Perioperative fluid management influences complication rates and length of hospital stay in the enhanced recovery after surgery (ERAS) protocol for patients with colorectal cancer.

PURPOSE: To evaluate the efficacy and safety of the enhanced recovery after surgery (ERAS) protocol and quantify the impact of each ERAS item on postoperative outcomes. METHODS: We used a generalized linear model to compare 289 colorectal cancer patients treated with the ERAS protocol between June, 2015 and April, 2021, with 99 colorectal cancer patients treated with the conventional colorectal surgery pathway between April, 2014 and June, 2015. RESULTS: The median length of hospital stay (LOHS) was significantly shorter in the ERAS group, at 9 days (range 3-104 days) vs. 14 days (range 4-44 days) (p < 0.001), but the complication rates (Clavien-Dindo grade 2 or more) were similar (16.6% vs. 22.2%; p = 0.227). However, in the ERAS group, the higher the compliance with ERAS items, the lower the complication rate and LOHS (both p < 0.001). Multiple regression analysis demonstrated that "Discontinuation of continuous intravenous infusion on POD1" and "Avoidance of fluid overload" were significantly associated with the LOHS (p < 0.001 and p = 0.008). CONCLUSION: The ERAS protocol is safe and effective for elective colorectal cancer surgery, and compliance with the ERAS protocol contributes to shorter LOHS and fewer complications. Items related to perioperative fluid management had a crucial impact on these outcomes.

[A Case of Complete Response to Lower Rectal Cancer after Preoperative Chemotherapy with CapeOX Therapy].

A 70 -year-old male patient was referred to our hospital with the chief complaint of hemafecia. Colonoscopy was performed and revealed bulky rectal cancer at 10 cm from the anal verge. After 4 courses of capecitabine plus oxaliplatin(Ca peOX)therapy as preoperative chemotherapy, colonoscopy and computed tomography(CT)revealed significant reduction of the tumor. We performed laparoscopic lower anterior resection and ileostomy. Histopathological examination revealed no residual tumor cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year postoperatively.

[A Case of Small Intestinal Cancer Repeating an Ileus Symptom Complicated with Refractory Arrhythmia].

A 56-year-old man had been treated for hypertrophic cardiomyopathy since childhood. He had been treated for refractory ventricular tachycardia (VT) with interventricular septum cauterization, catheter ablation, and implantation of a defibrillator. He had been treated at home for several years. The ileus that developed in July 2014 was relieved by conservative medical treatment once, but it recurred after oral intake of food a short time later. The obstruction was due to a small intestine cancer that was diagnosed by enteroscopy. After considering the risks of surgery due to the cardiac problem and the quality of life due to ileus caused by the mass, we resected it. This surgery was not a radical resection because of peritoneal dissemination. He started oral food intake postoperatively, and returned to home care. Three months after surgery, oral chemotherapy was administered after considering his stable cardiac function in addition to his coherent mental status. An adverse event of severe watery diarrhea developed, and VT caused by dehydration occurred. After the chemotherapy was discontinued, he recovered in intensive care. He returned to home care at his prior status for 9 months postoperatively.

[A Case of Carcinosarcoma of the Esophagus Treated with Chemoradiotherapy].

Carcinosarcoma of the esophagus is a rare malignant neoplasm. We report a case of an 87-year-old man treated with chemoradiotherapy. The main presenting complaint was hiccups. Histological analysis of a biopsy from the tumor demonstrated a carcinosarcoma. The clinical diagnosis was T2N0M0, cStageⅡ. In consideration of his advanced age, a past history of cerebral infarction, high blood pressure, aortic valve sclerosis, and chronic renal failure (Cr 1.5-1.8 mg/dL), chemoradiotherapy consisting of TS-1 40 mg/day with radiotherapy of 66 Gy was administered to the patient. The carcinosarcoma decreased in size on endoscopic examination in response to the chemoradiotherapy. Surgery with extended lymphadenectomy for esophageal carcinosarcoma is the standard treatment, but chemotherapy may be a good choice for local control for patients who cannot undergo surgical resection.

[A case of gastric cancer with multiple liver metastases that was successfully treated by chemotherapy].

