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.

Impact of a robotic system on intra-abdominal infectious complications after minimally invasive gastrectomy in patients with gastric cancer: A propensity score matching analysis regarding visceral obesity.

Background: The efficacy of robotic gastrectomy (RG) on postoperative complications in patients with gastric cancer (GC) is unclear in terms of the volume of intra-abdominal fat tissue. Patients and Methods: We enrolled 403 patients with GC who had minimally invasive surgery between January 2015 and July 2022. During this time, 197 RG and 206 laparoscopic gastrectomies (LG) were performed on the study participants. According to the computed tomography scan, patients were defined as having or not having visceral obesity based on the visceral fatty area (VFA). In each high and low VFA group, we compared short-term outcomes between the RG group and LG group. Results: After PS matching for patients with high VFA, the two groups were well matched, with 71 cases in both the RG and LG groups. The median surgical time in the RG group was significantly longer (420 vs. 365 min, p < 0.001). However, the RG group had a significantly lower rate of severe intra-abdominal infectious complications (IAIC), such as anastomotic leakage, pancreatic fistula, and intra-abdominal abscess (1.4% vs. 15.4%, p = 0.004). However, among the 77 patients with low VFA values, we found no significant difference in the rate of severe IAIC between the two groups (1.1% in the RG group vs. 2.6% in the LG group, p = 1.00). Conclusion: RG may be a viable alternative to LG because of the lower postoperative IAIC for patients with visceral obesity and GC. However, RG may not benefit non-obese patients.

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.

Inflammation Related to Association of Low Uric Acid and Progression to Severe Disease in Patients Hospitalized for Non-Severe Coronavirus Disease 2019.

Uric acid has antioxidant properties. To examine whether a low uric acid level is associated with severe coronavirus disease 2019 (COVID-19) progression via inflammation, alveolar damage, and/or coagulation abnormality, a retrospective observational study of 488 patients with non-severe COVID-19 and serum uric acid level ≤7 mg/dL at admission was conducted. Serum C-reactive protein (CRP), serum Krebs von den Lungen 6 (KL-6), and plasma D-dimer levels were also measured as markers of inflammation, alveolar damage, and coagulation abnormality, respectively. Median values for uric acid, CRP, KL-6, and D-dimer at admission were 4.4 mg/dL, 3.33 mg/dL, 252.0 U/mL, and 0.8 µg/mL, respectively. Among the total cohort, 95 (19.5%) progressed to severe COVID-19 with a median (interquartile range) time of 7 (4-14) days. Multivariable Cox proportional hazards regression analysis showed that low uric acid level was associated with a higher rate of severe COVID-19 progression. However, uric acid level was inversely associated with CRP level, and the association between the level of uric acid and severe COVID-19 progression was significantly different with and without CRP level inclusion. In contrast, no such association was found for KL-6 or D-dimer level. Low uric acid may contribute to severe COVID-19 progression via increased inflammation in subjects without hyperuricemia.

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.

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.

Glycated hemoglobin level on admission associated with progression to severe disease in hospitalized patients with non-severe coronavirus disease 2019.

AIMS/INTRODUCTION: Poor glycemic control is known to be associated with severe infection development. This retrospective observational study examined whether glycemic control before coronavirus disease 2019 (COVID-19) onset contributes to progression from non-severe to severe COVID-19. MATERIALS AND METHODS: Glycated hemoglobin (HbA1c) was measured on hospital admission in 415 patients with non-severe COVID-19. The outcome was determined from time of hospital admission to severe progression, based on clinical practice guidelines for COVID-19 in Japan. RESULTS: The median value for HbA1c on admission was 6.1%, with diabetes present in 138 patients (33.3%). Among the total cohort, 93 (22.4%) progressed to severe COVID-19 with a median (interquartile range) time of 4 days (3-7 days), whereas 322 (77.6%) were discharged after 13 days (10-17 days). A multivariable Cox proportional hazards regression model showed that HbA1c level on admission was independently associated with progression to severe COVID-19 (hazard ratio for 1% increase 1.237, 95% confidence interval 1.037-1.475; P = 0.018), with findings consistent among several sensitivity analyses. In subgroup analyses, such an association was significant in patients with diabetes, as well as older age, current smoking habit, lower estimated glomerular filtration rate, higher C-reactive protein level, moderate II COVID-19, dyslipidemia and chronic respiratory disease, with no remarkable inconsistency among the subgroups. Finally, higher HbA1c level (≥7%) was more strongly associated with severe COVID-19 progression than diabetes. CONCLUSIONS: The results suggest that poor glycemic control before COVID-19 onset contributes to progression from non-severe to severe COVID-19, even in patients with severe COVID-19 risk factors regardless of the presence of diabetes.

