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Recurrent gastric cancer(GC)with splenic metastasis showed poor prognosis, and its treatment strategy remains unclear. Recently, studies identified the considerable prognostic effect of metastasectomy in GC following intensive chemotherapy. Here, we successfully treated a patient with Epstein-Barr virus-positive esophagogastric junctional cancer with splenic metastasis who underwent metastasectomy and obtained pathological complete response following immune checkpoint therapy and had long-term survival. We reviewed the literature to discuss the clinical significance of our treatment strategy.

We report a case of pembrolizumab therapy as the fourth-line therapy for colorectal cancer and multiple lymph node recurrence with high-frequency microsatellite instability(MSI-High). The patient was a 75-year-old woman diagnosed with ascending colon cancer(pT4aN2bM0, Stage Ⅲc)and underwent laparoscopic right hemicolectomy, D3 dissection, and functional end-to-end anastomosis after inserting a self-expandable metallic stent. Postoperative adjuvant chemotherapy was performed, and the patient was followed. Postoperative 1 year 8 months, lymph node recurrence was indicated, and FOLFOX plus panitumumab therapy was introduced. FOLFIRI plus ramucirumab therapy and FTD/TPI were introduced as the second-line and third-line treatments, respectively; however, recurrent lymph nodes were further exacerbated and showed treatment resistance. Lymph node biopsy confirmed MSI-High, and pembrolizumab therapy was initiated as the fourth-line treatment. After the therapy, the lymph nodes reduced markedly. The patient remains undergoing chemotherapy without any adverse events.

No ideal and generally accepted method of reconstruction for laparoscopic proximal gastrectomy (LPG) has been established because of a high incidence of postoperative reflux and anastomotic stenosis. The aim of this study was to evaluate the short-term outcomes of LPG with a non-flap hand-sewn technique as a simple anti-reflux procedure for the upper part of clinical Stage I gastric cancer. Between November 2016 and June 2019, 23 consecutive gastric cancer patients, who underwent curative LPG with lymphadenectomy, were enrolled in the study. In this study, we devised a simple hand-sewn technique for esophagogastrostomy, which comprises a 5-cm pseudo-fornix as a fundoplication, the posterior pressure mechanism by the remnant stomach and bilateral crus, and a flat-shaped anastomotic hole as a valvuloplasty. The median operation time and hospital stay was 325 min and 10 days, respectively. There was no patient with anastomotic leakage and delayed gastric empting. No patient had symptoms of gastroesophageal reflux, but two patients (8.6% (2/23): Grade M and Grade A) had endoscopic findings during a follow-up period of more than 6 months. There was no patient with Grade B or more severe reflux esophagitis. One patient (4.3%, 1/23) developed anastomotic stenosis, which was resolved with endoscopic dilatation. The mean body weight loss at 6 months after surgery was 7.5% in comparison with the preoperative body weight. Our non-flap hand-sewn technique for esophagogastrostomy had favorable outcomes and might be one of reliable techniques as an anti-reflux procedure in LPG for gastric cancer.

Although single-port mediastinoscopic radical esophagectomy is ultimate minimally invasive surgery for esophageal cancer without thoracotomy or the thoracoscopic approach, the high incidence of recurrent laryngeal nerve (RLN) palsy remains a pivotal clinical issue.This study included 41 patients who underwent single-port mediastinoscopic radical esophagectomy with mediastinal lymphadenectomy between September 2014 and March 2022. Among these, continuous nerve monitoring (CNM) for RLN was done in 25 patients (CNM group), while the remaining 16 patients underwent without CNM (non-CNM group). Clinical benefits of CNM for RLN were evaluated.The overall incidence of postoperative RLN palsy was 14.6% (6/41). The CNM group showed a significantly lower incidence of postoperative RLN palsy as compared to the non-CNM group (P = 0.026: CNM vs. non-CRNM: 4.0% (1/25) vs. 31.2% (5/16)). The CNM group had a lower incidence of postoperative pneumoniae (CNM vs. non-CNM: 4.0% (1/25) vs. 18.8% (3/16)) and shorter days of postoperative hospital stay (CNM vs. non-CNM: 13 days vs. 41 days). Multivariate analysis revealed that the CNM use (odds ratio 0.07; 95% CI 0.05-0.98) was an independent factor avoiding postoperative RLN palsy.The CNM for RLN contributes to a remarkable reduction in the risk of postoperative RLN palsy and improvement in outcomes in single-port mediastinoscopic radical esophagectomy.

