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Background Lymphangioma originating from the small intestinal wall is a very rare finding. There have been only 15 case reports on the disease. Here, we report a case of lymphangioma in the small intestine that was resected laparoscopically. We also provide a literature review. Case Presentation A 37-year-old man came to our hospital with a chief complaint of abdominal pain. Physical examination showed mild tenderness in the lower abdomen, but rebound tenderness or guarding was absent. A contrast-enhanced computed tomography scan showed local poor enhancement in distal ileum, suggesting the possibility of mucous necrosis. Conservative therapy was started. On the eighth hospital day, although his abdominal symptoms improved, a follow-up computed tomography scan showed no improvement in the distal ileum lesion. Laparoscopic tumor resection was performed. The patient's postoperative course was unremarkable, and he was discharged on postoperative day 7. The pathologic result of the surgical specimen was lymphangioma of the ileum. The patient is still alive with no sign of recurrence 19 months after surgery. Conclusion Lymphangioma originating in the small intestinal wall is a very rare disease. Laparoscopic resection seems to be a preferable method for surgery.

Chemotherapy-induced nausea and vomiting(CINV)are typical side effects caused by chemotherapy. We analyzed CINV during first-line chemotherapy for gastric cancer.Thirty-one patients who received first-line chemotherapy for gastric cancer were retrospectively assessed for CINV.The median age was 70 years, and the gender(male/female)was 23/8 cases. NK1 receptor antagonist, 5-HT3 receptor antagonist, and dexamethasone were used as antiemetic agents in 29 patients(94%). Sixteen patients(52%)had Grade 1 or higher nausea, and 6 patients (19%)had Grade 1 or higher vomiting, and complete control of nausea and vomiting was achieved in 21 patients(68%). Nausea was significantly more frequent in patients with liver metastasis(p=0.0008), but there was no significant difference in vomiting(p=1.0000). There was no significant difference in the occurrence of CINV between chemotherapy regimens or combination of olanzapine.During first-line chemotherapy for gastric cancer, 3 antiemetic agents were used in 94% of cases, and the complete control rate of CINV was 67.8%.

We report a case of early gastric cancer with Adachi Type Ⅵ vascular anomaly treated by laparoscopic distal gastrectomy. An 81-year-old woman was admitted because of anorexia, and was diagnosed with early gastric cancer. Preoperative MDCT revealed Adachi Type Ⅵ vascular anomaly, where the hepatic artery does not appear at the superior border of the pancreas. The patient was treated successfully with laparoscopic distal gastrectomy with D1+lymph node dissection. At surgery, we identified the portal vein, then, dissection of No. 8a lymph nodes was performed. The postoperative course was uneventful and the patient was discharged 10 days after surgery. The final pathology result showed gastric cancer, M, Less, Type 0-Ⅱc+Ⅲ, 58×50 mm, tub1pap, pT1a(M), Ly0, V0, pN0(0/40), H0, P0, M0, pStage ⅠA. We understand the arterial running pattern before surgery by using MDCT, and performed laparoscopic surgery safely.

Background There is no consensus on the optimal timing of laparoscopic cholecystectomy (LC) after gallbladder drainage for acute cholecystitis (AC). To obtain evidence for a consensus, we investigated surgical outcomes of LC after gallbladder drainage with respect to the time elapsed from gallbladder drainage to surgery in a multi-institutional retrospective study. Methods This study enrolled 347 patients who underwent LC after gallbladder drainage for AC at 15 institutions. Surgical outcome of LC was investigated in the cases based on the interval from gallbladder drainage to surgery. Results The median interval from gallbladder drainage to surgery of the patients was 34 days, with a mean ± standard deviation of 58 ± 99 days. Patients were divided into four groups based on quartiles of the interval: Group A, cases with an interval of 1-12 days; Group B, cases with an interval of 13-34 days; Group C, cases with an interval of 35-73 days; and Group D, cases with an interval of ≥74 days. Surgical outcomes, which were evaluated with respect to intraoperative blood loss, operation time, postoperative hospital stay, rate of intraoperative accident, conversion from laparoscopic to open surgery, and postoperative complication, were worse in Group B than in the other groups. The finding was verified by propensity score-matched analysis. Conclusions Surgical outcome of LC after gallbladder drainage for AC was inferior in Group B compared with the other groups. This finding could be useful for determining the optimal timing of LC after gallbladder drainage for AC.

Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation.In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC.Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P .01), severity of cholecystitis (P = .04), previous history of treatment for common bile duct stones (CBDS) (P .01), and surgeon experience (P = .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P .0001) and previous history of treatment for CBDS (odds ratio 0.37; P = .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P .0001).Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.

A 71-year-old male had repeated resection and transcatheter arterial chemo-embolization(TACE)for hepatocellular carcinoma(HCC). Treatment with lenvatinib was started due to multiple liver recurrences and peritoneal disseminations. Since only the disseminated lesion had increased, it was decided to perform laparoscopic resection. Indocyanine green(ICG) was intravenously injected the day before surgery. Disseminated lesions could be easily detected with intraoperative fluorescence imaging, and we could completely resect disseminated lesions. The ICG fluorescence could be considered to be useful in laparoscopic resection for peritoneal dissemination of HCC.

