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Background: The number of patients with remnant gastric cancer (RGC) following gastrectomy for gastric cancer (GC) is increasing due to the increasing number of patients undergoing function-preserving gastrectomy and improved outcomes for patients with GC. Male sex, old age, intestinal type, tumor depth, and synchronous multiple GC were all associated with RGC development in a few studies with a small number of cases. However, the risk factors for RGC development remain unclear. This study aimed to examine the clinicopathological features of patients with GC; these patients were followed up after they underwent distal gastrectomy and the potential risk factors for RGC development were evaluated.Methods: A retrospective database review of 438 patients who underwent distal gastrectomy for GC at a single institution, from 2006 to 2017, was conducted. We used Cox proportional hazards analysis to estimate the relationship between clinicopathological features, operative findings, and postoperative course with RGC development. The cumulative incidence rates of RGC were calculated using the Kaplan–Meier method.Results: We retrospectively analyzed 405 cases. The median patient age was 69 years, and the patient cohort consisted of 263 men and 142 women. The Billroth-I reconstruction method was used in 204 cases, the Billroth-II method was used in 3 cases; the Roux-en Y method was used in 198 cases. RGC was diagnosed in 11 of the 405 patients. The median follow-up period was 5 years. The cumulative incidence rates of RGC calculated using the Kaplan–Meier method were 3.0%, 4.1%, and 9.1% at 5, 10, and 15 years after distal gastrectomy, respectively. During the initial surgery, intestinal-type GC was significantly associated with RGC development (hazard ratio [HR], 4.71; 95% confidence interval [CI], 1.02–21.80; p = 0.05). Male sex (HR, 2.97; 95%CI, 0.64–13.75; p = 0.16), old age (≥70) (HR, 2.72; 95%CI, 0.78–9.47; p = 0.11), and synchronous multiple GC (HR, 1.31; 95%CI, 0.28–6.08; p = 0.37) were not associated with RGC development.Conclusions: Distal gastrectomy for intestinal-type GC was significantly associated with RGC development. Hence, patients who underwent distal gastrectomy for intestinal-type GC would require intensive endoscopic surveillance.

An 86-year-old male underwent pancreatoduodenectomy with resection and reconstruction of portal vein for pancreatic cancer. He was admitted to our hospital because of severe anemia and dyspnea ten months later. Computed tomography showed varices at the biliary-enteric anastomosis in the elevated jejunum caused by portal venous stenosis, which was suspected as the cause of anemia. Therefore, the patient underwent balloon dilatation of the portal vein followed by stent placement and coil embolization of the collaterals using a transileocolic portal vein approach. After the procedure, portal venous flow was improved, and the collaterals disappeared. The patient has been asymptomatic with no recurrence for three years and four months.

A 72-year-old man with general fatigue was referred, and CT and MRI revealed a pancreatic mass with necrosis that was suspected of invading the stomach, splenic artery, celiac artery, liver, and portal vein. Upper gastrointestinal endoscopy showed an extrinsic mass with ulcer formation in the posterior wall of the upper gastric corpus and irregular mucosa in the lower esophagus incidentally. Biopsy showed squamous cell carcinoma from both lesions, leading to the diagnosis of pancreatic adenosquamous carcinoma and early esophageal cancer. We performed distal pancreatectomy with splenectomy, total gastrectomy, partial hepatectomy, superior mesenteric-portal vein resection, and reconstruction. The pathological results revealed pancreatic adenosquamous carcinoma and infiltration of cancer cells at the dissected peripancreatic margin. Therefore, we administered radiotherapy(50.4 Gy to the retroperitoneal region)in postoperative month 2. Endoscopic mucosal resection was performed for the early stage esophageal cancer lesion in postoperative month 5. Three courses of S-1 were administered as adjuvant therapy since postoperative month 7, and he is currently alive without recurrence 1 year and 8 months after surgery. Multidisciplinary treatment can be effective for locally advanced pancreatic adenosquamous carcinoma.