A man in his 60s received SP (S-1+CDDP) therapy for gastric cancer with multiple liver metastases. After completion of 3 courses, liver metastases had reduced significantly, and the paraaortic lymph nodes, which had swelled previously, had reduced in size. Furthermore, the serum carcinoembryonic antigen (CEA) level had also improved to the standard value from 814.3 ng/mL. The patient was able to discontinue the opioid he had needed for pain control. The chemotherapy was continued for 18 courses, with the dose reduced at the time of the adverse events along the way. By completion of the 18 courses, we recognized regrowth of the primary lesion and a rise in the serum CEA over the standard value. There was no sign of the regrowth of liver metastases and distant lymph nodes according to examinations for enhanced computed tomography (CT) and ¹8F-fluorodeoxyglucose positron-emission tomography (FDG-PET) CT.The patient received distal gastrectomy. The CEA level decreased in standard value or less after surgery and we believed the cancer was limited to the primary stomach lesion.

[Long-term survival of a patient with locally advanced unresectable pancreatic cancer treated with gemcitabine after chemoradiation therapy].

We report a case of long-term survival of a patient with locally advanced unresectable pancreatic cancer treated with gemcitabine after chemoradiation therapy( CRTx). A 61-year-old woman was diagnosed as having locally advanced unresectable pancreatic cancer, 3.0 cm in diameter, which had invaded the superior mesenteric artery by computed tomography (CT). She was treated with CRTx( gemcitabine[ GEM] at 250 mg/m2/week for 6 weeks+liniac irradiation of 50.2 Gy) followed by systemic chemotherapy (gemcitabine (GEM) at 1,000 mg/m2). Reassessment after CRTx yielded a diagnosis of stable disease (according to the Response Evaluation Criteria in Solid Tumors [RECIST] 1.1). To date, the patient has undergone 57 courses of chemotherapy in the outpatient clinic; however, she did require biliary stent placement because of occlusive jaundice.

[Utility of the WallFlexTM duodenal stent for unresectable advanced gastric cancer related to gastric outlet obstruction].

Duodenal stenting for malignant disease related to gastric outlet obstruction(GOO) has been covered by health insurance in Japan since April 2010. We inserted WallFlexTM duodenal stents(WDS) in 4 patients with GOO caused by unresectable gastric cancer. WDS insertion was successful in all 4 cases. Duodenal perforation occurred in 1 case. One case each of stent obstruction and stent migration occurred. All patients could eat a soft-food diet for 3-6 months (median, 5.3 months). Survival time ranged between 5 and 14 months (median, 6 months). Three patients underwent S-1 combination chemotherapy. Duodenal stenting is expected to be effective for advanced gastric cancer related to GOO.

[Two case reports of neuroendocrine cell carcinoma of the stomach].

We encountered 2 cases of endocrine cell carcinoma of the stomach. One patient had a type 3 tumor in the cardia, and the other patient had a submucosal tumor in the posterior wall of the gastric angle, both of which were detected by upper gastrointestinal endoscopy. The first patient underwent total gastrectomy(D1+No.7, 19) with cholecystectomy. Microscopic histological examination fortuitously revealed a tumor thrombus in the vessel of the gallbladder. Eight months after the operation, a paraaortic lymph node recurrence was detected, and the patient died 28 months after the operation. The second patient underwent distal gastrectomy, cholecystectomy, S5 subsegmental hepatectomy, and S8 radiofrequency ablation(RFA). Despite undergoing adjuvant chemotherapy[irinotecan(CPT-11)/cisplatin(CDDP)], multiple liver recurrences were detected 6 months after the operation. Consequently, systemic chemotherapy (S-1/CDDP) was performed.

[A case report of long-term survival of endocrine cell carcinoma of the esophagus with chemo-radiation therapy].

