[Current Status of ICG Fluorescence Navigation in Laparoscopic Liver Resection].

The indocyanine green(ICG)fluorescence navigation that we have standardized for laparoscopic liver resection is useful for partial liver resection and anatomical liver resection for liver cancer, and extended cholecystectomy for gallbladder cancer. In partial liver resection we believe that it is possible to secure a resection margin by not exposing the fluorescence emission around the tumor. In anatomical liver resection, real-time navigation becomes possible by transecting the liver at the boundary between colored and non-colored area, which contributes to precise liver surgery. In extended cholecystectomy, it is difficult to inject ICG from the cystic artery which was performed in open liver resection. So, we encircled Calot's triangle using the Glissonean approach from the ventral side of the gallbladder plate and then taped the hilar Glissonean pedicles. After clamping this tape, ICG was injected into the vein. By using this method, laparoscopic surgery has become possible in the same way as open surgery. With further spread in the future, it is hoped that liver resection using ICG fluorescence navigation will not only be precise, but also safe and highly curative surgery.

Laparoscopic resection of a gastric duplication cyst located near the esophagogastric junction.

We herein describe the rare case of a patient with a gastric duplication cyst who underwent laparoscopic resection. A 67-year-old man was referred to our hospital with an intra-abdominal lesion incidentally diagnosed on abdominal computed tomography. Esophagogastroduodenoscopy revealed normal esophageal and gastric mucosa without any lesions. Abdominal contrast-enhanced computed tomography revealed an 18 mm well-defined mass adjacent to the lesser curvature side of the esophagogastric junction. Following clinical diagnosis as an intra-abdominal mass, the patient underwent laparoscopic surgery in a five-port setting. The lesion originated from the stomach, near the muscular layer. The stomach muscle layer was partially resected; however, no communication between the mass and gastric mucosa was identified. Macroscopically, the resected specimen was 19 × 18 mm with a smooth surface and distinct margins. Microscopic examination confirmed the diagnosis of a gastric duplication cyst. The inner surface was covered with gastric gland pit-type columnar epithelial cells without atypia or neoplastic changes. The cyst wall presented layers of mucosa, muscularis mucosae, submucosa, muscularis propria, and subserosa. The patient's course after the procedure was uneventful, and he was discharged 8 days postoperatively. Gastric duplication cysts are rare and mostly asymptomatic, and their laparoscopic partial resection is safe and effective.

Gastric cancer with Fanconi anemia in adolescent and young adult patient diagnosed by comprehensive genome profiling using next-generation sequencing.

Recently, the results of gastric cancer treatment have improved; however, its characteristics in adolescents and young adults are not well known. We report the case of a patient with advanced gastric cancer, Fanconi anemia (FA), and primary biliary cholangitis. A 26-year-old woman visited a local physician complaining of epigastralgia. Esophagogastroduodenoscopy revealed edematous changes with poor distension and circumferential thickened folds with erosions in the gastric body. Biopsy results of the lesion specimens revealed poorly differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography revealed gastric wall with irregular thickness, several nodules in the peritoneal cavity, and a mass lesion in the right ovary. We diagnosed the patient with T4N2M1 stage IV gastric cancer accompanied by peritoneal and ovarian metastases and initiated nivolumab with S-1 plus oxaliplatin as the first-line treatment regimen. Because of immune-related adverse events after one course of systemic treatment, the regimen was changed to ramucirumab combined with nab-paclitaxel chemotherapy as the second-line treatment. After three cycles of weekly nab-paclitaxel with ramucirumab, the decreased platelet count did not recover, and her general condition gradually deteriorated. Comprehensive genome profiling using next-generation sequencing was performed to determine the feasibility of genotype-matched therapies. Alterations in FA complementation group A (FANCA) F1263del (49.1%) and E484Q (12.3%), which encode a key component of the multiprotein FA complex, were identified. The patient died 10 months after treatment initiation. In conclusion, when treating malignancies in adolescent and young adult patients, the genomic background should be considered.

Laparoscopic partial splenectomy in a patient with splenic hemangioma after distal gastrectomy for a neuroendocrine tumor.