Background Enhanced recovery after surgery (ERAS) protocols are now well-known to be useful for elective colorectal surgery, as they result in shorter hospital stays without adversely affecting morbidity. However, the efficacy and safety of ERAS protocols for patients with obstructive colorectal cancer have yet to be clarified. Methods We evaluated 122 consecutive resections for obstructive colorectal cancer performed between July 2008 and November 2012 at Tokyo Metropolitan Bokutoh Hospital. Patients with rupture or impending rupture and those who received simple colostomy were excluded. The first set of 42 patients was treated based on traditional protocols, and the latter 80 according to modified ERAS protocols. The main endpoints were length of postoperative hospital stay, postoperative short-term morbidity, rate of readmission within 30 days, and mortality. Differences in modified ERAS protocols relative to traditional care include intensive preoperative counseling (by both surgeons and anesthesiologists), perioperative fluid management (avoidance of sodium/fluid overload), shortening of postoperative fasting period and early provision of oral nutrition, intraoperative warm air body heating, enforced postoperative mobilization, stimulation of gut motility, early removal of urinary catheter, and a multidisciplinary team approach to care. Results Median (interquartile range) postoperative hospital stay was 10 (10–14.25) days in the traditional group, and seven (7–8.75) days in the ERAS group, showing a 3-day reduction in hospital stay (p

A 75-year-old woman who had undergone a Hartmann's operation for sigmoid colon cancer 2 years ago was hospitalized because she experienced small bowel obstruction several times. She had a treatment history of 6 other cancers, including 5 gastrointestinal tract cancers. However, the obstruction was relieved by conservative therapy each time. In September 2015, she was hospitalized for ileus. Abdominal computed tomography revealed that the lumen of intestine was partially dilated. Subsequently, a long tube was inserted, but the dilatation of the small intestine was not fully recovered. She was diagnosed with small intestinal obstruction due to adhesion, and she underwent an operation in October 2015. During the laparotomy, she was diagnosed with adhesion due to an intestinal tumor, and a partial intestinal resection, including the entire tumor, was performed. Because the tumor appearance and histological findings were very similar to those of sigmoid colon cancer, the tumor was diagnosed as a solitary metastasis of sigmoid colon cancer to the small intestine. Generally, peritoneal dissemination causes metastasis of colon cancer to the small intestine. However, this is a rare case because the lymphatic system or extra-wall invasion was the most likely cause of metastasis. Ileus repeating the improvement exacerbation, an examination must be performed while considering possible intestinal tumors, especially for a patient previously treated for multiple gastrointestinal cancers.

A 73-year-old man underwent laparoscopy-assisted partial resection of the rectum to treat rectal cancer diagnosed in September 2011 at a previous hospital. Lymph node dissection was not performed and the vertical margin was positive. When multiple liver tumors were detected 10 months later, the patient was referred to our hospital. A computed tomography (CT) scan revealed local recurrence of the rectal cancer, lymph node metastasis, and 9 liver metastases, which had a maximum diameter of 10 cm, and where curative resection would have been difficult. The rectal cancer expressed epidermal growth factor receptor (EGFR) and wild type K-ras gene, and we initiated cetuximab/irinotecan (CPT-11) chemotherapy. After 2 courses of chemotherapy, the liver tumors had markedly decreased in size and anterior resection of the rectum with regional lymph node dissection was performed. The pathological diagnosis of the rectal tumor was mixed adenoneuroendocrine carcinoma ( MANEC). Extended right hepatectomy was performed four months later. The liver tumors were also diagnosed as metastases of MANEC of the rectum. The therapeutic efficacy of chemotherapy was assessed as Grade 1b. The patient is alive without recurrence 34 months since the initial rectal surgery and 15 months after the liver resection. Thus, an anti-EGFR antibody agent might be effective against MANEC of the colon and rectum.

胃,十二指腸潰瘍穿孔に対する保存的治療法の適応を明確にすることを目的として,保存的治療の成功した32例をA群(胃6例,十二指腸26例),保存的治療から手術に移行した5例(胃2例,十二指腸3例)をB群としてretrospectiveに検討した. A群の特徴はB群に比し1) 若年である, 2) 初診時のCT, USにおいて左,右横隔膜下,脾腎境界,モリソン窩,肝下面,左,右傍結腸溝,ダグラス窩のうち腹水貯留部位は2カ所以内である, 3) 腹部筋性防御が初診後24時間以内に軽快する, 4) 腹水量は経時的に減少する,という点にあり,これらを満たすことが保存的治療の適応条件と考えられた.手術移行への遅延は合併症や入院期間を遷延させるため,保存的治療を行う場合には臨床所見の変化を緻密に観察し,手術に移行するタイミングを逃さないことが重要と思われた.

