[Two Cases of Transfusion-Free Hepatectomy Following Chemotherapy for H3 Grade of Simultaneous Liver Metastases].

We report 2 cases of transfusion-free treatment for H3 grade of simultaneous liver metastases of the colon which were treated with the chemotherapy followed by R0 liver resection. Case 1 was a 67-year-old woman bearing ascending colon cancer and a metastatic mass occupying the left lobe of the liver with 160 mm in diameter. Laparoscopic ileocecal resection and 30-day left hepatectomy were performed after the 7 courses of FOLFOX plus bevacizumab(BEV). Case 2 was a 72- year-old woman bearing transverse colon cancer with more than 10 foci of liver metastases ranging from 21 mm to 100 mm in diameter. After the transverse colon resection and 12 months of chemotherapy from FOLFOX plus BEV to FOLFIRI plus panitumumab, partial liver resection was performed for each of size-reduced foci. In both patients who declined blood transfusion, optimization of red cells and autologous transfusion with hemodilution contributed to the safe liver resection with no postoperative complications.

[A Case of Ascending Colon Cancer Metastasis to Right External Iliac Lymph Nodes].

We report a rare case of postoperative ascending colon cancer metastasis to the right external iliac lymph nodes. A 57- year-old woman underwent a laparoscopic right colectomy and D3 lymph node dissection. Pathological findings indicated a Stage Ⅲb, pT4aN1bM0 cancer. Because side effects were observed on adjuvant chemotherapy with FOLFOX, she was switched to S-1 administration every other week. Sixteen months postoperatively, right inguinal pain and elevated CEA values were noted. CT revealed two swollen right external iliac nodes with high FDG uptake on PET-CT. With the diagnosis of lymph node metastasis, an open celiotomy was performed to remove the lymph nodes. Pathological findings confirmed lymph node recurrence of ascending colon cancer. Postoperatively, her CEA values were normal and no recurrence was noted. This rare occurrence highlights the importance of examining adjacent lymph nodes for possible tumor recurrence. We report this case with the necessary literature review.

[Laparoscopic Total Gastrectomy for Jehovah's Witness Gastric Cancer Patient after Preoperative Blood Augmentation].

An 80-year-old female of Jehovah's Witness with anemia was diagnosed with advanced gastric cancer(cT4aN2M0, stage ⅢA). The first value of Hb at the clinic was 7.5 g/dL that made it difficult to perform total gastrectomy in safe. The treatment of blood augmentation included the administration of intravenous iron and oral intake of vitamins in the earlier period. The number of hemoglobin was not optimized sufficiently in the first 10 days, that necessitated administration of erythropoietin( ESPO® INJECTION: 24,000 unit×2 times). Hb value increased in 11.6 g/dL 34 days after the treatment, that enabled laparoscopic total gastrectomy to be performed. The tumor infiltrated left crus of diaphragm. The patient was discharged in 16th postoperative day with Hb value of 10.1 g/dL without any complications. Pathological findings showed pT4b(crus) N2M0, stage ⅢB. Preoperative blood augmentation benefited the patients with anemia who decline allogenic blood transfusion. Anemia with malignant tumors is associated with not only iron deficiency due to the chronic bleeding but also functional deficiency or iron sequestration due to malignant itself, inflammation and infection. Erythropoiesis along with infusion of iron contributed to the optimization of Hb value that ensure performing total gastrectomy in safe.

[A Case of Biliary Neuroendocrine Tumor with Neo Adjuvant Chemotherapy].

A 65-year-old man was diagnosed with biliary carcinoma. Abdominal CT showed a tumor at the inferior bile duct. Tumor cells with small cell carcinoma were confirmed with biopsy of ERCP. Although the tumor seemed to be resectable, ERCP caused pancreatitis. We decided to perform surgery after the pancreatitis had healed to initiate neoadjuvant chemotherapy. According to the guideline of pancreatic NET(G3), we adopted the regimen of CDDP plus VP-16. After 2 courses, CT revealed that there were no changes in tumor size and that the pancreatitis was healing. We then performed pancreatoduodenectomy. Histological examination of the specimen demonstrated small cell NEC of the bile duct. Five months after the operation, multiple liver metastases manifested, leading to liver failure and death. NEC of the bile duct is known to be a highly malignant tumor with a poor prognosis. Further evaluation is needed to elucidate optimal therapy for biliary NEC.