Herein, we report the case of a patient with splenic hemangioma after distal gastrectomy who was treated with laparoscopic partial splenectomy. A 64-year-old woman previously underwent laparoscopic distal gastrectomy with regional lymph-node dissection for a gastric neuroendocrine tumor (G3) with venous infiltration and no lymph-node metastases. Periodic follow-up abdominal computed tomography revealed a well-defined, heterogeneous mass in the lower pole of the spleen 5 years after the operation, which grew from 12 to 19 mm 1 year later. A laparoscopic partial splenectomy was planned. During surgery, a smooth-surfaced mass with a lighter color than that of the surrounding area was observed at the lower pole of the spleen. The inferior polar branch of the splenic artery was transected, and the ischemic area of the lower pole of the spleen, where the tumor was present, was confirmed. First, the line used to perform splenic transection was determined using soft coagulation. The splenic parenchyma was then gradually transected using a vessel-sealing device system, and partial splenectomy was possible with almost no bleeding. The patient was discharged on postoperative day 8 without any complications. Pathological examination revealed a hemangioma without any malignant findings. Laparoscopic partial splenectomy is a safe and useful procedure that can be performed, considering the tumor size and location.

Successful treatment of gastric cancer with gastroduodenal intussusception by laparoscopic distal gastrectomy.

We report a case of a 93-year-old woman with gastric cancer who presented with gastroduodenal intussusception and was treated with laparoscopic distal gastrectomy. Esophagogastroduodenoscopy showed a giant protruding lesion in the gastric antrum extending into the duodenal bulb, and biopsy confirmed a well-differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) revealed a well-defined mass with homogeneous enhancement and a stalk arising from the distal stomach extending into the duodenal bulb. With a clinical diagnosis of gastric cancer with gastroduodenal intussusception, the patient underwent laparoscopic distal gastrectomy with regional lymph node dissection and reconstruction using the Billroth I method. Reduction of the intussusception was performed through a 4 cm incision under the xiphoid process in the epigastric region because it could not be laparoscopically reduced. Gross examination of the resected specimen showed a well-circumscribed, elevated lesion measuring 11.2 × 4.7 × 3.6 cm in the antrum. Microscopic examination of the elevated tumor confirmed the diagnosis of well-differentiated adenocarcinoma invading the gastric submucosal layer without lymph node metastasis. There was no lymphatic or venous invasion or lymph node metastasis. The postoperative course was uneventful, and her hemoglobin level improved to 11.9 g/dL. The patient has been postoperatively well without evidence of recurrence for 3 months. Part of the superficial spreading-type tumor may be drawn into the duodenum under strong peristaltic movement because it does not infiltrate the muscle layer.

Effects of the COVID-19 pandemic on gastroenterological surgeries in 2020: A study using the National Clinical Database of Japan.

Aim: This study aimed to investigate the effect of the coronavirus disease pandemic on the number of surgeries for gastroenterological cancer cases in Japan. Methods: The data recorded in the National Clinical Database of Japan between 2018 and 2020 were utilized for this study. Five specific surgeries for primary cancers and surgery for acute diffuse peritonitis were considered the primary endpoints. We divided the study period into the prepandemic and postpandemic (after April 2020) periods and examined the number of surgeries in relation to clinical factors. Results: Overall, 228 860 surgeries were analyzed. Among the five primary cancer surgeries, the number of distal gastrectomies for gastric cancer decreased the most (to 81.0% of the monthly number in the prepandemic period), followed by that of low anterior resections for rectal cancer (91.4%). In contrast, the number of pancreaticoduodenectomies for pancreatic cancer increased by 7.1%, while that of surgeries for peritonitis remained stable. This trend was observed nationwide. We also noted a marked reduction in the number of distal gastrectomy (to 72.5%), low anterior resection (84.0%), and esophagectomy (88.8%) procedures for T1 tumors. The noncurative resection rate and mortalities were low despite the increased proportion of T4 tumors and older patients. Conclusion: A marked reduction in surgeries for gastric and rectal cancers with early T factors may reflect prioritization of surgeries and reduction in cancer screenings. Although the quality of the surgery was maintained in terms of reduced mortalities and morbidities, the long-term effects of this pandemic should be monitored.

What is the optimal range of glycemic control for non-diabetic patients undergoing gastroenterological surgery? A single-center randomized controlled trial using an artificial pancreas.

