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BACKGROUND/AIM To evaluate the outcomes of curative resection for Borrmann type IV gastric cancer through an analysis of the clinical, surgical and pathological data and through identifying which of these prognostic factors are associated with survival. PATIENTS AND METHODS We retrospectively analyzed 2798 patients who had undergone excision of the primary lesion and 122 patients with type IV gastric cancer undergoing curative resection (R0 or 1) at Yokohama City University Hospital and Kanagawa Cancer Center between November 1995 and May 2016. RESULTS Borrmann type IV gastric cancer had more advanced and unfavorable clinicopathological factors compared to other types. The 5-year overall survival rate was 28%, and the median survival was 21.8 months. The overall survival rate was influenced by the depth of invasion, lymph node metastasis, peritoneal lavage cytology (CY), stage and intraoperative blood loss. Of these, independent prognostic factors were intraoperative blood loss (

The effectiveness of lymph node dissection tends to be reduced clinically in elderly patients with colorectal cancer because of physical limitations, such as comorbidities and organ dysfunction. We investigated the influence of the level of lymph node dissection on the prognosis of elderly patients with colorectal cancer. A total of 137 patients with pT2 or more-advanced tumors or lymph node metastasis were retrospectively studied. The 5-year overall survival(OS)andrelapse free survival(RFS) rates were 74.1% and 63.9%, respectively. Lymph node dissection was an independent prognostic factor in the examination of prognostic factors of OS. In the propensity-matchedcohort, the 5-year OS rates were 87.2% and5 8.2%(p=0.02), and the 5-year RFS rates were 77.8% and4 6.4%(p=0.03)in the D3 andred ucedgroups, respectively. The D3 group hada significantly better prognosis than the reduced group. D3 lymph node dissection might contribute to the improvement of prognosis in elderly people with colorectal cancer.

Background/aim Lymphovascular invasion (LVI) is recognized as a prognostic predictor of recurrence in certain carcinomas. According to current Japanese guidelines, however, in gastric cancer, LVI is not clinically useful information, except for predicting the curability of endoscopic resection. We clarified the clinical significance of LVI in gastric cancer and its correlation with disease prognosis. Patients and methods A total of 2,090 cases of gastric cancer undergoing radical gastrectomy were enrolled. The correlation of LVI and other histopathological factors was evaluated with regards to patient prognosis. Results LVI(+) was noted in 894 cases. A multivariate analysis showed that pT, pN, and LVI were independent risk factors for patient prognosis. In pT2-4 patients with nodal metastasis, a significant difference was revealed, and the 5-year overall survival rates in LVI(+) cases were lower than those in LVI(-) (60.9% vs. 76.7%, p=0.005). Conclusion LVI in gastric cancer is an independent prognostic factor, and tends to worsen prognosis, especially in advanced cancers with lymph node metastases.

A 61-year-old man had a sudden severe abdominal pain and visited our hospital. He was diagnosed with intestinal perforation, given the peritoneal irritation symptoms, the thickening of the intestinal wall and free air as shown on enhanced abdominal computed tomography. He then underwent emergent surgery. A tumor with small perforation was found on the intestine about 15 cm distant from the terminal ileum. Partial resection of the ileum was performed. Microscopically, a type 2 tumor of 70×50mm in diameter, was observed in the resected intestine. The tumor was diagnosed as diffuse large B-cell lymphoma via immunochemical staining. He received 6courses of R-CHOP therapy after surgery without recurrence. A primary intestinal malignant lymphoma is easily perforated, which lead to poor prognosis of the patient. We report a case of perforated intestinal malignant lymphoma, which was induced to remission by multidisciplinary therapy.

A 52-year-old man whose fecal occult blood test was positive was found to have type 2 sigmoid colon cancer by colonoscopy. On enhanced barium enema study, the cecum was in the pelvis, and the ascending colon was running medially in the abdomen. Enhanced CT scan of the abdomen revealed rotation of the superior mesenteric vein(SMV). We diagnosed the case as sigmoid colon cancer(cT3N0M0, StageⅡA)with non rotation-type intestinal malrotation, and performed laparoscopic surgery. We confirmed the small intestine to be located on the right side of the abdomen, the cecum to be located in the pelvis, and the ascending colon to be running medially in the abdomen. The ascending mesocolon was adherent to the right of the sigmoid mesocolon. Following dissections of the ascending mesocolon from the sigmoid mesocolon, we performed surgery via the inside approach as usual. We dissected the root of the inferior mesenteric artery(IMA), and the operation was completed. In laparoscopic surgery for colorectal cancer with intestinal malrotation, there are some reports that it could be performed safely if attention is paid to adhesion of the mesenteries and vascular variation in the course of preoperative imaging diagnosis. We report a case of laparoscopic surgery that could be safely performed for sigmoid colon cancer with non rotation-type intestinal malrotation.