[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.

Survey Regarding Gastrointestinal Stoma Construction and Closure in Japan.

Background and Aim: In Japan, the actual number of stoma constructions and stoma closures is not known. The aim of this study was to conduct a survey to determine the number of gastrointestinal stoma constructions and closures in Japan. Methods: Enrolled participants comprised patients undergoing selected gastrointestinal surgeries who were recorded in the National Clinical Database. This database uses the "Common Items for Gastrointestinal Surgeons." These procedures were formulated by the Japanese Society of Gastroenterological Surgery during 2013-2018. Results: According to the National Clinical Database, a total of 154,323 gastrointestinal stomas were constructed between January 1, 2013 and December 31, 2018. By procedure, there were 78,723 cases of stoma construction, 39,653 of abdominoperineal resection, 2470 total pelvic exenteration procedures, and 33,572 Hartmann's procedures. The ratio of stoma closures to stoma constructions increased annually in patients under 70 y of age but not in older patients. Approximately 35% of total colectomies, 60% of proctocolectomies, and 20% of low anterior resections were accompanied by stoma construction. The number of patients with rectal cancer who underwent colostomy increased gradually during the study period and the number who underwent stoma construction increased among older patients. Conclusion: The number of cases of gastrointestinal stoma construction has increased gradually in Japan, and the proportion of older patients is increasing each year. The purposes and surgical techniques for stoma construction are diverse and are expected to increase in Japan, a super-aged society.

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.

[Surgical Resection of Pulmonary Oligometastases of Ampullary Cancer-A Case Report and Review of Seven Cases].

A 62-year-old woman underwent a subtotal stomach-preserving pancreatoduodenectomy for ampullary carcinoma (T3bN0M0, Stage Ⅱb). Histopathologically, the tumor was a tubular adenocarcinoma with mixed features, predominantly the intestinal type, following which adjuvant chemotherapy was not performed. Computed tomography performed 32 months after surgery showed a tumor measuring 6.7 mm in diameter at the apex of the right lung. The tumor had gradually increased in size and measured 10 mm in diameter, 47 months postoperatively. Since other metastatic lesions were absent, partial resection of the right lung under video-assisted thoracic surgery was performed 48 months postoperatively. Histopathological testing confirmed a diagnosis of lung metastasis from the resected specimen of ampullary carcinoma without mediastinal lymph node metastasis. Adjuvant chemotherapy was not performed, and recurrence was not observed even after 53 months following the partial lung resection. Previously, 7 resected cases of solitary lung metastasis from ampullary cancer have been reported. The histopathological sub-type of these 7 cases were intestinal type in 5 and pancreatobiliary type in 2 cases, respectively. No mortality or recurrence was observed for 8-119 months in any of the 7 cases(median, 19 months). In conclusion, owing to the good prognosis, solitary lung metastasis from an ampullary cancer can be classified as an oligometastatic disease, based on the concept proposed by Hellman and Weichselbaum.

[A Case of pStage IB Gastric Cancer Relapsed on Both Pleura and Peritoneum Eight Year after Radical Gastrectomy].

An 86-year-old man presented with upper abdominal pain and was diagnosed with type 0-Ⅲ gastric cancer located at the posterior wall of the upper stomach by upper gastrointestinal endoscopy. Laparoscopic total gastrectomy(D1+)was performed for gastric cancer of cStage Ⅰ. As final pathological diagnosis was pT2N0(0/27)M0H0P0CY0, pStage ⅠB, adjuvant chemotherapy was not administrated. The patient has been alive with no recurrence for 5 years after surgery. 8 years and 1 month after procedure, he visited our hospital with chief complaint of abdominal distention and anorexia. Chest and abdominal CT showed pleural fluid and ascites, but PET-CT could not detect any sites of recurrence. Cytopathology and cell blocks by immunohistochemical staining of ascites proved recurrence of previous gastric cancer. Any treatment was rejected, and the patient died 3 months after recurrence and 8 years and 4 months after gastrectomy. Late recurrence on both pleura and peritoneum of gastric cancer is very rare. We report a case of pStage ⅠB gastric cancer relapsed on both pleura and peritoneum 8 year after radical gastrectomy.

