Simple predictors for the completion of scheduled gemcitabine­cisplatin regimens based on real­world urothelial cancer data.

Gemcitabine plus cisplatin (GC) is the standard first line of chemotherapy for urothelial carcinoma. However, it is often difficult to complete scheduled GC therapy because of real-world adverse events. Therefore, the reasons behind delays, scheduled cancelations and determined predictive factors for completing scheduled GC therapy were retrospectively analyzed. Patients diagnosed with locally advanced or metastatic urothelial carcinoma from 2009 to 2020 received a 4-week GC therapy schedule in Oita University Hospital. Information was retrospectively extracted from medical records and all cycles were divided into two groups: One wherein all treatments were administered and completed on schedule and the other wherein treatment was either delayed or canceled in during the treatment schedule. Predictive factors were then statistically extracted between the two groups. In total, 70 patients received 201 cycles of a 4-week scheduled GC therapy. Of the 201 cycles, a total of 68 (33.8%) completed all scheduled treatments, while 133 (66.1%) did not complete the treatment as scheduled. In the group where administration was not completed on schedule, the factors of male, ureteral cancer, lower stage, <90% of gemcitabine and cisplatin dosage, solitary kidney, high creatinine level, low estimated glomerular filtration rate level, low platelet count and high alkaline phosphatase level at the initiation of each cycle were more significant. Additionally, the lowest anticancer drug percentage administration was on day 15. From these results, predictive factors for patients with various backgrounds who completed the scheduled 4-week GC therapy based on real-world data were identified. This information can be useful for clinical physicians when deciding the course of treatment.

The development of a risk assessment tool for patients with postoperative pneumonia after gastrectomy for gastric cancer.

BACKGROUND: Although frail patients are known to experience increased postoperative complications, this is unclear for postoperative pneumonia (POP). We investigated associations between frailty and POP in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: In this prospective study conducted between August 2016 and December 2022, we preoperatively assessed frailty in 341 patients with GC undergoing gastrectomy using a frailty index (FI). Patients were divided into high FI vs low FI groups to examine frailty and pneumonia rates after gastrectomy for GC. RESULTS: Of 327 patients, 18 (5.5%) experienced POP after gastrectomy. Multivariate analyses showed that a high FI and total or proximal gastrectomy (TG/PG) were independent risk factors for POP (high FI: odds ratio [OR], 5.00; 95% CI, 1.77-15.54; TG/PG: OR, 3.07; 95% CI, 1.09-8.78). The proportion of patients with POP was 2.4% in those with nonhigh FI and non-TG/PG, 5.3% in those with nonhigh FI and TG/PG, 7.1% in those with high FI and non-TG/PG, and 28.0% in those with high FI and TG/PG (P < .001). The area under the receiver operating characteristic curve for this risk assessment for predicting POP was 0.740. CONCLUSION: In patients with GC undergoing gastrectomy, POP was independently associated with preoperatively high FI and TG/PG. Our simple POP risk assessment method, which combines these factors, may effectively predict and prepare patients for POP.

Study of Short-Term and Long-Term Outcomes Between Esophagogastrostomy and Double-Tract Reconstruction After Proximal Gastrectomy.

BACKGROUND: As the opportunities for proximal gastrectomy (PG) for early gastric cancer in the upper third stomach have been increasing, the safety and feasibility of PG have been a great concern in recent years. This study aimed to compare the short-term and long-term outcomes between patients who underwent esophagogastrostomy (EG) and those who underwent double-tract reconstruction (DTR) after PG. METHODS: We retrospectively reviewed the medical records of 34 patients who underwent EG and 39 who underwent DTR at our hospital between 2011 and 2022. We compared the procedure data and postoperative complications including anastomotic complications within 1 year after surgery as short-term outcomes and the rates of change in nutritional status, skeletal muscle mass, and 3-year survival as long-term outcomes. RESULTS: Although operation time of the DTR group was significantly longer than that of the EG group, there were no significant differences in postoperative complications between 2 groups. Regarding the endoscopic findings, the incidence of anastomotic stenosis and reflux esophagitis was significantly higher in the EG group than in the DTR group (26.5% vs 0%, p < 0.001; 15.2% vs 0%, p = 0.020). In long-term outcomes, there were no significant differences in body weight, BMI, laboratory data, and skeletal muscle mass index between 2 groups for 3 years. The 3-year overall survival rates of 2 groups were similar. CONCLUSION: DTR after PG could prevent the occurrence of anastomotic complications in comparison to EG. The long-term outcomes were similar between these 2 types of reconstruction.