A 67-year-old woman with a pancreatic cancer diagnosed by endoscopic ultrasound with fine needle aspiration(EUS- FNA)was underwent distal pancreatectomy. Two years and 10 months after the operation, a computed tomography scan revealed a tumor in the posterior wall of the lower body of the stomach. Upper gastrointestinal endoscopy showed a 15 mm-sized submucosal tumor on the posterior wall of the angular region, and its biopsy showed tubular adenocarcinoma that it was resembling the resected pancreatic cancer. Needle tract seeding(NTS)of the pancreatic cancer to the gastric wall was suspected. After 5 courses of chemotherapy with gemcitabine and nab-paclitaxel, the tumor shrank and there were no other signs of metastasis, we performed distal gastrectomy. The pathological findings of the resected specimen showed a tubular adenocarcinoma, consistent with the primary pancreatic tumor. We finally diagnosed as the NTS of the pancreatic cancer to the gastric wall. In the case of EUS-FNA for the body or tail tumor of pancreas, it should be paid attention to the recurrence due to NTS because the surgical resection does not include the needle tract site.

When percutaneous transhepatic gallbladder drainage (PTGBD) is followed by laparoscopic cholecystectomy (LC), there is no consensus regarding whether the drainage tube should be preserved or removed before LC. We hypothesized that the surgical results of LC might differ between cases with PTGBD tube preservation versus removal. Here, we investigated how drainage tube preservation or removal affected the surgical outcome of LC.Using data from our previous multicenter study, we compared LC outcomes after PTGBD between patients with PTGBD tube preservation versus removal. This study included 208 patients who underwent LC over 12 days after PTGBD. In 83 cases, the PTGBD tube was preserved until LC, and in 125 cases, the tube was removed before LC. The results were verified by propensity score matching with 50 patients in each group.Cases with tube preservation versus removal exhibited significantly longer surgery duration (174 ± 105 min vs 145 ± 61 min, P = .0118) and postoperative hospital stay (14 ± 16 days vs 7 ± 7 days, P .0001), a significantly higher postoperative complication rate (13.2% vs 3.2%, P = .0061), and a marginally higher incidence of open conversion (12.0% vs 4.8%, P = .0547). Propensity score matching verified the inferior surgical outcomes in cases with tube preservation.These results imply that when LC is performed 12 days after PTGBD, the surgical outcome may be inferior when the drainage tube is preserved rather than removed before LC.

We report a case of advanced gastric cancer that was successfully treated with mFOLFOX6 therapy. A 78-year-old man presented to our hospital with a chief complaint of weight loss. Esophagogastroduodenoscopy(EGD)and computed tomography( CT)revealed the presence of type 3 advanced gastric cancer with distant lymph node metastasis and peritoneal dissemination. Biopsy specimen examination revealed moderately differentiated adenocarcinoma with a HER2 score of 1. Chemotherapy comprising 5-fluorouracil, Leucovorin, and oxaliplatin(mFOLFOX6)was administered because of renal failure. Subsequently, the gastric lesion, distant lymph node metastasis, and peritoneal dissemination were seen to be reduced on EGD and CT. After 7 courses, the regimen was changed to 5-fluorouracil and Leucovorin(5-FU/l -LV)chemotherapy because of thrombocytopenia. For more than 10 months, he has continued to receive chemotherapy without the recurrence of metastasis.

This is the first report of the double primary cancer of esophageal cancer (EC) and myelodysplastic syndromes (MDS) treated without esophagectomy. Previously reported cases of the double cancer mostly describe secondary MDS arising after treatment for EC. The double primary cancer was manageable with close follow‐ups for possible recurrence.

A 74‒year‒old man was diagnosed with advanced gastric cancer with para‒aortic lymph node metastasis and ascites. He has been treated with S‒1 plus oxaliplatin as the primary treatment, paclitaxel plus ramucirumab as the secondary treatment and CPT‒11 as the third‒line treatment, but the effect of all treatments were temporary and left adrenal metastasis appeared during the course. Nivolumab was started as the fourth‒line treatment. Two months later, para‒aortic lymph nodes and left adrenal metastasis were markedly shrank and ascites disappeared. A 79 years old woman was performed proximal gastrectomy for advanced gastric cancer of the upper stomach. S‒1 therapy was started as adjuvant chemotherapy, but tumor markers have been increased and para‒aortic lymph node recurrence was observed 4 months after the operation. After ramucirumab as the primary treatment was ineffective, nivolumab was started as the secondary treatment. Two months later, para‒aortic lymph nodes shrank below the significant size and tumor markers were normalized.

We report a case of gastrointestinal submucosal tumor with an intraluminal growth pattern resected by laparoscopic wedge resection. A 62-year-old man was admitted because of melena. Upper gastrointestinal endoscopy revealed gastrointestinal submucosal tumor with an intraluminal growth pattern just below the gastric junction, and the pathological diagnosis was GIST. A laparoscopic wedge resections(percutaneous endoscopic intragastric surgery)was performed by a single access port. After laparotomy 5 cm above the umbilicus, the anterior wall of the middle part of the stomach was incised and fixed to the skin, and the tumor was dissected with a linear stapler. The final pathology result showed a high risk GIST of 70×40 mm with 110 mitotic images/50 HPF, and the patient was treated with imatinib mesylate adjuvant chemotherapy. There were no complications, including postoperative transit disturbances, and there were no local or distant metastatic recurrences.

