be promising for patients with node-positive BTC.

[A Case of Breast Cancer That Was Able to Accomplish Six Courses of TAC for Preoperative Chemotherapy Using Pegfilgrastim].

The present study reports the case of a 45-year-old pre-menopausal woman treated with 6courses of TAC chemotherapy by the pegfilgrastim for preoperative chemotherapy. The patient visited our hospital in February 2010 with the chief complaint of a mass in the right breast. A 40mm tumor in the outer lower area of the right breast and the axillary lymph nodes was palpable. Pathological findings revealed scirrhous carcinoma with an ER(+), PgR(+), HER2(1+), and Ki-67 80%profile. Pre-operatively, the patient underwent 6courses of triweekly TAC(docetaxel[75mg/m / 2], adriamycin[50mg/m2], cyclo- phosphamide[500mg/m2])chemotherapy. Pegfilgrastim(3.6m g)was subcutaneously injected on the next day of each course. The side effect of 6courses of TAC was stomatitis and low back pain(Grade 2). Relative dose intensity(RDI)was not reduced and there was no occurrence of febrile neutropenia(FN). Partial resection of the tumor was facilitated. Pathologically viable tumor cells still lay scattered in the range of 45 mm, and a ductal carcinoma in situ was seen. However, metastasis to axillary lymph nodes was not observed. Radiation therapy(50 Gy)was performed on the residual breast. There was no recurrence, and now she survival free with tamoxifen(20mg/day)of 8 years four months after operation. TAC with pegfilgrastim therapy could be an effective pre-operative chemotherapy regimen in breast cancer.

[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.

Neoadjuvant CAPOX and bevacizumab alone for locally advanced rectal cancer: long-term results from the N-SOG 03 trial.

BACKGROUND: Neoadjuvant chemotherapy (NAC) alone for locally advanced rectal cancer (LARC) remains an experimental treatment, and the efficacy in terms of long-term outcome has not been fully elucidated. The N-SOG 03 trial examined the safety and efficacy of neoadjuvant CAPOX and bevacizumab (Bev) without radiotherapy in patients with poor-risk LARC. METHODS: Thirty-two patients with MRI-defined LARC received neoadjuvant CAPOX and Bev followed by curative resection between 2010 and 2011. The overall survival (OS), progression-free survival (PFS), and local-relapse rate (LRR) were calculated using the Kaplan-Meier method, and the risk factors were evaluated by multivariate analysis using the Cox proportional hazard models. This trial is registered with UMIN, number 000003507. RESULTS: In the entire cohort, the 5-year OS was 81.3%. Because of disease progression during chemotherapy, 3 patients ultimately did not undergo curative surgery. As a result, 29 patients underwent R0/1 resection. Among these 29 patients, the 5-year OS, PFS, and LRR were 89.7%, 72.4% and 13.9%, respectively. In multivariate analysis, cT4b tumor was an independent poor prognostic factor for OS and LRR, and ypT4b tumor and absence of N down-staging were independent poor prognostic factors for PFS. CONCLUSIONS: Patients with cT4b tumor were not suitable for NAC alone. However, the long-term outcomes of the other patients were satisfactory, and NAC alone might be an option for treatment of LARC. N down-staging was likely to bring favorable PFS, even in patients with cStage III.

[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.

Randomized controlled trial of hyperbaric oxygen therapy in adhesive postoperative small bowel obstruction.

BACKGROUND: Hyperbaric oxygen (HBO) therapy is a controversial treatment for adhesive postoperative small bowel obstruction (ASBO), with only a few retrospective studies reported. The aim of this study was to assess the clinical impact of HBO therapy in the treatment of ASBO. METHODS: Patients with ASBO were randomly assigned to no-HBO (standard arm) or HBO (intervention arm). Patients of the intervention arm were treated once daily at a pressure of 2.0 atm absolute and received 100% oxygen. The primary endpoint was the success rate of medical treatment. This study was registered at the UMIN Clinical Trial Registry as UMIN000010399. RESULTS: The no-HBO group included 40 patients, and the HBO group included 33 patients. Patient characteristics, time to oral intake, and length of hospital stay were similar between the two groups. No significant differences were noted between the no-HBO and HBO groups in the need for long intestinal tube decompression (20.0 versus 18.2%, respectively, p = 1.000) and the need for operative intervention (10.0 versus 18.2%, respectively, p = 0.332). The overall success rate of medical treatment was 72.5% in the no-HBO group and 78.8% in the HBO group (p = 0.594). CONCLUSIONS: In this randomized controlled trial, HBO for ASBO has no additional effect in medical treatment.

[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.

[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.

Cholecystectomy in octogenarians: be careful.

