[A Case of Primary Jejunal Cancer Treated with Laparoscopic Jejunectomy with Appearance of Ileus].

An 83-year-old man visited our hospital for vomiting. Chest-abdominal computed tomography(CT)revealed that a tumor whose inside was imaged in the jejunum about 15 cm after leaving the Treitz ligament was pointed out, and dilation of the oral intestinal tract of the tumor was observed. Upper gastrointestinal endoscopy showed a type 3 circumferential tumor at the jejunum. He was diagnosed with obstructive ileus due to jejunal cancer. Laparoscopic-assisted partial jejunal resection was performed. Although the patient was followed up without chemotherapy, CT showed multiple lung and liver metastases and a mass lesion was found in the right entire chest, and a biopsy revealed skin metastasis 6 months after the operation. The patient is being followed up 10 months after surgery, there is no progression of liver, lung, and skin metastasis.

[A Case of Advanced Rectal Cancer with the Metastatic Abdominal Aortic Bifurcation Lymph Node Performed by Laparoscopic Surgery after Chemotherapy].

A 63-year-old underwent examination for constipation and was found to have an unresectable advanced rectal cancer. Metastatic abdominal aortic bifurcation lymph node and lung metastasis were suspected upon CT(cT3N3M1a[PUL1], cStage Ⅳa), and chemotherapy was administered(CapeOX plus Bmab). After 4 courses of chemotherapy, the size of the primary tumor and the lymph nodes decreased(PR). We performed laparoscopic rectum resection and abdominal aortic bifurcation lymph node. The pathological diagnosis indicated partial response(residual cancer cells)(Grade 1a). After 4 courses of chemotherapy(CapeOX), we performed pulmonary partial resection for metastatic lung cancer. This case suggests that laparoscopic resection of rectum after chemotherapy with CapeOX plus Bmab for locally advanced rectal cancer is a potential- ly effective procedure.

[Locally Advanced Breast Cancer Successfully Treated with Abemaciclib and Fulvestrant-A Case Report].

A 78-year-old woman visited our hospital for a tumor in her left breast with discharge. The 10 cm tumor had ulceration and foul smell. Scirrhous breast carcinoma was diagnosed based on core-needle biopsy findings. Chest and abdominal computed tomography( CT) revealed the tumor invading the pectoralis major muscle and a large number of swollen lymph nodes from the left axilla to the subclavian region, but no distant metastases. After 6 months of locally advanced breast cancer treatment with abemaciclib and fulvestrant, ulceration improved. CT revealed that the tumor and lymph nodes tended to shrink. Left mastectomy with axillary lymph node dissection and combined resection of pectoralis major muscle was performed. Postoperative pathological histology revealed ypT2, ypN0, ypM0, ypStage ⅡA. Subsequently, abemaciclib plus fulvestrant therapy was continued as an adjuvant therapy. The patient has survived without recurrence 6 months after the operation. We report a case of locally advanced breast cancer in which abemaciclib and fulvestrant were effective.

[Palliative Laparoscopic Operation for an Extremely Elderly Patient with Cecum Cancer].

Symptomatic colorectal cancer in extremely elderly patients is difficult to treat. A 97-year-old woman was initially suspected of having appendicitis because of worsening right lower abdominal pain with persistent fatigue. After antimicrobial therapy, advanced cecum cancer with lymph node involvement was found. Palliative laparoscopy-assisted ileocecal resection without radical lymph node dissection was performed to prevent further inflammation. The patient was transferred to another hospital for rehabilitation on postoperative day 24, when she regained walking function. This palliative procedure can be an effective treatment for elderly patients with symptomatic advanced colon cancer.

"Silent Ruptures" of the Flexor Digitorum Profundus of the Little Finger due to Pisotriquetral Arthroses.

Asymptomatic pisotriquetral arthroses caused ruptures of the flexor digitorum profundus tendon of the little finger in 2 elderly patients. Ruptures occurred with unnoticeable onset, and bilateral ruptures separately occurred with interval of several years in one patient. The tendon was ruptured in zone IV with perforation of the gliding floor through which the degenerative pisiform was visible. The gliding floor was repaired followed with excision of the pisiform, and the ruptured tendon was then transferred to the profundus tendon of the ring finger. Asymptomatic pisotriquetral arthrosis in old age can be an aspect of the pathological background of flexor tendon ruptures of the little finger that occur unnoticed.

[Two Cases of Colon Metastasis of Gastric Cancer by Different Metastasis Pathway].