[A Successful Case of Locally Advanced Pancreatic Cancer Undergoing Curative Total Pancreatectomy after Chemotherapy].

A 68-year-old man with jaundice was diagnosed with pancreatic cancer. The tumor seemed to invade the portal vein, the common hepatic artery, and the splenic artery plexus. The initial diagnosis was unresectable pancreatic cancer. The patient was treated with gemcitabine plus nab-paclitaxel therapy. The tumor reduced in size, and invasion of the main vessels was alleviated after 3 courses. Therefore, we performed total pancreatectomywith total gastrectomy. Histopathological findings showed pancreatic adenocarcinoma, T4(PV)N2M0, fStage Ⅳb, R0. There are reports of curative resection for unresectable pancreatic cancer after chemotherapy. However, the majorityof these reports were about pancreatoduodenectomyor distal pancreatectomy. We present a rare case of curative total pancreatectomy after chemotherapy.

[A Case of HER2-Positive Advanced Gastric Cancer with a Pathological Complete Response to Conversion Chemotherapy with S-1 plus Oxaliplatin plus Trastuzumab].

A 71-year-old female, with nausea, was diagnosed with type 2 advanced gastric cancer in cardia. Examinations revealed cStage Ⅳ of cT4aN2M1 with paraaortic lymph node metastasis. S-1 plus oxaliplatin plus trastuzumab was performed for 6 courses. Because of adverse events, S-1 plus trastuzumab for 4 courses was followed. After that treatment, the primary tumor as well as metastatic lymph nodes were shown with marked reduction in size by CT scan, which enabled total gastrectomy with D2 plus paraaortic lymphadenectomy to be performed as a curative resection. The surgical specimen revealed pathological CR.

[A Successful Treatment for Stage III c Gastric Cancer with Low Cardiac Function Using S-1 plus Oxaliplatin(SOX)as a Neoadjuvant Chemotherapy].

A 83-year-old female, with oppression in her chest, was subjected to type 2 advanced gasteric cancer in esophagogastric junction. Examinations revealed Stage III c of cT4, cN2, cM0. For adopting neoadjuvant chemotherapy, S-1 plus CDDP was not on the list, but S-1 plus oxaliplatin (SOX) was, because massive load of infusion along with the chemotherapy was not appropriate for the patient with low cardiac function. After 2 courses of SOX, the primary tumor as well as metastatic lymph nodes were shown with marked reduction in size by CT scan, which enabled total gastrectomy with D2 lymphadenectomy to be performed as a curative resection, leading to patient living with no recurrence more than 3 years. SOX was considered as one of safe neoadjuvant agent for gastric cancer combined with low cardiac function.

[A Case of Locally Far-Advanced Colon Cancer Resected by Laparoscopic Surgery after Colonic Stent Insertion and Neoadjuvant Chemotherapy].

We report a case of locally far-advanced colon cancer resected by laparoscopic surgery after colonic stent insertion and neoadjuvant chemotherapy. A 71-year-old man with obstructive symptoms was admitted to our hospital in July 2015. CT revealed a sigmoid colon tumor infiltrating the retroperitoneum and small intestine. Lower gastrointestinal endoscopy showed a sigmoid colon cancer. Self-expandable metallic stent insertion for obstructive colon cancer alleviated the patient's symptoms quickly. Four courses of neoadjuvant chemotherapy(XELOX)reduced the primary tumor in size, allowing for laparoscopic surgical resection. Combination therapy with colonic stenting and neoadjuvant chemotherapy can be an effective treatment for obstructive colon cancer. However, further studies and additional cases are needed to assess the safety and efficacy of this combination therapy.

[Four Cases of Primary Small Intestinal Cancer].