BACKGROUND: This study aimed to determine the optimal target range of perioperative glycemic control for gastroenterological surgery. A closed-loop-type artificial pancreas (AP) was used to diminish the negative impact of hypoglycemia and glycemic variability during tight glycemic control. METHODS: In this single-center randomized trial, non-diabetic patients were assigned to tight (80-110 mg/dL) or moderate glycemic control (110-140 mg/dL) groups between August 2017 and May 2021. AP was used from the intraoperative period until discharge from the intensive care unit. The primary endpoint was the serum interleukin (IL)-6 level on the third postoperative day (3POD), and the secondary endpoints included clinical outcomes. RESULTS: Recruitment was closed before reaching the planned number of patients due to slow enrollment. Tight glycemic control (n = 62) resulted in lower mean glucose levels than moderate glycemic control (n = 66) (121.3 ± 10.8 mg/dL vs. 133.5 ± 12.0 mg/dL, p < 0.001). Insulin was administered at a 65% higher rate for tight glycemic control, achieving appropriate glucose control more than 70% of the treatment time. No hypoglycemia occurred during the AP treatment. No significant difference was observed in serum IL-6 levels on 3POD (23.4 ± 31.1 vs. 32.1 ± 131.0 pg/mL, p = 0.64), morbidity rate, surgical mortality rate, or length of hospital stay between the two groups. CONCLUSIONS: Clinically relevant short-term results did not differ, implying that 80-110 and 110-140 mg/dL are permissible glycemic control ranges when using AP in non-diabetic patients undergoing gastroenterological surgery. (Registered in UMIN; UMIN000028036).

Association between Serum Zinc Levels and Clinicopathological Characteristics in Patients with Gastric Cancer.

Introduction: Although it was reported that serum zinc levels were lower in patients with various malignancies, serum zinc levels of patients with gastric cancer were not well documented. Objectives: This study aimed to evaluate the association between clinicopathologic features and serum zinc levels in preoperative patients with gastric cancer. Methods: The study enrolled 83 patients scheduled for gastric cancer surgery at the Kochi Medical School. Clinical data were obtained to investigate associations between clinicopathological features, including nutritional indicators and serum zinc levels. Serum zinc deficiency was defined as serum zinc level <80 µg/dL. Results: The median zinc level of the 83 patients was 73 µg/dL (range, 20-152 µg/dL), and serum zinc deficiency was present in 66.3% of patients. Albumin was significantly lower in the zinc low level group than in the normal group (3.9 g/dL vs. 4.4 g/dL, p < 0.001), and the median serum zinc level was significantly lower in the albumin <4.1 g/dL group than in the albumin ≥4.1 g/dL group (69 µg/dL vs. 82 µg/dL, p < 0.001). Lymphocyte count was significantly lower in the zinc low level group than in the normal group (1,500 vs. 1810 years, p = 0.041). The median serum zinc level was significantly lower in the age ≥74 group than in the age <74 (71 µg/dL vs. 76 µg/dL, p = 0.002). Serum zinc levels showed a significant positive correlation with serum albumin (r = 0.637, p = 0.009). Conclusion: Serum zinc deficiency was found in 66.3% of preoperative patients with gastric cancer, which was highly correlated with serum albumin.

Ureteral rupture with retroperitoneal urinoma caused by peritoneal metastases of gastric cancer.

We describe the rare case of a patient with ureteric rupture during systemic drug treatment for peritoneal metastases of gastric cancer, who underwent double-J stent placement. A 66-year-old man with gastric cancer was referred to the authors' hospital. Esophagogastroduodenoscopy showed an irregular elevated lesion with thickened gastric folds, and biopsy specimens revealed a poorly differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) revealed extensive wall thickening with homogeneous enhancement of the stomach, enlarged lymph nodes in the perigastric area, and nodules in the peritoneal cavity, suggesting peritoneal metastases. The clinical diagnosis was cT4N2M1 with peritoneal metastases, and the patient received chemotherapy (S-1 plus oxaliplatin). After six courses of chemotherapy, the patient presented to the emergency outpatient department with a complaint of acute severe pain in the left lower back. Emergency abdominal contrast-enhanced CT showed extravasation of the contrast medium from the left upper ureter in the periureter area along with the retroperitoneum, and there was no mass lesion or stone in the kidney, ureter, or bladder. A double-J stent was placed under cystoscopic guidance, and no resistance was felt when the stent was inserted. The patient's postprocedural course was uneventful, and he received ramucirumab in combination with paclitaxel after double-J stent placement. However, 2 months later, systemic drug treatment was discontinued because of loss of appetite and increased general fatigue and changed to the best supportive care. His general condition gradually deteriorated, and he died 3 months after the ureteral rupture. Prompt interventions, including retrograde placement of ureteral stents with concurrent use of antibiotics, will reduce mortality and morbidity in this rare entity.

