Safety of laparoscopic distal gastrectomy for gastric cancer when performed by trainee surgeons with little experience in performing open gastrectomy.

PURPOSE: This study aimed to evaluate the surgical outcomes and clinical safety of laparoscopic distal gastrectomy (LDG) when performed by trainee surgeons with little prior experience in performing open gastrectomy, under the guidance of trainer surgeons. METHODS: From January 2008 until March 2015, 17 trainee surgeons and 5 trainer surgeons performed LDGs to treat 371 patients with clinical stage T1-T3 gastric cancer. Of these patients, 140 and 231 underwent LDG performed by trainee surgeons and trainer surgeons, respectively. We retrospectively analyzed the surgical outcomes of the two groups. RESULTS: Trainee surgeons required significantly longer operation times than the trainer surgeons, with respective mean operation times of 262 and 223 min (p < 0.001). However, the mean blood loss volumes, average numbers of retrieved lymph nodes, postoperative complications, and postoperative hospital stay lengths did not differ significantly between LDGs performed by trainee surgeons and trainer surgeons. CONCLUSIONS: The study findings suggest that, under the guidance of trainer surgeons, trainee surgeons with little experience with open gastrectomy and even without prior experience with LDG can perform radical surgeries safely.

[A Case of Successful Management of Postoperative Chylous Ascites by Combination Therapy with Octreotide and Etilefrine].

We have report a case of an 81-year-old woman who underwent distal pancreatectomy for pancreatic body cancer. Chy- lous ascites with high triglyceride(TG)level, 201mg/dL, occurred on postoperative day 2. Continuous drainage and conservative management, such as low fat diet, fasting, total parental nutrition, and octreotide monotherapy, could not resolve the problem. Successful treatment was achieved using subcutaneous octreotide injection and intravenous etilefrine infusion without any adverse side-effect. These medications were able to cause smooth muscle contraction in the thoracic duct, and also to reduce chyle flow. The amount of drainage decreased and the TG level was restored to 66mg/dL. The drainage tube was removed on postoperative day 22, 5 days after the start of both octreotide and etilefrine. This combination therapy with octreotide and etilefrine would be one of effective and safety treatment for management of postoperative intractable chylous ascites.

[A Patient Underwent Pancreaticoduodenectomy with Reconstruction of Replaced Right Hepatic Artery].

A 78 year-old man was diagnosed as a pancreatic cancer in department of gastroenterology in our hospital. Enhanced computed tomography demonstrated an aberrant right hepatic artery(ARHA)arising from superior mesenteric artery(SMA). We conducted sub-stomach preserving pancreaticoduodenectomy(SSPPD- II A-1). As the preoperative diagnosis, right hepatic artery(RHA)was arising from SMA and running through the tumor, and we resected the ARHA with the tumor and reconstructed RHA to gastroduodenal artery(GDA). Pathological diagnosis was non invasive tumor with neither lymph node metastasis nor invasion of the vasculature. We report a case of the patient underwent pancreaticoduodenectomy with reconstruction of aberrant right hepatic artery.

[Two Cases of Hepatic Encephalopathy after Chemotherapy for Metastatic Colorectal Cancer].

We reported 2 cases of hepatic encephalopathy after chemotherapy for advanced colorectal cancer. Case 1: A 49-year-old male was diagnosed advanced sigmoid colon cancer with peritoneal dissemination, multiple liver metastasis and multiple osseous metastasis. After resection of primary lesion, we administered mFOLFOX6 plus bevacizumab combination therapy. He was in comatose(Japan coma scale 200)3 days after 2 courses of administration of this regimen. Case 2: A 57-year-old female was diagnosed advanced rectal cancer with multiple huge liver metastasis and multiple osseous metastasis. We administered mFOLFOX6 plus panitumumab combination therapy. She was in comatose(Japan coma scale 100)3 days after 10 courses of administration of this regimen. In both cases, radiographic imaging showed no abnormal sign and blood examination revealed a high level of serum ammonia. We diagnosed their disturbance of consciousness as a symptom of hepatic encephalopathy. Branched-chain amino acid infusion rapidly improved disturbance of consciousness. We must consider the symptom, hepatic encephalopathy in patients receiving chemotherapy for advanced colorectal cancer.

[A Resected Case of the Vaginal Metastasis from Rectal Cancer].

