[A Case of Submucosal Invasion(SM2)Gastric Cancer with Peritoneal Dissemination Three Years after Surgery].

The patient is a 90-year-old man. Three years and 3 months after laparoscopic distal gastrectomy for early gastric cancer, pT1b(SM2)pN1M0, Stage Ⅰ, the patient visited our hospital with abdominal pain, and a large amount of ascites and stenosis of transverse colon were pointed out. He underwent a right hemicolectomy under laparotomy. Histopathologically, it was diagnosed as peritoneal recurrence of previous gastric cancer. Postoperatively, he died of aspiration pneumonia. As for the cause of death after surgery of early gastric cancer, there are many causes of death from other diseases and few from primary malignancy. Furthermore, recurrence of peritoneal dissemination is extremely rare and considered to be a valuable case.

[Association between the Preoperative Nutritional Index and Postoperative Complications/Prognosis in Older Adults with Gastric Cancer Who Have Undergone a Gastrectomy].

We analyzed the relationship between preoperative nutritional indices and postoperative complications/prognoses in patients with pStage Ⅰ and Ⅱ gastric cancer aged ≥75 years who had undergone gastrectomy in our hospital. Between January 2012 and March 2021, a total of 79 cases of pStage Ⅰ and Ⅱ gastric cancer were examined in individuals aged ≥75 years who had undergone gastrectomy. We investigated the correlation between short- and long-term outcomes and the nutritional index. CONUT, GPS, and GNRI were employed as indicators of nutritional status. CONUT and GPS showed associations with postoperative complications and an extended postoperative hospital stay, whereas GNRI did not exhibit such associations. Among the patients, 7 deaths were attributed to primary diseases, whereas 16 deaths were attributed to other diseases. No correlation was found between survival rate and preoperative nutritional status. Conclusions: There were minimal cancer recurrences among older adults with gastric cancer who had undergone gastrectomy. Although preoperative nutritional status was associated with postoperative complications, it did not show an association with prognosis.

[A Case of Perforation at the Stump of Descending Colon after Hartmann's Operation Performed after Transverse Colostomy].

A 77-year-old man with complaining of anemia and abdominal pain was admitted to our hospital. An abdominal computed tomography showed the sigmoid colon tumor with bowel obstruction. Laparoscopic transverse colostomy was performed to release intestinal obstruction. After first operation, he was diagnosed the sigmoid colon cancer: cT4b(bladder), cN0, cM0, and cStage Ⅱc. Radical laparoscopic operation(Hartmann's operation)was performed. On the 4th postoperative day, fecal juice was discharged from the abdominal drain placed in the Douglas fossa, so emergency laparotomy was performed. The intraoperative findings showed perforation in the blind end of the descending colon. The descending colon was resected from a site approximately 5 cm anal side of the transverse colostomy to the blind end. It was thought that perforation occurred due to an increase in internal pressure in the residual intestinal tract after Hartmann's surgery without blood flow disorder. We believe that further attention is required to the management of residual intestinal tract at the blind end for the obstructive colorectal cancer.

[Small Bowel Obstruction Due to Internal Hernia Caused by the Vermiform Appendix, Mesentery of the Small Intestines, and Greater Omentum in a Patient with No History of Abdominal Surgery].

Our patient was a 69-year-old man being treated for hyperlipidemia. He was admitted to our hospital with the chief complaint of vomiting and abdominal pain. Abdominal computed tomography(CT)showed dilation of the distal small intestines, a small amount of ascites in the small intestines near the right pelvis, and a closed loop of the small intestine. Enhanced abdominal CT was performed to evaluate intestinal ischemia. Given the adequate blood flow to the wall, the small intestines forming the closed loop, and no increase in ascites, the patient was treated conservatively. Diagnostic laparoscopy was performed because of the narrowed lumen and incomplete obstruction observed on the abdominal CT and contrast- enhanced imaging of the ileal tube. The tip of the appendix adherent to the mesentery of the small intestines, approximately 80 cm from the ileum, and the omentum adherent to the bottom of the right pelvis caused the obstruction. A cord dissection and appendectomy were performed. Making the diagnosis was difficult because there was no history of appendicitis and the small intestinal obstruction was caused by adhesions in 2 places with no history of laparotomy.

[Surgical Outcomes of the Patients with Gastric Cancer in Aged 85 and Older at Our Hospital].

