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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.

Background Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by thrombocytosis and a propensity for both thrombotic and hemorrhagic events. ET rarely occurs simultaneously with colorectal cancer. Here, we report a case of colorectal cancer in an ET patient treated using laparoscopic ileocecal resection. Case presentation A 40-year-old woman was admitted to our hospital after presenting with liver dysfunction. She had been previously diagnosed with ET; aspirin and anagrelide had been prescribed. Subsequent examination at our hospital revealed cecal cancer. Distant metastasis was absent; laparoscopic ileocecal resection was performed. Anagrelide was discontinued only on the surgery day. She was discharged on the seventh postoperative day without thrombosis or hemorrhage. However, when capecitabine and oxaliplatin were administered as adjuvant chemotherapy with continued anagrelide administration, she experienced hepatic dysfunction and thrombocytopenia; thus, anagrelide was discontinued. Five days later, her platelet count recovered. Subsequently, anagrelide and aspirin administration was resumed, without any adjuvant chemotherapy. Her liver function normalized gradually in 4 months. One-year post operation, she is well without tumor recurrence or new metastasis. Conclusions To our knowledge, this is the first report of laparoscopic colectomy performed on an ET patient receiving anagrelide. Our report shows that complications such as bleeding or thrombosis can be avoided by anagrelide administration. Contrastingly, thrombocytopenia due to anagrelide intake should be considered when chemotherapy that could cause bone marrow suppression is administered.

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.

閉塞性大腸炎は大腸の閉塞病変の口側にびらんや潰瘍などが生じる非特異的炎症性疾患であるが，閉塞病変のために術前診断は困難とされる．今回われわれは，術前診断に難渋した閉塞性大腸炎合併S状結腸癌の1例を経験したので報告する．症例は64歳，男性．便秘・腹痛，高度貧血で前医入院中に，敗血症性ショックになり転院搬送，人工呼吸器管理となった．全身検索を行うもスコープが通過する程度の狭窄を伴うS状結腸癌以外には明らかな疾患はなかった．耐術可能となった緊急入院後60日目に手術を行った．術中所見で，横行結腸中央部の漿膜面まで閉塞性大腸炎を疑う所見があり，同部位まで切除範囲に含めて拡大結腸左半切除術を行った．病理結果は，SE，N1（1/58）で，H0，M0，P0，f Stage IIIaであった．癌の口側に広汎に閉塞性大腸炎を認め，その潰瘍部位に核内封入体を認めた．サイトメガロウイルス感染の合併が重症化の一因と考えられた．

症例は63歳，男性．2010年7月に腹痛と嘔気を主訴に当院を受診した．腹部単純エックス線検査で大腸イレウスと判断，腹部造影CT検査でS状結腸に造影効果を伴う壁肥厚像およびその口側に2cm大の異物を認めた．種子嵌頓による大腸癌イレウスを疑い，緊急下部消化管内視鏡検査を行った．S状結腸に2型病変による全周性の狭窄を認め，経肛門的イレウス管を挿入して口側腸管を減圧した．入院6日後にリンパ節郭清を伴うS状結腸切除術を行った．切除標本では腫瘍口側に梅の種子が確認できた．総合診断SSN1H0P0M0，fstageIIIa．術後は合併症なく経過し，術後7病日で退院．植物種子は大きさや形状から通常イレウスの原因となりにくく，植物種子によるイレウスを疑った際は，器質的疾患，特に大腸イレウスに関しては大腸癌を念頭においた治療方針を検討する必要があると考えられた．

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.

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.

Colonic metastasis from other organs is very rare. Here we report the case of a 62-year-old man with a history of pancreatoduodenectomy for stage IIB pancreatic head cancer performed seven years back. He presented with abdominal distension and pain. Under the preoperative diagnosis of bowel obstruction, surgical treatment was performed, and a circumferential lesion causing bowel obstruction of the ascending colon was detected. A right hemicolectomy with lymph node dissection was performed. The specimen showed a 5-cm wall thickening with a cobble-stone like appearance of the ascending colon, which morphologically appeared scirrhous. Histological examination revealed cancer nests invading from the subserosa to the muscular and submucosal layers of the colon. Immunohistochemical analysis of the tumor cells demonstrated positive staining for cytokeratin 7, but negative for cytokeratin 20, which was the same as the previous pancreatic cancer specimen. These pathological and immunohistochemical features strongly supported the diagnosis of colonic metastasis from the pancreas. Thereafter, the patient received systemic chemotherapy, but unfortunately, he died 14 mo after the surgery.

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.

Background Japan has one of the highest five-year relative survival rates for colorectal cancer in the world, with its own traditions of perioperative care and a unique insurance system. The benefits of enhanced recovery after surgery (ERAS) protocols in the Japanese population have yet to be clarified. Methods We evaluated 352 consecutive cases of colorectal cancer resection at Tokyo Metropolitan Bokutoh Hospital between July 2009 and November 2012. Of these, 95 cases were performed according to traditional protocols (traditional group), and 257 according to ERAS protocols (ERAS group), which were introduced to the hospital in July 2010. Primary endpoints included length of postoperative hospital stay, postoperative short-term morbidity, and rate of readmission within 30 days. Intensive pre-admission counselling, no pre- and postoperative fasting (provision of oral nutrition), avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of ERAS protocols. Results The median (interquartile range) length of postoperative hospital stay was 10 (10–12.75) days in the traditional group and seven (6–8) days in the ERAS group, i.e., a three-day reduction (p