Incidence, clinicopathological characteristics, and therapeutic strategy for gastric cancer patients with metastasis to the central nervous system.

AIM: This study aimed to analyze the clinicopathologic features and treatment outcomes of central nervous system (CNS) metastasis from gastric cancer. METHODS: A total of 419 patients diagnosed with unresectable advanced or recurrent gastric cancer at Kochi Medical School between January 2007 and December 2021 were evaluated. Data of patients were reviewed, and clinicopathological information and survival outcomes of those with CNS metastases were compared to patients without CNS metastases. RESULTS: In total, 12/419 (2.9%) patients (median age: 66.5 years [range, 41-82 years]) were diagnosed with CNS metastasis from gastric cancer. Eleven had diffuse-type gastric cancer which was significantly more common than in those without CNS metastasis (91% vs. 61%, p = .034). Human epidermal growth factor receptor 2 status was positive in one of the 12 patients. The median survival time was significantly lower for patients with CNS metastasis than for those without CNS metastasis (1.8 months vs. 11.4 months, p < .001). The median survival time for patients who underwent surgical resection, radiation, or chemotherapy for CNS metastasis was significantly higher than those who received only best supportive care (3.5 months vs. .6 months; p = .007). CONCLUSIONS: CNS metastasis was found in 2.9% (12/419) of patients with unresectable advanced or recurrent gastric cancer. Diffuse-type histology was a risk factor for CNS metastasis. Multidisciplinary treatment, including surgical resection, radiation treatment, or chemotherapy, for CNS metastasis from gastric cancer may benefit selected patients.

Laparoscopic total gastrectomy for concurrent gastric cancer and complete agenesis of the dorsal pancreas.

We present an unusual case of laparoscopic total gastrectomy with lymph node dissection in a 56-year-old woman with gastric cancer and agenesis of the dorsal pancreas (ADP). Esophagogastroduodenoscopy revealed erosive lesions with thickened gastric folds; biopsy specimens revealed a poorly differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography showed a thickened wall of the gastric body; the distal pancreas was not visualized. Under the clinical diagnosis of gastric cancer with ADP, the patient underwent laparoscopic total gastrectomy with standard lymphadenectomy. The absence of a pancreatic neck, body, and tail was confirmed; lymph nodes along the splenic artery were dissected. Pathological analysis demonstrated a poorly differentiated adenocarcinoma invading the serosa, with five lymph node metastases. The postoperative course was unremarkable; postoperative adjuvant chemotherapy was performed using S-1 plus oxaliplatin. No symptom recurrence was observed at the 6-month follow-up. Laparoscopic surgery, with careful preoperative anatomic evaluation, can be considered for concurrent gastric cancer and ADP.

Staple Line Reinforcement for Intracorporeal Anastomosis Reduces Time for Reconstruction During Laparoscopic Gastrectomy for Gastric Cancer.

BACKGROUND/AIM: Despite the widespread use of laparoscopic surgery, intracorporeal anastomosis remains a complicated procedure that often prolongs the operation time. This study aimed to investigate the efficacy of a novel staple line reinforcement (SLR) during laparoscopic gastrectomy for gastric cancer. PATIENTS AND METHODS: The study included 30 patients who underwent laparoscopic gastrectomy for gastric cancer at the Kochi Medical School between November 2021 and May 2022. A review of these patients was conducted, and perioperative outcomes were compared according to the use of SLR. RESULTS: The reconstruction time using SLR was significantly shorter compared to when SLR was not used (20.5 min vs. 32.0 min, p=0.048). The incidence of hemostasis during anastomosis was significantly lower in the SLR group than in the non-SLR group (0 vs. 3 times, p=0.041). There were no significant differences in the operating time and estimated blood loss after surgery between the two groups. Furthermore, there were no significant differences in postoperative complications or nutritional status between the two groups. CONCLUSION: The usefulness of SLR in reducing the time for intracorporeal reconstruction and archiving the best interaction between device and tissue during laparoscopic gastrectomy for gastric cancer, was herein demonstrated.

