[A Case of the Huge GIST in the Transverse Colon Mesentery with Intra-Tumoral Hemorrhage and Jejunal Infiltration].

A 38-year-old woman was admitted to our hospital due to severe anemia. CT showed a 13×12 cm tumor with moderately enhanced wall thickening in the right upper abdomen. The huge tumor located adjacent to the jejunum and compressed the right transverse colon. Hemorrhagic necrosis and air were observed within the tumor, suspecting tumor penetration into the jejunum. The patient was diagnosed with abdominal GIST with jejunal infiltration. Laparotomy revealed a 13× 11 cm solid mass with intra-tumoral hemorrhage and invasion into the jejunum, located in the transverse mesocolon. Tumor resection combined with partial jejunectomy and transverse colectomy were performed. Immunohistochemical findings of the resected specimen was positive for c-kit and DOG-1, and the MIB-1 positive rate was 10%. Three weeks after the operation, re-anastomosis was performed due to transverse colon anastomotic stricture. She was discharged 45 days after first operation. Currently, 9 months after the operation, patient has been prescribed imatinib and is alive without recurrence.

Malignant diagnosis and prognostic analysis of 89 GIST patients using preoperative FDG-PET.

There is no preoperative imaging accurately diagnose malignancy of gastrointestinal stromal tumor (GIST). To evaluate the usefulness of preoperative [18F]2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in the malignant diagnosis and prognostic analysis of GIST. Eighty-nine consecutive patients with GIST who underwent curative surgery were reviewed retrospectively. PET scan was performed within 2-3 weeks before surgery and maximum standardized uptake values (SUVmax) were assessed for GIST. The relationship between prognostic factors and prognosis of GIST and SUVmax were evaluated. Tumor size, mitotic count, and Ki-67 index showed significant positive correlations with the SUVmax. When the cutoff value was set as SUVmax 5.68, the accuracy was 86.5% for the high-risk group, 76.4% for the recurrence group, and 73.0% for the death group. The group with SUVmax ≥ 5.68 demonstrated a significantly lower 10-year relapse-free survival than the group with SUVmax < 5.68 (55.2% vs. 98.2%, P < 0.001), while the group with SUVmax ≥ 5.68 demonstrated a significantly lower 10-year overall survival than the group with SUVmax < 5.68 (68.0% vs. 97.6%, P < 0.001). In GISTs, FDG-PET is a very useful imaging marker for the diagnosis of malignant GISTs, such as those in high-risk and poor-prognosis groups.

[S-methyl-11C]-L-methionine positron emission tomography/computed tomography imaging parameters to evaluate early response for esophageal cancer with neoadjuvant carbon ion radiotherapy.

This study aimed to evaluate the uptake of the clinical effectiveness of [S-methyl-11C]-L-methionine positron emission tomography/computed tomography (MET PET/CT) in patients with esophageal cancer and to investigate MET PET/CT imaging parameters to assess early response for esophageal cancer with neoadjuvant carbon ion radiotherapy (CIRT). MET PET/CT scans were performed in nineteen patients before and 3 weeks after completion of CIRT. After Surgery, the effect of neoadjuvant CIRT was investigated by examining the relationship between each parameter of MET uptake and the histological assessment (grade and tumor residual ratio). Four parameters of MET uptake were the maximum and minimum standardized uptake values of pre and post CIRT (pre-SUVmax, pre-SUVmean, post-SUVmax, and post-SUVmean). MET PET/CT imaging of esophageal cancer was clearly demonstrated. The post-SUVmax was the most suitable parameter. When the cutoff value was set as post-SUVmax = 6.21, the sensitivity, the specificity, and the accuracy of Grades 3 were 100.0%, 63.6%, and 78.9%, respectively. And there was a positive relationship between the tumor residual ratio and post-SUVmax (R2 = 0.38, p < 0.005). MET PET/CT is clinically useful for the assessment of early response to neoadjuvant CIRT in esophageal cancer. Particularly, post-SUVmax is considered a promising PET imaging parameter.

