Survival in a Case of Emphysematous Cholecystitis With Sepsis Caused by Clostridium perfringens.

A 77-year-old man presented to the Department of Internal Medicine with a chief complaint of abdominal pain. During the outpatient examination, a computed tomography (CT) scan showed gallstones. The patient developed worsening abdominal pain and fever and was admitted to the emergency department. He was diagnosed with cholecystitis and hospitalized. Treatment with antimicrobial agents was initiated. On the second day of hospitalization, the patient developed a fever of 39°C, hypotension, and oliguria. An emergency CT scan was performed, which showed gas production in the gallbladder. He was diagnosed with emphysematous cholecystitis, and emergency percutaneous transhepatic gallbladder drainage was performed. The patient was transferred to the high-care unit, and intensive care was initiated. On the eighth day, a follow-up CT scan showed an abscess in the gallbladder bed, and drainage was performed percutaneously. His general condition gradually improved, and he was discharged from the hospital on day 24. The patient was readmitted for cholecystectomy three months after the initial admission. The prognosis of sepsis caused by Clostridium perfringens is extremely poor, with a mortality rate of 70%-100%. We present a case of emphysematous cholecystitis successfully treated with multimodal treatment despite the presence of sepsis due to Clostridium perfringens and discuss the possible prognostic factors by reviewing the literature.

[A Case of Colorectal Cancer with Asymptomatic Idiopathic Pneumatosis Intestinalis during Bevacizumab Administration].

We present the case of a 75-year-old woman who received CapeOX plus Bmab therapy(capecitabine, oxaliplatin, and bevacizumab)after primary excision for an unresectable advanced sigmoid colon cancer with remote metastasis. Pneumatosis intestinalis(i.e., the presence of isolated gas in the abdominal cavity)was revealed accidentally during a periodical imaging examination in the small intestine and transverse colon, albeit no subjective symptoms were reported. Owing to the absence of definitive evidence of pneumatosis intestinalis and gastrointestinal perforation, the patient was diagnosed with idiopathic pneumatosis intestinalis. Bmab was discontinued, and CapeOX therapy alone was continued after follow-up. Approximately 4 months later, pneumatosis intestinalis had completely disappeared. Bmab is a vascular endothelial growth factor antibody with well-known side effect of gastrointestinal-perforation. However, there have been few reports on pneumatosis intestinalis; to our knowledge, there have been no reports on pneumatosis intestinalis associated with colorectal cancer in Japan. Further, the report suggests the need for appropriate and immediate management of pneumatosis intestinalis following diagnosis.

Increased frequency of ESR1 mutation in metastatic breast cancer by dosing selective estrogen receptor modulator followed by aromatase inhibitor.

In several recent studies on metastatic breast cancer (MBC), ligand binding domain mutations of the estrogen receptor, which is coded by the ESR1 gene, were induced by long-term endocrine therapy and resulted in acquired endocrine therapy resistance and poor outcomes. Knowledge of the association between the development of ESR1 mutation and the clinicopathologic features may guide the decision-making process of metastatic breast cancer treatment, including endocrine therapy. The aim of the present study was to evaluate the association between the development of ESR1 mutation and the clinicopathologic characteristics of patients with MBC. To evaluate the association between the development of ESR1 mutation and clinicopathologic features, a cohort of 22 patients with MBC were retrospectively analyzed using next generation sequencing. In 14 of 22 patients, four mutations were detected on the metastatic site, including Tyr537Ser, Glu542Asp, Leu536Arg and Arg548Cys. Univariate analysis demonstrated that the duration of aromatase inhibitor and selective estrogen receptor modulator treatment, as well as the age of treatment initiation for early-stage breast cancer, were significantly associated with the development of ESR1 mutation. ESR1 mutation was identified in all five patients who received selective estrogen receptor modulators in the adjuvant setting followed by aromatase inhibitors in the metastatic setting, as well as in two of the three patients who received no selective estrogen receptor modulators in adjuvant setting followed by aromatase inhibitors in the metastatic setting. In conclusion, the results of the present study suggested that administrating adjuvant selective estrogen receptor modulator followed by aromatase inhibitor for metastasis may increase the frequency of ESR1 mutation.

Simultaneously Diagnosed and Successfully Treated Rectovaginal and Vesicovaginal Fistulae after Low Anterior Resection with Concomitant Resection of Female Genitalia.

Rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) are infrequent but distressing complications after pelvic surgery. However, their adequate treatment is not well described. Here, we simultaneously encountered and successfully treated RVF and VVF after radical surgery for rectal cancer. A 70-year-old woman underwent low anterior resection (LAR) combined with resection of the uterus, the bilateral adnexa, and the upper side of the vagina, as well as diverted ileostomy for rectal cancer. A month after the surgery, she developed urinary incontinence and underwent medical treatment, but her symptoms did not improve. Evaluation with contrast enema before stoma closure revealed the presence of RVF and VVF. We repaired the VVF and RVF via transabdominal and transperineal approaches. After 6 months, ileostomy was closed and the patient had no recurrence of cancer and fistula. In LAR with hysterectomy and resection of the vaginal wall, there is a risk of RVF and VVF. The excision and closure of the fistula tract and omental flap can be effective to treat both fistulae.

A case of diffuse cavernous hemangioma of the appendix: laparoscopic surgery can facilitate diagnosis and treatment.