Pancreatic fistula is one of the most critical complication following distal pancreatectomy. We report here a successfully treated case with intractable pancreatic fistula using Trafermin® consisting of basic fibroblast growth factor(bFGF). A 60- year-old man underwent laparoscopic distal pancreatectomy. After surgery, pancreatic fistula was occurred. Pancreatic fistula persisted for 3 months despite of several conservative treatments. After obtaining informed consent, we started to inject 50μg/day of Trafermin® through a drainage tube into the dehiscence of pancreas. Consequently, pancreatic fistula was successfully closed within a week. This technique could be one of the treatment choices for intractable pancreatic fistula following distal pancreatectomy.

Stage Ⅳ gastric cancer(GC)with ovarian metastasis showed poor prognosis and its treatment strategy remains unclear. Recent studies identified the favorable prognostic effect of conversion surgery in Stage Ⅳ GC following intensive chemotherapy. We report here a case with advanced GC and ovarian metastasis, who underwent conversion surgery for them followed by chemotherapy and had a long-term survival. We reviewed the literatures in order to discuss clinical significance of our treatment strategy.

KEYNOTE-158 and 061 trials revealed the efficacy and safety of pembrolizumab(KEYTRUDA®)treatment in patients with recurrent high microsatellite instability(MSI-high)gastric cancer following gastrectomy. Here, we successfully treated an elderly case with recurrences following radical gastrectomy for advanced gastric cancer using pembrolizumab as a second- line chemotherapy. Even in elderly patients, pembrolizumab might contribute to effective and safe treatment in late-line chemotherapy for recurrent MSI-high gastric cancer.

Mediastinoscopic esophagectomy(ME)is a minimally invasive approach without thoracotomy and pulmonary atelectasis during surgery. Here, we report the case of a 67-year-old patient who was successfully treated with thoracic esophageal cancer and severe chronic pulmonary infection using ME and home enteral nutrition therapy. Esophageal cancer patients with severe lung dysfunction have a risk of postoperative pneumoniae. ME could be a promising procedure for patients with severe lung dysfunction. We highlight the usefulness of ME as a safe approach to avoid pulmonary complications.

G-CSF producing esophageal carcinosarcoma is extremely rare, and its effective treatment strategy remains undefined. Here, we report the case of a 69-year-old woman who underwent successful two-stage surgery using mediastinoscopic esophagectomy and laparoscopic reconstruction for the management of severe anemia, malnutrition, and inflammation due to G-CSF producing esophageal carcinosarcoma(G-CSF 265 pg/mL). Chemoradiotherapy could not manage lymph node recurrences in the patient; however, nivolumab was found to be effective and helped achieved a prolonged partial response.

Postoperative low nutrition, body weight loss and poor QOL are pivotal clinical issues for elderly patients following total gastrectomy for advanced gastric cancer. Here, we report a successfully treated high-risk elderly case using home night enteral nutrition and adjuvant chemotherapy following laparoscopic total gastrectomy for advanced gastric cancer. Home night enteral nutrition might not impair oral intake and daily QOL, and could be a useful treatment strategy for elderly patients following total gastrectomy.

TAGS trial revealed the efficacy and safety of trifluridine/tipiracil(Lonsurf®)treatment in patients with metastatic gastric cancer following gastrectomy. Here, we successfully treated 38 months survival case after recurrences following radical gastrectomy for advanced adenocarcinoma of esophago-gastric junction using historical recommended chemotherapy regimens and trifluridine/tipiracil as a fifth-line chemotherapy. Trifluridine/tipiracil therapy contributed to effective and safety treatment even in late-line chemotherapy for recurrent gastric cancer.