Preoperative neutrophil-to-lymphocyte ratio may contribute to the prediction of postoperative infectious complications in patients with acute appendicitis: a retrospective study.

BACKGROUND: Several studies have assessed various clinical variables to identify risk factors for postoperative complications in patients with acute appendicitis. However, few studies have focused on the relationships between systemic inflammatory variables and postoperative complications in patients with acute appendicitis. We investigated the relationships between postoperative complications and systemic inflammatory variables, and assessed the clinical utility of these variables as predictors of postoperative complications in patients with acute appendicitis. METHODS: We retrospectively reviewed 181 patients who underwent immediate appendectomy for acute appendicitis. All postoperative complications were classified as infectious or noninfectious, and we evaluated the relationships between postoperative complications and clinical factors including the preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio. RESULTS: In total, 28 patients (15.5%) had postoperative Clavien-Dindo grade II-IV complications; 17 patients (9.4%) and 11 patients (6.1%) were categorized as the infectious and noninfectious complication groups, respectively. The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for all complications was 11.3, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of any postoperative complication (odds ratio: 4.223, 95% confidence interval: 1.335-13.352; P = 0.014). The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for infectious complications was 11.4, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of infectious complications (odds ratio: 4.235, 95% confidence interval: 1.137-15.776; P = 0.031). CONCLUSIONS: In patients with acute appendicitis, the preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of all postoperative complications, especially infectious complications.

[Laparoscopic Right-Sided Colon Cancer Surgery Using Pancreas/Duodenum 3DCT(PDCT)].

BACKGROUND AND PURPOSE: The right colic artery(RCA)and gastrocolic trunk(GCT)traverse around the pancreas and duodenum and branch divergently, thus, complicating right-sided colon cancer surgery. The usefulness of pancreatic/duodenum 3DCT imaging(pancreas/duodenum CT: PDCT)for laparoscopic right-sided colon cancer surgery was investigated. PATIENT AND METHOD: The patient was a woman, in her 80's with 2 sites of ascending colon cancer:(1)A-C, cT4b(retroperitoneum) N2aM0, Stage Ⅲc;(2)A, cT3N1bM0, Stage Ⅲb. A radical surgery was planned. Contrast-enhanced CT colonography( CTC)was performed preoperatively, and 3 3DCT images(CTC, arteriovenous 3DCT, and PDCT)were created using Workstation: Ziostation 2®(Ziosoft). These 3DCT images were combined and used for preoperative simulation and intraoperative navigation. RESULT: Composite images of CTC and arterial 3DCT identified the dominance of ileocolic artery(ICA)and RCA. In addition, a composite venous 3DCT image confirmed the branching and course of ileocolic vein(ICV)and right colic vein(RCV). Composite images of PDCT and arteriovenous 3DCT showed that the RCA branched from the superior mesenteric artery at the level of the third part of duodenum and ran ventral to the pancreatic head, while the RCV branched from the GCT in front of the pancreatic head, with the right gastroepiploic vein(RGEV). A laparoscopic combined ileal and retroperitoneal resection and D3 lymph node dissection with ICA/V and RCA/V root dissection were planned. Surgical simulation facilitated the identification of ICA/V and RCA/V and surgical procedure. The operative time was 310 minutes, and blood loss was 90 mL. Histopathological examination confirmed the diagnosis of(1)pT3(SS)N1bM0, Stage Ⅲb and(2)pT3 (SS)N1aM0, Stage Ⅲb. The patient was discharged 10 days post-surgery, without any complications. Currently, there is no apparent recurrence at 1-year follow-up. CONCLUSION: PDCT clarified the location of the RCA and GCT in relation to the pancreas and duodenum and complemented the laparoscopic right-sided colon cancer surgery.

