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Endoscopic resection, particularly endoscopic submucosal dissection (ESD), for colorectal cancers enables a precise pathological diagnosis and safe R0 resection. The recurrence rate after ESD is generally extremely low, with annual surveillance colonoscopy recommended. However, surveillance may not be considered for super-elderly patients owing to their condition. This is a case report of an 85-year-old man in whom curative resection was achieved for an intramucosal adenocarcinoma with ESD. The patient presented with a hypoechoic mass located in his lower right abdomen, diagnosed via surveillance abdominal ultrasound. He had undergone curative ESD for intramucosal cecal cancer 2 years prior. Colonoscopy revealed a type 2 epithelial tumor at the proximal aspect of the ESD scar. Ileocolic resection with lymph node dissection was performed. An epithelial tumor and well-differentiated adenocarcinoma but not a submucosal tumor was detected in the mucosal layer. The lesion was diagnosed not as a local recurrence after ESD but as a newly emerged original advanced cancer. After ESD for colorectal cancer, a newly developed advanced cancer may occur at the site of the ESD scar in a shorter term than usual. Surveillance colonoscopy after ESD is necessary even for super-elderly patients.

Abstract Background Upper gastrointestinal (GI) bleeding is the most important presentation of an aorto-duodenal fistula (ADF). Early diagnosis is difficult, and the disease is associated with high mortality. The present study aimed to examine the clinical and the endoscopic characteristics of ADF in eight patients who presented to our hospital. We also sought to clarify the diagnostic approach towards the disease. Methods The present study examined the clinical and the endoscopic/computed tomography (CT) characteristics of ADF in eight patients who were definitively diagnosed with this condition in a 12-year period at our hospital. Results The patients comprised of five men and three women, with a mean age of 69.8 years. Upper gastrointestinal bleeding was the chief complaint for all the patients. Out of these, two patients presented with shock. The patients’ mean haemoglobin at presentation was 7.09 g/dL, and the mean number of blood transfusions was 7.5. All patients had undergone intervention to manage an aortic pathology in the past. As the first investigation, an upper GI endoscopy in 5 and a CT scan in 3 patients were performed. In cases where CT scan was performed first, no definitive diagnosis was obtained, and the diagnosis was confirmed by performing an upper GI endoscopy. In cases where endoscopy was performed first, definitive diagnosis was made in only one case, and the other cases were confirmed by the CT scan. In some cases, tip attachments, converting to long endoscopes, and marking clips were found useful. Conclusions In patients who have undergone intervention to manage an aortic pathology and have episodes of upper gastrointestinal bleeding, ADF cannot be definitively diagnosed with only one investigation. In addition, when performing upper GI endoscopy in cases where an ADF is suspected, tip attachment, converting to a long endoscope, and using marking clips can be helpful.

Abstract Background Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery. Methods We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality. Results We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90–3.40), 1.29 (0.90–1.85), 2.86 (1.54–5.32), and 2.76 (1.55–4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60–89, 30–59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results. Conclusions The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Summary: Background/objective: Patients with left-sided malignant colorectal obstruction require emergency treatment. Emergency stoma surgery has traditionally been recommended, however many stomas became permanent, decreasing patient quality of life. Recently, self-expandable metallic stents (SEMS) and transanal decompression tubes (TDT) have become widely used decompression methods to avoid stoma surgery. In this study, we evaluated: 1) the efficacy of SEMS compared with TDT and emergency surgery (ES) to avoid permanent stomas; and 2) the safety and success rate of each treatment. Methods: We retrospectively reviewed data from 56 patients who underwent SEMS, TDT, or emergency surgery for malignant left-sided colon obstruction. We compared the permanent stoma rate of each group, and assessed whether or not each treatment was an independent risk factor for permanent stomas. We compared morbidity and mortality for each treatment group (SEMS, TDT, ES), and the success rate of the decompression procedures (SEMS and TDT). Results: The permanent stoma rates in the SEMS, TDT, and ES groups were 5.3%, 50.0%, and 56.0%, respectively. Emergency surgery (vs. SEMS) and TDT (vs. SEMS) were independent risk factors for permanent stomas, as was age ≥ 75 years. Operative morbidity, mortality, and hospital stay were not different between groups. The success rate of SEMS was significantly higher than TDT; however, two deaths, including one perforation, occurred in the former group. Conclusion: SEMS seems to be effective in avoiding permanent stomas, but caution should be taken to avoid complications. Keywords: Emergency stoma surgery, Left-sided malignant colon obstruction, Self-expandable metallic stents, Transanal decompression tubes

Background: In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG. Patients and Methods: A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures. Results: No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13–60) mm. Conclusion: Stomach resection with intraoperative fluoroscopic guidance was safe and effective.

Background. Thoracic endovascular aortic repair of an aortoesophageal fistula is an effective emergency treatment for patients with T4-esophageal cancer, as it prevents sudden death, and is a bridge to surgery. However, the course of unresectable malignant aortoesophageal fistula treated with thoracic endovascular aortic repair alone is not well-known. Case Presentation. We report a 67-year-old Japanese man with T4-esophageal cancer who experienced a chemoradiation-induced aortoesophageal fistula and was rescued with thoracic endovascular aortic repair. He recovered after the procedure and survived for 4 additional months with management of a mycotic aneurysm and secondary aortoesophageal fistula with the exposure of the stent graft into the esophagus. Thoracic endovascular aortic repair of aortoesophageal fistula with T4-esophageal cancer extended life for nearly an average of 4 months in the reported cases. As a postoperative complication, the exposure of the stent graft into the esophagus is rare but life-threatening; the esophageal stent insertion was effective. Conclusions. With postoperative management advances, thoracic endovascular aortic repair can improve survival and increase the quality of life of patients with T4-esophageal cancer.