A complete response to Pembrolizumab for metastatic collecting duct carcinoma of the kidney.

Collecting duct carcinoma, also known as Bellini duct cancer, is a rare subtype of renal cell carcinoma with a poor prognosis in the metastatic setting. There are limited data to suggest the efficacy of targeted therapy or immune checkpoint inhibitors for collecting duct carcinoma, except for small series and case reports. Herein, we present the case of a patient with collecting duct carcinoma who exhibited a complete response to pembrolizumab and long-term remission approximately 5 years after drug withdrawal.

Impact of Fish Intake Frequency on Cardiovascular Disease-Specific Survival in Hemodialysis Patients.

Introduction: Cardiovascular disease (CVD) is the leading cause of death in hemodialysis patients (HPs). As a food source, fish contains both CVD-preventive and CVD-promoting fatty acids; however, there is no consensus on fish consumption as a preventive measure for CVD in HPs. This single-center longitudinal cohort study aims to assess the impact of fish intake frequency (FIF) per week on CVD in Japanese HPs. Methods: Upon the initiation of the study, 148 HPs were evaluated to determine the FIF, and blood samples were analyzed. These patients were then monitored for 6 years.The relationships between each FIF and blood sampling data, CVD-specific survival (CSS), and new CVD-free survival (nCFS) were statistically calculated using Kaplan-Meier survival curves. Results: During the observation period, 65 deaths were reported, 16 of which were attributed to CVD. Further, 53 patients developed new CVD onset, and no association was found between the FIF and blood sampling data. Based on the Kaplan-Meier survival curves, there was a significant difference in the CSS probability rates at 72 months between patients with an FIF of ≥4 (0.719, 95% confidence interval (CI): 0.530-0.842) and those with an FIF of ≤3 (0.930, 95% CI: 0.851-0.968) (p < 0.01). However, the nCFS probability at 72 months did not significantly differ between patients with an FIF of ≥4 and those with an FIF of ≤3. Multivariate Cox proportional hazards regression showed that an FIF of ≥4 (hazard ratio: 3.64, 95% CI: 1.22-10.9, p = 0.02) was an independent predictor of CSS, but not of nCFS. Conclusions: It was suggested that a higher FIF in HPs might be one of the risks for developing CVD with increased mortality.

The Cancer Cachexia Index Can Be Used to Prognostically Predict Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Cancer cachexia occurs in cancer patients more frequently as the cancer progresses, with a negative impact on treatment outcomes. In this study, we sought to clarify the clinical impact of a cancer cachexia index (CXI) in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: Between January 2013 and December 2018, we reviewed data from 556 patients treated for GC at our hospital. CXI was calculated using skeletal muscle index (SMI), serum albumin, and neutrophil-lymphocyte ratios (NLR). Patients were divided into high (n = 414) or low CXI (n = 142) groups. We investigated the clinical impact of CXI in patients with GC undergoing gastrectomy. RESULTS: Multivariate analyses of 5-year overall survival (OS) and cancer-specific survival (CSS) rates indicated that a low CXI was independently associated with unfavorable outcomes for patients with GC. In multivariate analyses, SMI was independent predictor of OS but not CSS. NLR was not an independent predictor of either OS or CSS. Complication incidences (≥ Clavien Dindo 3) were non-significantly higher in the low (vs. high) CXI group. CONCLUSION: CXI was a more valuable prognostic biomarker when compared with SMI or NLR in GC patients undergoing gastrectomy. We suggest that patients with low CXI values should be given more comprehensive treatment, including exercise and nutritional therapy to improve clinical outcomes.