Depletion of skeletal muscle mass adversely affects long-term outcomes for men undergoing gastrectomy for gastric cancer.

BACKGROUND: Although low skeletal muscle mass has an adverse impact on the treatment outcomes of cancer patients, whether the relationship between preoperative skeletal muscle mass and gastrectomy outcomes in gastric cancer (GC) differs between men and women is unclear. The study aimed to clarify this relationship based on gender. METHODS: Between January 2007 and December 2015, 1054 patients who underwent gastrectomy for GC at Osaka City General Hospital were enrolled in this study. We evaluated sarcopenia by the skeletal muscle index (SMI), which was measured by computed tomography (CT) using areas of muscle in the third lumbar vertebral body (L3). Male and female patients were each divided into two groups (low skeletal muscle and high skeletal muscle). RESULTS: The SMI emerged as an independent predictor of 5-year overall survival (OS) in male GC patients (Hazard ratio 2.51; 95% confidence interval (CI) 1.73-3.63, p < 0.001) based on multivariate analysis. However, this index was not an independent predictive determinant of 5-year cancer-specific survival (CSS). The SMI was not an independent predictor of either OS or CSS in female GC patients. The incidence of leakage and major complication (Clavien Dindo grade ≧ 3) did not differ significantly across groups. CONCLUSIONS: Preoperative skeletal muscle mass is a valuable prognostic predictor of OS in male GC patients.

Percutaneous transesophageal gastro-tubing for the management of anastomotic leakage after upper GI surgery: a report of two clinical cases.

BACKGROUND: Anastomotic leakage is a serious, sometimes critical complication of upper gastrointestinal (GI) surgery. The cavity and target drainage tubes are difficult to reach; therefore, a nasogastric tube (NGT) and fasting are required for an extended period. We successfully treated and managed two patients with anastomotic leakage using percutaneous transesophageal gastro-tubing (PTEG). CASE PRESENTATION: In case 1, a 79-year-old man with gastric cancer underwent total gastrectomy; 1 week later, he underwent emergent open laparotomy due to panperitonitis attributed to anastomotic leakage-related jejunojejunostomy. We resected the portion between esophagojejunostomy and jejunojejunostomy and reconstructed it using the Roux-en-Y technique. On postoperative day (POD) 9, anastomotic leakage was diagnosed at the esophagojejunostomy site and jejunotomy staple line. After using a circular stapler for jejunojejunostomy, a stapled jejunal closure was added. We inserted an NGT and performed aspiration for bowel decompression. As he did not improve within 2 weeks, we decided to perform PTEG to free him of the NGT. We kept performing intermittent aspiration; leakage stopped shortly after, due to effective inner drainage. The PTEG catheter was removed after oral intake was restarted. In case 2, an 81-year-old man with esophagogastric junction cancer underwent resection of the distal esophagus and proximal stomach. After shaping the remnant stomach, esophagogastrostomy was performed under the right thoracotomy. On POD 11, anastomotic leakage was identified, along with a mediastinal abscess. We inserted an NGT into the abscess cavity through the anastomotic leakage site. On POD 25, we performed PTEG and inserted a drainage tube, instead of an NGT. Although the abscess cavity disappeared, anastomotic leakage persisted as a fistula. We exchanged the PTEG with a double elementary diet (W-ED) tube with jejunal extension, with the side hole located near the anastomosis. The anastomotic fistula disappeared after treatment. Dysphagia persisted due to disuse atrophy of swallowing musculature; PTEG was useful for enteral feeding, even after the leakage occurred. CONCLUSION: Patients are sometimes forced to endure pain for a long time for transnasal inner drainage. Using PTEG, patients will be free of sinus pain and discomfort; PTEG should be helpful for patients withstanding NGT.

Successful surgical treatment for nonocclusive mesenteric ischemia of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy for esophageal cancer: a case report and review of the literature.