This is a case of a 76-year-old man who had no significant past medical or family history. In the current medical history, in November 2017, upper gastrointestinal endoscopy showed a semicircular protruding lesion in the posterior wall of the gastric antrum, and gastric cancer was diagnosed following biopsy. Endoscopic submucosal dissection(ESD)was performed in the same year for the treatment of gastric cancer(cT1aN0M0). Pathological findings after ESD treatment showed invasion into the submucosa requiring non-curative resection. For this reason, laparoscopic pylorus side gastrectomy(D1 dissection)and Billroth Ⅰ reconstruction were performed as additional procedures in March 2018. The patient was discharged on the 10th postoperative day and was followed-up on an outpatient basis. On the postoperative day 14, he was re-admitted with complaints of upper abdominal pain and exacerbation of inflammation. Medical treatment, such as antibiotic administration was followed, however, a high degree of inflammatory response, renal dysfunction, and occult blood in urine were observed. Because of suspicion of vasculitis-related nephritis, the case was diagnosed as anti-GBM antibody type rapid progressive nephritis. We came across a case of rapidly progressive glomerulonephritis after laparoscopic pylorus side gastrectomy performed for early gastric cancer, and hence, We will review the related literature.

A 64-year-old woman was diagnosed with hereditary spherocytosis 30 years ago and underwent splenectomy. She presented to the hospital with lower abdominal pain and was diagnosed with sigmoid colon cancer(cT3N3M1[LYM], H1, Stage Ⅳ)for which sigmoidectomy was performed. On the 7th postoperative day, a fever of 40℃ and an inflammatory reaction were observed. She developed a consciousness disorder the next day, and her condition rapidly deteriorated along with the development of septic shock and disseminated intravascular coagulation(DIC). With the aid of a ventilator, immediate treatment for DIC was started, but reversion of septic shock and DIC was not possible, and the patient died of multiple organ dysfunction on the 17th postoperative day. Computed tomography and urinalysis performed during the course of treatment showed no infected lesion, but Citrobacter spp. was detected thrice in venous blood culture. Hence, the patient was diagnosed as a case of Citrobacter overwhelming post splenectomy infection(OPSI). To our knowledge, this is the first report of Citrobacter spp. infection following an abrupt course of OPSI.

Laparoscopic surgery in patients with retroperitoneal fibrosis has been reported to be difficult due to mesenteric and retroperitoneal fibrotic thickening. Here, we report a case of laparoscopic surgery with IgG4-related disease.A 60-year-old man with IgG4-related kidney disease and autoimmune pancreatitis was diagnosed with cecal cancer. Laparoscopic ileocecal resection was performed. Preoperative CT showed no evidence of retroperitoneal fibrosis but showed a localized fibro-inflammatory lesion between the retroperitoneum and mesentery in front of the right kidney due to interstitial nephritis. Intraoperative findings revealed focal adhesions in the duodenal front within the range consistent with CT findings.This report shows that the degree and extent of fibrosis were similar between preoperative CT and actual surgical findings. Thus, it is possible that tissue fibrosis in patients with IgG4-related disease could be predicted by preoperative CT.

This case involved a 42-year-old woman who had no remarkable findings in terms of case history and family history. Upper gastrointestinal series performed during a medical examination revealed ulcerative lesions in the anterior wall of the stomach body. Upper gastrointestinal endoscopy was performed, and a submucosal tumor with a maximum diameter of 50mm accompanied by an ulcerative lesion was found in the anterior wall of the lower part of the stomach. She was diagnosed with a schwannoma based on endoscopic ultrasonography-guided fine needle aspiration, and we received consultation for surgical purpose. Surgery was performed with laparoscopic partial resection of the stomach and lymph nodes in the lesser curvature of the stomach. She was discharged on the 7th day after the surgery. The postoperative pathologic findings showed no nuclear fissure or atypia with a diagnosis of a schwannoma and no lymph node metastasis. Gastric schwannoma is a rare disease that arises from Schwann cells of the Auerbach's plexus of the gastric wall muscularis and comprises 0.1-0.2% of all stomach tumors. Preoperative diagnosis is often extremely difficult, and there are reports of malignancy. Treatments and surgical methods should be carefully considered. Herein, we encountered a case of a resected giant gastric schwannoma by laparoscopic surgery, which is reported with a literature review.