Since delirium has various adverse effects in patients with malignant tumors, it is important to eliminate the cause. We investigated delirium in patients with malignant tumors.Seventy seven malignant tumor patients who admitted to palliative care unit from May 2015 to March 2016 were subjected to a retrospective analysis of delirium.Delirium was present in 17 patients(22.1%)on admission, and in 38 patients(49.4%)before discharge. After hospitalization, delirium improved without relapse in 5 patients(29%)and the onset of delirium was avoided in 34 patients(57%). Factors of delirium at admission were nausea and day/night reversal, factors of delirium at discharge were dementia, pain, and day/night reversal.In the present study, we investigated the causes and course of delirium in patients with malignant tumors.

Generally, the first treatment plan for anal canal squamous cell carcinoma(SCC)is chemo-radiation therapy(CRT). We experienced an extremely rare surgery case of anal canal SCC after prostate brachytherapy. A man in his 70s who had undergone brachytherapy for prostate cancer 8 years before visited our hospital because of blood in feces. A tumor prolapsed from the anal verge, and biopsy revealed SCC. Contrast-enhanced computed tomography showed front-wall thickness in the lower rectum, but we could not evaluate it in detail because of the halation by brachytherapy seeds. We performed laparoscopic abdominoperineal resection to avoid an overdose of radiation for the rectum. Pathological staging was pT2N1aM0, pStage ⅢA. These findings might suggest radiation-induced cancer after brachytherapy.

A 65-year-old male received the positive result of fecal occult blood. Colonoscopy was performed to reveal a tumor in the ascending colon. The result of biopsy was neuroendocrine carcinoma. Under the preoperative diagnosis of neuroendocrine carcinoma in the ascending colon, cT3N0M0, cStage Ⅱ, laparoscopic ileocecal resection with D3 lymph node dissection was performed. The pathological result was neuroendocrine carcinoma in the ascending colon, pT4aN2M0, pStage Ⅲc. The R0 resection was achieved. As adjuvant chemotherapy, the regimen of cisplatin plus irinotecan was administered for 4 courses. No recurrence was seen until 9 months after the operation, when multiple peritoneal and hepatic metastasis were detected on CT scan. The chemotherapy regimen of etoposide plus carboplatin was started and is now ongoing. The patient is now alive 13 months after the operation.

A 96-year-old woman was brought to our hospital for epigastric pain. Abdominal contrast-enhanced CT and MRCP showed wall thickness of the fundus and extravasation in the gallbladder. With a diagnosis of gallbladder hemorrhage from the tumors, we performed laparoscopic cholecystectomy. The histopathological diagnosis was gallbladder cancer. Herein, we report on this case and also provide a literature review.

A 76-year-old man had undergone right lobectomy after transcatheter arterial chemoembolization(TACE)for hepatocellular carcinoma(HCC)in segment 5/6 of the liver. He had undergone TACE for intrahepatic recurrence in segment 1 eight months after the operation. Abdominal CT revealed intrahepatic recurrence in segment 2 and segment 3 and a hepatic portal lymph node swelling 13 months after the operation, he underwent TACE and radiofrequency ablation for intrahepatic lesions. There was neither intrahepatic recurrences nor new extrahepatic lesions, and the hepatic portal lymph node resection was performed. He was discharged on postoperative day 8, and there has been no subsequent recurrence over 42 months after initial treatment. The lymph node metastasis of HCC is rare and systemic chemotherapy such as molecular targeted argent is the standard treatment, but its prognosis is poor. When a patient has a resectable metastasis with controlled intrahepatic lesions, lymph node resection appears to be an effective option.

We report a case of early gastric cancer in the remnant stomach after successful treatment with endoscopic submucosal dissection(ESD). A 64-year-old woman had undergone distal gastrectomy, D2 dissection, and Billroth Ⅰ reconstruction for advanced gastric cancer 11 years previously. During a routine upper gastrointestinal endoscopy, an elevated lesion was detected at the lesser curvature of the upper gastric body of the remnant stomach, and biopsy indicated a Group 4 tumor. Curative en bloc resection of the lesion was achieved via ESD, although there was severe fibrosis along the suture line. The pathological result was 0-I, pT1a, tub1, 3×3 mm, UL(－), ly(－), v(－), HM0(8 mm), VM0(800 μm), indicating curative resection. Surveillance of the upper gastrointestinal tract 5 years after gastric cancer surgery enabled the early detection of the gastric cancer and curative resection with ESD.

We report a case of laparoscopic repair of a diaphragmatic hernia after left hepatectomy for liver cancer. A woman in her 70s had undergone left hepatectomy for liver cancer 9 months earlier, and she was admitted because of epigastric pain after vomiting immediately following contrast-enhanced CT. On the next day, contrast-enhanced CT revealed an incarcerated diaphragmatic hernia, for which laparoscopic diaphragmatic hernia repair was performed. The incarcerated stomach was pushed back into the abdominal cavity, and the diaphragm was closed with 2-0 proline sutures. Gastric resection was not performed because the blood flow gradually improved. The postoperative course was good; the patient was discharged on the 7th postoperative day and is under outpatient follow-up.