We investigated the surgical outcomes of the patients with gastric cancer in aged 85 and older. There were 9 males and 8 females, with a median age of 86 years. All had comorbidities and 7 had double cancers. Type of surgery was distal gastrectomy in 14 and total gastrectomy in 3, respectively. Postoperative complications occurred in 8 cases, and case with adhesion ileus or mesenteric bleeding performed reoperation. The postoperative hospital stay was 15 days. The cause of death was recurrent diseases in 2 cases and other diseases in 4. The overall survival rate was 63.9% for 3 years and 42.6% for 5 years, respectively. Elderly patients with gastric cancer may be increase in Japan, but they have large individual differences about tolerance of surgical intervention. Therefore, it is important to evaluate the detail of general condition in such patients.

Anastomosis behind the sternoclavicular joint is associated with increased incidence of anastomotic stenosis in retrosternal reconstruction with a gastric conduit after esophagectomy.

Anastomotic stenosis after esophagectomy is a major cause of long-term morbidity because it leads to poor dietary intake and malnutrition that markedly reduces the quality of life. The aim of this study was to test the hypothesis that anastomosis behind the sternoclavicular (SC) joint in retrosternal reconstruction is associated with an increased risk of anastomotic stenosis compared with anastomosis deviated from the joint. Among 226 patients who underwent esophagectomy for esophageal cancer between April 2010 and March 2019, we selected 114 patients who underwent retrosternal reconstruction using a gastric conduit for this study. They were classified into two groups according to the location of the anastomosis as determined by axial sections on postoperative computed tomography scans: anastomosis located behind the SC joint (Group B; n = 71) and anastomosis deviated from the joint (Group D; n = 43). The primary endpoint was the difference in the incidence of anastomotic stenosis between the two groups. Whether the occurrence of anastomotic leak affected the likelihood of anastomotic stenosis was also investigated. The incidence of anastomotic stenosis was significantly higher in Group B than in Group D (71.8% [n = 51] vs. 18.6% [n = 8]; P < 0.0001). The incidence of stenosis in patients who developed an anastomotic leak was significantly higher in Group B than in Group D (88.0% vs. 41.7%; P = 0.0057), although the findings were similar in patients who did not develop anastomotic leak (63.0% and 9.7%, respectively; P < 0.0001). We conclude that anastomosis located behind the SC joint in retrosternal reconstruction with a gastric conduit after esophagectomy is associated with an increased risk of anastomotic stenosis regardless of the development of anastomotic leak.

[A Case Report of an Appendiceal Goblet Cell Carcinoid].

A 56-year-old woman complaining of right lower abdominal pain was admitted to our hospital. An abdominal computed tomography showed the enlarged appendix tip and a high density area around the appendix to retroperitoneum. The patient was diagnosis with acute appendicitis and underwent emergency laparoscopic appendectomy. Histopathological findings of the resected specimens revealed a component with signet ring cell carcinoma morphology that was positive for neuroendocrine markers by immunohistochemical staining, which led to the diagnosis of goblet cell carcinoid(GCC)of appendix. GCC cells were found to infiltrate the surrounding serosa and Ly positive. An additional laparoscopic ileocecal resection with D3 dissection was performed. In the appendix GCC, additional resection is considered because the lymph node metastasis rate increases(SS/13%)as the depth of wall progresses. Appendiceal tumors including GCC may develop acute appendicitis and may be followed by additional resection. Therefore, it is important to consider how to deal with the first surgery.

[A Case of Multiple Small Bowel GIST Complicated with von Recklinghausen's Disease].

The case was a 55-year-old woman. She have been pointed out von Recklinghausen's disease for several years. She was referred to our hospital due to multiple abdominal tumor and severe anemia. Enhanced CT examination revealed multiple intraabdominal tumors with central necrosis. The tumors diagnosed mesenchymal tumors associated with von Recklinghausen's disease, and tumor resection was indicated under laparotomy. Tumors were resected together with small and large bowel. The tumor in the pelvic space was resected together with the uterus and right ureter. She was discharged without any postoperative complications at 15 days after the operation. Because immunostaining was positive for CD34, c-kit and DOG1 and Ki-67-positive cells were 18%, the tumors were diagnosed with high-risk GIST for small bowel.

[Outcomes of Salvage Thoracoscopic Esophagectomy after Definitive Radiochemotherapy for Clinical Stage â £a Esophageal Cancer].