e16055 Background: Nivolumab, an immune-checkpoint inhibitor for unresectable or recurrent esophageal cancer is used as second-line treatment. On the other hand, the relationship between indicators of cancer immunity (GPS, NLR, PLR), indicators of nutritional status (PNI, BMI), and prognosis of patients treated with nivolumab is unclear. Methods: We investigated the prognostic factors of nivolumab for unresectable or recurrent esophageal cancer. The subjects were 62 patients who received nivolumab as a second-line or later treatment for unresectable or recurrent esophageal cancer before January 2021. Of these 13 patients had previously been treated with taxan. We used GPS (Glasgow prognostic score), NLR (Neutrophil-Lymphocyte Ratio: cutoff value is 3.5), PLR (Platelet-Lymphocyte Ratio: cutoff value is 200), PNI (Prognostic nutrition index: cutoff value is 40), BMI (Body mass index: cutoff value is 18.5 for under 70 years old, and 20 for over 70 years old defined by Asian GLIM standard) as prognostic indicators. We examined the association between age, gender, PS, GPS, NLR, PLR, PNI, BMI and prognosis in patients treated with nivolumab. And we also examined the relationship between the history of taxan administration, the presence of adverse events and the prognosis. Results: Of the 62 cases, 48 cases were male and 14 cases were female. The median age was 70 years. Median OS was 359 days, and median PFS was 97 days. OS in patients with no prior taxan treatment group was significantly longer (P

302 Background: The preoperative stage and intraoperative stage of gastric cancer were unified as the clinical stage in the 8th edition of the TNM classification (UICC). Although there are some reports about the relationship between preoperative stage and prognosis, the relationship between intraoperative stage and prognosis remains unclear. The aim of this study was to clarify the impact of intraoperative diagnosis and staging on long-term survival. Methods: Overall survivals were examined in 915 patients who underwent curative resection for gastric adenocarcinoma between April 2011 and March 2019 in our hospital. Results: The median age of the patients was 69 years (27-90 years), including 585 male and 330 female. The median follow-up period was 33.6 months (0.1-86.7 months). The number of the patients according to intraoperative stage were 641(70.1 %) in stageI, 15(1.6%) in stageIIA, 135(14.8%) in stageIIB, 111(12.1%) in stageIII, 12(1.3%) in stageIVA and 1(0.1%) in stageIVB. The hazard ratios of intraoperative stage for overall survival were as follows (ref: StageI); StageIIA, 6.990 (95% CI: 2.473-19.760, p < 0.001), StageIIB, 2.234 (95% CI: 1.220-4.092, p = 0.009), StageIII, 4.091 (95% CI: 2.416-6.928, p < 0.001), StageIVA, 6.061 (95% CI: 2.150-17.080, p < 0.001), StageIVB, 14.92 (95% CI: 2.035-109.3, p = 0.008). Conclusions: The survival of intraoperative StageIIA was poorer than StageIIB/III. Intraoperative positive lymph node metastasis could be negative impact of survival, even if tumor invasion was T1 or T2.

336 Background: Esophageal cancer treatment, especially esophagectomy, is highly invasive, so treatment strategies are considered in view of existing double cancers. On the other hand, in Japan, 90% of esophageal cancers are squamous cell carcinoma, and it is known that there are a large proportion of head and neck cancers for double cancers as field cancerization. Methods: The aim of this study is to investigate the types of double cancer, simultaneous/metachronous, and the frequency and treatment policy of head and neck cancer as a particularly high coexistence rate for esophageal cancer surgery patient. The subjects were 304 patients who underwent esophagectomy performed from April 2010 to December 2017. All patients were examined with high-definition endoscopy with NBI by certificated endoscopist at the first visit as a search for simultaneous double cancer from the pharynx to the stomach. And after esophagectomy, endoscopy was also performed to check for metachronous double cancers in the remaining esophagus, gastric tube, and pharynx at least every 2 years. Results: The number of double cancer cases was found in 94 cases (30.9%), and the total number of double cancer cases was 122. Head and neck cancer(33 cases), stomach cancer(16 cases), and colon cancer(12 cases) were observed as the main course of double cancers. In double cancer cases, 47cases(50.0%) were metachronous, 35cases(37.2%) were simultaneous, and 12cases(12.8%) were both synchronous. The most common double cancer was head and neck cancer(33 cases:35.1%), and 23 cases were simultaneous, 10 cases were metachronous. As treatment strategy for head and neck cancer, endoscopic laryngo-pharyngo surgery(ELPS) were 19 cases. 10 cases(52.7%) were synchronous cancers, and 9 cases (47.3%) were metachronous cancers which were detected during follow-up after esophagectomy. Conclusions: Head and neck cancer associated with esophageal cancer surgery is the most common type of double cancer, and 1/3 of ELPS cases have been detected by follow-up endoscopy after esophagectomy, so endoscopic surveillance was also considered important.