Background Due to the development of diagnostic imaging technology, we have increased chance of detecting multiple primary cancers. However, simultaneous triple cancer is still a very rare finding whose frequency is not yet known. Treatment of simultaneous triple cancer is a clinical challenge because it requires multimodal strategies including surgery, chemotherapy and radiotherapy. Case presentation Here, we present the case of a 74-year-old male with triple cancer involving esophageal and pancreatic cancer, and rectal carcinoma. Each cancer was surgically resectable, but simultaneous resection of all cancers seemed to cause too much surgical stress for the patient. First, we performed a laparoscopic Hartmann’s operation for rectal cancer to minimize the risk of postoperative complications. Then treatment for pancreatic cancer was initiated by administering neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel. The pancreatic tumor shrank in size, so pancreatoduodenectomy was performed. We chose S-1 as adjuvant chemotherapy. The esophageal cancer showed regression during the treatment of the other two cancers, likely because the chemotherapeutic agents administered for pancreatic cancer had some effect on the esophageal cancer. Definitive chemoradiotherapy was selected instead of esophagectomy because the patient had already undergone two major surgeries. The patient is still alive nine months after the whole course of treatment with no sign of recurrence. Conclusions The treatment of triple cancer requires an elaborate strategy to determine which cancer has to be dealt with first and which can be treated later. An aggressive multimodal treatment strategy may be an important option for a patient with triple cancer.

A 71-year-old man underwent laparoscopic lower anterior resection(D3 dissection)for rectal cancer and bilateral lung metastases. Histopathological findings indicated Ra, type 2, tub2, ly0, v2, pN0, pM1(PUL1), pStage Ⅳ. The lung metastases had disappeared after postoperative chemotherapy and the patient entered cCR. Two years after the surgery, the patient's anal fistulas appeared sclerotic. Biopsy revealed recurrent rectal cancer. We performed an abdominoperineal resection and rectus abdominis muscle flap. Currently, the patient is alive at 9 months after surgery with no re-recurrence.

We report a case ofadvanced colon cancer, stage cT4bN0M0 in the descending colon with formation ofabscesses in the retroperitoneal space ofa 66-year-old woman. After constructing a transverse colostomy and percutaneous abscess drainage, chemotherapy was initiated with CAPOX. After 4 courses of CAPOX, the tumor had significantly regressed; therefore, the regimen was switched to a triplet combination called CAPOXIRI. After 3 courses of CAPOXIRI, the tumor had become smaller and had separated from the iliopsoas muscle, which led us to perform surgical resection. Left hemicolectomy was performed with R0 resection, and the tumor was pathologically diagnosed as ypT3N0M0. The patient is alive 12 months after the surgery, with no signs of recurrence.

A 60-year-old man was diagnosed with advanced gastric cancer(cT4a, N1, M1[No. 16LYM], cStage Ⅳ). He was treated with a neoadjuvant chemotherapy of a regimen consisting of capecitabine plus oxaliplatin, followed by distal gastrectomy with D2 and No. 16lymph node dissection and partial hepatectomy of S3 and S6. He had an uncomplicated postoperative course and was discharged early from hospital. Capecitabine was started at POD 40 as an adjuvant chemotherapy. Postoperatively, the histological effect was determined to be Grade 2, and hepatic tumors and lymph nodes showed no residual cancer. He started capecitabine monotherapy as adjuvant chemotherapy. At 10 months postoperatively, the patient was alive and relapse-free.

In general, distant metastasis is uncommon in colorectal submucosal(SM)invasion without lymph node metastasis. We experienced an extremely rare case of synchronous pulmonary metastases for colon cancer in SM invasion. A man in his 70s was seen at the hospital for a positive fecal occult blood test. Colonoscopy revealed 3 lesions in the sigmoid colon and endoscopic mucosalresection revealed 2,000 mm SM invasion in all 3 lesions. Computed tomography showed no signs of distant lymph node or liver metastasis but showed small nodules in both lungs. Radical treatment included laparoscopic anterior resection with lymph node dissection. Histological examination showed no residual tumor in the colon and no lymph node metastasis. Two years after surgery, the number of lung nodules gradually increased and we performed partial resection of the left lung, which was diagnosed as pulmonary metastasis from colon cancer by histological examination. Therefore, we resected the opposite-side pulmonary metastases. The patient has exhibited no other signs of recurrence in the 2 years since the last operation.

A 73-year-old man underwent a subtotal stomach preserving pancreaticoduodenectomy(SSPPD)for biliary carcinoma without regional lymph node metastasis. Although S-1 was administrated as adjuvant chemotherapy after the operation, the serum CA19-9 level was gradually elevated, and a liver metastasis of 27mm in diameter was detected in Couinaud's segment 8 during chemotherapy. We administrated gemcitabine(GEM)and cisplatin(CDDP)combination therapy(GC therapy). The liver tumor was immediately shrunk to 6mm and kept up the PR state after 15 courses of GC therapy. A stereotactic body radiation therapy(SBRT)was performed 1 year 8 months after the operation. The patient has been alive without recurrence for 4 years since the SBRT. Although systemic chemotherapy is the standard treatment for the recurrence of biliary carcinoma, a loco-regional therapy such as SBRT may be an effective alternative when a patient has a solitary metastasis to the liver with no other evidence of recurrence.