The vaginal metastasis from colorectal cancer has rarely been reported. Here, we report a resected case of the vaginal metastasis from rectal cancer. A 51-year-old woman underwent radical hysterectomy and bilateral oophorectomy for uterus cancer. Five years after the operation, vaginal tumor was observed during an internal examination. Biopsy was positive for adenocarcinoma. Enhanced computed tomography demonstrated the wall thickening of the lower rectum and the mass of 20 mm at the inferior lobe of the left lung. Colonoscopy revealed the wall thickening of the lower rectum, and biopsy indicated a diagnosis of rectal cancer. We performed abdominoperineal resection and partial resection of the vagina. Pathological examination confirmed the vaginal metastasis from the rectal cancer.

[Experiences of Colonic Stents in Patients with Colonic Stenosis Due to Peritoneal Dissemination of Gastric Cancer].

Stoma is a treatment option often adopted for large bowel obstruction accompanying peritoneal dissemination of gastric cancer, but the invasiveness of this intervention can be an issue for patients with limited prognosis and reduced quality of life. In our hospital, colonic stenting for bowel obstruction due to peritoneal dissemination from gastric cancer was performed for 7 consecutive patients. Oral ingestion became possible in 5 cases, and colonic stent was considered a useful treatment choice for appropriate cases.

[A Case of Unresectable Advanced Gastric Cancer Treated with Palliative Radiation Therapy for Massive Bleeding].

The patient was a 77-year-old man. He was diagnosed with Stage IV gastric cancer with pancreatic invasion and pyloric stenosis. After gastrojejunostomy, S-1 monotherapy was started. Melena and fatigue appeared 2 months after chemotherapy, and Grade 3 anemia was confirmed. Palliative radiotherapy of 30 Gy in 10 Fr was administered to control bleeding from the lesion. The progression of anemia stopped and outpatient chemotherapy became possible. Palliative radiotherapy for persistent bleeding from unresectable advanced gastric cancer is considered an effective treatment option to control bleeding.

[A Colorectal Cancer with Invasive Micropapillary Carcinoma].

A 76-year-old woman with bloody stool visited a nearby hospital. Colonoscopy showed a type 1 tumor in the rectum, and the biopsy indicated moderately differentiated adenocarcinoma. She was referred to our hospital. Abdominal contrast-enhanced CT did not show swollen lymph nodes in the regional nodes or distant metastases. Laparoscopic lower anterior resection was performed. Histopathological examination indicated pT1b, pN3, ly3, and v1, fStage III b, which had a partial invasive micropapillary carcinoma(IMPC)component of papillary adenocarcinoma. Although she received postoperative adjuvant chemotherapy, she died of a thromboembolism with paraneoplastic syndrome 20 months after the operation. IMPC has a high incidence of lymphatic invasion and lymph node metastases. IMPC is rare in cases of colorectal cancer and it is important to accumulate and investigate colorectal cancer patients with IMPC.

[A Case Report of Inguinal Malignant Lymphoma after Surgery for Hepatocellular Carcinoma].

An 81-year-old woman was followed up for hepatitis C from 1994. Sheh ad a previous history of hypertension and appendicitis. In October 2014, the patient underwent subsegmentectomy(S8)and cholecystectomy for hepatocellular carcinoma (HCC)(T2N0M0, Stage II ). From December 2015, the patient had taken ledipasvir-sofosbuvir orally for hepatitis C virus (HCV). In January 2016, we confirmed HCV-RNA shade transformation. In September 2016, enhanced CT showed a mass in theright lower quadrant of her abdomen. Shehad a hard 3 cm mass in thesameplaceon physical exam. PET-CT showed no significant abnormality except for the mass in the right lower quadrant of her abdomen. Therefore, we identified the differential diagnosis as a lymph node metastasis of HCC, an abdominal wall primary tumor, or a malignant lymphoma. We resected theinguinal malignant lymphoma to confirm thediagnosis. Examination of tissuefrom theinguinal malignant lymphoma indicated diffuselargeB -cell lymphoma. We report an interesting case of an inguinal malignant lymphoma in a patient with chronic HCV who had experienced hepatectomy.

[Anorectal Malignant Melanoma Is a Very Rare Disease and Has a Poor Prognosis].

We performed abdomino-perineal-resection(APR)on 2 cases of anorectal malignant melanoma. The first case was a 70- year-old woman suffering from bloody stool. Colonoscopy showed a black tumor in the rectum. Biopsy revealed a malignant melanoma. A CT scan showed multiple lung metastases and liver metastasis. She underwent surgery for the purpose of bleeding control, but died shortly thereafter because her liver and lung metastases had worsened. The second case was a 43- years-old man suffering from bloody stool. He had a black type 3 tumor in the rectum. A biopsy revealed malignant melanoma. A CT scan showed lateral lymph node swelling. He underwent APR with right side-lateral dissection. An established treatment for anorectal malignant melanoma has not been agreed upon and it is controversial. We experienced 2 cases that underwent surgery and we report them along with relevant information from the literature.