Primary small intestinal cancer is very rare. We experienced 4 cases from 2001 to 2013. Case 1: A 46-year-old man presented with abdominal pain and melena. Computed tomography (CT) revealed a tumor in the jejunum. We performed partial resection and lymph node dissection. The histological examination confirmed the diagnosis of moderately differentiated adenocarcinoma, SEN0H0P0M0. He has been recurrence-free for 13 years. Case 2: An 84-year-old woman presented with abdominal pain and vomiting. Gastroscopy showed a tumor in the upper jejunum, and she was diagnosed with adenocarcinoma. Postoperative diagnosis was SEN0H0P0M0. She has been alive for 7 years. Case 3: A 66-year-old woman presented with epigastric discomfort and back pain. Examinations confirmed poorly differentiated small intestinal adenocarcinoma with multiple liver and lymph node metastases. She refused chemotherapy and died 1 month later. Case 4: A 60-year-old man presented with abdominal pain and vomiting. CT revealed a tumor in the jejunum. Gastroscopic biopsy led to a diagnosis of poorly differentiated adenocarcinoma. We performed partial resection but there was extensive lymph node metastasis and peritoneal dissemination (cSIN2H0P3M1) so curative resection was impossible. Two courses of chemotherapy with S-1 and CDDP were administered. However, chemotherapy was not effective. He died 3.5 months after the first operation. Based on 2 of our cases, the prognosis for primary small intestine adenocarcinoma with lymph node metastasis or peritoneal dissemination was poor, with survival of less than 6 months. However, N0 cases without peritoneal dissemination can achieve long-term survival with curative resection. We report these cases with a review of previously reported cases in the literature.

[New FP Therapy Was Effective for a Case of Massive Hepatocellular Carcinoma].

A 62 year-old woman was hospitalized with the diagnosis of pneumonia, and a huge mass was recognized in the right lobe of the liver during a CT scan. AFP and PIVKA-Ⅱ were elevated to 101.05 ng/mL and 2,177 mAU/mL. The liver function test indicated Child-Pugh classification A, liver damage degree B, and ICG R15 34%. We judged a radical cure resection impossible. We treated the patient with arterial injections of modified new FP therapy. No side effect occurred during the first course. Liver dysfunction with fever and hematuria occurred during the second course, leading to discontinuation of therapy. Because a prominent reduction in the size of the tumor was achieved, liver resection is scheduled. New FP therapy can be expected to attain a favorable result that may allow for curative resection of the tumor.

[A Case of Locally Advanced Gastric Cancer after Neoadjuvant Chemotherapy].

A 60s male was admitted to our hospital because of appetite loss and nausea. After examination, he was diagnosed with type 3 advanced gastric cancer in the antrum. Abdominal computed tomography showed gastric cancer invasion to the left liver lobe. We initiated neoadjuvant chemotherapy using S-1 plus CDDP after laparoscopic gastrojejunostomy. S-1 was orally administered for 3 weeks followed by a 2-week drug-free period. CDDP was administered intravenously on day 8 of each course. After 5 courses of chemotherapy, the gastric cancer was reduced in size. We therefore performed total gastrectomy with D2-affiliated left liver resection. S-1 plus CDDP is expected to improve outcomes in unresectable or locally advanced gastric cancer.

[Retrospective study on the effect of weekend admission for the treatment of the spontaneous pneumothorax].

Our aim is to evaluate whether outcomes differ by admission day of the week in patients with spontaneous pneumothorax. One hundred twenty five patients undergoing video-assisted thoracic surgery(VATS) in Fukuoka Tokusyukai Hospital from 2007 through 2011 for spontaneous pneumothorax were reviewed. The clinical characteristics and outcomes were compared between patients in weekend admission and weekday admission groups. Patients were divided in 2 groups based on admission between Monday thru Friday vs on Saturday or Sunday. Another 2 groups by admission between Sunday thru Thursday vs on Friday or Saturday were also examined. Time to operation was significantly shorter for admission on period between Sunday thru Thursday compared to admission on Friday or Saturday. But there was no difference in the other clinical factors and postoperative outcomes between 2 groups. Patients admitted on the weekend proved to experience delayed operation, but did not have increased adverse outcomes or longer length of hospital stay compared to those admitted on a weekday. No significant "weekend effect" for spontaneous pneumothorax was demonstrated by the present study.