Surgeons are increasingly being faced with the challenge of treating elderly patients with colon cancer. The present study therefore aimed to compare the short-term outcomes of single-port laparoscopic surgery (SILS) for elderly patients with colon cancer (≥70 years) with those in younger patients (41–69 years; control group). Among 100 patients with colorectal cancer who had been treated with single-port laparoscopic surgery between January 2011 and December 2014, 56 (56.0%) were ≥70 years of age. The results of treatment and short-term outcomes in the elderly group (n=56) were retrospectively compared with the younger patients in the control group (n=44). The sex distribution, body mass index, history of prior surgery and the American Society of Anesthesiologists physical status classification were similar between the groups. Onodera's prognostic nutritional index demonstrated significant differences between the elderly and control groups (38.3 vs. 49.8; P

Urinary tract resection is the only procedure that can cure colorectal cancer that directly invades the ureter. In these cases, open surgery is commonly used. Here, we describe our experience of a case of sigmoidectomy following Boari flap construction with single-incision laparoscopic surgery (SILS) for advanced colon cancer with ureteric invasion. A 68-year-old woman was referred to our hospital with left flank pain. Left hydroureteronephrosis was detected on ultrasonography. Computed tomography revealed a solid mass in the sigmoid colon and hydroureteronephrosis due to swelling of a mesenteric lymph node. Computed tomography detected no signs of distant metastasis. Colonoscopy revealed an ulcerated, bleeding, and stricturing lesion in the sigmoid colon, which was identified as an adenocarcinoma with a moderate degree of differentiation at histological examination. Under general anesthesia, the patient was placed in the Trendelenburg semi-right lateral position. An umbilical incision was made for the insertion of a single multichannel port for SILS. Sigmoidectomy and Boari flap reconstruction were performed. There were no perioperative complications. The total operating time was 572 minutes (including Boari flap procedure of 174 minutes), and estimated blood loss was 200 mL. Single-incision laparoscopic sigmoidectomy with Boari flap construction is technically feasible with sigmoid cancer and ureteral invasion.

The patient was a man in his 70s who visited our hospital to undergo an examination for fecal occult blood, which detected a 20 mm, Ⅱa lesion in the lower rectum on colonoscopy. He was diagnosed with SM-invasive cancer and was planned to undergo trans-anal local excision. After the surgery, he had a good postoperative course without complications. The pathological findings were Ⅱa, tub1, 22×16 mm, pT1a(950 mm), int, INF a, ly0, v0, pHM0, pVM0(300 mm). He was followed up after the surgery, but was diagnosed with lateral lymph node recurrence 4 years after a local surgery. The surgery involved right-sided lateral lymphadenectomy with resection of the ureter, spermatic duct, seminal vesicle, and piriformis muscle. He was diagnosed with lymph node metastasis with invasion of the spermatic duct based on pathology. Eight courses of adjuvant chemotherapy containing CapeOX was administered. Unfortunately, primary squamous cell lung cancer was detected, and he died after surgery for recurrence in the second year. It is suggested that it is necessary to note lateral lymph node recurrence on postoperative follow-up for lower rectal cancer at any stage.

We report a case of surgical resection of an early gastric cancer that coexisted with multiple submucosal heterotopic gastric glands.A man in the 80's referred to our department because of an increased level of CEA.He had undergone hepatectomy for heterochronous liver metastasis of colon cancer.Gastrointestinal endoscopy revealed an early gastric cancer that coexisted with multiple submucosal gastric glands.He underwent segmental gastrectomy for gastric cancer.He exhibited no symptoms at the time of discharge.He has had no recurrence of gastric cancer 6 months after the surgery.We should appropriately care for synchronous or heterochronous gastric cancer in the remnant stomach if total gastrectomy is not performed in cases of therapy for gastric cancer with multiple submucosal heterotopic gastric glands.

In general, anastomotic recurrence of colorectal cancer occurs within 3 years after surgery. We encountered an extremely rare case of anastomotic recurrence over 20 years after surgery. A 70-year-old woman who had undergone low anterior resection for rectal cancer 22 years previously was admitted to the hospital because of anal bleeding. Colonoscopy revealed a 1.5 cm sized, elevated lesion on the anastomotic site, and a biopsy revealed an adenocarcinoma(tub2). EUS demonstrated that the tumor was located on the staples, and the depth of the tumor was expected to be within the muscle layer of the rectum. Computed tomography showed no signs of distant metastasis. Given the diagnosis of anastomotic recurrence of rectalcancer 22 years after surgery, laparoscopic abdominoperinealresection was performed. Histologicalassessment showed that the tumor was on the staples, and did not exhibit vascular and lymphatic invasion. Finally, she was diagnosed with anastomotic recurrence due to implantation. The patient has exhibited no other signs of recurrence in the 3 years since the last surgery.

The safety of single-incision laparoscopic surgery (SLS) in elderly patients with colorectal cancer has not been established. The aim of the current study was to compare the outcomes of SLS and multi-port laparoscopic surgery (MLS) and to assess the feasibility of SLS in colorectal cancer patients aged ≥70 years. A retrospective case-control study of colon cancer patients undergoing elective surgical intervention between 2011 and 2014 was conducted. A total of 129 patients with colon cancer underwent surgery and were included in the analysis. Data regarding patient demographics, surgical variables, oncological outcomes and short-term outcomes were evaluated for statistical significance to compare MLS (n=79) and SLS (n=50) in colon cancer patients. No significant differences were observed in patient characteristics. No case required re-admission within 30 days post surgery. The mean surgery times were similar for the MLS and SLS groups when cases with left and right hemicolectomies were combined (207.7 and 215.9 min, respectively; P=0.47). In addition, overall perioperative outcomes, including blood loss, number of lymph nodes harvested, size of the surgical margin and complications, were similar between these groups. Thus, we suggest that SLS can be performed safely in elderly patients with colon cancer.