We investigated the clinical outcomes of salvage thoracoscopic esophagectomy for residual or recurrent cases after radical radiochemotherapy for cStage Ⅳa esophageal cancer. Thoracic procedure was started thoracoscopically in all cases, but converted to thoracotomy in 2 cases. The operation time was 315 minutes and the blood loss was 300 mL. Lymph node metastasis was diagnosed in 5 cases, and 2 cases were finished in R1or 2. Nine cases died of recurrence and 1 case died of pneumonia. The 2-year and 5-year survival rates(OS)of all cases were 46.1% and 28.3%, respectively. R1,2 cases and pN+ cases had significantly poor prognosis. Surgical treatment after radical radiochemotherapy for cStage Ⅳa esophageal cancer can be safely performed thoracoscopically. If R0 is not obtained, the long-term prognosis cannot be expected, and selection of R0 resectable cases is important.

[Clinical Outcomes of Recurrent Diseases after Esophagectomy According to Time of Recurrence].

We analyzed retrospectively the difference in treatment selection and prognosis according to timing of recurrence after radical resection of esophageal cancer. Of 190 patients who underwent radical esophagectomy for esophageal cancer from April 2010 to December 2017, 56 patients(29.5%)had recurrent diseases during the postoperative periods. These cases were divided into 27 cases with recurrence diagnosed less than 180 days after initial surgery(Group A)and 29 cases with recurrence diagnosed more than 180 days(Group B). Although there was no difference in the pathological staging, preoperative treatment, and type of recurrence between the 2 groups, there were significantly more cases with symptomatic recurrence in Group A. Surgical intervention was possible in 1 case in Group A and 10 cases in Group B, respectively. There was significantly more in Group B. Second-line treatment was possible in only 5 cases in Group B. Survival after recurrence was tend to have better in Group B. There are few cases who indicated surgical intervention and second-line treatment in early recurrence cases after radical esophagectomy for esophageal cancer, and the prognosis is poor in such cases.

Clinical and pathological features of sarcopenia-related indices in patients with non-alcoholic fatty liver disease.

BACKGROUND: Sarcopenia is diagnosed with the skeletal muscle index (SMI) or the sarcopenia index (SI). We previously reported that the ratio of skeletal muscle mass to body fat mass (SF ratio) was a novel index of sarcopenia in patients with non-alcoholic fatty liver disease (NAFLD). The aim of this retrospective study was to evaluate sarcopenia with these indices in patients with NAFLD. METHODS: One hundred and fifty-six consecutive patients with biopsy-proven NAFLD and alanine aminotransferase (ALT) >40 IU/L were enrolled. Liver function and body composition were evaluated in 121 patients after 12 months. We evaluated the relationship between histological findings, changes in liver function, and the SMI, SI, and SF ratio. RESULTS: Of the 156 patients enrolled, 13.5% and 26.3% were diagnosed with sarcopenia with the SMI and SI. In patients with hepatic fibrosis stage <2, the SI and the SF ratio were significantly greater than in patients with fibrosis stage ≥2. There was no difference in SMI between groups. In the cohort assessed at baseline and 12 months later, transaminase activity and SMI decreased significantly, and the SF ratio increased over time. A multivariate analysis revealed the presence of the PNPLA3 G allele and an increase in SF ratio (odds ratio, 7.406) as predictive factors of ALT reduction >30% from baseline. CONCLUSIONS: Due to the high prevalence of obesity, we should consider both skeletal muscle mass and body fat mass in the diagnosis and treatment of NAFLD. The SF ratio could be a useful index in sarcopenic NAFLD.

Presence of varices in patients after hepatitis C virus eradication predicts deterioration in the FIB-4 index.

AIMS: The liver function of patients with hepatitis C virus (HCV) infection who obtained sustained virologic response (SVR) has been known to improve after HCV eradication. However, a predictor of liver function after SVR has not been definitively identified. The aim of this retrospective study was to identify a predictor of deteriorated liver function and Fibrosis-4 (FIB-4) index after SVR was achieved by direct-acting antiviral (DAA) treatment. METHODS: This study retrospectively enrolled 248 patients who obtained SVR by DAA treatment. None of the patients developed hepatocellular carcinoma during this study. Liver function was assessed at the end of treatment (EOT) and at 24, 48, 72, and 96 weeks after EOT. RESULTS: At 96 weeks after EOT, the serum aspartate aminotransferase and alanine aminotransferase levels were significantly decreased from those at EOT. The platelet count was significantly increased from 14.9 × 104 /µL at EOT to 17.1 × 104 /µL at 96 weeks after EOT. Ten patients showed an increased FIB-4 (>1.00) index. Multivariate analysis with 171 patients who underwent endoscopic assessment revealed that the presence of varices was an independent predictor of deterioration in the FIB-4 index (odds ratio, 5.56; P = 0.041). CONCLUSION: Most of the study patients who obtained SVR showed improved liver function after EOT. Patients without increasing platelet counts after SVR due to DAA therapy should be evaluated for complications induced by portal hypertension.