[A case of carcinoma arising in a diverticulum of the transverse colon].

A 64 year-old woman presented with advanced, transverse colon cancer arising in the diverticulum. Tumor invasion extended beyond the serosa to the anal side of the colon. Anemia and fatigue progressed after 6 months of iron administration. The hemoglobin value was 5.3 g/dL and carcinoembryonic antigen (CEA) level was elevated to 44.2 ng/mL. A palpable and tender fist-sized mass was found in the right upper abdomen. Computed tomography (CT) revealed a low-density mass in the transverse colon invading beyond the serosa to the anal side of the colon. Right hemi-colectomy with lymph node dissection was performed. The resected specimen contained multiple diverticula including the one from which the tumor arose. Histological examination revealed a well-differentiated, tubular adenocarcinoma (UICC TNM T4bN0M0) arising in a transverse colon diverticulum. There has been no recurrence for 2 years. Colon cancer arising in a diverticulum may expand to the extra-serosa and easily invade to the adjacent organ. In such cases, malignancy should be considered.

[A case of juvenile colon cancer with peritoneal dissemination treated effectively by use of resection and chemotherapy].

A 37 -year-old man experienced abdominal pain and vomiting. Computed tomography showed massive ascites and obstruction of the colon by a tumor at the left colic flexure. The tumor was classified as advanced Borrmann type 3 on the basis of a colonoscopy. Palliative resection of the colon and colostomy on the oral side were performed. Operative findings showed massive peritoneal dissemination of the tumor. We administered palliative chemotherapy consisting of capecitabine/oxaliplatin (XELOX) and bevacizumab. After 4 courses of chemotherapy, the primary and disseminated tumors and ascites had disappeared, and tumor marker expression levels were within normal range. Palliative resection and subsequent chemotherapy was effective for this young patient with very advanced colon cancer that had disseminated and caused obstruction.

[A case of small intestinal gastrointestinal stromal tumor (GIST) with peritoneal dissemination, treated effectively with molecular target drug after operation].

A 54-year-old man, presenting with sudden onset of abdominal pain, was admitted to our hospital. Blood examination revealed high white blood cell counts and elevated C-reactive protein (CRP) levels. Ultrasonography and computed tomography detected a 12 cm mass in the lower abdomen, some ascites, and multiple small nodules spread through the abdomen. The preoperative diagnosis of the tumor was either a gastrointestinal stromal tumor (GIST) or a possible lymphoma. The 12 cm tumor and greater omentum with multiple nodules were resected. Upon pathological examination, the tumor was diagnosed as a GIST, and appeared KIT positive by immunostaining. After the operation, imatinib was administered; however, psoriasis vulgaris developed within 5 months. As the next line of therapy, sunitinib treatment was initiated; however, since peripheral nerve disorder developed, sunitinib dose was halved and maintained. Two years after the operation, the patient is still alive. Small intestinal GISTs, which make up only 20-30% of all GISTs, are considered to be more malignant than others. We report a rare case of GIST with peritoneal metastases originating from the small intestine, which was treated effectively with molecular target drugs.

[Large bowel malignant obstruction treated with SEMS placement as a bridge to surgery procedure].

We treated 5 cases of preoperative decompression using the self-expandable metallic stent (SEMS) against obstructive left side colon cancer since October 2013. The obstruction site was the descending colon in one patient, sigmoid colon in 2, rectal-sigmoid colon in 1, and rectum in 1. Colonic stent placements were successful in all cases. Oral intake started an average of 3.7 days after SEMS placement. All patients underwent radical surgery an average of 17.2 days after SEMS placement. Two patients waited for surgery while out of the hospital. All patients underwent colonoscopy. One patient had advanced colon cancer. Our findings show that SEMS placement can treat obstructive left-sided colon cancer.

Development of a novel controllable, multidirectional, reusable metallic port with a wide working space.