We treated 2 cases ofcolon metastasis ofgastric cancer considered to be caused by different pathway. Case 1 was a 55- year-old male with gastric cancer associated with metastases for lymph node, gallbladder, and liver. Curative surgical treatment of distal gastrectomy, partial hepatectomy, cholecystectomy and lymph node dissection was performed. The final find- ing was, L, Less, Type 3, pT4b(GB), tub2, pN3a(10/20), sP0, CY0, pH1, pM1, Stage IV , R0. Ten months after, ileocecal resection was performed, as a tumor was detected in the cecum. It was a submucosal tumor of well to moderately differentiated adenocarcinoma, and diagnosed as a metastasis ofgastric cancer. Case 2 was a 59-year-old male who received total gastrectomy. The final finding was UE, Less, Type 4, tub2-por2, pT4a, pN2(5/19), cM0, sP0, CY0, Stage III B, R1. One year and 10 months later, unevenness and redness in the mucosal membrane ofthe transverse colon occurred. Signet-ring cells were observed by the endoscopic biopsy, and colon metastasis ofstomach cancer was diagnosed. Consequently, transverse colectomy was performed. Diffused invasion of cancer cells was observed in all layers of the wall, which was considered as metastasis via gastrocolic ligament. Although colon metastasis ofstomach cancer is rare, its pathway varies, such as infiltration, direct invasion, hematogenous, and lymphogenous. Form oflesion also varies. For diagnosis ofcolon lesion occurring during follow-up after gastric cancer, these points should be noted.

[Laparoscopic Transverse Colectomy by Cranial Approach Preceding Medial Approach after Stenting for Obstructive Transverse Colon Cancer].

Surgery for obstructive colon cancer was highly invasive due to poor nutritional status of patients, risk of emergency surgery, and unavoidable colostomy formerly. However, recently, we have been able to perform laparoscopic elective surgery safely without colostomy, by using self-expanding metallic stents(SEMS). Laparoscopic colectomy for transverse colon cancer is inherently very difficult because of variations in the vascular system, small number of patients, and absence of large, randomized trials. Laparoscopic complete mesocolic excision(CME)for colectomy has been shown to be technically feasible and effective. We report the treatment strategy for obstructive transverse colon cancer which involves laparoscopic transverse colectomy by cranialapproach preceding medialapproach after successfuldecompression by stenting, along with a review of relevant literature. We consider it a s minimally invasive treatment for obstructive transverse colon cancer.

[A Very Elderly Patient Successfully Treated by Multimodality Treatment for Pancreas Cancer with Synchronous Multiple Liver Metastases and Liver Dysfunction].

We report an 86-year-old patient successfully treated by multimodality treatment for advanced pancreatic cancer with synchronous multiple liver metastases and liver dysfunction. Systemic chemotherapy(SC)(gemcitabine[GEM]1 g and 5-FU 1 g biweekly)was initiated. Two weeks after, the radiation therapy(55 Gy/25 days)was added. Three weeks after, the short period's high dose hepatic artery infusion(SPHDHAI)(5-FU[1 g]×3 days: 1 day rest: 5-FU[1 g]×3 days)was started. By these treatments, liver dysfunction was completely improved and abdominal pain was disappeared. After 2 times of weekly high dose hepatic artery infusion(WHDHAI)(5-FU 1,500mg), the mixed chemotherapy(MC)(GEM 800 mg[systemic] and 5-FU 1,500 mg hepatic artery infusion:[HAI]biweekly)were started. She could live without admission for about 1 year. About 13 months after lung metastases was appeared and she died about 19 months after first chemotherapy. Our multimodality treatment(systemic and HAI therapy and radiation)was effective for keeping patient quality of life and for improving the survival even if the patient was a very old age and showed liver dysfunction.

[Laparoscopy-Assisted Surgery for Descending Colon Cancer in a Patient with Persistent Descending Mesocolon-A Case Report].

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. We report a case of laparoscopy-assisted surgery for descending colon cancer in a patient with PDM. An 88-year-oldfemale patient complaining of abdominal pain was diagnosed with bowel obstruction, and referred to our hospital. A computed tomography(CT)scan showed bowel obstruction due to descending colon cancer. After decompression of the colon by insertion of a transanal drainage tube, she underwent laparoscopy-assistedleft hemicolectomy. Intraoperatively it was observed that the descending colon was not fixed to the retroperitoneum, and the patient was diagnosed with persistent descending mesocolon. The accessory middle colic artery and the inferior mesenteric vein branched radially. In patients with PDM, the inferior mesenteric artery often branches radially. However, the various morphologies of branching of the accessory middle colic artery and the inferior mesenteric vein have not been reported. It is not clear whether the radial branching of the accessory middle colic artery and the inferior mesenteric vein is characteristic of patients with PDM. We should however expect radial branching of the accessory middle colic artery and the inferior mesenteric vein in such cases.