[Surgical Outcome of Palliative Surgery for Gastric Cancer Patients with Bowel Obstruction Due to Peritoneal Dissemination].

A retrospective cohort analysis was performed for 21 consecutive patients who underwent palliative surgery for bowel obstruction due to peritoneal metastasis from gastric cancer. Surgical site infection occurred in 5 of 21 patients, but there were no severe(Clavien-Dindo Grade III or higher)complications, and symptoms of bowel obstruction were improved in 20 of 21 patients. The median survival time was 6.6 months. The survival rate was significantly worse for patients in modified Glasgow prognostic score(mGPS)group D compared with those in mGPS group non-D(p=0.0001). Surgery for malignant bowel obstruction was feasible and effective for palliation.

[Treatment Experience with Sorafenib for Lung Metastases of Hepatocellular Carcinoma Complicated with Interstitial Pneumonia].

A 74-year-old man was diagnosed with hepatocellular carcinoma(HCC; S4/8)and underwent anterior segment resection of the liver in 2015. He was hospitalized with a wound infection 2 months after surgery. On the 8th hospital day he complained of respiratory discomfort. A CT showed multiple lung metastases and a ground-glass appearance in both lungs. We diagnosed interstitial pneumonia with metastatic lung tumors. Steroid therapy was performed for the interstitial pneumo- nia(prednisolone 1,000mg/day×3 days), and sorafenib therapy was initiated for the metastatic lung cancer(starting from 200mg/day to 800mg/day). The prednisolone improved his symptoms. The lung metastatic tumors shrunk by the 36th hospital day after the CT. However, he developed difficulty in breathing again on the 58th hospital day, and again showed a ground-glass appearance in both lungs by CT. We thought it was drug-induced interstitial pneumonia and we discontinued oral sorafenib. He underwent steroid pulse therapy, but his symptoms did not improve and he died.

[Clinical Experience with Nutrition and Anticoagulation Therapy for a Patient with a 30 cm Residual Jejunum].

Patients with short bowel syndrome experience malabsorption and digestive disorders. They are unable to maintain adequate nutrition by the oral or enteral route alone, and their requirements for liquids, electrolytes, nutrients, microelements, vitamins, etc., are not completely met. Managing the nutritional needs of these patients is important. Another concern is these patients' inability to absorb medication, because the small intestine that is shortened in short bowel syndrome is the principal site of drug absorption. Here, we report a case of a 74-year-old woman with a 30 cm residual jejunum after surgery for acute occlusion of the superior mesenteric artery and the clinical management of nutrition and anticoagulant medication in this patient.

[Endoscopic Stent Placement to Alleviate Afferent Loop Syndrome Following Recurrence of Pancreatic Cancer].

We report a case of endoscopic stent placement to alleviate afferent loop syndrome following recurrence of pancreatic cancer. A 73-year-old man who had undergone pancreatic duodenectomy with portal vein resection for pancreatic cancer had developed a local recurrence and was treated with chemotherapy. He developed a high-grade fever and general fatigue, and laboratory data revealed anemia and a high inflammatory reaction; therefore, he was admitted to our hospital. CT scans revealed intestinal stenosis and upper dilatation, known as afferent loop syndrome, caused by the recurrence. We safely implanted a metallic stent(non-covered Niti-S stent, Century Medical, Inc.)at the point of intestinal stenosis using a double balloon endoscope. As the stent was adequately expanded and the afferent loop syndrome was relieved, the patient was discharged with a better quality of life and there were no complications associated with the stent until he died 6 months later.

[A Case of Appendiceal Mucinous Cystadenoma Treated Using Laparoscopic Appendectomy].

A 73 year-old woman who was treated for breast cancer and visited our hospital regularly was suspected of having a mucinous cystadenoma of the appendix. Malignancy could not be determined using abdominal computed tomography, magnetic resonance imaging, or colonoscopy. Even if mucinous cystadenoma is benign, there is the possibility that the tumor will rupture, discharge its contents, and cause pseudomyxoma peritonei. We performed laparoscopic appendectomy. According to the histopathological results, the tumor was diagnosed as a low grade appendiceal mucinous neoplasm. We report a case of mucinous cystadenoma of the appendix treated using laparoscopy-assisted appendectomy and discuss the case with literature reviews.

[A Case of an Elderly Patient with Advanced Gastric Cancer Successfully Treated with Combination S-1 and Oxaliplatin Therapy].