Prognostic impact of postoperative infection after resection of biliary malignancy: A multicenter retrospective cohort study.

BACKGROUND: The aim of this study was to investigate the prognostic impact of postoperative infections in patients who underwent resection for biliary malignancy, including intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, gallbladder carcinoma, and carcinoma of the ampulla of Vater. METHODS: This study was conducted in an 11-center retrospective cohort study. Patients with biliary tract cancer who underwent curative resection between April 2013 and March 2015 at 11 institutions in Japan were enrolled. We analyzed the prevalence of postoperative infection, infection-related factors, and prognostic factors. RESULTS: Of the total 290 cases, 33 were intrahepatic cholangiocarcinoma, 60 were perihilar cholangiocarcinoma, 120 were distal cholangiocarcinoma, 55 were gallbladder carcinoma, and 22 were carcinoma of the ampulla of Vater. Postoperative infectious complications, including remote infection, were observed in 146 patients (50.3%), and Clavien-Dindo ≥III in 115 patients (39.7%). Postoperative infections occurred more commonly in the patients who received pancreaticoduodenectomy and bile duct resection. Patients with infectious complications had a significantly poorer prognosis than those without (median overall survival 38 months vs 62 months, P = .046). In a diagnosis-specific analysis, although there was no correlation between infectious complications and overall survival in intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, and carcinoma of the ampulla of Vater, infectious complications were a significantly poor prognostic factor in gallbladder carcinoma (P = .031). CONCLUSION: Postoperative infection after surgery for biliary tract cancer commonly occurred, especially in patients who underwent pancreaticoduodenectomy and bile duct resection. Postoperative infection is relatively associated with the prognosis of patients with biliary malignancy, especially gallbladder carcinoma.

Current magnetic resonance imaging-based diagnostic strategies for prostate cancer.

Recent developments in multiparametric MRI and MRI-targeted biopsy have made it possible to detect clinically significant cancers more accurately and efficiently than ever before. Furthermore, software that enables easy MRI/US image fusion has been developed and is already available on the market, and this has provided a tailwind for the spread of MRI-based prostate cancer diagnostic strategies. Such precise diagnosis of prostate cancer localization is essential for highly accurate focal therapy. In addition, a recent large-scale study applying MRI to community screening for prostate cancer has reported its usefulness. By contrast, concerns about overdiagnosis and overtreatment, the existence of inter-reader variability in MRI diagnosis, and issues with current MRI-targeted biopsy have emerged. In this article, we review the development of multiparametric MRI and MRI-targeted biopsy to date and the current issues and discuss future directions.

A case of adrenal myelolipoma complicated with Prader-Willi syndrome.

Introduction: Prader-Willi syndrome is a congenital disorder that occurs in one in 10 000-30 000 children and is characterized by obesity, short stature, and intellectual disability. Case presentation: A 24-year-old male patient with Prader-Willi syndrome presented with an enlarged adrenal tumor. Computed tomography detected a well-defined mass. Magnetic resonance imaging revealed an increased signal intensity predominantly in fatty areas, suggesting adrenal myelolipoma. Laparoscopic left adrenalectomy was performed. Postoperatively, the patient developed mild pulmonary atelectasis, myelolipoma was confirmed by histopathology, and there was no recurrence at approximately 2 years postoperatively. Conclusion: This is the first report of Prader-Willi syndrome complicated with adrenal myelolipoma, which was removed laparoscopically.

Survival impact of surgical site infection in esophageal cancer surgery: A multicenter retrospective cohort study.