Thrombocytopenia is a common clinical manifestation of HIV infection, and when it does not respond to medical therapy such as steroids and anti-HIV drugs, patients are eligible for splenectomy.A HIV-positive 31-year-old man was admitted to the hospital because of diffuse purpura in the lower imbs. On admission, platelet count was 0.1×104/mm3 and bone marrow examination showed increased numbers of megakaryocytes. Under the diagnosis of thrombocytopenia associated with HIV-Infection, the patient was placed on prednisolone, anti-HIV drugs, and γ-globulin, but did not respond. Laparoscopic splenectomy vas performed, resulting in marked improvement in both clinical symptoms and laboratory data soon after.Considering the safety and effectiveness of the treatment, laparoscopic approach should be encouraged in candidates of splenectomy for thrombocytopenia with HIV infection.

We experienced a case of metastatic liver tumor from a rectal cancer which invaded the cardia. A 58-year-old man who had an abdominal rectal resection for a rectal cancer in June 1991 become complained of dysphagia, vomiting and loss of body weight in February 1994. CT scan and ultrasonography showed a space occupying a lesion of 5cm in diameter in the liver S2 extending from the aorta to lesser omentum, and endscopy showed complete stenosis beneath the EC junction. In May, he was admitted to the hospital and was operated on. The tumor existed in the left lateral segment of the liver involving the diaphragma and cardia, and invaded the vena cava inferior and caudal lobe. Extended left lobectomy, caudal lobectomy, partial S5 resection, proximal gastrectomy, partial diaphragma and vena cava inferior resection, cholecystectomy were performed. A few reports of hepato-cellular carcinoma invading the adjacent organs have been seen, but so far we have never seen the case of metastatic liver tumor from a rectal cancer which invaded the cardia. We considered that, in this case, the metastatic liver tumor on the edge spreaded both inside and outside the liver. We think that such cases can be candidates for aggresive extended operation, if the tumor is able to be resected macrospically.

A 68-year-old man undergoing hemodialysis (HD) was diagnosed with recurrence of colon cancer and liver metastasis. He was treated with oxaliplatin, folinic acid and 5-fluorouracil (FOLFOX4), folinic acid, 5-fluorouracil and irinotecan (FOLFIRI), FOLFIRI+bevacizumab (BV), and cetuximab+irinotecan (CPT-11) as third-line therapy. Each drug was adequately reduced over time, but cetuximab was administered at the standard dose. The patient died of methicillin-resistant Staphylococcus aureus (MRSA) meningitis during the course of cetuximab+CPT-11 therapy, but there was no relation between the meningitis and the therapy. Therefore, each regimen can be safely performed, and cetuximab+CPT-11 therapy showed a significant anti-tumor effect and hence may be an effective regimen.

Anatomic resection of the liver is one of the essential techniques in liver surgery. However, parenchymal transection precisely along intersegmental planes is still a technically demanding procedure, and an optimal navigation method is required.Real-time ultrasound monitoring with a probe applied from behind the liver was tried as a means of locating the site where resection was proceeding in the liver and confirming the direction of hepatic parenchymal transection to facilitate anatomic resection of the liver.The ultrasound navigation technique was performed during 11 hepatectomies in 10 patients in whom adequate retrohepatic space could be obtained to position the ultrasound probe. Continuous monitoring of the site in the liver where the resection was being performed was feasible, and the optimal direction of parenchymal transection was easily determined on the basis of the ultrasound images without interrupting the surgical maneuvers. The mean speed of parenchymal transection was faster (2.4cm2/min vs. 1.2cm2/min, p=0.009) and the amount of blood loss per transected area was smaller (4.4mL/cm2 vs. 7.2mL/cm2, p=0.05) in patients treated with the current technique.Continuous ultrasound monitoring of the liver facilitates the safe and precise parenchymal transection during anatomic resections of the liver.

A38 -year-old man complaining of abdominal pain was diagnosed with small intestinal cancer. Small intestinal endoscopy and PET-CT showed a primary jejunal cancer and five peritoneal metastases. Partial resection of the jejunum with three metastases was performed, but the others were unresectable. After surgery, FOLFOX chemotherapy was adapted. Follow-up pelvic CT showed a remarkable reduction of tumor size during FOLFOX chemotherapy after 4 courses, and follow-up PET-CT showed no tumor intake FDG after 10 courses. We judged him to be a complete response and stopped chemotherapy. After 7 months, the patient's level of tumor markers elevated, and there was recurrence. We resumed FOLFOX, and the chemotherapy for this patient is still being continued.