The patient was an 80-year-old man. He had a chief complaint of epigastric pain. The upper gastrointestinal endoscopy showed a type 4 tumor of the stomach, and the CT scan showed multiple para-aortic lymph node metastases. The patient was diagnosed with cStage IV gastric cancer. At first, he could take only small amounts of liquid. After starting S-1 and oxaliplatin (SOX), he was able to resume a full diet and his general condition was improved. A CT scan after 4 courses of chemotherapy showed a significant reduction in the wall thickness of the stomach and the size of the lymph nodes. SOX chemotherapy could be a promising treatment option for elderly patients with advanced gastric cancer.

[Pathological Complete Response in a Case of Multiple Liver Metastases from Rectal Cancer Treated with XELOX plus Bevacizumab(Bev)Therapy].

The patient was a 56-year-old woman who had synchronous multiple liver metastases and underwent laparoscopic-assisted high anterior resection for rectal cancer. According to the Japanese classification of colorectal carcinoma(8th edition), the tumor was considered to be pStage IV (pT4bN2M1a[H3]). Following resection of the primary tumor, she received XELOX plus bevacizumab(Bev)therapy. After 5 courses, the tumors were markedly reduced in size. According to the RECIST criteria, the tumor response was determined to be a partial response(-44%). Therefore, on the basis of the morphologic response criteria, the patient had Group 1 disease. Because the chemotherapy seemed to be effective, we performed partial hepatectomies. Histologically, no cancer cells were detected in any of the resected tumors. After the partial hepatectomies, she received no additional chemotherapy. Her CEA levels decreased to a normal range and no tumor recurrence was detected over 2 and a half years. XELOX plus Bev therapy may be effective for unresectable multiple liver metastasis from rectal cancer.

[A Case of Metastatic Colorectal Cancer Refractory to Standard Chemotherapies Treated with TAS-102 with Bevacizumab].

A 51-year-oldwoman with lung, liver, andd istant lymph node metastases from sigmoidcolon cancer was treatedusing TAS-102 with bevacizumab as fourth-line chemotherapy. There was a 35%decrease in the size of target lesions after the first 4 cycles of therapy, and disease control has been maintained for 9 months. The only Grade 3 or worse adverse event experiencedwas neutropenia. In patients with refractory colorectal cancer, the combination of TAS-102 with bevacizumab might be an effective andsafe treatment.

[A Case of Multiple Pancreatic Metastases from Renal Cell Carcinoma Diagnosed Using EUS-FNA].

The patient was a 79-year-old man, who underwent left nephrectomy for left renal cell carcinoma in 2007. In March 2015, he complained ofthirst, polydipsia, and polyuria. A slight elevation ofamylase levels was detected following laboratory testing. Abdominal CT revealed well-enhanced tumors in the pancreatic head and tail. MPD was dilated in the pancreatic body and tail. Endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA)was used to obtain additional pathological findings. We diagnosed multiple pancreatic metastases from renal cell carcinoma using cell block sections from EUS-FNA ofthe pancreatic head tumor. We also identified worsening of diabetes control due to pancreatic disease. A subtotal stomachsparing pancreaticoduodenectomy and a distal pancreatectomy were performed in June 2015. Histological examination confirmed clear cell carcinoma metastases from RCC in both tumors. The patient remains alive without recurrence approximately 1 year after surgery. Glycemic control has improved with a decrease in insulin levels. Cell block sections from EUS-FNA are useful in the diagnosis of pancreatic disease. Although postoperative follow-up ofthe remnant pancreas is important, preservation ofthe pancreas should be considered for multiple pancreatic metastases when complete tumor removal is possible.

[A Case of Penetrating Diverticulum of the Small Intestine that Occurred during Chemotherapy for Esophageal Cancer].

An 80-year-old man was seen by his family doctor with chief complaints of fatigue and loss of appetite. Upper gastrointestinal endoscopy showed a type 2 tumor of the lower thoracic esophagus, and the patient was referred to our hospital. Squamous cell carcinoma was diagnosed on biopsy, and computed tomography (CT) showed multiple pulmonary metastases. The patient was diagnosed with Stage Ⅳ thoracic esophageal carcinoma, and was started on combined chemotherapy with 5-FU plus CDDP. Seven days after the start of chemotherapy, the patient developed mild intermittent pain. By day 18, the blood tests showed a marked inflammatory response, and a CT scan showed an abscess in the small bowel mesentery. We suspected an intra-abdominal abscess caused by small bowel perforation, and performed a partial resection of the small bowel and abscess drainage. Postoperatively, pathology tests revealed a diagnosis of a small intestinal diverticulum, which had penetrated the mesentery. We report our experience of a rare case of penetrating diverticulum of the small intestine that occurred during chemotherapy for esophageal cancer, and review the literature.