Cholecystectomy is the standard treatment for symptomatic gallstone or acute cholecystitis, and a growing number of elderly patients are undergoing resection. The aim of this study is to evaluate the clinical outcome of cholecystectomy in elderly patients. We retrospectively reviewed the medical records of 337 patients with symptomatic gallstone or acute cholecystitis who underwent cholecystectomies between January 2011 and June 2013. Perioperative data were compared between octogenarians and younger patients. A subgroup undergoing cholecystectomy for acute cholecystitis (n = 146, 43.3 %) was further analyzed. The octogenarian group included 34 patients (10.1 %), while the younger patient group included 303 patients (89.9 %). The octogenarian group was associated with higher rates of comorbidities and acute cholecystitis. The octogenarian group had significantly low laparoscopic completed rates, high postoperative complication rates, and longer postoperative hospital stays. Among the acute cholecystitis group, 24 patients (16.4 %) were octogenarians and 122 patients (83.6 %) were younger patients. No significant difference was found in the morbidity and postoperative hospital stay between the two groups. Only one patient (0.3 %), an octogenarian, died of pneumonia. Cholecystectomy for symptomatic gallstone or acute cholecystitis can be safely performed even in octogenarians. However, care should be taken because they have comorbidities and limited functional reserves.

Pathobiological implications of mucin (MUC) expression in the outcome of small bowel cancer.

Mucins have been associated with survival in various cancer patients, but there have been no studies of mucins in small bowel carcinoma (SBC). In this study, we investigated the relationships between mucin expression and clinicopathologic factors in 60 SBC cases, in which expression profiles of MUC1, MUC2, MUC3, MUC4, MUC5AC, MUC6 and MUC16 in cancer and normal tissues were examined by immunohistochemistry. MUC1, MUC5AC and MUC16 expression was increased in SBC lesions compared to the normal epithelium, and expression of these mucins was related to clinicopathologic factors, as follows: MUC1 [tumor location (p = 0.019), depth (p = 0.017) and curability (p = 0.007)], MUC5AC [tumor location (p = 0.063) and lymph node metastasis (p = 0.059)], and MUC16 [venous invasion (p = 0.016) and curability (p = 0.016)]. Analysis of 58 cases with survival data revealed five factors associated with a poor prognosis: poorly-differentiated or neuroendocrine histological type (p<0.001), lymph node metastasis (p<0.001), lymphatic invasion (p = 0.026), venous invasion (p<0.001) and curative resection (p<0.001), in addition to expression of MUC1 (p = 0.042), MUC5AC (p = 0.007) and MUC16 (p<0.001). In subsequent multivariate analysis with curability as the covariate, lymph node metastasis, venous invasion, and MUC5AC and/or MUC16 expression were significantly related to the prognosis. Multivariate analysis in curative cases (n = 45) showed that SBC with MUC5AC and/or MUC16 expression had a significantly independent high hazard risk after adjusting for the effects of venous invasion (hazard ratio: 5.6, 95% confidence interval: 1.8-17). In conclusion, the study shows that a MUC5AC-positive and/or MUC16-positive status is useful as a predictor of a poor outcome in patients with SBC.

A comprehensive expression analysis of mucins in appendiceal carcinoma in a multicenter study: MUC3 is a novel prognostic factor.

BACKGROUND: Mucins are implicated in survival in various cancers, but there have been no report addressed on survival in appendiceal carcinoma, an uncommon disease with different clinical and pathological features from those of other colon cancers. We aimed to investigate the clinical implications of expression of mucins in appendiceal carcinoma. METHODS: Expression profiles of MUC1, MUC2, MUC3, MUC4, MUC5AC, MUC6, MUC16 and MUC17 in cancer tissue were examined by immunohistochemistry in 108 cases of surgically resected appendiceal carcinoma. RESULTS: The following relationships of mucins with clinicopathologic factors were identified: MUC1 with positive lymphatic invasion (p = 0.036); MUC2 with histological type (mucinous carcinoma, p<0.001), superficial invasion depth (p = 0.007), negative venous invasion (p = 0.003), and curative resection (p = 0.019); MUC3 with non-curative resection (p = 0.017); MUC5AC with histological type (mucinous carcinoma, p = 0.002), negative lymphatic invasion (p = 0.021), and negative venous invasion (p = 0.022); and MUC16 with positive lymph node metastasis (p = 0.035), positive venous invasion (p<0.05), and non-curative resection (p = 0.035). A poor prognosis was related to positive lymph node metastasis (p = 0.04), positive lymphatic invasion (p = 0.02), positive venous invasion (p<0.001), non-curative resection (p<0.001), and positive expression of MUC3 (p = 0.004). In multivariate analysis, positive venous invasion (HR: 6.93, 95% CI: 1.93-24.96, p = 0.003), non-curative resection (HR: 10.19, 95% CI: 3.05-34.07, p<0.001) and positive MUC3 expression (HR: 3.37, 95% CI: 1.13-10.03, p = 0.03) were identified as significant independent prognostic factors in patients with appendiceal carcinoma. CONCLUSIONS: Expression of MUC3 in appendiceal carcinoma is an independent factor for poor prognosis and a useful predictor of outcome in patients with appendiceal carcinoma after surgery.