[Long-Term Survival of an Adolescent and Young Adult Patient with Unresectable Advanced Gastric Cancer in Whom Multidisciplinary Treatment Was Effective].

We report the case of a long-term-surviving adolescent and young adult patient with unresectable advanced gastric cancer for whom multidisciplinary treatment was effective. A 29-year-old woman was referred to our hospital for further examination following a diagnosis of gastric cancer by a local physician. Esophagogastroduodenoscopy showed a deep ulcerated lesion in the lower third of the stomach, and analysis of biopsy specimens revealed an adenocarcinoma. Abdominal contrast- enhanced computed tomography showed gastric wall thickening in the lower third of the stomach. The patient underwent distal gastrectomy with lymph node dissection, including resection of localized peritoneal metastases, followed by Roux-en- Y reconstruction. The pathological diagnosis was serosa-invading poorly differentiated adenocarcinoma with 1 lymph node metastasis measuring 6.0×5.5 cm in the posterior wall of the lower third of the stomach and negative immunohistochemical staining for human epidermal growth factor receptor 2. The patient received postoperative chemotherapy with S-1 and oxaliplatin. She developed bilateral ovarian metastases measuring 13.0 cm and 7.8 cm after 17 months. The patient presented with severe lower abdominal pain and underwent an emergency bilateral ovarian metastasectomy, which revealed torsion of the right ovarian tumor, which had twisted twice on its pedicle, and a left ovarian mass. After the operation, 41 courses of ramucirumab with nab-paclitaxel were administered as a second-line treatment, and she received systemic drug treatment. Sixty months after the gastrectomy, the patient developed left hydronephrosis due to peritoneal metastases and was treated with nivolumab after ureteral stent replacement. No effective treatment was proposed in cancer multigene panel testing, and she died 66 months after the initial treatment because of disease progression. Comprehensive multidisciplinary treatment, including surgical and local therapy for peritoneal dissemination based on drug therapy for unresectable advanced gastric cancer, may result in long-term survival. Further research and accumulation of such cases would lead to the development of novel treatments.

Successful conversion surgery after FOLFIRINOX therapy in a patient with advanced pancreatic acinar cell carcinoma with a solitary peritoneal dissemination: A case report.

BACKGROUND: Pancreatic acinar cell carcinoma is rare; it accounts for 1% of all malignant pancreatic exocrine tumors. Although surgical resection is an option for curative treatment, the safety and efficacy of conversion surgery in patients with pancreatic acinar cell carcinoma with metastasis remain unknown. CASE: A 67-year-old man with epigastric pain and a pancreatic tumor was referred to our hospital. Computed tomography revealed a large tumor with a maximum diameter of 67 mm at the pancreatic head and a 23-mm mass in the left upper abdominal cavity. Because a definitive diagnosis could not be made based on endoscopic ultrasonography-guided fine needle aspiration biopsy findings, a diagnostic laparoscopy was performed. The tumor in the greater omentum at the left upper abdomen, resected under laparoscopy, was histopathologically diagnosed as pancreatic acinar cell carcinoma. Therefore, the pancreatic tumor was diagnosed as an unresectable pancreatic acinar cell carcinoma with a solitary peritoneal dissemination. The size of the main pancreatic tumor decreased to 15 mm after 18 courses of FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin). Subsequently, the patient underwent conversion surgery, and the initial diagnosis of pancreatic acinar cell carcinoma was confirmed on pathological examination. The patient was discharged 31 days postoperatively, following which he received adjuvant chemotherapy with S-1. No sign of recurrence has been observed for 32 months after surgical resection. CONCLUSION: FOLFIRINOX may be effective in patients with pancreatic acinar cell carcinoma, and conversion surgery after FOLFIRINOX may be applicable to selective patients.

Frequency and therapeutic strategy for patients with ovarian metastasis from gastric cancer.