Preoperative Neutrophil-to-Lymphocyte Ratio may Predict Postoperative Pneumonia in Stage I-III Gastric Cancer Patients After Curative Gastrectomy: A Retrospective Study.

BACKGROUND: Several studies have demonstrated that diverse systemic inflammatory-based prognostic parameters predict a poor prognosis in patients with gastric cancer. However, few studies have focused on the relationships between postoperative complications and systemic inflammatory-based prognostic parameters after curative gastrectomy. We investigated the relationships between postoperative complications and these parameters and assessed the clinical utility of the parameters as predictors of postoperative complications in patients with stage I-III gastric cancer. METHODS: We retrospectively reviewed 300 patients who underwent curative gastrectomy for stage I-III gastric cancer. All postoperative complications were classified as infectious or noninfectious. We evaluated the relationships between postoperative complications and clinical factors, including systemic inflammatory-based prognostic parameters. RESULTS: In total, 101 patients (33.7%) had postoperative Clavien-Dindo grade II-IV complications, and 54 (18.0%) patients developed infectious complications including pancreatic fistula, pneumonia, anastomotic leak, intra-abdominal abscess, and cholecystitis. The relationships between postoperative complications and systemic inflammatory-based prognostic parameters were evaluated by the areas under the receiver operating characteristic curves. Postoperative pneumonia was identified as the most sensitive complication to the systemic inflammatory-based prognostic parameters. Multivariate analysis revealed that preoperative neutrophil-to-lymphocyte ratio (odds ratio, 14.621; 95% confidence interval, 1.160-184.348; p = 0.038) was an independent predictor of pneumonia. CONCLUSIONS: Preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of postoperative pneumonia in patients with stage I-III gastric cancer after curative gastrectomy.

[Investigation for Arc of Riolan-Conserving High Ligation Using Simulation CT Colonography in Preoperative Colorectal Cancer].

BACKGROUND AND PURPOSE: Simulation computed tomography colonography(sCTC), which combines CTC and 3-dimensional vascular imaging, is popular for the surgery of colorectal cancer. We experience anomaly, called arc of Riolan(aR), rarely but its definition and details are unclear. Using sCTC, we identified aR and investigated the simulation of aR-conserving high ligation. PATIENT AND METHOD: The patients were 3 cases of sigmoid colorectal cancer with aR in 369 patients who underwent sCTC before colorectal cancer surgery. We identified the running morphology of aR. And we classified Griffiths' point as presence(P)and absence(A). Narrow or mesh-shaped artery which were ischemic risk factors of intestinal tract was P groups and normal artery was A groups in the marginal artery of splenic flexure. We simulated aR-conserving lymph node dissection using sCTC. RESULT: Case 1. The patient was 60-year-old man with rectal cancer, cT4aN1M0, Stage Ⅲa. The running morphology of aR was between the left branch of middle colic artery(MCA lt)and LCA. Griffiths point: P. Surgical simulation was D3 lymph node dissection with preservation of aR and high ligation of IMA. Pathological findings was pT3N1M0, Stage Ⅲa. Case 2. The patient was 65-year-old woman with sigmoid colon cancer, cT3N2M0, Stage Ⅲb. The running morphology of aR was between MCA lt and IMA. Griffiths point: P. Surgical simulation was D3 lymph node dissection with preservation of aR and high ligation of IMA. Pathological findings was pT3N2M0, Stage Ⅲb. Case 3. The patient was 75-year-old woman with sigmoid colon cancer, cT1bN0M0, Stage Ⅰ. The running morphology of aR was between first jejunal artery and IMA. Griffiths point: A. Surgical simulation was D3 lymph node dissection with preservation of aR and high ligation of IMA. Pathological findings was pT1bN0M0, Stage Ⅲb. CONCLUSION: Using sCTC, we could identify the various running morphology of aR and simulate aR-conserving lymph node dissection in high ligation.