Creation of a cholecystojejunostomy has been recommended as one option in the palliation of biliary obstruction due to pancreatic carcinoma.However, it was a technique used for biliary drainage for acute cholecystitis a long time ago.We describe a patient who underwent a cholecystojejunostomy for acute cholecystitis 50 years prior to presentation, and then revealed a gallbladder carcinoma.

Hepatocellular carcinoma(HCC)is not commonly observed with bile duct thrombosis.Here, we report a case of HCC with bile thrombi that extended to the liver hilum.The patient was a 61-year-old man who visited us due to untreated type B hepatitis.He underwent screening with a CT scan that revealed LDA on the right posterior lobe of his liver with infiltration of the bile duct.Generally, bile resection and reconstruction should be considered for curative resection for bile thrombi; however, we attempted to conserve the common bile duct to preserve the options of percutaneous therapy in case of tumor recurrence.We performed right lobectomy of the liver.The bile duct thrombus was extracted without bile duct resection or reconstruction.The patient is alive 6 months after the surgery without any development.

Solid serous cystadenoma of the pancreas is the rarest subtype of serous cystadenoma. Cystic structures are difficult to recognize by imaging studies. In the clinical setting, it is crucial to discriminate a solid serious cystadenoma from other solid pancreatic tumors. The present study reported a case of solid serous cystadenoma in which the magnetic resonance cholangiopancreatography (MRCP) findings were useful for diagnosis and decision-making regarding the surgical strategy, with a review of the previous reports of solid serous cystadenoma. A 50-year-old woman was referred to our hospital for investigation of a pancreatic body mass. A 2-cm hypervascular solid tumor was revealed by computed tomography. No typical radiological imaging findings of small cysts were detected, such as a honeycomb structure, and an adequate specimen could not be gained by biopsy under endoscopic ultrasonography. However, the tumor showed high intensity on MRCP, suggesting its cystic nature. A solid serous cystadenoma was suspected based on these radiological findings, and middle segment pancreatectomy was performed as a function-preserving surgery. The histological findings were compatible with a solid serous cystadenoma. In conclusion, MRCP imaging may be helpful for diagnosis and decision-making regarding the most appropriate surgical method for solid serous cystadenomas.

A 70's woman with a history of abdominal surgery for gastric cancer visited our hospital for the evaluation of bleeding during defecation.We diagnosed her with advanced rectal cancer and performed laparoscopic low anterior resection.As postoperative pathological staging was pT3N2M0, pStage III b, we included CapeOx therapy as adjuvant chemotherapy.One year and 4 months after the surgery, lung and liver metastases were revealed by CT and PET-CT scans.At the same time, dilatation of the main pancreatic duct(intraductal papillary mucinous neoplasm: IPMN)was detected.Thus, we first performed liver resection and then lung resection.After the surgery, new lung nodules and a mass lesion with IPMN with superior mesenteric venous invasion was found on CT scans.We then administered chemo-radiation therapy(CRT).After CRT, the lung and pancreatic lesions seemed to decrease slightly.Accidentally, a nodule on the cystic bladder was found, resected by transurethral resection of the bladder tumor(TUR-Bt), and diagnosed as a bladder cancer.Thirty months after the rectal surgery, she is continuing the S-1 chemotherapy with stable disease.

Limited data on laparoscopic and robotic total pelvic exenteration (TPE) for gynecologic, urologic, and rectal malignancies have been published in the literature. Single-incision laparoscopic surgery (SILS) has been successfully introduced for colon cancer. Here, we describe our experience of TPE with SILS + 1 port (SILS+1) for advanced rectal cancer. A 64-year-old man was referred to our hospital with anemia. Computed tomography (CT) revealed a rectal tumor that was contiguous with the seminal vesicle and bladder. Rectoscopy revealed an ulcerated, bleeding, and stricturing lesion in the rectum, which was defined as an adenocarcinoma with a moderate degree of differentiation on histologic examination. The patient received neoadjuvant chemotherapy using capecitabine, oxaliplatin, and bevacizumab. After 3 courses of chemotherapy, a rectovesical fistula was suspected from examination of CT images. CT demonstrated intramural gas in the urinary bladder, which suggested a diagnosis of emphysematous cystitis. Thus, we constructed a transverse loop colostomy. Two months after the last administration of chemotherapy, we performed SILS+1 TPE. The procedure involved a 35-mm incision in the right side of the umbilicus for the insertion of a single multichannel port, and insertion of a 12-mm port into the right lower quadrant. Total operating time was 751 minutes, and estimated blood loss was 1100 mL (including urine). SILS+1 TPE is a technically promising alternative method for the treatment of selected patients with advanced rectal cancer.