A 74-year-old woman presented with abdominal discomfort and was diagnosed with an unresectable advanced gastric cancer(T4aN3aM1, stage Ⅳ)based on a thorough examination. S-1/cisplatin therapy was administered as first-line treatment and paclitaxel/ramucirumab therapy as the second-line treatment. However, because the patient developed a peritoneal dissemination and her lymph node metastasis increased despite these regimens, nivolumab was introduced as a third- line treatment. The CT scan revealed that after the 5 courses of nivolumab, both the peritoneal dissemination and metastatic lymph nodes shrunk; after 12 courses of nivolumab, the peritoneal dissemination almost disappeared. Although nivolumab, an anti-programmed cell death-1(PD-1)antibody, has the possibility to cause immune-related adverse events not seen with conventional chemotherapy, in the present case, these events did not occur and the antitumor effects were maintained for a relatively long period without a decrease in the performance status(PS). We experienced a case of peritoneal metastasis from gastric cancer with a good response to nivolumab. Herein, this case is reported with some literature review.

Nivolumab, a fully human IgG4 monoclonal antibody inhibitor of programmed death-1(PD-1), was approved for use in the treatment of patients with advanced gastric or gastroesophageal junction cancer who had been previously treated with B2 chemotherapy regimens in Japan.We investigated the efficacy of nivolumab therapy in 15 consecutive patients with advanced gastric cancer between October 2017 and December 2018 in our facility.In our study, the 6-month overall survival rate was 67.7%, and the median survival time(MST)was 6.3 months. Immune-related adverse events(irAEs)occurred in the following patients: 2 patients, interstitial pneumonia(13%); 1 patient, myocarditis (6.7%); 1 patient, hypothyroidism(6.7%); and 1 patient, liver dysfunction(6.7%). Of the patients with an absolute lym- phocyte count(ALC)of C2,000/mL at baseline, 33%(4/12)experienced irAEs, while of those with an ALC of2,000/mL, 67% had irAEs. The 6-month overall survival rate was better in patients with an ALC1,600/mL(100%, 4/4)than in those with an ALC of C1,600/mL(35%, 4/11). The 6-month overall survival rate of the patients with a neutrophil-to-lymphocyte ratio(NLR)of4 was 63%, which was better than the 33% rate in those with an NLR of B4.Nivolumab therapy was a safe and feasible treatment option. The cutoff values of ALC of 2,000/mL for irAEs and of ALC of 1,600/mL and NLR of 4 for prognosis might be effective surrogate markers in nivolumab treatment.

Laparoscopy and endoscopy cooperative surgery(LECS)is an excellent surgical procedure that prevents excessive resection of the gastrointestinal wall and maintains gastrointestinal functions. However, LECS is not recommended for large gastrointestinal stromal tumor(GIST)sized more than 5 cm and/or ulcerative GIST because of the oncological risk of peritoneal dissemination. Here, we report the case of an elderly patient who was successfully treated with LECS-assisted open partial gastrectomy for an ulcerative GIST near the esophagogastric junction.

The stomach is an organ considered resistant to ischemia because of the microvascular networks in the stomach wall, and gastric remnant necrosis following gastrectomy is rare. Herein, we report a case of gastric remnant necrosis following gastrectomy successfully treated using a conservative approach.An 83-year-old woman underwent laparoscopic distal gastrectomy, D1 plus lymphadenectomy, Billroth Ⅰreconstruction, and suture closure of the esophageal hiatus for early gastric cancer and giant esophageal hiatal hernia. The amylase level of the drainage fluid was abnormally high on postoperative day(POD)3, and contrast-enhanced CT confirmed gastric remnant necrosis. The patient was treated using a conservative approach, as her general condition was stable. Postoperative fluoroscopy on POD 21 revealed contrast media leakage from the gastric remnant; however, adequate drainage was observed. Upper gastrointestinal(GI)endoscopy on POD 23 demonstrated circumferential gastric remnant necrosis, whereas GI endoscopy on POD 52 revealed a decrease in the size of the gastric remnant, proliferation of the granulation tissue, and regeneration of mucosa in the gastric remnant.Gastric remnant necrosis following gastrectomy is a rare complication and is associated with poor prognosis. In most cases, total resection of the remnant stomach is warranted. However, for high surgical risk cases, conservative treatment options should be considered based on an assessment of patients' general condition.

