[A Case of Left Upper Abdominal Evisceration for Transverse Colon Cancer with Multiple Organ Invasion].

The case is a 73-year-old woman. She visited primary care doctor for abdominal pain, vomiting, diarrhea, and melena that persisted for 2 weeks. She was referred to our department because she had an elevated inflammatory response and CT showed a mass in her left upper quadrant. Contrast-enhanced CT showed a tumorous lesion mainly in the splenic flexure of the transverse colon, involving the greater curvature of the stomach, the tail of the pancreas, and the hilus of the spleen, accompanied by abscess formation. We suspected highly advanced colon cancer with multiple organ involvement, but we opted for multiple visceral resection because it was associated with high-grade inflammatory findings due to abscess formation. After she was treated with antibiotics, she underwent laparotomy on the 6th day of illness. Intraoperative findings showed no clear nodular lesions suggesting dissemination in the abdominal cavity and intraoperative washing cytology was negative. Since the mobility of the mass that invaded the posterior wall of the greater curvature of the stomach, the tail of the pancreas, and the splenic hilum centered on the splenic flexure was confirmed, the entire left upper abdominal evisceration was resected by resecting the splenic flexure of the colon, the stomach, the tail of the pancreas, and the spleen. The postoperative course was uneventful, and she was discharged on postoperative day 9. Histopathological examination confirmed invasion of colon cancer into the pancreas, spleen, and retroperitoneum. In this report, we present a case of colon cancer with multi-organ invasion that underwent left upper abdominal evisceration.

[A Case of Radical Resection of Mucinous Cystadenocarcinoma of the Appendix by Laparoscopic Partial Cecal Resection].

A 70-year-old man was admitted to our hospital with a chief complaint of right lower abdominal pain during defecation. The contrast-enhanced CT scan showed a highly expanded appendix, so we suspected an appendiceal mucinous neoplasm, but the diagnosis did not clearly suggest cancer. So, we decided to perform laparoscopic surgery. Based on the intraoperative findings, it was considered that radical resection may be possible by partial cecal resection, and the patient underwent the procedure. Mucinous adenocarcinoma(MACA)was revealed by the postoperative pathological diagnosis. However, because the histological type was G1(well-differentiated)and no metastasis to regional lymph nodes(No. 201)was observed, we decided not to perform an additional ileocecal resection with LN dissection. The patient had a good postoperative course and was discharged from the hospital on postoperative day 4. The patient is still alive, 9 months postoperatively, with no recurrence.

[Preoperative Chemoradiotherapy for Advanced Rectal Cancer Resulting in Pathological Complete Response].

A 73-year-old woman was referred to our institution due to the presence of narrow and bloody stools. On rectal examination, a rectal mass was observed. Colonoscopy revealed a type 2 tumor in the rectum(RbP)that extended to the dentate line. On biopsy, the tumor was diagnosed as tub1/tub2. No enlarged lymph nodes or metastases were noted on CT. On MRI, the tumor did not invade outside the rectum, and was noted to be proximal to the levator ani muscle. The patient was diagnosed with rectal cancer(cT4a, cN0, cM0, cStage Ⅱb). Preoperative chemoradiotherapy(CRT)was performed to preserve the patient's anus. A total dose of 50.4 Gy of radiation was administered in daily fractions of 1.8 Gy, and chemotherapy was administered with S-1(80 mg/day)orally. Colonoscopy revealed that the tumor significantly reduced in size post-CRT. Further, the boundary between the tumor and levator ani muscle was observed to be more distinct. The patient underwent a laparoscopic intersphincteric resection(D3)+ileostomy. Pathological examination revealed no viable tumor cell in the removed specimen. No tumor recurrence was observed 2 years postoperatively. We report a case in which preoperative CRT for advanced rectal cancer resulted in a pathological complete response.

[A Case of Colitic Cancer with a Total Proctocolectomy in the Second Term].