[Stoma Site Marking of Colostomy Using Colostomy Simulation 3D-CT-A Case Report].

BACKGROUND AND PURPOSE: Stoma site marking is performed by inspection and palpation of the body surface. In stoma site, it is estimated that transverse colon is epigastric lesion and sigmoid colon is left hypogastric lesion. We try making colostomy simulation(Cs)3D-CT by which stoma site marking is able to be performed considering exact form of colon. PATIENT AND METHOD: The patient was 50s man with advanced rectal cancer and unresectable multiple liver metastases. Colonostomy was scheduled for strong rectal stenosis. Standard contrast-enhanced CT scan was performed before operation, and 3D-CT imaging was maked using Workstation Ziostation2(ziosoft, Tokyo, Japan). 3D-CT imaging of abdominal wall was maked by synthesizing 3D-CT imaging of body surface and rectus abdominis muscle. Cs3D-CT is maked by synthesizing CT colonography and 3D-CT imaging of abdominal wall. RESULT: The simulation of stoma site marking was performed using Cs3D-CT. Inferior epigastric artery(IEA)was identified, it was to simulate elevated colons and the stoma sites to enable easy elevation of colon through rectus abdominis muscle avoiding injury of IEA. It was possible to measure the distance from navel to stoma site marking on 3D-CT imaging, final stoma site marking was decided by applying the simulation to real stoma site marking. The difficulty of operation was assessed from positional relationship between colon and abdominal wall. It seemed to be relatively easy to elevate sigmoid colon because sigmoid colon was directly under the rectus abdominis muscle. Sigmoidostomy was scheduled considering rectal cancer, and trephine sigmoidostomy with double orifices was performed in fact. CONCLUSION: Cs3D-CT was possible to simulate colostomy considering the exact form of colon and positional relationship to abdominal wall and to perform stoma site marking considering the exact form of rectus abdominis muscle and position of IEA. Using Cs3D-CT, it seems to be able to perform optimal stoma site marking which is difficult by conventional method.

A Novel Parameter Identified Using Indocyanine Green Fluorescence Angiography may Contribute to Predicting Anastomotic Leakage in Gastric Cancer Surgery.

BACKGROUND: Anastomotic leak is one of the most serious postoperative complications, and intraoperative adequate perfusion plays a key role in preventing its development in gastric cancer surgery. This study aimed to investigate the relationships between anastomotic leak and the parameters defined by an assessment of intraoperative anastomotic perfusion using a near-infrared indocyanine green (ICG) fluorescence system and to evaluate the usefulness of this ICG fluorescence assessment in gastric cancer surgery. METHODS: We retrospectively reviewed data of 100 patients who underwent gastric cancer surgery. In a visual assessment based on fluorescence intensity, we classified ICG fluorescence image patterns as homogeneous, heterogeneous, or faint. In a chronological assessment, the first or second time point of ICG fluorescence appearance on one or the other side of the anastomosis was defined as FT or ST, respectively. The time difference in ICG fluorescence appearance between FT and ST was defined as TD. The relationships between anastomotic leak and the evaluated clinical factors, including the parameters identified by the ICG fluorescence assessment, were evaluated using univariate or multivariate analysis. RESULTS: Although no signs of leak were found by surgeons' subjective judgments, four patients developed postoperative anastomotic leak of Clavien-Dindo grade III or IV. Multivariate analysis revealed that TD was an independent predictor of anastomotic leak (odds ratio 35.361, 95% confidence interval 1.489-839.923, p = 0.027). CONCLUSIONS: A novel parameter identified using near-infrared ICG fluorescence assessment may be useful to predict anastomotic leak in gastric cancer surgery. TRIAL REGISTRATION: UMIN Clinical Trials Registry: #UMIN000030747 ( https://www.umin.ac.jp/ctr/index.htm ).

Laparoscopic surgery for an esophageal duplication cyst using a near-infrared indocyanine green fluorescence system: A case report.