Massive gastrointestinal bleeding from gastrointestinal varices is one of the most serious complications in patients with portal hypertension. However, if no bleeding point can be detected by endoscopy in the predilection sites of gastrointestinal varices, such as the esophagus and stomach, ectopic gastrointestinal variceal bleeding should be considered as a differential diagnosis. Herein, we report a case of ectopic ileal variceal bleeding in a 57-year-old woman, which was successfully diagnosed by multi-detector row CT (MDCT) and angiography and treated by segmental ileum resection. To date, there have been no consensus for the treatment of ectopic ileal variceal bleeding. This review was designed to clarify the clinical characteristics of patients with ectopic ileal variceal and discuss possible treatment strategies. From the PubMed database and our own database, we reviewed 21 consecutive cases of ileal variceal bleeding diagnosed from 1982 to 2017. MDCT and angiography is useful for the rapid examination and surgical resection of an affected lesion and is a safe and effective treatment strategy to avoid further bleeding.

The 8th edition of the UICC TNM Classification was released in 2017 and introduced N3a/N3b groupings for gastric cancer. The purpose of this study was to evaluate the validity of the new classification for Stage Ⅲ gastric cancer.Clinical and pathological data on 388 patients who underwent R0 resection from January 1992 to December 2016 in our institution were retrospectively analyzed. The survival in the 7th and 8th edition stage groupings were compared. Differences in survival according to N classification were also examined in the groups with T4a tumor depth.1. The 5-year overall survival(OS)probabilities for Stage ⅢA, ⅢB, and ⅢC of 7th edition were 47.6%, 55.0%, and 28.5%(p=0.0003)and the recurrence-free survival(RFS)rates were 81.1%, 79.4%, and 58.7%(p=0.0013), respectively. In contrast, the OS probabilities of the 8th edition were 50.2%, 41.3% and 30.1%(p=0.0009)and the RFS were 81.6%, 70.9% and 50.0%(p=0.0003), respectively. 2. For T4a tumor depth, the OS probabilities of N1, N2, N3a, and N3b were 48.8%, 54.0%, 27.5%, and 25.1%(p=0.0012)and the RFS were 82.7%, 81.2%, 57.0% and 48.7%(p=0.0013), respectively.The 8th edition of the UICC TNM classification may provide better accuracy than that of the 7th edition in predicting the prognosis of Stage Ⅲ gastric cancer.

Laparoscopy and endoscopy cooperative surgery(LECS)is an excellent surgical procedure that utilizes the advantages of both methods. Furthermore, non-exposed endoscopic wall-inversion surgery(NEWS)is a more promising procedure that enables avoidance of tumor exposure of and dissemination to the abdominal cavity. However, NEWS has the potential risk of postoperative ulceration, leading to delayed perforation because of mucosal defect. We invented a modified NEWS, which was a safe procedure, by including the all-layer suture to close the mucosal defect. We present a case of gastrointestinal stromal tumor(GIST)near the esophagogastric junction, which was treated with modified NEWS.

The REGATTA trial revealed that chemotherapy is the standard strategy for gastric cancer patients with Stage Ⅳ factors. However, some recent studies have identified the prognostic effect of conversion surgery after complete response to Stage Ⅳ factors during chemotherapy. Here, we report a case with Stage Ⅳ factors successfully treated via intensive chemotherapy and conversion surgery without any adverse events and complications, using preoperative parenteral hyper-nutrition and postoperative enteral nutrition. Nutrition might be the key strategy during the treatment of gastric cancer patients with Stage Ⅳ factors.

Lesser curvature lymph node dissection is often performed at the end of the procedure in laparoscopic distal gastrectomy. In obese patients, it can be difficult to secure a visual field, and bleeding or injury of the remnant stomach may occur.After separating the duodenum using an automated suturing instrument, the stomach is rolled under the left diaphragm. An assistant holds the gastric angle near the lesser curvature with forceps in the right hand, and pulls the stomach cephalad toward the left side of the patient. As a result, the region from the esophagogastric junction to the gastric angle is aligned, enabling use of an ultrasonically activated scalpel from the right side of the operator. Dissection is performed from around the posterior wall of the esophagogastric junction to the gastric angle. After dissecting the posterior wall as much as possible, dissection of the anterior wall is performed to complete the lesser curvature procedure.This technique enables safe and reliable dissection of the lesser curvature while avoiding bleeding and damage to the stomach wall.