FIB-4 Index and Diabetes Mellitus Are Associated with Chronic Kidney Disease in Japanese Patients with Non-Alcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) is associated with chronic kidney disease (CKD). The aim of this retrospective study was to determine the risk factors for progression of CKD in patients with biopsy-proven NAFLD including patatin-like phospholipase domain containing 3 (PNPLA3) polymorphism. A total of 344 patients with biopsy-proven NAFLD were enrolled consecutively in this study. Multivariate analysis identified males (odds ratio (OR) 5.46), age (per 1 year, OR 1.07), and FIB-4 index (≥1.30, OR 3.85) as factors associated with CKD. Of the 154 patients with a baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min, 30 had a deterioration in CKD stage and 15 developed CKD after 3 years. Multivariate analysis identified diabetes mellitus (OR 2.44) as a risk factor for deterioration in CKD stage, while diabetes mellitus (OR 21.54) and baseline eGFR (per 1 mL/min OR 0.88) were risk factors for development of CKD. PNPLA3 did not affect the change in eGFR. In NAFLD patients, a high FIB-4 index was associated with CKD to increases in the index linked to reductions in eGFR. In order to prevent development of CKD, an appropriate therapy focusing on renal function is needed for NAFLD patients, especially those with diabetes.

Impact of Insufficient Response with an Increase in Tumor Number in Predicting Transcatheter Arterial Chemoembolization Refractoriness for Hepatocellular Carcinoma.

AIM: In Japan, transcatheter arterial chemoembolization (TACE) refractoriness for hepatocellular carcinoma has been defined as an insufficient therapeutic effect after ≥2 procedures. Insufficient TACE for intrahepatic lesions is defined as the presence of > 50% viable lesions (ineffective) or an increase in their number (progressive). This study aimed to examine the possibility of earlier evaluation of TACE refractoriness. METHODS: Patients who underwent TACE for hepatocellular carcinomas > 3 cm in size or with > 3 nodules at our hospital between 2010 and 2014 were analyzed. The cases assessed as TACE insufficient for the first time were divided into 2 groups: the "either" group, evaluated as either "ineffective" or "progressive," and the "both" group, that is, both "ineffective" and "progressive." RESULTS: The study participants included 40 of 212 consecutive patients who underwent TACE, divided into the either (n = 23) and both (n = 17) groups. Seventeen of 23 (73.9%) patients in the either group and all 17 (100%) in the both group had TACE refractoriness (p = 0.0295). CONCLUSIONS: Patients with both "ineffective" and "progressive" lesions are extremely likely to be TACE -refractory at a significantly higher frequency than are those with either condition. Thus, when both of these factors are observed, switching to other therapies should be considered.

Influence of incomplete neoadjuvant chemotherapy on esophageal carcinoma.

BACKGROUND: Neoadjuvant chemotherapy (NAC) involving two cycles of cisplatin plus fluorouracil is recommended in Japan as a standard treatment for resectable, locally advanced esophageal squamous cell carcinoma (ESCC). We have encountered patients who were administered incomplete chemotherapy because of adverse events or the patient's refusal of treatment. Here, we retrospectively investigated the influence on perioperative outcomes and long-term prognosis of patients with ESCC who underwent complete (two cycles) or incomplete (one cycle) NAC. METHODS: We retrospectively investigated 133 patients with locally advanced ESCC of the thoracic esophagus who underwent NAC. We compared the perioperative results and prognoses of patients who underwent complete or incomplete NAC because of adverse events or the patient's refusal of treatment. RESULTS: Of 133 patients, 37 patients did not receive the second cycle of NAC; the remaining 96 patients received the second cycle of NAC as scheduled. There were no significant differences in the clinical backgrounds, surgical results, or operative morbidity rates between the groups. Patients in both groups were similarly administered postoperative chemotherapy regimens. There was no significant difference in disease-free survival or overall survival. CONCLUSIONS: We suggest that perioperative outcomes and long-term prognosis of patients with locally advanced ESCC were not significantly influenced, even if the patients did not receive a complete cycle of NAC. When certain adverse events occur after the first cycle of NAC, we believe that it is nevertheless possible to discontinue chemotherapy.

[A Case of Recurrent Ascending Colon Cancer with Concomitant Dementia Successfully Treated with Chemotherapy].