The patient was an 84-year-old man, who was diagnosed with cT3N2 (101L, 109L) M0, stage III esophageal cancer. The tumor, immunohistochemically, was stained positive for CD56 and NSE yielding a definitive diagnosis of endocrine cell carcinoma of the esophagus. We selected chemo-radiation therapy (5-FU/CDDP and 2 Gy/day total 60 Gy) for this patient. As adjuvant chemotherapy, 7 courses of chemotherapy with 5-FU/CDDP, was performed. At 8 months from the chemo-radiation therapy, the disease was diagnosed as cCR. But two years later, lung metastasis appeared, so we started chemotherapy with docetaxel/CDDP/5-FU. After 2 courses, lung metastasis was almost disappeared. He has been survived for four years and five months after chemo-radiation. This case suggests that chemo( FP) -radiation therapy and adjuvant chemotherapy could be an effective treatment for endocrine cell carcinoma of the esophagus.

[A case of S-1/CDDP chemotherapy for inoperable advanced gastric cancer which led to gastrectomy with histological complete response].

As the treatment for inoperable advanced gastric cancer, S-1/CDDP combination therapy (SP chemotherapy) has become a standard treatment. In our hospital, a second course of chemotherapy was performed on an outpatient basis in order to improve a traditional QOL. In this case, it showed remarkable effects in 15 months after starting chemotherapy. Then gastrectomy was performed. Histological findings of the resected specimens confirmed pCR in all tumors. We report on progress of this case and explain about the ingenuity of SP chemotherapy.

[Schwannoma in the brachial plexus resected by thoracoscopic approach].

A 50-year-old male was detected an abnormal shadow in the right apical region by chest X-ray examination. Computed tomography (CT) scan and magnetic resonance imaging (MRI) findings suggested the mass to be a neurogenic tumor. The tumor was originated from lower brachial plexus and enuclated by thoracoscopic approach with no major nerve damage. The pathological finding was benign schwannoma.

[A case of advanced gastric cancer responding to S-1/paclitaxel was pathologically complete response].

A 63-year-old man was found to have advanced gastric cancer and staging laparoscopy revealed positivity of peritoneal washing cytology. Since curative surgery was deemed not possible, we started chemotherapy using S-1 (80 mg/m2) orally administered for 2 weeks and paclitaxel (50 mg/m2) administered intravenously on days 1 and 8. After 3 courses of chemotherapy, the primary lesion and regional metastatic lymph node were diminished by CT. We confirmed a peritoneal washing cytology negative by laparoscopic examination. We performed a total gastrectomy and dissection of regional lymph node (D2). Pathologically, cancer cells disappeared both in the main tumor and lymph nodes, and histological efficacy was evaluated as grade 3. Adjuvant chemotherapy was done with same regimen, and he has had no recurrence as of 15 months after surgery.

[A case of AFP producing gastric cancer for which radiation therapy was effective in paraaortic lymph node recurrence].

The patient was a 75-year-old woman, who was diagnosed with type 3 gastric cancer. Total gastrectomy with D2-#10 lymph node dissection and partial hepatic resection was performed. Histological findings showed it to be stage IV (pT2N1M0P0CY0H1) and AFP producing gastric cancer. After the operation, liver metastasis was found, and RFA, partial hepatic resections, hepatic intra-arterial infusion chemotherapy (5-FU, CDDP), intravenous chemotherapy (docetaxel, paclitaxel, CPT-11) were applied. Although liver metastasis was disappeared, paraaortic lymph node recurrence appeared, and chemotherapy was not effective. Radiation therapy (2 Gy/day, total 50 Gy) for paraaortic lymph node metastasis was performed. The metastatic node underwent complete remission following a radiation therapy. Three years and six months passed since the first operation, and the patient has shown no signs of relapse. Therefore, our case suggests radiation therapy could be an effective treatment modality for the lymph node metastasis in AFP producing gastric cancer.

Intraabdominal actinomycosis resulting in a difficult to diagnose intraperitoneal mass: A case report.