A 67-year-old man presented with abdominal pain and fever. Many abdominal tumors were detected by enhanced computed tomography(CT). The largest tumor, measuring 20 cm, had perforated the ileum and formed an abscess. Emergency surgery was performed to remove multiple tumors in the peritoneal cavity as much as possible. Immunostaining showed c-kit and CD34 positivity, and the tumors were diagnosed as gastrointestinal stromal tumor(GIST). During postoperative imatinib therapy for the residual tumor, low-dose intermittent administration was required due to side effects, but the disease was controlled for over 91months. For advanced GIST with peritoneal dissemination, 200mg/day imatinib or intermittent administration after volume reduction surgery might be effective depending on the patient's general condition.

The prognosis of patients with gastric cancer and stage IV factors is poor. However, several recent studies have identified that curative surgery followed by S-1 chemotherapy for cytology positive (CY1) only patients contributed to a better prognosis. This study was designed to compare the prognosis between curative and palliative gastrectomy followed by chemotherapy in CY1 only stage IV gastric cancer. Between 2001 and 2016, 1507 patients underwent gastrectomy for gastric cancer. Of these, 51 consecutive patients with only CY1 factor who underwent gastrectomy followed by chemotherapy were enrolled in this study. (1) Twenty three (45%) patients underwent curative D2 or D2+ gastrectomy, and the remaining 28 (55%) patients underwent palliative gastrectomy, followed by S-1 based or another historical recommended chemotherapy postoperatively. (2) Compared with patients undergoing palliative gastrectomy, patients undergoing curative gastrectomy had a significantly better prognosis (P = 0.042; median survival time: curative vs. palliative, 22.6 months vs. 11.8 months) and a lower incidence of recurrences (P = 0.091). Two- and five-year overall survival rates of patients following curative gastrectomy were 48.2% and 18.2%, respectively. A multivariate analysis showed that venous invasion [P = 0.006; hazard ratio (HR), 3.70 (95% CI: 1.27–9.43)] and curative gastrectomy [P

Background/aim The self-expandable metallic stent (SEMS) is an excellent non-invasive tool for emergent bowel obstruction. This study was designed to evaluate the clinical usefulness of the SEMS for avoiding perioperative complications. Patients and methods We analyzed a total of 47 consecutive patients who had a bowel obstruction due to colorectal cancer at initial diagnosis between 2012 and 2017 from hospital records. Results Perioperative complications occurred in 30% (14/47) of patients. Univariate and multivariate logistic regression analyses identified an age of more than 75 years [p=0.037, OR=6.84 (95% CI=1.11-41.6)] and the absence of an SEMS treatment [p=0.028, OR=18.5 (95% CI=1.36-250.0)] as independent risk factors for perioperative complications. Pneumonia (12.7% (6/47)) was the most common complication. There were no pneumonia patients (0% (0/15)) who were treated with the SEMS. In contrast to patients with the non-SEMS treatment, 18.7% (6/32) of all patients and 35.7% (5/14) of elderly patients had pneumonia. Conclusion The SEMS is a safe and effective treatment for avoiding perioperative complications, particularly pneumonia, and may be a crucial strategy in elderly patients with acute obstruction due to colorectal cancer.

Re-laparotomy with resection of the mesh after abdominal incisional hernia repair may cause recurrence of the hernia and infection of the mesh. In the present study, we performed laparoscopic distal gastrectomy(LDG)for early gastric cancer without the resection of the mesh in such a case. A 82-year-old man who had undergone abdominal vascular replacement, cholecystectomy, abdominal incisional hernia repair with the mesh, sigmoidectomy had local recurrence of gastric cancer after endoscopic submucosal resection. We diagnosed as cStage IA and performed LDG without resection of the mesh. He had no recurrence of hernia nor infection of the mesh. Minimizing damage to the abdominal wall by laparoscopic surgery can prevent them.