A case is a woman of 81-year-old. She was admitted to our hospital for a close examination of anemia from her family doctor. Gastroscopy revealed a 15 mm diameter of the type 0-IIa+IIc lesion at the posterior wall to the lesser curvature of the gastric body. And the biopsy of the lesion revealed a moderately differentiated adenocarcinoma (tub2). In consideration of the gastrectomy at this point, but firstly, an endoscopic submucosal dissection (ESD) was planned to perform for gaining the total pathological diagnosis of the lesion. Pathological findings revealed that the cancer cell invaded massively to submucosa (sm2), and that lymphatic permeation and venous permeation were also presented (ly2, v2). We explained it to the patient about the necessity of additional gastric resection, but she rejected the operation. So we had no choice but to observe the patient closely. Two months after the ESD, gastroscopy revealed no recurrent signs. But six months after the ESD, the local area of the stomach was revealed type 2 advanced gastric cancer, and computed tomography (CT) revealed a lymphoid swelling at the side of lesser curvature. We performed distal gastrectomy and D2 lymphoid dissection at this point. The final pathological diagnosis was T2 (ss) N2H0P0M0, Stage IIIA, based on the Japanese classification of gastric cancer. Adjuvant chemotherapy (oral fluoropylimidine) was interrupted in short period because of the side effects such as nausea, appetite loss, and diarrhea. There has been no recurrence for 1 year and six months since the operation. ESD is a minimally invasive technique and it is safe, convenient, and efficacious from the gastric functional point of view. However, the therapeutic strategies of the early gastric cancer, especially submucosally invasive gastric cancer, must be decided carefully and individually, considering the risk factors and the postoperative quality of life (QOL).

A case is a woman of 55-years-old. We performed right hemicolectomy with liver S7 partial excision (a postoperative diagnosis of the hepatic lesion, adenoma) for ascending colon carcinoma of type 2 with hepatic metastasis. Postoperative diagnosis was ss, n2, ly2, v2, Stage IIIb, based on the Japanese classification of colon cancer. Twelve months after the first operation, she was developed intestinal atresia by an abdominal wall recurrence, and we performed the operation of abdominal wall mass resection with a partial resection of small bowel. Afterwards she developed a recurrence three times in the abdominal wall or intra-abdominal lymph nodes during the next 1 year and six months, and we performed a local excision each time. The pathological findings in reoperations were all metastasis from ascending colon carcinoma of primary operation. After the final operation, we did not perform chemotherapy because the patient wished not to have it. There has been no recurrence for 6 years since the first operation, or 3 years since the last operation. Recently, the therapy for recurrent colon cancer has been shifted to more effective chemotherapy such as FOLFOX or FOLFIRI regimen, and a surgical resection is becoming rare. However, we experienced a case of recurrent colon cancer treated with four aggressive surgical resections that was beneficial for a long-term survival.

We report a patient for whom systemic chemotherapy using gemcitabine was effective against local recurrence of pancreatic cancer. A 58-year-old man underwent pancreatoduodenectomy for a pancreatic head cancer. The diagnosis was Stage IVb poorly-differentiated tubular adenocarcinoma, scirrhous type, pT4, PL (+), P0, H0, pN2. However, after 21 months, gastrointestinal bleeding occurred. Gastroscopy and CT examination revealed a mass at the cut-end of the pancreas invading the stomach. The serum CA19-9 level was found to be elevated. Systemic chemotherapy was performed with a regimen of gemcitabine 1,000 mg/m2/week for 2 weeks, followed by a week rest. The recurrent tumor in the stomach disappeared, and the mass at the cut-end of the pancreas became small. The serum CA 19-9 level regained the normal value. Two years after the diagnosis of recurrence, he returned to work, and his chemotherapy is being continued as an outpatient.

The significance of hepatic arterial infusion chemotherapy (HAI) for the prognosis of metastatic colorectal cancer is controversial. We applied a clinical scoring system to find good candidates for HAI after hepatic resection. Ninety-four consecutive cases of hepatic metastases resected at a single institute were analyzed retrospectively. The cases were divided into 4 subgroups: those with a low risk score (0-2 points) with and without HAI and those with a high risk score (3-5 points) with and without HAI. The number of cases and the cumulative 5 year survival rate of each case were as follows: low risk score with HAI (n = 17) 64.1%, low risk score without HAI (n = 25) 27.4%, high risk score with HAI (n = 28) 16.9%, and high risk score without HAI (n = 24) 14.7%, respectively. These results suggest that hepatic resection with HAI seemed to contribute to the outcome for selected cases. The clinical scoring system may identify good candidates for HAI as well as predict recurrence after hepatic resection for metastatic colorectal cancer.