Aim: This study was performed to evaluate the oncological impact of surgical site infection (SSI) and pneumonia on long-term outcomes after esophagectomy. Methods: The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 407 patients with curative stage I/II/III esophageal cancer at 11 centers from April 2013 to March 2015. We investigated the association of SSI and postoperative pneumonia with oncological outcomes in terms of relapse-free survival (RFS) and overall survival (OS). Results: Ninety (22.1%), 65 (16.0%), and 22 (5.4%) patients had SSI, pneumonia, and both SSI and pneumonia, respectively. The univariate analysis demonstrated that SSI and pneumonia were associated with worse RFS and OS. In the multivariate analysis, however, only SSI had a significant negative impact on RFS (HR, 1.63; 95% confidence interval, 1.12-2.36; P = 0.010) and OS (HR, 2.06; 95% confidence interval, 1.41-3.01; P < 0.001). The presence of both SSI and pneumonia and the presence of severe SSI had profound negative oncological impacts. Diabetes mellitus and an American Society of Anesthesiologists score of III were independent predictive factors for both SSI and pneumonia. The subgroup analysis showed that three-field lymph node dissection and neoadjuvant therapy canceled out the negative oncological impact of SSI on RFS. Conclusion: Our study demonstrated that SSI, rather than pneumonia, after esophagectomy was associated with impaired oncological outcomes. Further progress in the development of strategies for SSI prevention may improve the quality of care and oncological outcomes in patients undergoing curative esophagectomy.

Temperature dependence of nitrogen solubility in bridgmanite and evolution of nitrogen storage capacity in the lower mantle.

Relative nitrogen abundance normalized by carbonaceous chondrites in the bulk silicate Earth appears to be depleted compared to other volatile elements. Especially, nitrogen behavior in the deep part of the Earth such as the lower mantle is not clearly understood. Here, we experimentally investigated the temperature dependence of nitrogen solubility in bridgmanite which occupies 75 wt.% of the lower mantle. The experimental temperature ranged from 1400 to 1700 °C at 28 GPa in the redox state corresponding to the shallow lower mantle. The maximum nitrogen solubility in bridgmanite (MgSiO3) increased from 1.8 ± 0.4 to 5.7 ± 0.8 ppm with increasing temperature from 1400 to 1700 °C. The nitrogen storage capacity of Mg-endmember bridgmanite under the current temperature conditions is 3.4 PAN (PAN: mass of present atmospheric nitrogen). Furthermore, the nitrogen solubility of bridgmanite increased with increasing temperature, in contrast to the nitrogen solubility of metallic iron. Thus, the nitrogen storage capacity of bridgmanite can be larger than that of metallic iron during the solidification of the magma ocean. Such a "hidden" nitrogen reservoir formed by bridgmanite in the lower mantle may have depleted the apparent nitrogen abundance ratio in the bulk silicate Earth.

Risk factors of "loss of independence" in elderly patients who received gastrectomy for gastric cancer.

OBJECTIVE: The aim of this study was to clarify the risk of loss of independence (LOI) following gastrectomy in elderly patients with gastric cancer (GC). METHODS: In this prospective study, frailty was assessed preoperatively by a frailty index (FI) in 243 patients aged ≥ 65 years who underwent gastrectomy for GC between August 2016 and December 2020. Patients were assigned into two groups (high FI vs. low FI) to investigate frailty and the risk of LOI after gastrectomy for GC. RESULTS: Overall and minor (Clavien-Dindo classification [CD] 1, 2) complication rates were significantly higher in the high FI group, but the two groups had similar rates of major (CD ≥ 3) complications. The frequency of pneumonia was significantly higher in the high FI group. In univariate and multivariate analyses for LOI after surgery, high FI, older age (≥ 75 years), and major (CD ≥ 3) complications were independent risk factors. A risk score assigning 1 point for each of these variables was useful in predicting postoperative LOI (LOI: score 0, 7.4%; score 1, 18.2%; score 2, 43.9%; score 3, 100%; area under the curve [AUC] = 0.765.) CONCLUSIONS: LOI after gastrectomy was independently associated with high FI, older age (≥ 75 years), and major (CD ≥ 3) complications. A simple risk score assigning points for these factors was an accurate predictor of postoperative LOI. We propose that frailty screening should be applied for all elderly GC patients before surgery.

Do postoperative infectious complications really affect long-term survival in colorectal cancer surgery? A multicenter retrospective cohort study.