The patient was a 68-year-old man who underwent Hartmann's procedure for a fistula due to rectal cancer in August 2012. The cancer was tub2tub1, pSE, pN2, pH2, pM1(intrapulmonary metastasis), stage IV. The patient received 5 courses of FOLFOX and bevacizumab as adjuvant chemotherapy. In December 2012, the patient was seen by Otolaryngology for hoarseness. A neck examination revealed induration of the left lobe of the thyroid, and FNA biopsy strongly suggested metastasis of rectal cancer to the thyroid. FDG-PET was performed and revealed extensive accumulation of FDG at the same site. The patient was diagnosed with thyroid metastasis of rectal cancer and underwent a left thyroid lobectomy and lymph node dissection in January 2013. Histopathology confirmed the thyroid metastasis of rectal cancer. Thyroid metastasis of rectal cancer is extremely rare: there are 11 such cases in the Japanese literature, including the case encountered by the current authors. This case is reported here, along with a discussion of some of the literature.

Nearly 70% of gastric cancer recurrences occur as peritoneal dissemination. Most of the treatment for recurrence of gastric cancer dissemination is chemotherapy; depending on the symptoms and the site of recurrence, palliative bypass surgery may be performed. Intensive treatment is often difficult for elderly patients over 85-years-old. This case was a 91-year-old female who underwent total gastrectomy for gastric cancer(signet-ring cell carcinoma)7years prior. Two years ago, a stenosis due to recurrence was revealed in the small intestine and bypass surgery was performed. At that time, she was 89-years-old, and chemotherapy was continued for 1 year. Six months ago, recurrence was revealed in the esophago-jejuno anastomosis. Since the stenosis was severe, it was possible to resume oral reconstitution by inserting a metallic stent. Chemotherapy(S-1)is currently ongoing. There are few reports of long-term treatment for recurrence of gastric cancer peritoneal dissemination in elderly people over 80 years of age. This report is a case of long-term survival involving multidisciplinary treatments, which improved the quality of life(QOL)over the age of 90 years.

A 67-year-old male was referred to our hospital for further investigation of fecal occult blood. We diagnosed him with rectal cancer with osseous metastasis. Chemo-and radiation therapy were administered following resection of the rectal cancer. There were no other lesions except for the osseous metastasis remaining after these interventions. The osseous lesion was then resected. There have no signs of recurrence for 1 year and 9 months since the last operation. We report a case of successful resection of osseous metastasis from rectal cancer.

Retroperitoneal liposarcoma is a relatively rare tumor. The only established therapy is surgical resection and the tumor often recurs. This paper deals with a case of a retroperitoneal liposarcoma in which frequent surgical resections for recurrent tumors have provided relatively long-term survival for the patient. The patient was a 70-year-old woman who had undergone surgical resection for a right retroperitoneal tumor. The pathological diagnosis was dedifferentiated liposarcoma. Thereafter she experienced frequent recurrences which required 3 surgical resections. By means of positive margin for the last surgery, chemotherapy with eribulin was administered. There has been no recurrence 13 months after the last surgery.

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

大腸癌の異時性脾転移の1例を経験した.症例は76歳の男性で, 平成5年4月他院で上行結腸癌に対し結腸右半切除術施行した.平成15年10月近医でCEA高値, 腹部超音波検査にて脾臓に直径10cmの腫瘤を指摘され紹介となった.腹部CTで腫瘤はlow density で, 横隔膜, 左腎臓に浸潤が疑われ, 左腎静脈背側にリンパ節腫脹を認めた.以上より, 大腸癌脾転移を疑い, 平成16年1月脾臓・左腎臓・左副腎摘出術と横隔膜合併切除術を施行した.摘出標本で脾転移巣は高度壊死に陥り, 左腎臓, 左副腎, 横隔膜に直接浸潤し, 組織学的に高分化から中分化腺癌であり, 大腸癌の孤立性脾転移が他臓器に浸潤したと考えられた.大腸癌の孤立性脾転移は非常にまれで, 術後10年目に再発した症例は報告がない.大腸癌術後でも長期フォローが必要で, CEA上昇を来した場合, 再発・転移巣の検索対象に脾臓も考慮にいれるべきと考えられた.