PURPOSE: This study aimed to analyze the clinicopathological features and treatment outcomes of ovarian metastasis from gastric cancer. METHODS: This study included 155 female patients with unresectable advanced or recurrent gastric cancer at the Kochi Medical School between January 2007 and December 2021. A review of patients with ovarian metastasis was conducted, and their clinicopathological information and survival outcomes were compared with respect to ovarian metastasis. RESULTS: Fifteen patients were diagnosed with ovarian metastasis from gastric cancer with a median age of 54 years (range: 30-87 years) and an incidence of 9.7%. The median age of patients who developed ovarian metastasis was significantly lower those without ovarian metastasis (54 years vs. 71 years, P = 0.014). The median survival time (MST) for 15 patients with unresectable advanced gastric cancer who developed ovarian metastasis was 21.4 months (range: 0.2-41.4 months). The MST for 15 patients who underwent surgical resection and systemic drug treatment including chemotherapy to ovarian metastasis was significantly higher than those who received systemic drug treatment alone (28.1 months vs. 10.0 months; P = 0.021). CONCLUSION: Ovarian metastasis was found in 9.7% of female patients with unresectable advanced or recurrent gastric cancer and in younger patients than in those without ovarian metastasis. Multidisciplinary treatment, including surgical resection and systemic drug treatment for ovarian metastasis from gastric cancer, may benefit selected patients.

Frequency and prognostic impact of cachexia during drug treatment for unresectable advanced gastric cancer patients.

PURPOSE: Patients with unresectable advanced metastatic gastric cancer have a poor prognosis. This study examined the incidence and prognostic impact of cachexia during systemic drug treatment in such patients. METHODS: We enrolled patients with unresectable advanced gastric cancer who were treated with chemotherapy at Kochi Medical School from 2007 to 2020. Cancer cachexia was defined as > 5% weight loss or > 2% weight loss with a body mass index of < 20 kg/m2 within the past 6 months. Associations between clinicopathological parameters, cancer cachexia, and the overall survival were analyzed. RESULTS: Cancer cachexia occurred in 55.2% of 134 enrolled patients 6 months after chemotherapy. The incidence of cancer cachexia in initial unresectable gastric cancer was significantly higher than that in patients with recurrent cancer after curative resection. The median overall survival was significantly lower in the patients with cancer cachexia than in those without cancer cachexia at 6 months after starting systemic chemotherapy (13.7 months vs. 21.6 months, P = 0.032). Cancer cachexia at 6 months of starting treatment and CRP > 0.14 were identified as significantly associated with poor outcomes in a multivariate analysis (hazard ratio [HR] 1.339, 95% confidence interval [CI] 1.160-2.085, P = 0.019; HR 1.885, 95% CI 1.124-3.161, P = 0.016); respectively). CONCLUSIONS: Cancer cachexia was frequently observed in unresectable advanced gastric cancer patients who received chemotherapy and was useful as a prognostic factor for the overall survival.

[Brain Metastasis Arising from Gastric Cancer during Long-Term Treatment Using Nivolumab].

Metastasis to the central nervous system from gastric cancer is exceedingly uncommon. We report a gastric cancer patient with cerebral metastasis during the period when durable response was obtained by systemic drug treatment using nivolumab. A 78-year-old male was referred to our hospital for further examination following diagnosis of gastric cancer by a local medical doctor. Esophagogastroduodenoscopy showed a slightly elevated lesion with central depressed area in the upper-third of the stomach, and analysis of biopsy specimens revealed an adenocarcinoma. The patient underwent laparoscopic total gastrectomy with lymph nodes dissection followed by Roux-en-Y reconstruction, resulting in submucosal invasive carcinoma and no lymph node metastasis. The patient developed solitary splenic metastasis measuring 4.2 cm after 28 months later, and the patient underwent a splenectomy, since there was no evidence of further metastatic lesions in any other organs. Subsequently, the patient was received S-1 plus oxaliplatin chemotherapy based on negative immunohistochemical staining of the resected specimens for human epidermal growth factor receptor 2. Four months after the splenectomy, the patient developed multiple liver metastases and was treated with ramucirumab plus paclitaxel. Because of disease progression, the patient was administered 3 mg/kg, iv, nivolumab every 2 weeks. After 4 courses of systemic treatment using nivolumab, abdominal computed tomography revealed marked shrinkage of the liver metastases. After 12 courses of nivolumab, the liver metastases had disappeared completely. The patient developed hypothyroidism, which could be controlled by thyroid hormone replacement treatment. The patient continues to receive nivolumab, and there is no evidence of disease recurrence in the 33 month period since starting nivolumab. However, he developed cerebral metastases after 69 months after surgery, complaining of articulation disorder. The patient underwent tumor resection by craniotomy followed by radiation therapy; however, he died 3 months after the operation. Although brain metastasis arising from gastric cancer is rare, future identification of risk factors and development of novel treatments are desired by further investigations and accumulation of these cases.