We herein describe a case of laparoscopic surgery for an esophageal duplication cyst using a near-infrared indocyanine green fluorescence system. A 64-year-old woman with a cystic tumor adjacent to the esophagogastric junction was referred to our hospital for treatment. Esophagogastroduodenoscopy and abdominal CT revealed a 70-mm submucosal tumor derived from the abdominal esophagus. We performed laparoscopic resection and then evaluated the tissue perfusion of the abdominal esophagus by using a near-infrared indocyanine green fluorescence system. A Dor fundoplication was performed to prevent postoperative gastroesophageal reflux disease and reinforce the mucosal layer defect. The postoperative course was uneventful, and pathological evaluation confirmed that the tumor was an esophageal duplication cyst. The patient did not develop recurrence in the 24 months after surgery. We have demonstrated that laparoscopic resection of an esophageal duplication cyst may be performed effectively with intraoperative assessment of tissue perfusion using a near-infrared indocyanine green fluorescence system.

Diagnostic performance of diffusion-weighted magnetic resonance imaging in assessing lymph node metastasis of esophageal cancer compared with PET.

BACKGROUND: Although diffusion-weighted magnetic resonance imaging (DWI) for detecting lymph node (LN) metastasis is reported to be a successful modality for primary malignant tumors, there are few studies relating to esophageal cancer. This study aimed to clarify the diagnostic performance of DWI for assessing LN metastasis compared with positron emission tomography (PET) in patients with esophageal squamous cell cancer (eSCC). METHODS: Seventy-six patients with histologically proven eSCC who underwent curative esophagectomy without neoadjuvant treatment were reviewed retrospectively. Harvested LNs were divided into 1229 node stations with 94 metastases. Diagnostic abilities and prognostic significance were compared. RESULTS: In a station-by-station evaluation, the sensitivity was higher in DWI than PET (67% vs. 32%, P < 0.001). DWI showed more than 80% sensitivity for middle- and large-sized cancer nests and large area of cancer nests. The DWI-N0 group had a better 5-year relapse-free survival rate than the DWI-N+ group (78.5% vs. 34.2%, P < 0.001), as did the PET-N0 group. DWI-N status was an independent prognostic factor (hazard ratio [HR], 2.642; P = 0.048), as was PET-N status (HR 2.481; P = 0.033). CONCLUSIONS: DWI, which depends on cancer cell volume followed by elevated intranodal density, is a non-invasive modality and showed higher sensitivity than PET. It has clinical impact in predicting postoperative survival for patients with eSCC alongside its diagnostic ability and has significant performance in clinical practice.

Etiology and management of low anterior resection syndrome based on the normal defecation mechanism.

Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.

Hepatic blood flow by perfusion computed tomography as an imaging biomarker for patients with gastric cancer.

Perfusion computed tomography (PCT) is a less invasive imaging modality that provides information about tissue hemodynamics at the capillary level. The present study aimed to investigate the correlation between hepatic perfusion and gastric cancer progression. A total of 136 patients with gastric adenocarcinoma were evaluated in the present study. Prior to initial treatment, liver PCT was performed across the hepatic hilar plane and the hepatic blood flow (HBF) was measured using the dual-input deconvolution method. HBF was compared with clinicopathological factors, patient prognosis and circulating serum proangiogenic cytokines. The median HBF was 217 ml/min/100 g tissue. Patients with high HBF had larger tumors (43 mm vs. 71, P<0.001) and more advanced tumor-node stages (P<0.001 for both). When both patient groups of operable and inoperable were compared by their respective median HBF values, each high-HBF group had a significantly worse prognosis (P=0.002 and P=0.024), notably in the inoperable group, with <1-year survival. In 17 postoperative recurrent patients, the high-HBF at recurrence group also had a significantly worse postrecurrent prognosis (P=0.019). HBF was an independent prognostic factor (hazard ratio, 2.019; P=0.048) and was strongly associated with serum vascular endothelial growth factor level (R=0.607, P<0.001). HBF was significantly correlated with gastric cancer progression, and is an easily measured imaging biomarker reflecting patient survival.