The patient was 70-years-old women, 27 years ago, she was diagnosed with total colitis-type ulcerative colitis. Eighteen years after the diagnosis, she self-suspended his hospital visit because her condition was stable. After 4 years, ulcerative colitis rekindled, she resumed taking a 5-ASA. And 2 years later, colonoscopy revealed type 3 tumor in the descending colon. Tumor biopsy indicated an adenocarcinoma(tub1, tub2)derived from ulcerative colitis. Originally total proctocolectomy is necessary, but patient strongly hoped to leave the colon. We performed laparoscopic left hemicolonectomy(D2, SST). The pathological diagnosis was pT3, pN2, pM0, pStage Ⅲc. After the operation, chemotherapy(mFOLFOX6)was carried out for 6 months. We regularly checked tumor markers and followed up with a colonoscopy once every 6 months. But 3 years and 9 months after surgery, ulcerative colitis rekindled and adenocarcinoma in the transverse colon found by colonoscopy. We performed total proctocolectomy with ileal J-pouch anal-canal anastomosis. Four months after the second operation, advanced defecation disorder has not been observed.

[A Case Involving Successful Resection of Advanced Lower Rectal Cancer with Perineum Reconstruction after Preoperative Chemotherapy and Chemoradiotherapy].

A 58-year-old woman visited our hospital for diagnosis and treatment of rectal tumor. The tumor was diagnosed as adenocarcinoma metastasizing to the uterus and vagina. Using CT, metastases were detected in the lung, liver, and right inguinal lymph node. First, we performed sigmoid-loop-colostomy. Thereafter, the patient received chemotherapy(CapeOX plus Bev) for 8 courses and chemoradiotherapy(total 50 Gy plus S-1 therapy). Ten months after the initial examination, we performed abdominoperineal resection of the rectum combined with the resection of the posterior wall of the vagina, hysterectomy, and bilateral adnexectomy. Because of a large defect in the perineal region, we also performed reconstruction using the left gracilis muscle flap. The postoperative course was uneventful, and the patient was discharged 22 days after surgery. Once the wound healed, chemotherapy(CapeIRI plus Bev)was initiated. After 10 courses of chemotherapy, metastasis and local recurrence could no longer be detected. This suggests that preoperative chemotherapy, chemoradiotherapy, and perineum reconstruction could enable the radical resection of advanced rectal cancer.

[A Case Involved Successful Treatment of Cecum Colon Cancer with Idiopathic Thrombocytopenic Purpura(ITP)by Laparoscopic Resection].

A 91-year-old woman visited a local hospital with the chief complaint of bloody stool. The patient was noted that her platelet count is 1,000/µL, so she was referred to our hospital. Also after admission, she had bloody stool continuously. Then lower gastrointestinal endoscopy was done and it indicated that the reason for these symptoms is cecum colon cancer (cT3N0M0). We decided to perform an operation. Before the operation, in order to improve her platelet count to 100,000/µL high dose intravenous immunoglobulin, steroid therapy and platelet transfusion had done. The operation is laparoscopic ileocecal resection and the amount of bleeding is 10 g. The postoperative course was uneventful, and her platelet count became within normal range by platelet transfusion for 4 days. Until latest follow-up she has neither recurrence of the cancer nor thrombocytopenia. This case suggests that appropriate treatments make it impossible laparoscopic surgery for cecum colon cancer with ITP perform safety and resection for cancers may contribute to improve ITP.

Esophageal bypass using a gastric tube and a cardiostomy for malignant esophagorespiratory fistula.

Esophageal bypass with a gastric tube and a cardiostomy is a method recently devised for malignant esophagorespiratory fistula. This method separates completely the alimentary and respiratory tracts. Four patients underwent these procedures. No operative deaths occurred, nor was there any anastomotic leakage or disruption of the excluded esophagus. The average survival time was 7 months. However, all patients were allowed to consume food orally up to the last moment of life. This bypass procedure is simple and safe to perform, and is thus a feasible treatment choice for patients with such fistulas.