Aim: To investigate the impact of postoperative infection (PI), surgical site infection, and remote infection (RI), on long-term outcomes in patients with colorectal cancer (CRC). Methods: The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 1817 curative stage I/II/III CRC patients from April 2013 to March 2015. Patients were divided into the No-PI group and the PI group. We examined the association between PI and oncological outcomes for cancer-specific survival (CSS) and overall survival (OS) using Cox proportional hazards models and propensity score matching. Results: Two hundred and ninety-nine patients (16.5%) had PIs. The 5-year CSS and OS rates in the No-PI and PI groups were 92.8% and 87.6%, and 87.4% and 83.8%, respectively. Both the Cox proportional hazards models and propensity score matching demonstrated a significantly worse prognosis in the PI group than that in the No-PI group for CSS (hazard ratio: 1.60; 95% confidence interval: 1.10-2.34; P = .015 and P = .031, respectively) but not for OS. RI and the PI severity were not associated with oncological outcomes. The presence of PI abolished the survival benefit of adjuvant chemotherapy. Conclusions: These results suggest that PI after curative CRC surgery is associated with impaired oncological outcomes. This survival disadvantage of PI was primarily derived from surgical site infection, not RI, and PI induced lower efficacy of adjuvant chemotherapy. Strategies to prevent PI and implement appropriate postoperative treatment may improve the quality of care and oncological outcomes in patients undergoing curative CRC surgery.

[Neuroendocrine Carcinoma of the Non-Ampullary Duodenum-A Case Report].

A 69-year-old woman was admitted to a territory hospital because of severe right hypochondoralgia after 2 weeks of internal medicine for persistent epigastralgia. Gastroduodenal endoscopy revealed a large tumor with a fistula in the duodenal bulb that expanded to the stomach. Histopathologically, the biopsy specimen indicated a poorly differentiated adenocarcinoma and HER2 negative. Computed tomography revealed that the tumor invaded the left lobe of the liver. The patient was referred to our hospital for cancer treatment. After 1 course of chemotherapy with S-1 and CDDP, laparoscopic gastroenterostomy bypass was performed because of tumor hemorrhage and poor food intake. However, the tumor hemorrhage and poor food intake continued, and the tumor enlarged. Therefore, left hemihepatectomy and distal gastrectomy with resection of the duodenal bulb were performed 1 month after bypass surgery. Histological testing confirmed the diagnosis of duodenal large-cell neuroendocrine carcinoma invading the liver without lymph node metastasis. Adjuvant chemotherapy was not administered, and the patient has been alive without recurrence for 7 years and 3 months. Neuroendocrine carcinoma of the non-ampullary duodenum is very rare; however, a large cell type without lymph node metastasis may be a factor in the long-term prognosis.

Jejunal Mesentery Preservation Reduces Leakage at Esophagojejunostomy After Minimally Invasive Total Gastrectomy for Gastric Cancer: a Propensity Score-Matched Cohort Study.

PURPOSE: The mesentery of the jejunum (MJ) of the Roux limb is conventionally divided when Roux-en-Y reconstruction is performed after total gastrectomy for gastric cancer (GC). However, the impact of dividing or preserving the MJ on anastomotic leakage (AL) at the esophagojejunostomy (EJS) site after minimally invasive total gastrectomy for GC is unclear. METHODS: This retrospective cohort study enrolled 226 patients with GC who underwent EJS after laparoscopic or robotic total gastrectomy, including preservation of the MJ (n = 87) and division of the MJ (n = 137). The prevalence of anastomotic complications at the EJS and short-term outcomes were compared between groups using propensity score (PS) matching. RESULTS: After PS matching, 69 patients were selected for the preserving and dividing MJ groups. There were no significant intergroup differences in patient backgrounds, including oncological stage, body mass index, and gender ratio. After PS matching, overall and severe complications after surgery were compared between the preserving and dividing MJ groups (21.7% vs. 27.5%, p = 0.554 and 8.7% vs. 13.8%, p = 0.137, respectively). However, the rate of AL at the EJS was significantly lower in the preserving than that in the dividing MJ group (1.4% vs. 13.0%, p = 0.017). In addition, the median postoperative hospital stay was significantly shorter in the preserving than that in the dividing MJ group (13.0 days vs. 16.0 days, p = 0.005). CONCLUSIONS: Preserving the MJ significantly reduced AL at the EJS after minimally invasive total gastrectomy for GC.