[Transverse Colectomy with D2 Lymph Node Dissection with a Small Incision Using Body Surface 3D-Simulation CT Colonography].

BACKGROUND: Laparoscopic transverse colectomy is technically difficult. In mini-laparotomy surgery, colectomy for midtransverse colon cancer can easily be performed, but exact D2 lymph node dissection is very difficult for a variety of vessels in the transverse colon. Using 3D-CT imaging, we present a case of D2 lymph node dissection where mini-laparotomy transverse colectomy was performedby a small incision similar to that usedin laparoscopic surgery. METHOD: The patient was a 60-yearoldwoman with early transverse colon cancer, which was locatedin the mid-transverse colon. Surgical treatment was plannedfor pT1b(1.5mm)andpVM1 in pathological findings after EMR. Using CT colonography(CTC), the location of the primary tumor was identified. Using simulation CTC(sCTC), composedof CTC and 3D imaging of the arteries andveins, the dominant artery was identified and D2 lymph node dissection was simulated. In addition, body surface 3D imaging and permeable surface 3D imaging of the abdominal trunk were performed. Using body surface 3D-sCTC, composedof sCTC and body surface 3D imaging, the minimum incision to enable D2 lymph node dissection was simulated. RESULT: Using sCTC, it was identified that the dominant artery was the right branch of the middle colic artery(MCA Rt)andthe accompanying vein was branchedfrom the gastrocolic trunk(GCT). D2 lymph node dissection to separate the branching root of MCA Rt and the accompanying vein was simulated. Next, surgical incision was simulated using body surface 3D-sCTC. Because the branching roots of MCA Rt andGCT were locatedabout 5 cm cranial from the upper rim of the navel, a 7 cm upper abdominal midline incision was designed in addition to a 2 cm umbilical incision. Mini-laparotomy transverse colectomy with a 7 cm incision was performedin accordance with the simulation. The operation time was 2 hours and5 1 minutes, andbloodloss was due to occult bleeding. The patient was discharged 7 days after surgery without complications, and the final diagnosis was pT1bN0M0, StageⅠwith no recurrence for 4 years and2 months after surgery. The cranial incision from the upper rim of the navel has shrank about 3 cm, and the umbilical incision is not noticeable. CONCLUSION: D2 lymph node dissection of minilaparotomy transverse colectomy can be a treatment option for early transverse colon cancer through using body surface 3DsCTC.

An increase in the neutrophil-to-lymphocyte ratio during adjuvant chemotherapy indicates a poor prognosis in patients with stage II or III gastric cancer.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are associated with poor prognoses in patients with gastric cancer; however, few studies have focused on the dynamic changes in these ratios during the treatment of patients with gastric cancer. Here, we assessed the clinical utility of changes in these ratios as prognostic indicators in patients with stage II or III gastric cancer who received adjuvant chemotherapy. METHODS: We retrospectively reviewed 100 patients who received S-1 adjuvant chemotherapy at ≥70% of the relative dose intensity, and their NLRs and PLRs were evaluated at different times: prior to gastrectomy and upon commencement and termination of adjuvant chemotherapy. To assure the clinical utility of the changes in NLR and PLR as prognostic indicators, other clinical factors were assessed as well. RESULTS: Disease recurred in 35 patients as follows: lymph node metastasis (17 patients, 17.0%), peritoneal metastasis (12 patients, 12.0%), and hematogenous metastasis (6 patients, 6.0%); 24 patients died. An increase in the NLR during adjuvant chemotherapy with S-1 was identified as an independent indicator associated with overall survival (hazard ratio [HR] 6.736, 95% confidence interval [CI] 2.420-18.748; P < 0.001), and relapse-free survival (HR 5.309, 95% CI 2.585-10.901; P < 0.001). CONCLUSION: An increase in the NLR during S-1 adjuvant chemotherapy may be a useful prognostic indicator in patients with stage II or III gastric cancer.