BACKGROUND: A cavenous hemangioma of the appendix (CHA) is rare. The clinical pathophysiology and adequate management of a CHA have not been sufficiently explained since reports on CHA are scarce. CASE PRESENTATION: A 56-year-old woman presented with chronic right lower quadrant pain. Abdominal contrast-enhanced computed tomography revealed a thickened appendix (1.5 cm in diameter) and some focal calcifications in the appendiceal wall. No acute inflammatory signs were visible around the appendix. For diagnosis and treatment, we performed a laparoscopic surgery. Intraoperative findings included purple granular lesions that were spread diffusely along the surface of the appendix. Since these lesions were spread to the terminal ileum, laparoscopic ileocecal resection was performed. Upon macroscopic inspection, purple-colored, raspberry-like lesions were found diffusely on the serosal surface of the appendix. No lesions were found on the mucosal surface. Hematoxylin and eosin staining indicated the presence of blood-filled sinus-like spaces largely in the subserosal layer. Immunohistochemistry analysis indicated that CD34-positive cells lined these spaces. Given these findings, we diagnosed the patient with a diffuse cavernous vascular malformation of the appendix. CONCLUSIONS: CHA is difficult to diagnose. A laparoscopic approach may be useful for both the diagnosis and treatment of the disease.

Successful Resection of Isolated Para-Aortic Lymph Node Recurrence from Advanced Sigmoid Colon Cancer following 156 Courses of FOLFIRI Regimen.

Isolated para-aortic lymph node (PLN) recurrence from colorectal cancer (CRC) is rare, with no currently validated treatments. Few reports have described the successful resection of isolated PLN involvement from CRC following chemotherapy. We report the case of a 63-year-old man who underwent sigmoidectomy for sigmoid colon cancer at our hospital. Pathological examination demonstrated advanced sigmoid colon cancer with metastatic involvement in both of the tested PLNs. Palliative chemotherapy was initiated four weeks after surgical resection, with administration of the FOLFIRI regimen. Four years after the operation, computed tomography (CT) revealed an enlarged PLN below the left renal vein. As PLN enlarged to 15 mm in the minor axis on a CT scan in 2014 after receiving a total of 156 courses of the FOLFIRI regimen, we considered the enlarged PLN to represent an isolated metastasis. Accordingly, lymph node resection was performed with microscopically negative margins. The patient maintained a good quality of life without any side effects throughout the whole course of his treatment and remains disease-free at 24 months without chemotherapy after resection of the isolated PLN. Curative resection following chemotherapy may improve survival of carefully selected advanced CRC patients with locoregional recurrence, such as isolated PLN involvement.

Effects of laparoscopic surgery on the patterns of death in elderly colorectal cancer patients: competing risk analysis compared with open surgery.

PURPOSE: The effects of laparoscopic colorectal surgery (LAC) on the long-term outcomes of elderly patients remain unclear. This study aimed to assess the short- and long-term outcomes of LAC in elderly colorectal cancer patients and to quantify the effects of LAC on the patient death patterns. METHODS: The clinicopathological data of elderly colorectal cancer patients aged ≥80 years old who were treated between 2006 and 2014 were extracted. The relationships between the clinicopathological factors and overall survival (OS) were assessed using the Cox proportional hazards model and Kaplan-Meier analyses. The risk factors for the types of death were estimated using a competing risk analysis. RESULTS: A total of 107 patients were included. Fifty-two patients underwent LAC, whereas 55 underwent open surgery (OC). There were no significant differences in the American Society of Anesthesiologists grade or comorbidity rate between the groups. The postoperative complication rate was significantly lower with LAC than OC (p < 0.001). After adjustment for covariates, laparoscopic surgery was not a significant risk factor for any of the types of death. CONCLUSIONS: LAC is an effective and safe technique for elderly patients with colorectal cancer. Furthermore, there was no significant association between the surgical procedure and the pattern of death.

[A case of gastrointestinal stromal tumor of the duodenum with a huge abscess].

A 36-year-old man admitted for upper abdominal pain and fever. Enhanced abdominal computed tomography showed a cystic tumor with an air fluid level, measuring 140mm in size, along the side of the first and second portions of the duodenum. The common bile duct, portal vein, and proper hepatic artery were displaced by the tumor. Upper gastrointestinal endoscopy showed duodenal ulcer, but fistula was not confirmed. Combining all imaging and clinical findings, it was clinically diagnosed as duodenal submucosal tumor with abscess, and elective surgery was performed. There was a huge mass in the Morrison pouch, with severe adhesion to the second portion of the duodenum, gall bladder, common bile duct, and transverse colon. Subtotal stomach-preserving pancreaticoduodenectomy with transverse colectomy was performed. A fistula from the second portion of the duodenum to the tumor was confirmed on the resected specimen. Histological examination showed gastrointestinal stromal tumor originating in the duodenum.

[A case of advanced rectal cancer responding to neoadjuvant chemotherapy with CPT-11, 5-FU and l-LV after coronary artery bypass graft].

A 75-year-old man was referred to our hospital with a diagnosis of lower rectal cancer. Unstable angina attack occurred after admission and cardiac angiography revealed stenosis of three coronary arteries which were treated by percutaneous transluminal coronary angioplasty unsuccessfully. Coronary artery bypass graft was performed after colostomy. It is possible for operative stress, extracorporeal circulation and blood transfusion to diminish immunocompetence and increase the risk of recurrence. Therefore, CPT-11/5-FU/l-LV combination therapy (CPT-11 80 mg/m(2), 5-FU 500 mg/m(2), l-LV 250 mg/m(2) day 1, 8, 15 every 5 weeks) was carried out as neoadjuvant chemotherapy. The tumor decreased in size, and the level of tumor marker was normalized after two courses of the combination therapy. The patient is alive without recurrence three years after abdominoperineal resection.