A 72-year-old man with advanced dementia presented with a right lower abdominal painful mass, and on detailed examination and investigation, was diagnosed to have moderately differentiated circumferential tubular adenocarcinoma infiltrating the abdominal wall in the middle of the ascendingcolon. It was extremely painful, and there was also a risk of ileus if left untreated. Therefore, laparoscopic right hemicolectomy was performed. One year after surgery, examination revealed local recurrence. After consultation with family members, we started with chemotherapy, usingcapecitabine and bevacizumab. It is our policy to administer chemotherapy under adequate surveillance. Thus, outpatient chemotherapy was safely administered in a dementia patient with shrinkage of local recurrent lesions.

[Azygos Arch Preserving Thoracoscopic Esophagectomy for Less Invasiveness].

We reported the technique ofthoracoscopic esophagectomy with preservation ofazygos arch for less invasivenesss. Among thoracoscopic esophagectomy, this retchnique indicated for the patients with the tumor located at middle or lower thoracic and don't reach adventitia. Twenty-eight patients was performed this procedure and azygos arch were preserved in all cases. None the cases were converted conventional thoracotomy. The operation time was 133.5 minutes(median), and estimated blood loss was 30 mL(median)in thoracic procedure. As for thoracoscopic esophagectomy, could preserved respiratory function, further less surgical stress can obtain this technique.

Safety and feasibility of thoracoscopic esophagectomy after neoadjuvant chemotherapy for esophageal cancer.

PURPOSE: Neoadjuvant chemotherapy (NAC) with cisplatin and fluorouracil is the recommended standard treatment for resectable locally advanced esophageal cancer (EC) in Japan. We investigated the effects of NAC on the safety and feasibility of thoracoscopic esophagectomy with total mediastinal lymphadenectomy for EC. METHODS: This retrospective study analyzed data from 225 consecutive patients who underwent thoracoscopic esophagectomy with lymph node dissection between April 2007 and December 2015. Patients with clinical stage IB, IIA, IIB, IIIA, or IIIB EC, and no active concomitant malignancy were included. We compared intraoperative outcomes, and postoperative morbidity and mortality between patients who received NAC (n = 139; NAC group) and patients who did not (n = 86; non-NAC group). RESULTS: Preoperative laboratory data revealed that anemia, thrombopenia, and renal dysfunction were more common in the NAC group than in the non-NAC group. There were no differences between the groups in operating times, blood loss, number of dissected lymph nodes, overall complication rates, or length of postoperative hospital stay. CONCLUSION: Based on our findings, thoracoscopic esophagectomy is safe and effective for locally advanced EC, even after NAC.

[A Case of Uterine Body Metastasis from Sigmoid Colon Adenocarcinoma].

We report a case of metastatic carcinoma to the uterine body from a colorectal adenocarcinoma. A 73-year-old woman underwent laparoscopic sigmoidectomy for sigmoid colon carcinoma 2 years before. In the following study, her serum carcinoembryonic antigen level was elevated, and a uterine body tumor invading the rectal wall was detected via enhanced computed tomography. Colonoscopic examination revealed an elevated lesion at the rectum, which was diagnosed as an adenocarcinoma. Based on these results, we diagnosed the uterine tumor as metastatic tumor from the colon carcinoma. Immunostaining was negative for CK7, but positive for CK20. Thus, we confirmed metastasis of the sigmoid colon cancer to the uterus. Metastasis to the female genital tract from extragenital malignancies are rare, and the prognosis is extremely poor. However, some patients attain long-term survival by surgical intervention even in such cases.

[Treatment Outcomes and Prognosis of Patients with Recurrent Diseases after Esophagectomy for Esophageal Cancer].

We retrospectively analyzed the treatment outcomes of 52 patients with recurrent diseases after radical esophagectomy for esophagealcancer. Median time of diagnosis of recurrent diseases was 180 days after surgery, and 90.4%of allpatients were diagnosed with recurrent diseases within 2 years. Twenty-seven patients were diagnosed with single area recurrence, and the remaining 25 were diagnosed with complex recurrence. Among patients with single area recurrence, surgical intervention was indicated in 9, and chemoradiotherapy(CRT)was indicated in 14. Meanwhile, among patients with complex recurrence, surgicaltreatment was indicated in only 2 patients. Median survivaltime was 293 days in allpatients, 611 days in single area recurrence, and 148 days in complex recurrence. Among patients with single area recurrence, those treated with surgical intervention or CRT had significantly better survival than those who underwent other treatment modalities. Although the prognosis of the patients with recurrent diseases after esophagectomy was poor, the patients with single area recurrence or treated with local therapy were expected to survive longer than patients with complex recurrence or those treated with other modalities.