INTRODUCTION: Actinomycosis is a chronic suppurative granulomatous disease caused by Actinomyces israelii. Preoperative confirmed diagnosis is very difficult, so most cases are diagnosed preoperatively as malignant tumors. We report a case of intraabdominal actinomycosis which was difficult to diagnose preoperatively. PRESENTATION OF THE CASE: A woman, 60 years old, experienced discomfort in her lower right abdomen. She complained of nausea and anorexia and visited our hospital. Laboratory blood tests, abdominal CT, and abdominal MRI led to a diagnosis of a uterine sarcoma or primary intestinal mass, and she underwent surgery. Her histopathological diagnosis was intraabdominal actinomycosis. DISCUSSION: Actinomycosis is a chronic purulent granulomatous inflammation caused by Actinomyces israelii. No clinical symptoms or laboratory findings are characteristic of abdominal actinomycosis, so this disorder is very difficult to diagnose preoperatively. Therefore, many cases are diagnosed as malignant tumors and undergo surgery. After surgery, long-term antibiotic treatment (penicillin) is usually administered. CONCLUSIONS: We reported a case of intraabdominal actinomycosis that resulted in a difficult to diagnose intraperitoneal mass. When a large intraperitoneal mass is found, actinomycosis needs to be included as one of differential diagnoses.

[The prognostic value of positive peritoneal lavage cytology and the prevention of peritoneal dissemination after colorectal surgery].

Peritoneal washing cytology during surgery was done in 745 patients with colorectal cancer. The positive washing cytology rate was 49/745 (6.6%). The peritoneal recurrence rates were 12/22 (54.5%) and 8/682 (1.3%) among patients with positive and negative peritoneal washing, respectively (p < 0.0001). The 5-year survival rate is 89.4% of the patients with positive cytology and 38.2% with negative cytology. The patients with positive cytology have a significantly lower survival rate than the negative one (p < 0.0001). Eleven patients of the positive cytology received intraperitoneal administration of MMC. Peritoneal dissemination occurred in 3/11 (27.3%) of the MMC treated group and 9/11 (81.8%) in the untreated group (p = 0.030). Our results indicated that intraperitoneal administration of MMC was an effective method of preventing peritoneal dissemination after resection of colorectal cancer.

[A case of refractory inguinal lymphorrhea cured by lipiodol lymphangiography].

We report a case of inguinal lymphorrhea cured by Lipiodol lymphangiography. The patient was a 80-year-old female who underwent an abdomino-perineal resection with lateral pelvic lymph node dissection and inguinal lymph node extraction for anal canal cancer. Histologically, the tumor was a poorly differentiated adenocarcinoma and considered to be stage IV (a2, n3 (+), P0, H3, M (-), cur C) in the Japanese classification of colorectal cancer. We recognized a lot of lymph node metastases in dissected lateral pelvic lymph node and inguinal lymph node. By hepatic arterial infusion using 5-FU (1250 mg/body weekly), the liver metastases had a complete response after 15 courses. She noticed a left inguinal lymph node swelling and an elevation of serum CEA level (79.5 ng/mL) was observed. There was no evidence of recurrence except left inguinal lymph nodes. She underwent a left inguinal lymph node dissection. Serous discharge from a surgical site persisted despite of conservative therapy such as compression. She received lymphangiography using 8 mL of Lipiodol from left dorsum of foot. We found three lymph ducts heading to left groin and observed a lot of Lipiodol leakage from ducts. We determined not only the site of leakage but we also confirmed a gradual decrease and a complete stop of lypmphorrhea in 7 days after lymphangiography. Slight lymph edema of left lower extremity appeared but gradually relieved. Lymphangiography using Lipiodol helps determine the site of leakage and may be an effective therapeutic modality for treating refractory lymphorrhea.

Early ligation of the inferior pancreaticoduodenal artery to reduce blood loss during pancreaticoduodenectomy.

When performing a pancreaticoduodenectomy, a considerable amount of congested blood is lost, especially during the period when the pancreatic head area is being isolated from the superior mesenteric vessels. Following Kocher's maneuver, a 4-cm dissection was continued along the right margin of the superior mesenteric artery. The root of the inferior pancreaticoduodenal artery was disclosed and ligated prior to the following resection procedures. The early ligation of the inferior pangreaticoduodenal artery decreased blood loss (from 194+/-24 mL to 86+/-50 mL) during the period when the pancreatic head area was isolated from the superior mesenteric vessels. This approach was feasible in reducing blood loss presumably related to blood congestion.