320 Background: Postoperative complications increased recurrence in gastric cancer (GC) patients. However, there was no study evaluating impact of postoperative complication among patients receiving adjuvant chemotherapy. The aim of present study was to investigate the impact of postoperative complications in pStage II/III GC patients who received adjuvant S-1 chemotherapy. Methods: The present study retrospectively examined GC patients who received curative gastrectomy followed by adjuvant S-1 chemotherapy between January 2000 and December 2011 at Kanagawa Cancer Center. The patients with postoperative complications were classified into PC group, and those without postoperative complications were into NC group. Clinicopathological characteristics and recurrence-free survival (RFS) were compared between the groups. Results: 226 patients were included in this study. Postoperative complication occurred in 30 patients (13.3%). Age (Median, range) is significantly higher in NC group (64, 24-86) than in PC group (59, 36-82) (p = 0.033). Total gastrectomy was predominant type of surgery in the PC group (73.3%) than in NC group (52.0%) (p = 0.031). There was no difference in gender, ASA score, tumor location, pathological stage (TNM 7th) and pathological type between two groups. Conclusions: Postoperative complications were an independent risk factor for RFS in pStage II/III GC patients who received curative gastrectomy followed by adjuvant S-1 chemotherapy.

370 Background: We examined the association between postoperative pneumonia and prognosis of patients with esophageal cancer after curative surgery. Methods: We enrolled 122 patients who underwent curative resection for esophageal cancer between 2008 and 2018. The patients who had postoperative pneumonia were categorized into the pneumonia group, while those without postoperative pneumonia were classified into the non-pneumonia group. We identified the risk factors for the recurrence-free survival (RFS) and the overall survival (OS). Postoperative pneumonia was defined using the revised Uniform Pneumonia Score. Results: Thirty-four of the 122 patients (27.9%) had postoperative pneumonia. The 5-year OS rate after surgery in the pneumonia group was significantly lower than that in the non-pneumonia group (28.2% versus 55.1%, p = 0.006). Although not significant, the 5-year RFS rate after surgery in the pneumonia group tended to be lower than that in the non-pneumonia group (18.9% versus 49.2%, p = 0.061). A multivariate analysis identified postoperative pneumonia as a significant independent risk factor for the OS (hazard ratio = 2.15; 95% confidence interval, 1.25 to 3.68; P = 0.006). Conclusions: Our analysis showed postoperative pneumonia was an independent risk factor for worse overall survival in patients who underwent curative resection for esophageal cancer. This finding suggests that we should plan the surgical procedure, perioperative care and surgical strategy to prevent postoperative pneumonia.

428 Background: Lymphovascular invasion (LVI) of malignant tumor is regarded as an initial state of metastasis, including the lymph nodes, and therefore may be a prognostic factor in many malignancies. However, in gastric cancer, according to the current Japanese guidelines, LVI is not clinically useful information, except for in predicting the curability of endoscopic resection, and its clinicopathological characteristics and biological behavior remain unclear. The present study explored the histopathological significance of LVI in gastric cancer and clarified its correlation with the prognosis. Methods: From January 2000 to December 2013, a total of 2090 cases of gastric cancer undergoing radical gastrectomy were enrolled in this study. The correlation of LVI and other histopathological factors with the prognosis was evaluated. Lymphatic vessel invasion (ly) and venous invasion (v) were diagnosed followed the current Japanese classification. LVI positivity (LVIP) and LVI negativity (LVIN) were defined as the presence of lymphatic vessel and/or venous invasion and the absence of LVI, respectively. Results: LVIP was noted in 894 cases (42.8%). The age (p < 0.001), depth of tumor invasion (pT) (p < 0.001), lymph node metastasis (pN) (p < 0.001), and maximum tumor size (p < 0.001) were significantly correlated with the presence of LVI. A multivariate analysis showed that pT (p < 0.001), pN (p < 0.001), and LVI (p = 0.03) were independent risk factors for the prognosis of all patients. On analyzing the significance of every T factor and N factor for the overall survival of LVIP and LVIN cases, no significant difference was recognized in the prognosis among all pT1 patients and pT2-4 patients without nodal metastasis. However, in pT2-4 patients with nodal metastasis, a significant difference was revealed, and the 5-year overall survival rates in LVIP cases were lower than those in LVIN (60.9% [95% confidence interval: 56.3-65.3] vs. 76.7% [95% confidence interval 65.2-84.8], p = 0.005). Conclusions: LVI in gastric cancer is an independent prognostic factor, and its effect tends to be particularly strong in advanced cancer with lymph node metastasis. These patients may therefore require more effective adjuvant therapy.