Sulfur-directed carbon-sulfur bond cleavage for Rh-catalyzed regioselective alkynylthiolation of alkynes.

Sulfur-directed sp C-S bond cleavage along with a regioselective reaction with alkynes proceeded to give (Z)-enyne sulfides in high to excellent yields. Mechanistic studies were conducted, including characterization of an intermediate. An intramolecular variant realized the construction of a dibenzodithiepin skeleton, which is a seven-membered ring with two sulfur atoms.

[Combination Treatments to the Huge Ovarian Cancer with Liver Metastases].

We report a CR case of huge ovarian cancer with peritoneal and liver metastases who was operated bilateral ovaries, uterus and peritoneal metastases at first, followed by systemic chemotherapy and performed 4 times of radiofrequency ablation (RFA)and 2 times of liver resection(LR). The case was a 50-year-old woman. She suffered with bowel enlargement from over 1 year ago. Preoperative MRI finding was huge ovarian serous cyst with partial solid tumor inside. The major axis was about 30 cm. CA125 and CA19-9 levels were elevated. Tumor reduction surgery was performed with bilateral salpingooophorectomy and hysterectomy with resecting peritoneal metastatic lesions. Postoperative systemic chemotherapy(carbo- platin 550mg/day 1 plus paclitaxel 130mg/day 1, 8, 15)(CBDCA plus PTX)were performed amount 6 courses. Unfortu- nately liver metastases at S3, S4, S6, S7 and S8/5 appeared about 7months after operation.We restarted the CBDCA plus PTX therapy from 15 months after operation when the tumor maker elevated. After 18 courses of CBDCA plus PTX therapy liver metastases remained only at S3. But gradually tumors grew up and size of tumors increased in spite of 3 more courses of CBDCA plus PTX therapy. So we challenged 2 times of RFA at S8/5 metastases that grew most rapidly and the values of increasing tumor makers stopped elevating. Then we performed LR at S3 and S4 metastases and the values of tumor makers returned to the normal level. But next S6 and S7 metastases appeared, we chose the RFA at first. At last recurrence of S7 was resected and all of liver metastases were treated. We checked no peritoneal metastases twice at the time of operation. The values of tumor makers became the normal level. Now she is alive well without metastases over 6 years after first operation. RFA and LR were effective at liver metastases from ovarian cancer that became resistant to systemic chemotherapy.

[Single Incision Laparoscopic Ileocecal Resection for Small Intestinal Malignant Lymphoma - A Case Report].

A 76-year-old man with the chiefcomplaint ofmelena visited our hospital. A mass was palpable in the right lower abdomen. We diagnosed the illness as small intestinal malignant lymphoma in the terminal ileum and performed a single incision laparoscopic ileocecal resection "TANKO-ICR" with D3 lymph node dissection with the idea ofobtaining a wide visualization and surgical field. The Aesculap®internal organ retractor(B BRAUN)is very useful in such cases. We grasped the pedicle of the ileocecal artery using the retractor and pulled out the nylon line connected to the retractor by using ENDO CLOSETM (COVIDIEN)to extraabdomen for drawing the pedicle. Single incision laparoscopic surgery can be performed with only an umbilical wound; therefore, it is minimally invasive and has a superior aesthetic outcome. Small intestinal malignant lymphoma is a relatively rare malignant tumor ofthe digestive organs. We report this case demonstrating that single incision laparoscopic surgery was possible and provide a review ofthe relevant literature.

[A Case Report of Huge Liver Synchronous Metastases of Colon Cancer that Occurred after Right Liver Lobectomy].