Early anal gland adenocarcinoma with a characteristic submucosal tumor-like appearance: a case report.

BACKGROUND: The clinical findings of early anal gland carcinoma (AGC) have not been well delineated because AGC is a rare malignancy usually diagnosed at an advanced stage. Knowledge of the characteristic findings will be helpful for both diagnosis and determination of the treatment options for early AGC. CASE PRESENTATION: A 62-year-old man was referred to our hospital for treatment of a rectal submucosal tumor (SMT) detected during a medical checkup at another hospital. Trans-sacral resection of the tumor was performed under the diagnosis of a rectal benign cyst. Pathological examination of the resected tumor showed a mucin-producing adenoma. About 14 months later, a new cystic lesion was found by follow-up examination, and trans-sacral resection of the tumor was performed again. The second pathological diagnosis was a mucinous adenocarcinoma with a possible remnant tumor at the local site. After providing sufficient informed consent, the patient underwent intersphincteric resection (ISR) of the rectum to preserve anal function. The final diagnosis was mucinous adenocarcinoma of the anal gland, T1N0M0. The patient remained alive without recurrence or complications for 6 years 7 months postoperatively. CONCLUSION: We have herein reported a case of early AGC with a characteristic SMT-like appearance. Because the anal gland is located within both the submucosal layer and the internal sphincter muscle, ISR may be selected when the tumor is limited to inside the gland.

Management of complicated diverticulitis of the colon.

Diverticular disease of the colon occurs quite frequently in developed countries, and its prevalence has recently increased in Japan. The appearance of diverticulosis increases with age, although mostly remaining asymptomatic. Approximately 20% of cases require treatment. As the Western lifestyle and number of elderly people increase, the need for medical treatment also increases. Computed tomography (CT) is the gold standard for diagnosing diverticulitis. Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis. Each case should be classified based on clinical and computed tomography (CT) findings and then treated appropriately. Most patients with uncomplicated diverticulitis (stages 0-Ia) can be treated conservatively. Diverticulitis with a localized abscess (stages Ib-II) is generally resolved with conservative treatment. If the abscess is larger or conservative treatment fails, however, percutaneous drainage or surgery should be considered. Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis (stages III-IV). Colonic diverticulitis treated conservatively frequently recurs. Elective surgery after recovery should be considered carefully and decisions made on a case-by-case basis. Because cases of colonic diverticulitis will undoubtedly increase in Japan, it is likely that we will be confronted with increasing numbers of treatment decisions. We therefore need to have a systematic strategy for treating the various stages of colonic diverticulitis appropriately. We herein review the management of complicated diverticulitis.

Safety of mFOLFOX6/XELOX as adjuvant chemotherapy after curative resection of stage III colon cancer: phase II clinical study (The FACOS study).

PURPOSE: Adjuvant chemotherapy with oxaliplatin combined with a fluoropyrimidine derivative is widely accepted as standard therapy for patients with stage III colon cancer, since few clinical data are available for Japanese patients. The FACOS trial investigated the tolerability of modified FOLFOX6 (mFOLFOX6) and XELOX regimens in Japanese colon cancer patients. METHODS: Twelve cycles of mFOLFOX6 or 8 cycles of XELOX were given to patients with eligibility: stage III curatively resected colon cancer, performance status of 0-1, age from 20 to 75 years, and adequate organ function. The primary endpoint was 3-year disease-free survival. Secondary endpoints were the incidence of adverse events (AEs) and the completion rate of study therapy. RESULTS: From April 2010 to April 2014, a total of 132 patients were enrolled. Safety was analyzed in 130 patients, with finalized data from 73 patients receiving mFOLFOX6 and 57 patients receiving XELOX. A total of 130 patients (100%) experienced AEs (any grade), and 52 patients (40.0%) experienced AEs of grade ≥ 3. No significant difference in the frequency of grade ≥ 3 AEs was observed between mFOLFOX6 and XELOX groups. Continuation of the planned cycle rate of protocol treatment was 69.9% in the mFOLFOX6 group and 68.4% in the XELOX group. Treatment was discontinued because of AEs in 14 patients (19.2%) in the mFOLFOX6 group and 8 (14.0%) in the XELOX group. Mean relative dose intensity for oxaliplatin was 78.0% in the mFOLFOX6 group and 82.8% in the XELOX group. CONCLUSION: As adjuvant chemotherapy for stage III colon cancer, mFOLFOX6/XELOX regimens are acceptable.