BACKGROUND: Endoscopic surgery is currently a standard procedure in many countries. Furthermore, conventional four-port laparoscopic cholecystectomy is developing into a single-port procedure. However, in many developing countries, disposable medical products are expensive and adequate medical waste disposable facilities are absent. Advanced medical treatments such as laparoscopic or single-port surgeries are not readily available in many areas of developing countries, and there are often no other sterilization methods besides autoclaving. Moreover, existing reusable metallic ports are impractical and are thus not widely used. MATERIAL AND METHODS: We developed a novel controllable, multidirectional single-port device that can be autoclaved, and with a wide working space, which was employed in five patients. RESULTS: In all patients, laparoscopic cholecystectomy was accomplished without complications. CONCLUSION: Our device facilitates single-port surgery in areas of the world with limited sterilization methods and offers a novel alternative to conventional tools for creating a smaller incision, decrease postoperative pain, and improve cosmesis. This novel device can also lower the cost of medical treatment and offers a promising tool for major surgeries requiring a wide working space.

[A case of delayed subcutaneous metastases of gastric carcinoma effectively treated with S-1 plus cisplatin chemotherapy].

We encountered a case of delayed subcutaneous metastases of gastric carcinoma. The patient underwent distal gastrectomy for advanced gastric carcinoma 11 years ago. Postoperative pathological diagnosis indicated stage IIIB disease, poorly differentiated adenocarcinoma (scirrhous, T4a, ly2, v2, N2, H0, P0). Three courses of adjuvant chemotherapy with 5-fluorouracil (5-FU)+cisplatin (CDDP) were administered; however, the patient discontinued the treatment. No signs of recurrence were observed for 11 years after the treatment. However, subcutaneous metastases in the front portion of the head and the back and an ovarian tumor were detected after the remission period. The specimen from the resected subcutaneous tumor from the back indicated signet-ring cell carcinoma, and delayed subcutaneous and ovarian metastases of the gastric carcinoma was diagnosed. Therefore, 8 courses of the S-1+CDDP combination therapy were administered. The cutaneous metastases disappeared, but the ovarian tumor progressed and was therefore resected. Analysis of the resected ovarian tumor also indicated signet-ring cell carcinoma. We report a case of delayed recurrence of gastric carcinoma that was effectively treated with chemotherapy.

[A case of solitary ectopic medullary carcinoma in the right submandibular region].

A 77-year-old woman consulted our hospital because of an indolent mass in the right submandibular region, which developed approximately 4 months previously. Ultrasonography revealed a 19.5×9.2 mm homogeneous low echoic mass in the submandibular region and a 9.8×3.1 mm low echoic mass in the left thyroid lobe. Blood examinations revealed high levels of carcinoembryonic antigen (CEA) and calcitonin. Analysis of the cytological specimens obtained from the submandibular tumors indicated class IV disease. First, we resected the mandibular tumor for diagnosis, and the specimen showed medullary carcinoma. Later, the patient underwent left thyroid lobe resection. The pathological diagnosis was adenomatous goiter. We report a rare case of ectopic medullary carcinoma in the right mandibular region.

Pancreatic injury in children: review of 7 cases and the pertinent literature.

BACKGROUND/AIMS: Treatment of blunt injury of the pancreas in children remains controversial. Some prefer non-surgical treatment, whereas others prefer surgical management in selected cases. This report reviews our management strategies of children with blunt pancreatic trauma and their outcomes. METHODOLOGY: Medical records of 7 children with traumatic pancreatic injury were retrospectively analyzed in our institutions. In addition, we reviewed the pertinent literature. RESULTS: There were 2 males and 5 females with a median age of 7.6 years. Pancreatic injury was classified in 3 patients as grade I, in 2 patients as grade II, and in 2 patients as grade III (AAST). The two grade III children underwent ERCP preoperatively. ERCP showed injury to the main pancreatic duct in both of these patients, and emergency surgery was performed for both of them. These operative methods were spleen-preserving distal pancreatectomy and only drainage at the margin of the pancreas with non-resection, respectively. All 7 cases survived. CONCLUSIONS: ERCP is helpful for the diagnosis of suspected cases in pancreatic injury with grade III. In hemorrhagic shock state, appropriate surgical procedures with only drainage at the margin of the pancreas are useful for the treatment of pancreatic fistula in children.