Prognostic impact of postoperative infection in patients with pancreatic cancer: A multicenter cohort study.

BACKGROUND: Postoperative infection after pancreatectomy in patients with pancreatic cancer often leads to poor prognosis. The aim of this study was to determine the prognostic effect of postoperative infection in patients with pancreatic cancer. METHODS: A multicenter cohort study was performed using a common database of patients with pancreatic cancer who underwent curative pancreatic resections between April 2013 and March 2015 at 15 high-volume centers in Japan. The rate of postoperative infection was determined, and patient demographic characteristics, clinicopathologic factors, and prognostic factors for overall survival were analyzed. RESULTS: Of the 462 eligible patients who underwent curative pancreatectomy, postoperative infection occurred in 141 patients (31%), including 114 surgical site infections (25%), 50 remote infections (11%), and 23 combined infections (5%). Risk factors for postoperative infection included high body mass index, nondiabetes, and longer operation time. In the survival analysis, patients with postoperative infection had significantly worse overall survival than patients without postoperative infection. The median survival times were 21.9 and 33.0 months (P = .023), respectively, for patients with and without postoperative infection. According to the multivariate analysis for overall survival, lack of adjuvant therapy (P = .002), but not postoperative infection (P = .829), predicted poor prognosis. The multivariate analysis revealed that postoperative infection (P < .001) was an independent risk factor for lack of adjuvant therapy. CONCLUSION: Postoperative infection in patients with pancreatic cancer may indirectly worsen the prognosis by preventing timely adjuvant therapy.

Ingenuity and tips for laparoscopic local resection for local recurrence of early gastric cancer after endoscopic submucosal dissection: A case report.

INTRODUCTION AND IMPORTANCE: The presence of severe comorbidities is associated with poor surgical outcomes in patients who undergo curative resection for gastric cancer. Herein, we present a report of laparoscopic local resection (LLR) for the local recurrence of gastric cancer in a patient with severe comorbidities. CASE PRESENTATION: A 73-year-old man underwent endoscopic submucosal dissection (ESD) for an early gastric cancer located at the greater curvature of the gastric antrum. One year after the ESD, follow-up gastroscopy revealed a local recurrence. CLINICAL DISCUSSION: LLR was performed owing to severe comorbidities such as chronic heart failure, severe chronic obstructive pulmonary disease, and diabetes mellitus. We confirmed the location of the tumor with an endoscope, and full-thickness stitches were placed outside the tumor to prevent displacement between the submucosal and serosal muscular layers. Full-thickness resection of the stomach wall was performed along the stitch points using an ultrasonic shear. The edge of the resection line was closed using a laparoscopic stapling system. The patient had an uneventful postoperative course and was discharged 8 days after the operation. The patient had no disease recurrence and late complications such as digestive symptom and weight loss at the 9-month follow-up after the operation. CONCLUSION: LLR might be a suitable treatment option for high-risk patients with gastric cancer. During full-thickness resection of the stomach wall, our method enables the maintenance of a negative margin without the need for ESD.

[Synchronous Double Primary Non-B, and Non-C Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma-A Case Report].