We prove the safety and feasibility of single-incision plus 1 port (SILS+1) laparoscopic total mesorectal excision (TME) + lateral pelvic lymph node dissection (LPLD) via a medial umbilical approach for rectal cancer. Only a few reports have been published about single-incision multiport laparoscopic low anterior resection with LPLD. Recently, minimally invasive surgery such as single-incision plus 1 port (SILS + 1) for advanced rectal cancer has been reported as safe and feasible. To our knowledge, this is the first reported case of SILS + 1 used for LPLD. A wound protector was inserted through a 30-mm transumbilical incision. Next, a single-port access device was mounted to the wound protector and 3 ports (5 mm each) were placed. A 12-mm port was inserted in the right lower quadrant. Super-low anterior resection of the rectum and bilateral LPLD and temporary ileostomy were performed with SILS + 1, with a blood loss of 50 mL and a total surgical time of 525 minutes. The time for right lateral dissection was 74 minutes; the time for left lateral dissection was 118 minutes. The total number of dissected lymph nodes was 57 and the number of lateral lymph nodes dissected was 21 (8 left pelvic lymph nodes, 13 right pelvic lymph nodes). No postoperative anastomotic insufficiency or voiding dysfunction was observed. We have documented the safety and feasibility of SILS + 1-TME + LPLD via a medial umbilical approach for rectal cancer.

With regard to laparoscopic and robotic abdominoperineal resection (APR) for primary rectal malignancies, limited data have been published in the literature. Single-incision laparoscopic surgery (SLS) has been successfully introduced for treating colorectal cancer. Here we describe our experience of APR with SLS plus one port (SLS + 1) for treating advanced rectal cancer. A 65-year-old man underwent the procedure, which involved a 35-mm incision in the left side of the umbilicus for the insertion of a single multichannel port as well as the insertion of a 5-mm port into the right lower quadrant. The sigmoid colon and rectum were mobilized from the pelvic floor using a medial and lateral approach. After the rectum with the mesorectum was completely mobilized according to the total mesorectal excision, the sigmoid colon was intracorporeally transected. The specimen was removed through the perineal wound. Terminal colostomy was fashioned at the left lower trocar site. Lateral pelvic lymph node dissection was bilaterally performed. There were no perioperative complications. The total operating time was 592 minutes, and the estimated blood loss was 180 mL. To our knowledge, this is the first reported case of SLS + 1 APR with lateral pelvic lymph node dissection for treating rectal cancer. We conclude that SLS + 1 APR is a technically promising alternative method for treating selected patients with advanced rectal cancer.

Minimally invasive liver resection (MILR) is considered a safe and feasible treatment for malignant liver tumors. However, few studies have investigated the surgical outcomes of MILR in patients with impaired liver function. Liver damage is used for consideration of hepatectomy. The aim of this study is to clarify the efficacy of MILR for patients with impaired liver function by using propensity score matching.Ninety-nine patients with liver damage B underwent hepatic resection were analyzed. The patients were divided into two groups, the MILR group (n = 24) and the open liver resection (OLR) group (n = 75). After matching of a propensity score, we compared clinicopathological features and surgical outcomes.After matching, 36 patients (18 patients from each group) were selected and the patients' characteristics and tumor characteristics were not significantly different between the two groups. Blood loss (P = 0.0163) and complication rate (P = 0.0162) were significantly decreased in the MILR group. Complications were observed in eight patients, comprising one patient in the MILR group and seven patients in the OLR group. The postoperative hospital stay was significantly shortened in the MILR group (P = 0.0118).Minimally invasive liver resection might be effective for patients with impaired liver function. It reduces surgical complications and consequently shortens hospitalization time.

Pancreatic ductal adenocarcinoma (PDAC) is a lethal neoplasm that spreads to surrounding tissue or distant sites. This study investigated distant metastases in PDAC patients with or without preoperative chemoradiation therapy (CRT), focusing on vitamin D levels and bone density. This study included 146 patients with PDAC who underwent surgery from 2007 to 2014. Bone density was evaluated using computed tomography, and the preoperative vitamin D level was calculated by enzyme-linked immunosorbent assay (ELISA) for patients with available plasma (48 cases). When the patients were divided into two groups according to the change in bone density, the group with decreased bone density had a shorter distant metastasis-free survival time (DMFS) after surgery than the other group (p

A 50-year-old woman had a 12mm liver tumor at segment 4 and was diagnosed with hemangioma. Two years later, the liver tumor had grown to 27mm in diameter, and a new pancreatic tumor was detected using CT examination. The pancreatic tumor was suspected of being pancreatic carcinoma, based on the results of endoscopic-ultrasound-guided fine-needlebiopsy( EUS-FNA)of the pancreas. The liver tumor was diagnosed as adenocarcinoma using liver biopsy. Because of its slow growth and the solitary liver tumor, synchronous pancreatic cancer and intrahepatic cancer were suspected. We therefore performed pancreaticoduodenectomy with portal vein resection and partial liver resection of segment 4. Upon histological analysis, carcinoma in situ was detected in the liver tumor and the patient was diagnosed with synchronous double cancers of the liver(cholangiocellular carcinoma)and pancreas(invasive ductal carcinoma). Our case indicated that it is very difficult to distinguish cholangiocellular carcinoma from metastatic liver tumor using diagnostic images. We should therefore consider the possibility of cholangiocellular carcinoma when a solitary tumor in the liver is detected at the same time as pancreatic cancer.