Clinical and oncologic safety of laparoscopic surgery for obstructive left colorectal cancer following transanal endoscopic tube decompression.

BACKGROUND: Little information has been available concerning the safety of laparoscopic resection of obstructive colorectal cancer after transanal endoscopic tube decompression (TETD). The aim of this study was to assess the short- and long-term outcomes of laparoscopic surgery following TETD for such advanced colorectal cancer. METHODS: A retrospective review was performed of 40 patients with obstructive left colorectal cancer whose distended bowels were treated with TETD before laparoscopic surgery, between January 2001 and March 2011 (TETD group). The elective surgery resulted in potentially curative resection of the tumor in all cases. Their clinical records were compared to those of 80 matched controls with nonobstructive left colorectal cancer resected laparoscopically during the same period (control group). RESULTS: Operative time, blood loss, and the rate of conversion to laparotomy were comparable between the two groups. There were no significant between-group differences in morbidity rates. Five-year overall survival rates in the TETD and control groups were 71.9 and 75.4%, respectively, with no statistical difference. Disease-free survival rates after 5 years were also similar (TETD group, 64.5% vs. control group, 66.3%). There were no significant differences between the two groups in recurrence rates and patterns. CONCLUSION: These results suggest that laparoscopic surgery following TETD is clinically and oncologically safe and could be a treatment of choice for obstructive left colorectal cancer.

A 12-mm carcinoid tumor of the minor duodenal papilla with lymph node metastases.

Carcinoid tumors located in the minor duodenal papilla are extremely rare, with only a few cases reported in the literature. Herein, we report the case of a 71-year-old man with a 12-mm carcinoid tumor at the minor duodenal papilla with lymph node metastases. Multidetector-row computed tomography with contrast enhancement revealed a 12-mm well-enhanced tumor in the duodenum. Upper gastrointestinal endoscopy showed a 12-mm submucosal tumor at the minor papilla of the duodenum. Biopsy specimens revealed a carcinoid tumor, and a subtotal stomach-preserving pancreatoduodenectomy was performed. Carcinoid tumors at the minor duodenal papilla have a high prevalence of nodal disease, even for tumors <2 cm in diameter. Therefore, we believe that radical resection with tumor-free margins (i.e. pancreatoduodenectomy) is the treatment of choice.

[A case of breast reconstruction surgery using flap of latissimus dorsi after neoadjuvant chemotherapy].

We performed breast reconstruction surgery with mastectomy after neoadjuvant chemotherapy(NAC)for a patient with NAC indication desiring breast conservation. The case was a 34-year-old single woman. In March, 2007, she was aware of a lump in her left breast and visited our hospital. The diagnosis was solid-tubular carcinoma 3 cm in diameter from close examination. We performed preoperative chemotherapy with EC(epirubicin 90 mg/m(2), cyclophosphamide 600 mg/m(2))x4, followed by 3w-paclitaxel 175 mg/m(2)x4, and then performed mastectomy with axillary dissection and breast reconstruction surgery using the flap of latissimus dorsi at the same time. Pathologically, pCR was provided. We thought that there are many advantages to both treatment of breast cancer and the cosmetic characteristics. The patient was very satisfied. But further cumulative examinations are awaited because there is not much evidence at present.

Biliary bile acid concentration is a simple and reliable indicator for liver function after hepatobiliary resection for biliary cancer.

BACKGROUND: The functional recovery of the remnant liver after an extended hepatectomy is critical for the outcome of the patient. The aim of this prospective study was to examine whether biliary bile acids could be an indicator for postoperative liver function. METHODS: Externally drained bile samples were obtained from 51 patients with biliary or periampullary carcinomas before and after surgery. Patients were categorized into 3 groups: group A, 29 hepatectomized patients without liver failure; group B, 7 hepatectomized patients with liver failure (maximum serum bilirubin level, >10 mg/dL); and group C, 15 patients who underwent biliopancreatic resection without hepatectomy, with a good postoperative course. Bile samples were withdrawn 1 day before surgery and on postoperative days 1, 2, 3, 4, 6, and 7. Total bile acids were measured with a 3 alpha-hydroxysteroid dehydrogenase method. RESULTS: Before surgery, the concentration of bile acids was higher in groups A and C than in group B, and correlated significantly with the indocyamine green disappearance rate (KICG) values (R(2) = 0.557; P <.0001). After surgery, bile acid concentrations decreased in all 3 groups until postoperative day 2, which was followed by a gradual increase. The concentration recovered to the preoperative level in groups A and C but remained low in group B. Biliary bile acid concentrations on day 2 correlated significantly with remnant liver KICG values (R(2) = 0.257; P =.0019). Among several parameters studied, including KICG, remnant liver KICG, biliary bile acids, and biliary bilirubin, biliary bile acid concentration had the most predictive power for occurrence of postoperative liver failure. CONCLUSION: Biliary bile acid concentration could be a simple, real-time, reliable indicator of preoperative and postoperative liver function.