A 78-year-old man without hepatitis virus B or C underwent right hemi-hepatectomy and lymph node dissection for a tumor 5 cm in diameter located in the hepatic hilum of the posterior segment of the liver with portal vein thrombi extending into the main portal trunk and a tumor 1.5 cm in diameter in the peripheral side of segment 5 of the liver. Histopathologically, the former was diagnosed as intrahepatic cholangiocarcinoma and the latter as hepatocellular carcinoma(HCC). Five months after the surgery, intrahepatic and lymph node metastases were diagnosed based on computed tomography(CT); therefore, chemotherapy with S-1 for 3 months and gemcitabine and cisplatin(GC)for 5 months was administered, after which the metastatic lesions were not detected. Nineteen months after the surgery, partial resection of segment 2 of the liver was performed for a tumor 3 cm in diameter, which was diagnosed as HCC histopathologically. Two years after the second surgery, 2 recurrent nodules in the liver in segments 3 and 4 were detected on CT. Platinum-based hepatic arterial infusion chemotherapy(HAIC)and transcatheter arterial chemoembolization(TACE)were performed, and chemotherapy with GC was then administered for 7 months. For a new tumor detected in segment 1 in the liver, TACE was performed 17 months after initial HAIC. Seventy-four months after the initial surgery, 5 new nodules less than 1 cm in diameter were detected, and chemotherapy with sorafenib was administered for 5 months, after which the patient died of coronavirus disease 2019.

Laparoscopic lithotripsy and lithotomy of impacted stone at the terminal end of the common bile duct using a laparotomy biliary lithotomy spoon: A case report.

INTRODUCTION AND IMPORTANCE: Endoscopic intervention is considered first-line therapy for common bile duct (CBD) stones, in recent times. However, surgically altered anatomy and consequent inaccessibility of the duodenal papilla necessitate surgery in some patients. CASE PRESENTATION: A 61-year-old woman presented with fever and right subcostal pain. She underwent total gastrectomy and Roux-en-Y reconstruction for gastric ulcer, 4 years prior to presentation. Based on the clinical findings, she was diagnosed with acute obstructive cholangitis secondary to a CBD stone. Endoscopic retrograde biliary drainage was attempted; however, the duodenal papilla was endoscopically inaccessible owing to the previous Roux-en-Y reconstruction, and we performed percutaneous transhepatic gallbladder drainage (PTGBD). She underwent laparoscopic cholecystectomy and choledocholithotomy, 6 days after the PTGBD. Choledocholithotomy was attempted using basket forceps under choledochoscopic guidance; however, this procedure was unsuccessful, and we performed laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon. CLINICAL DISCUSSION: Usually, laparoscopic cholecystectomy concomitant with CBD exploration is performed in patients with an endoscopically inaccessible duodenal papilla. However, an inadequately opened basket may not capture large impacted stones at the duodenal end of the CBD. Intraductal shock wave lithotripsy (electrohydraulic or laser lithotripsy) is considered in such cases; however, the specialized instruments required for this procedure are unavailable at all centers. Laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon may be useful to overcome this surgically challenging situation. CONCLUSION: A laparotomy biliary lithotomy spoon is a simple, user-friendly, and economical device that may be useful for laparoscopic lithotripsy and lithotomy of impacted stones.

[A Case of Recurrent Gastric Cancer of Multiple Organ Metastasis with Long-Term Survival Due to Multimodal Treatment].

A 67-year-old man was introduced to examine for abnormal findings in physical examination. Upper gastrointestinal endoscopy detected the 3 lesions and diagnosed multiple gastric cancers with biopsy. Laparoscopic total gastrectomy was performed and final pathological diagnosis was pT2N1M0, pStage ⅡA with HER2 positive(3+). Adjuvant chemotherapy was not administrated. CT findings 6 months after procedure showed 2 liver metastases(S6, S7)and laparoscopic partial liver resection was performed. Pathological findings proved the metastasis of previous gastric cancer. Although adjuvant chemotherapy of S-1 was started 2 months after hepatectomy, CT findings showed second recurrences in liver and right adrenal gland. Chemotherapy was changed to S-1 plus cisplatin(SP)plus trastuzumab. AS these recurrence sites and ascites could not be detected by CT after 6 courses, therapeutic effect was judged as clinical CR(cCR)and SP plus trastuzumab was stopped due to side effect. Since then, regular follow-up CT showed preservation of status of cCR without chemotherapy and he has been alive without recurrence for 8 years and 9 months after gastrectomy. We report a case of recurrent gastric cancer of multiple organ metastasis with long-term survival due to multimodal treatment.