BACKGROUND: Nonocclusive mesenteric ischemia (NOMI) has been reported to be a life-threating disease. Gastric conduit necrosis is known as a critical postoperative complication after esophagectomy for esophageal cancer. We encountered a rare case of NOMI of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy, which was successfully treated with an emergency operation. CASE PRESENTATION: A 67-year-old man presented with dysphagia. He was diagnosed with middle thoracic advanced esophageal cancer. After neoadjuvant chemotherapy, he underwent subtotal esophagectomy with lymphadenectomy and gastric conduit reconstruction. On postoperative day (POD) 2, he had diarrhea, high fever, and low blood pressure, which were treated with catecholamines. Laboratory data revealed acidosis and severe sepsis with multi-organ failure, including the kidneys. Although enhanced computed tomography did not exhibit definite findings of bowel ischemia, upper gastrointestinal endoscopy revealed necrotic mucosal changes in the whole gastric conduit. Therefore, we made a diagnosis of septic shock caused by gastric conduit necrosis and performed an emergency operation. When we explored the abdominal cavity, we found not only gastric conduit necrosis but also intermittent necrotic changes in the intestinal wall from the jejunum to the rectum. Therefore, NOMI was diagnosed. We performed an excision of the gastric conduit and 2 m of the small intestine, as well as total colectomy. After the second operation, prostaglandin E1 was administered intravenously as the treatment for NOMI, and sepsis was improved. On POD 122, he was self-discharged. He died of recurrence of lung metastasis from the esophageal cancer 9 months after the first operation. CONCLUSION: When a patient has a critical status, including severe sepsis or severe acidosis, after esophagectomy, we should consider the possibility of NOMI in addition to gastric conduit necrosis and aim to diagnose and treat it immediately with an urgent operation.

[Descending Colon Cancer with Synchronous Solitary Small Intestinal Metastasis-A Case Report].

A 77-year-old man presented with biliary colic and was diagnosed with descending colon cancer and cholelithiasis.During the surgery, a mass was detected in the upper jejunum, located 5 cm from the Treitz ligament on the anal side.Open left hemicolectomy with partial jejunal resection was performed.The mass in the small intestine was diagnosed as solitary small intestinal metastasis of colon cancer through immunohistopathological examination.Isolated intestinal metastases of colorectal cancers are rare.Furthermore, synchronous metastases are rare among these cases.A previous study reported poor prognosis in patients with small intestinal metastasis; therefore, more studies on the small intestinal metastasis of colorectal cancer are necessary.

[A Case of Disturbance of Consciousness Due to Hyperammonemia during Chemotherapy for Metastasis of Sigmoid Colon Cancer].

A 76-year-old woman had underwent 5-fluorouracil(5-FU), oxaliplatin(L-OHP)combination therapy(mFOLFOX6)as first-line chemotherapy for peritoneal recurrence after resection of sigmoid colon cancer. She showed severe general fatigue and disturbance of consciousness on the second day of the 12th course of chemotherapy. Computed tomography of the head detected no abnormal findings in the central nervous system. The laboratory results revealed a marked hyperammonemia. She was diagnosed as a disturbance of consciousness due to hyperammonemia and treated her with branched- chain amino acid solution. Then the disturbance of consciousness resolved on the following day. After changing the regimen of chemotherapy, the disturbance of consciousness was not found. Recently, it has been reported that high-dose 5-FU regimen such as mFOLFOX6 causes hyperammonemia as a rare adverse event. We should take hyperammonemia into account when disturbance of consciousness occurs during high-dose 5-FU chemotherapy.

[Laparoscopic Liver Resection for Liver Metastasis from Unresectable Pancreatic Ductal Adenocarcinoma Well-Controlled by Chemotherapy-A Case Report].

A 45-year-old man with unresectable locally advanced pancreas head cancer with multiple synchronous liver metastases was treated with gemcitabine plus nab-paclitaxel therapy as a first-line chemotherapy. During 24 months of 30 courses of this therapy, the primary lesion remained stable and liver metastases were completely disappeared on CT. Three months later, however, solitary relapse of liver metastasis occurred in segment 2. Therefore, we changed the chemotherapy regimen to the second-line treatment, FOLFIRINOX. After 3 courses of FOLFIRINOX, the primary lesion was kept well-controlled, but the solitary metastatic liver lesion was enlarged. An interdisciplinary team suggested surgical resection of the liver metastasis to control disease progress. We performed laparoscopic lateral segmentectomy of the liver. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. The patient underwent another round of gemcitabine therapy owing to the good response of the primary pancreatic lesion to this drug. Three years after starting the first-line chemotherapy, the patient is still alive with well-controlled PDAC without distant metastasis. Surgical intervention for liver metastases may be a promising treatment option when unresectable primary PDAC is well controlled by chemotherapy.