目的)膿胸に対する有茎性大網法につき,有用性,限界を検討する.方法)閉鎖困難な有瘻性症例,大きな腔を有するが十分な筋肉弁を作成困難な症例,菌陰性化しない症例,胸郭成形術を避けたい症例を有茎性大網法の適応とし,有茎性大網法を行った膿胸10例につき,背景因子,術式,術式選択理由,治療成績,腹部合併症を検討した.結果)全例一度治癒退院したが,醸膿胸膜が遺残した2例が,晩期再発した.有瘻性症例,菌陰性化しない症例,腔遺残した症例,一期的手術も成功率が高かった.腹部合併症は軽度であった.結論)瘻孔閉鎖が成功しやすい,非耐性菌であれば菌陰性化を要さない,腔遺残しても治癒率が高いなどの利点から膿胸治療上有茎大網法は成功率が高く有用である.一方,膿胸壁残存症例で晩期再発を認めた.限界を理解した上で適応,治療手順を考え,有茎性大網法を施行することが重要である.

症例は77歳の女性で,6年前より痔瘻,痔核を指摘されていたが放置していた.難治性痔瘻の診断にて腰椎麻酔下に痔瘻根治術を施行した.瘻孔内に粘液様物質を認め,これを迅速病理診断に提出したところ粘液癌の診断であったため,臨床的に痔瘻癌の診断にて根治術として二期的に全身麻酔下に腹会陰式直腸切断術を施行した.ところが術後病理診断にて痔瘻癌の診断(P, 5, a2, P(-), HO, n(-), M(-)stage II)とともに皮膚切除断端に悪性細胞(Paget cell)陽性であったため,皮膚科にてmappingの上,後日皮膚,皮下脂肪織追加切除を行い根治を得た.慢性炎症を伴う痔瘻は癌の合併に注意が必要である.今回,肛門周囲Paget病に関して,その拡がりの評価にmappingが有用であった.

今回われわれは胃切除術後40年目に発症した腸重積症の1例を経験したので報告する.症例は75歳,男性.突然の腹痛と嘔吐を主訴に近医より当院に絞扼性イレウスの診断で救急搬送された.既往歴として約40年前に胃潰瘍に対して胃切除術(BillrothII法)を受けていた.入院時現症は左上腹部に腫瘤を触知し同部に圧痛,反跳痛,筋性防御を認め,腹部CT検査にてtarget signを認め腸管内に重積腸管の横断面が層状構造を呈して描出された.腸重積と診断,緊急開腹手術を施行した.開腹所見として輸出脚空腸が逆行性にBraun吻合を通り3筒性に重積を起こしていた. Hutchinson手技にて整復するも腸管の色調が悪かったため,空腸切除術を付加した.胃切除術後の腸重積症は稀な疾患であるが,術後の腸閉塞の診断においては本症も念頭におき, CT検査などを有効に用い早期に適切な治療を行う必要があると考えられた.

A 70-year-old woman with unresectable advanced gastric cancer accompanied by peritoneal dissemination underwent jejunostomy, and was treated with S-1 and low-dose CDDP. One course consisted of S-1 (80 mg/day) via an intestinal fistula tube from days 1 to 14. This was followed by 7 days rest, and CDDP (20 mg/day) was administered by 1-hour continuous intravenous infusion on day 1 and 8. She continued to receive this chemotherapy for a total of 14 courses, followed by 3 courses of a weekly paclitaxel regimen. She died 14 months after surgery. All chemotherapy had been conducted in an outpatient setting. We concluded that the administration of S-1, combined with low-dose CDDP (div) through a jejunostomy, can improve the quality of life (QOL) of a patient who has unresectable advanced gastric and is incapable of oral intake. We report this rare case with a review of the literature.