Unresectable advanced esophageal cancer is often treated with chemotherapy or chemoradiotherapy(CRT). Nutritional disorders caused by dysphagia may lead to a poor prognosis. Placing a PEG before starting CRT for advanced esophageal cancer may maintain better nutritional status.The purpose of this study is to evaluate the clinical significance of placing a PEG before starting CRT for advanced esophageal cancer.Fifty-one cases were evaluated, 22 PEG (+) and 29 PEG (-). The rate of a CRT was better in PEG (+) than PEG (-) cases (91% vs 79%). Infection around the PEG was the only type of complication, affecting 5%.PEG feeding during CRT is important in the development of effective treatments for unresectable advanced esophageal cancer.

Background Definitive chemoradiotherapy (dCRT) is one of the treatment strategies for patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC). In this report, we investigated the timing, pattern of recurrence, and prognosis in patients with LA-ESCC who achieved clinical complete response (cCR) following dCRT. Methods dCRT was performed for 71 patients with LA-ESCC from April 2006 and December 2017. We retrospectively examined the clinical records of 27 patients (38%) with ESCC who achieved cCR following dCRT assessed by the Response Evaluation Criteria in Solid Tumors (RECIST). These patients were classified into two groups: 19 patients (Group A) who did not recognize recurrence thereafter and 8 cases (Group B) who were confirmed to have recurred until Deccember 2017. Clinicopathological features and clinical course for two groups were examined. Results Clinical stages before treatment were cT1/2/3/4 = 7/3/6/3 cases, cN0/1/2/3 = 8/3/6/2, cM0/1 = 18/1 and cStage I/II/III/IV = 6/4/6/3 in Group A, and cT1/2/3/4 = 1/3/2/2, cN0/1/2/3 = 1/2/4/1, cM0/1 = 8/0, cStage I/II/III/IV = 1/0/5/2 in Group B, respectively. Patients in Group B had more advanced cases than Group A. In group A, 16 out of 19 patients (84%) are still alive without recurrence and 3 have died because of hypopharyngial cancer, lung cancer, and senility, respectively. Double cancers were confirmed in 12 patients (63%) including 6 head and neck cancers. In Group B, the recurrences were confirmed at 7–26 months (Median: 12.5M) from the diagnosis of cCR. Six out of 8 patients (6/8:75%) had the recurrence of mediastinal lymph nodes. In Group B, 6 out of 8 cases (75%) confirmed death, and the period from recurrence to death was 5–18 months (median: 9.5M). Conclusion After cCR was obtained by dCRT, recurrence was observed in 8/27 cases (29.6%) in about 13 months. In patients with recurrence, 75% of patients had mediastinal lymph node recurrence and had poor prognosis of about 10 months. Also in patients without recurrence, double cancers were observed in 12/19 cases, suggesting the importance of surveillance for the purpose of 2nd primary cancer screening. Disclosure All authors have declared no conflicts of interest.

Background Various attempts have been reported as nutritional therapy in the treatment of esophageal cancer, but there is not enough evidence. Preparing jejunostomy catheter during esophagectomy may allow early nutritional management after surgery, and may continue after leaving hospital. On the other hand, peri-operative chemotherapy or chemoradiotherapy are frequently performed in esophageal cancer treatment, and postoperative malnutrition may become a problem. Postoperative malnutrition affects treatment outcome, such as delaying recovery and difficulty of continuing treatment after surgery. Methods We considered that postoperative treatment can be continued while restoring and maintaining postoperative nutritional status by placing jejunostomy catheter during esophagectomy and we examined the safety and treatment outcome of the procedure. Results Out of 76 cases of thoracic esophageal cancer surgery from January 2008 to December 2017, 59 cases(77.6%) of jejunostomy catheter were prepared. The median age was 69 years old(50–82), cStageI/II/III/IV was 7/16/33/3 cases respectively, and 25 cases(42.4%) administered neoadjuvant chemotherapy. There was no complication of surgery related to preparing jejunostomy catheter, but 1 tube bending(1.7%), tube deviation in 3 cases(5.1%) and tube occlusion in 5 cases(8.5%) were confirmed during feeding period. The median day of start feeding was 2 days after surgery(1–12), the transition to home jejunostomy feeding was carried out in 45 cases(76.3%), the median period of feeding was 55 days(4- 521), and the median of caloric value was 400Kcal/day(200- 200). Postoperative chemotherapy and chemoradiotherapy were performed in 11 cases(14.5%), jejunostomy feeding was prepared in 10 cases(90.9%), nine cases(90%) continued feeding after leaving hospital. The median duration of jejunal catheter feeding was 71 days(21–101) and the median caloric value was 400Kcal/day(200 - 800). Conclusion Surgery for esophageal cancer is invasive, and in addition to malnutrition from preoperative state, adjuvant therapy is also frequent. Recovery of nutritional condition after surgery is not easy, and jejunal feeding is considered to help in perioperative period. Particularly in cases requiring postoperative treatment, the continuation rate of jejunal feeding is higher and the duration of jejunal feeding tends to be longer. Although jejunal catheter preparing surgery can be performed safely, countermeasures such as tube occlusion and deviation in tube management are necessary, and cooperation of medical staff is indispensable. Disclosure All authors have declared no conflicts of interest.