We report a patient who experienced a weight loss, general fatigue, and appetite loss and had huge hepatic metastases of colon cancer after right lobectomy for hepatic stone. After 2 courses of treatment with high-dose hepatic arterial infusion of 5-FU (HDHAI; 5-FU 6 g/week), the appetite loss decreased, and low anterior resection was performed. Unfortunately, the other symptoms continued, and she received 5 additional courses of HDHAI during about 6 months. Finally, all of the symptoms disappeared, and she could receive systemic chemotherapy and HAI. Bone metastasis at vertebra TH 9 was observed about 9 months after radiotherapy, and local recurrence at the anastomosis site was observed at about 1 year 1 months after radiotherapy. Both the metastasis and local recurrence were well controlled. Although the lung metastases were growing slowly (number and size), the patient was well enough to go to the hospital on her own and her weight loss almost disappeared. If liver metastases were the most threatening factor of life, HDHAI may be effective for the improvement of symptoms.

[Laparoscopic Surgery for Adult Intussusception Due to Rectal Cancer--A Case Report].

An 87-year-old woman with the chief complaint of bloody stool was referred to our hospital from an institution for the aged. The abdomen was soft and flat, and a tumor was not palpable on digital rectal examination. Tumor markers were within normal ranges. Abdominal enhanced CT scan showed a multiple concentric ring sign at the rectum. Colonoscopic and barium examination led to a diagnosis of rectal intussusception due to rectal cancer. We first tried to reposition it preoperatively, but it was impossible. She fortunately had no symptoms of ileus; therefore, we chose to perform laparoscopic surgery. We achieved the reposition intraoperatively and performed Hartmann's operation with D2 lymph node dissection because she was a very elderly patient with high-risk comorbidities. The pathological diagnosis was as follows: RS, 40×40 mm, type 2, tub2, pT3 (SS), pN0, ly0, v0, pStageⅡ, R0, Cur A. Adult intussusception due to rectal cancer is extremely rare. We report that in this case that laparoscopic surgery was possible, along with a review of the relevant literature.

[Five-year-survival in a case of large synchronous liver metastases from colon cancer treated with local (operation, HAI, RFA, and TAE) and systemic combined therapy].

A 58-year-old woman was suffering from abdominal pain due to large liver metastases(LM)and lung metastasis from sigmoid colon cancer. After laparoscopic sigmoidectomy, three 6 g/wk high dose hepatic arterial infusions(HDHAI)of5 - fluorouracil (5-FU) were administered and the tumor decreased in size. Unfortunately, the patient had an infectious pseudoaneurysm at the site of puncture. She was given a drainage and femoro-femoral(F-F)bypass. At last, a hepatectomy, radiofrequency ablation(RFA), and catheter insertion from gastroepiploic artery, were performed successfully. Subsequently, she received a half HDHAI and several systemic chemotherapy drugs. However, residual liver metastases developed thrice and we operated on all of them. Finally, when the hepatic arterial infusion(HAI)catheter became unavailable, we only continued the systemic therapy (Erbitux+FOLFIRI). However, inoperable residual liver metastases(maximum 13 cm in size)occurred. We chose to administer hepatic transarterial embolization(TAE)therapy 3 times. From the second time, we performed TAE from the right subphrenic artery and in the third time, we added 1-day HAI therapy. Finally, the tumor size decreased(maximum 9 cm). The patient is still an outpatient 5 years after the first HDHAI.

Parenteral nutrition decreases hepatic dihydropyrimidine dehydrogenase activity and modulates catabolism of 5-fluorouracil in rats.

BACKGROUND: Dihydropyrimidine dehydrogenase (DPD) is a rate-limiting enzyme in the catabolism of 5-fluorouracil (5-FU). The effect of parenteral nutrition (PN) on hepatic DPD activity and metabolism of 5-FU remains unknown. MATERIALS AND METHODS: Rats were divided into two groups: a sham-operated oral feeding group (FED) and a PN group. After 7-day PN infusion, hepatic DPD activity, serum 5-FU levels and thymidylate synthase (TS) levels in the jejunum and tumor were measured. RESULTS: PN administration significantly decreased hepatic DPD activities. After infusion of 5-FU (40 mg/kg body), the serum 5-FU concentration and 5-fluoro-2'-deoxyuridine-5'-monophosphate (FdUMP)-bound TS levels in the jejunum were significantly higher in the PN group than the FED group (156.8 +/- 51.9 vs 100.5 +/- 51.9 ng/ml, p < 0.001 and 38.55 +/- 7.61 vs 22.89 +/- 4.46 pmol/g of tissue, p < 0.01, respectively). In Yoshida sarcoma-bearing rats, the FdUMP-bound TS level in the tumor did not differ significantly between the PN and FED rats. CONCLUSION: PN decreases hepatic DPD activity, which may lead to increased toxicity of 5-FU.