Indocyanine green fluorescence-guided laparoscopic deroofing of a liver cyst: A case report.

In performing laparoscopic deroofing (LD) of liver cysts, indocyanine green (ICG) fluorescent imaging is particularly useful for delineating adequate margins for the procedure and for avoiding duct injuries. However, the optimal timing of ICG injection has not yet been clarified. Herein, we describe a patient who had a large liver cyst, in whom safe and efficient LD was performed under sharp fluorescent imaging obtained by intravenous injection of ICG 1 hour before cyst fenestration.

Neutrophil-to-lymphocyte ratio and C-reactive protein-to-albumin ratio as prognostic factors for unresectable advanced or recurrent gastric cancer.

PURPOSE: This study evaluated the prognostic value of C-reactive protein-to-albumin (CAR) and neutrophil-to-lymphocyte ratios (NLR) in conjunction with host-related factors in patients with unresectable advanced or recurrent gastric cancer. METHODS: A total of 411 patients with unresectable advanced gastric cancer were treated at Kochi Medical School between 2007 and 2019. Associations between clinicopathological parameters and systemic inflammatory and nutritional markers, including CAR and NLR, with overall survival were analyzed retrospectively. RESULTS: The optimal cut-off values of predicted median survival time were 0.096 (sensitivity, 74.9%; specificity, 42.5%) for CAR and 3.47 (sensitivity, 64.1%; specificity, 57.5%) for NLR, based on the results of receiver operating characteristic analysis. A weak significant positive correlation was identified between CAR and NLR (r = 0.388, P < 0.001). The median survival time was significantly higher in patients with intestinal-type than those with diffuse-type histology (18.3 months vs. 9.5 months; P = 0.001), CAR < 0.096 than those with CAR ≥ 0.096 (14.8 months vs. 9.9 months; P < 0.029), and those with NLR < 3.47 than NLR ≥ 3.47 (14.7 months vs. 8.8 months; P < 0.001). Multivariate survival analysis revealed that diffuse-type histology (hazard ratio (HR) 1.865; 95% confidence interval (CI) 1.397-2.490; P < 0.001)), 1 or more performance status (HR 11.510; 95% CI 7.941-16.683; P < 0.001), and NLR ≥ 3.47 (HR 1.341; 95% CI 1.174-1.769; P = 0.023) were significantly associated with independent predictors of worse prognosis. CONCLUSIONS: High CAR and NLR are associated with poor survival in patients with unresectable and recurrent gastric cancer.

Solitary port-site metastasis 42 months after laparoscopic distal gastrectomy for gastric cancer.

We report a case of solitary port-site recurrence after laparoscopy-assisted distal gastrectomy for advanced gastric cancer. A 66-year-old man had previously undergone laparoscopy-assisted gastrectomy with regional lymph-node dissection for advanced gastric cancer, which was a poorly differentiated adenocarcinoma invading the subserosal layer with lymphatic infiltration and no lymph-node metastases. He experienced dull pain in the left upper quadrant of the abdomen 42 months after the surgery. On physical examination, erythematous induration of the skin around the scar of the port insertion was observed in the left upper quadrant of the abdomen. Abdominal ultrasonography and contrast-enhanced computed tomography revealed a subcutaneous lesion with a well-defined mass measuring 3.0 cm in diameter located in the left upper quadrant of the abdomen. A skin biopsy revealed a metastatic adenocarcinoma from gastric cancer. Since there was no evidence of further metastatic lesions in other organs, the patient underwent surgical resection of the metastatic tumor arising at the port site. The abdominal wall tumor was resected with a leaf-skin incision and an adequate safety margin, and the inferior border of the tumor reached the muscular layer, which was resected with the tumor. Pathological examination confirmed the diagnosis of a poorly differentiated adenocarcinoma in the subcutaneous tissue with invasion of the muscle layer at the port site. The postoperative course was uneventful; chemotherapy using oxaliplatin plus S-1 was administered, and the patient was in good health with no evidence of the disease for 3 months postoperatively. Although port-site metastasis after laparoscopic gastrectomy for gastric cancer is a rare recurrence form, we should be aware of this issue, and further studies and assessments of additional cases are needed to establish a treatment strategy.