A patient was 60-year-old man. In March 2011, the small bowel tumor with perforation was found and the partial resection of small intestine was urgently performed. KIT of resected specimen was positive. Then, diagnosis as GIST was defined. Oral administration of imatinib was started, but it was finished in 5 months because of development of the systemic edema. In February 2013, the abdominal CT revealed a tumor of 20 cm in size in the pelvis. Upon laparotomy, we detected the GIST recurrence generated at the region of small intestine anastomosis where manipulated previously, then resected all of tumor and partially small intestine. Afterward, we diagnosed as a recurrence of GIST. In March 2014, the abdominal CT found 4 cm sized mesenteric tumor and 2 cm sized abdominal wall tumor. The laparotomy was performed and we found 5 disseminated nodules intraperitoneally. We confirmed that all of these disseminated nodules were successfully removed. We defined them as re-recurrence of GIST. Six years and 5 months have elapsed since the first operation was performed, but there is no sign of three times recurrence.

A 71-year-old man with a positive fecal occult blood test was diagnosed with transverse colon cancer and referred to our hospital. Colonoscopy revealed type II transverse colon cancer with circumferential involvement. Contrast-enhanced computed tomography (CT)revealed a tumor with an unclear boundary in the pancreas. No metastases to the liver or lungs were detected, and there were no significantly enlarged regional lymph nodes. During open surgery, the tumor of the transverse colon was found to have formed a mass in the pancreatoduodenum, and it was difficult to separate them. As curative resection was considered possible, resections of both the pancreatoduodenum and transverse colon cancer were performed. Laboratory findings revealed fistula formation between the transverse colon cancer and the duodenum. The cancer was diagnosed as stageII, T4bN0M0, and R0 surgery was successfully performed. The patient was alive without recurrence 14- months after the surgery. Colorectal cancer is more likely to advance locally and directly invade the surrounding organs. However, fistula formation with the duodenum has rarely been reported, occurring at an estimated incidence of 0.1%. Such tumors are typically large; however, metastases rates to the lymph nodes are low. Histopathological examination of the resected specimen revealed a severe inflammatory adhesion, and fistula formation between the traverse colon and the duodenum. There was no evidence of invasion of the lymphatic system or blood vessels, which enabled us to perform a high curative surgery. We propose that it is important to consider high curative resection with positive lymph node dissection for cases of colorectal cancer associated with duodenal fistula formation.

Background A partial anomalous pulmonary venous connection is a rare congenital defect in which blood from the pulmonary vein is returned to the right atrium. Asymptomatic patients with a partial anomalous pulmonary venous connection with a small left-to-right shunt do not require surgical treatment. If such patients require a major lung resection, the surgical procedure could precipitate fetal right heart failure if the anomalous venous connection remains uncorrected. Case presentation A 59-year-old man was found to have an abnormal shadow on chest roentgenogram. Chest computed tomography imaging showed a mass in the right upper lobe. At the same time, we incidentally found an anomalous vessel. We diagnosed the abnormality as a partial anomalous pulmonary venous connection. Because the mass may have been lung cancer, a right upper lobectomy was performed using video-assisted thoracoscopic surgery. The right upper lobe vein drained into the superior vena cava. The anomaly was not corrected and the surgery was successful. His postoperative course was uneventful without cardiac failure. Conclusions Before performing a major lung resection, surgeons should be aware of this rare anomaly and carefully interpret clinical images of all pulmonary veins.