The patient was a 74-year-old man whose chief complaint was epigastralgia. A detailed examination revealed a gastric cancer located from antrum to duodenal bulb with multiple liver metastases. Because of a difficulty with oral intake, we performed a distal gastrectomy at first. After the operation, a combination chemotherapy with S-1 and weekly paclitaxel was performed, and liver metastases were successfully disappeared after 4 courses of the regimen. A subsequent CT evaluation after 6 courses of the regimen revealed that liver metastases maintained the clinical complete response (cCR), but a right adrenal tumor was detected. We performed a right adrenalectomy after 13 months from gastrectomy, and a histopathological examination revealed that the adrenal tumor was a recurrent gastric cancer. After the second operation, only one course treatment of S-1 alone was performed because the patient rejected the chemotherapy. The patient is alive without a chemotherapy and maintained cCR for 75 months after the second operation.

Recently sigmoid-visceral fistula which is a candidate for surgical treatment is increasingly encountered, with an increase in the frequency of sigmoidal diverticulitis. In patients complaining of bladder distress and intestinal dysfunction, the early diagnosis with barium enema and cystoscopic examination is important, bearing in mild a possible occurrence of sigmoid-visceral fistula. Careful attitude is mandatory to rule out probable association of malignant disease from the overlapping of the sigmoid colon in barium enema examination and the inflammatory changes in cystoscopic examination. As for the operation, an one stage procedure consisting of resection of the fistula with the bowel is recommended. Partical cystectomy was not necessary in two cases experienced. This paper reports a case of sigmoid-visceral fistula with a review of the literature.

A 64-year-old man was admitted to our hospital with anal pain on evacuation. MRI revealed a large rectal submucosal tumor, more than 6 cm in diameter. Fine needle histological diagnosis indicated GIST with moderate risk. The patient was treated with imatinib mesylate in order to preserve the anus. The anal pain and tumor size decreased. Trans-anal local excision was performed. This case suggests that imatinib mesylate can make it possible to treat large rectal GIST cases by preserving anus, if neoadjuvant chemotherapy can be effective.

近年, 平均寿命の上昇に従い高齢者胃癌患者数も増加しつつある.教室で切除した過去15年間の75歳以上の高齢者胃癌症例数は前期 (1973～1977);17例, 中期 (1978～1982);23例, 後期 (1983～1987);38例の計78例であり, 前期に比べ後期では約2倍に増加した.表在癌の占める割合が, 5.9%から39.5%へと時期とともに飛躍的に増加したのに反し, 進行癌は94.1%から60.5%と著明に減少した.手術直接死亡は中期に1例のみであり, 各自期間に差はなかった.リンパ節郭清程度はいずれの時期にも60%前後にR2郭清がなされたが, 絶対的治癒切除率は29.4%から63.2%へと上昇し累積5年生存率も9.3%から50.5%へと有意に向上した.これには早期胃癌の発見率が高くなったことが大きく寄与していると考えられた.

Little is known about the clinicopathological features of intermediate-stage T2 gastric cancer, defined as tumors invading the muscularis propria or subserosa.Of 808 patients with gastric cancer, 210 patients (25.9%) who underwent gastrectomy for T2 gastric cancer were selected for this retrospective study. The clinicopathologic findings of these patients were analyzed retrospectively from their hospital records.Of all 808 patients with gastric cancer, 73 patients (9.0%) had tumors invading the muscularis propria (mp). The remaining 137 patients (16.9%) had tumors invading the subserosa (ss). Compared with ss gastric cancer, mp gastric cancer was associated with smaller tumor size, an absence of lymphatic spreading, and hematogenous and late recurrence [disease-free interval: 654.5 days (mp) vs. 365.5 days (ss)]. Univariate analysis of cases with curative operations showed that lymphatic invasion, and lymph node metastasis were significant prognostic factors in patients with T2 gastric cancer. Further examination by multivariate analysis demonstrated that pN2 or higher as classified by both the JCGC (Japanese Classification of Gastric Cancer) and the TNM lymph node staging systems was a predictor of poor prognosis.JCGC and TNM lymph node staging systems were the most reliable prognostic factors for T2 gastric cancer. Close follow-up should be required for patients with stage pN2 or higher gastric cancer. Long-term follow-up should be required for mp cancers, in particular.