[Partial Gastrectomy for Elderly Patients with Early-Stage Gastric Cancer].

The aim of this study was to assess the impact of partial gastrectomy on postoperative outcomes in elderly patients with gastric cancer. Sixty -three consecutive elderly patients aged 75 years and older with histologically proven Stage ⅠA gastric adenocarcinoma who underwent partial gastrectomy(PG, n=7)or normal gastrectomy(NG, n=56)were investigated. PG was performed by segmental gastrectomy or local gastrectomy due to poor performance status, severe comorbidities, and social background instead of normal gastrectomy(distal, proximal, and total gastrectomy). Both body mass index(BMI)and body weight changes 12 months postoperatively were significantly higher in those who underwent PG(20.5 kg/m2 vs 18.4 kg/m2, p=0.043; and 96.6% vs 86.4%, p=0.016)despite being statistically similar preoperatively. The 5-year cause-specific survival rate of those who underwent PG was 100% excluding relapse cases. The 5-year overall survival rates were 86% in those who underwent PG and 67%in those who underwent NG, although they differed significantly. Partial gastrectomy may be a valid surgical procedure that may yield better prognosis compared to that with normal gastrectomy for elderly patients with Stage ⅠA gastric cancer.

[D2 Lymph Node Dissection in Mini-Laparotomy Transverse Colectomy Using Non-Contrast Simulation CT Colonography].

BACKGROUND AND PURPOSE: It is reported that simulation computed tomography colonography(S-CTC), which combines CTC and 3-dimensional(3D)vascular imaging, is useful in colorectal cancer surgery. However, it is difficult to create 3D vascular images using non-contrast CT. Laparoscopic transverse colectomy is said to be technically difficult. Mini-laparotomy surgery for mid-transverse colon cancer is quite easy to perform. However, exact D2 lymph node dissection is very difficult. We present a case of D2 lymph node dissection during mini-laparotomy transverse colectomy performed using S-CTC, which involves the creation of 3D vascular images using non-contrast CT. PATIENT AND METHOD: The patient was a 77-year-old man with transverse colon cancer located in the mid-transverse colon, cT2N0M0, Stage Ⅰ. He had coexisting chronic renal failure. Non-contrast CT was performed prior to surgery, and the images were processed using workstation Zaiostation2. RESULTS: Both the artery and the vein created from non-contrast CT could be visualized clearly until the marginal vessels. Using noncontrast S-CTC in combination with CTC and 3D artery imaging, it was identified that the dominant artery was the left branch of the middle colic artery(MCA Lt), while the right branch of the MCA(MCA Rt)and accessory MCA(AMCA)were 10 cm or more apart. The fusion of 3D artery and vein imaging made it evident that the vein accompanying MCA Lt branched from the superior mesenteric vein. Using non-contrast S-CTC, D2 lymph node dissection, dissection of the branching root of MCA Lt and the vein at the same level was simulated. Thus, mini-laparotomy transverse colectomy was performed through a 7 cm incision, in accordance with the simulation. CONCLUSION: Non-contrast S-CTC was useful for performing D2 lymph node dissection during mini-laparotomy transverse colectomy.