[A Case of Locally Advanced Sigmoid Colon Cancer Occupying the Pelvis with Successful Total Posterior Pelvic Exenteration after Triplet Chemotherapy].

We report a case of locally advanced colon cancer that directly invaded the rectum wall and uterus resulting in huge mass in the whole pelvis that we could successfully made complete radical resection of the whole tumor without exposing the tumor to the surgical margin after the triplet chemotherapy. The patient was a 57-year-old woman complaining of anus pain, melena, fever, and weight loss. Although swelling of the regional lymph node was observed, no distant metastasis was found resulting in clinical diagnosis of Stage Ⅲb. However, oncologically safe complete resection seemed difficult; thus, chemotherapy( 3 courses of FOLFOX followed by 3 courses of FOLFOXIRI plus bevacizumab)was administered. As a result, significant tumor reduction was observed; therefore, the tumor was completely resected with posterior pelvic exenteration. Final staging was ypT4bypN0M0(ypStage Ⅱ). Eight courses of CapeOX was administered as adjuvant chemotherapy.

[A Case of Duodenum Dissemination after Surgery for Transverse Colon Carcinoma Which Was Unresponsive to Chemotherapy, but Immunotherapy Was Significantly Effective].

The patient was a 73-year-old woman who received surgery for transverse colon cancer(laparoscopic right hemicolectomy) in December 2014. Histopathologic examination findings were tub2, pT4b, pN1, sH0, sM0, ly2, v0, Stage III a. XELOX 2 courses→FOLFIRI plus panitumumab(Pmab)12 courses was performed after surgery. Stenosis due to duodenum dissemination was observed in the follow-up period(December 2015), and a laparoscopic gastrojejunostomy was performed. Later, the patient's tumor marker value significantly increased, and enlargement of duodenum dissemination was observed by abdominalCT. From April 2016, treatment was switched to mFOLFOX6 plus Pmab and 5 courses were subsequently performed. Still, metastasis to the abdominal wall was observed. According to results of the microsatellite instability test of MSIH, the patient was registered into a clinicaltrialfor pembrolizumab, which is anti-PD-1, and administration began from June. The tumor marker value significantly decreased, and a reduction in the size of the duodenum dissemination over time could also be observed by abdominal CT. Significant tumor reduction was observed, indicating that immune therapy may be significantly effective in some cases.

[A Case Where Rectal Cancer Ileus Caused Perforation in the Ascending Colon].

The patient was a 65-year-old man. He had not defecated for a week in early December 2015, and had noticed abdominal pain and abdominaldistension from 4 days prior. The pain and distension worsened, and the patient was rush transported to our hospital. Via abdominal CT we found free air in the upper abdomen, expansion of the small and large intestines, and notably, significant intestinal tract expansion and a gas reservoir in the ascending colon. We found significant narrowing as well as hypertrophy along the entire circumference of the rectum and suspected gastrointestinal perforation due to rectal cancer ileus. Inflammation findings were abnormally high and we performed emergency surgery. We found a laceration on the ascending colon, which had expanded markedly. We elevated that location and installed a colostomy. Following surgery the patient developed mild SSI and ileus, which were alleviated through conservative treatment. A month after the operation we performed a colonoscopy and found a tumor along the entire circumference of the rectum Rs. It was diagnosed as group V tub1-2 via biopsy. We performed surgery in late January 2016(colostomy closure, laparotomy rectal low anterior resection). We are reporting a rare case where rectal cancer ileus caused perforation in the ascending colon.

[Surgical treatment for gall bladder cancer with a confluence stone-a case report].

The patient was a 71-year-old man. In September 2011, he experienced abdominal pain with high fever. Abdominal computed tomography (CT) diagnosed acute cholecystitis with a confluence stone (corlette classification type II). He underwent total cholecystectomy and placement of a T-tube in the main bile duct through the gall bladder duct. However, pathological investigations revealed gall bladder cancer in the neck and body part of the gall bladder, leading to a diagnosis of gall bladder adenocarcinoma(Gbn, Flat type, tub2, INF ß,pSS, pHinf0, pBinf1, pPV0, pA0, pT3) with a confluence stone. We suspected that the tumor was present in the common bile duct. Therefore, in October 2011, he underwent choledochectomy, resection of the liver bed, lymph node dissection, and choledocho-jejunostomy. Pathological findings revealed that the tumor was present in the common bile duct. He died 8 months after the last surgery because of recurrence of peritoneal metastasis.

Impact of the two-layer method on the quality of isolated pancreatic islets.

BACKGROUND/AIMS: We have already reported that the two-layer method (UW/PFC) reduces warm and cold ischemic injuries before islet isolation, and results in improvement of islet yield and viability. In this study, we try to evaluate the effect of the two-layer method on isolated islets. METHODOLOGY: We used male Wister rats. Isolated islets were cultured or preserved in various conditions for 24 hours. In group 1, islets were not cultured (control). In group 2, islets were cultured in RPMI at 37 degrees C. In groups 3 and 4, islets were cultured with "modified" two-layer method (RPMI/PFC) at 37 degrees C and 4 degrees C, respectively. In groups 5 and 6, islets were preserved in UW and with the two-layer method (UW/PFC), respectively at 4 degrees C. Islets in each group were evaluated in terms of function and viability in vitro. RESULTS: Stimulation Indices were 1.3, 2.6, 3.7, 1.2, 1.4, and 2.4 in groups 1, 2, 3, 4, 5 and 6, respectively. Islets in groups 2, 3 and 6 showed clear response to glucose stimulation. Among these 3 groups, the total viability of islets assessed by FDA/PI staining was 88%, 92%, and 76% in groups 2, 3, 6, respectively. CONCLUSIONS: Although in vivo studies are mandatory, the present study is supportive that the "modified" two-layer method (RPMI/PFC), which uses oxygenated PFC and RPMI, may be superior to conventional culture method with RPMI. This method may achieve further improvement of islet viability before implantation.

Pancreas preservation by the 2-layer cold storage method before islet isolation protects isolated islets against apoptosis through the mitochondrial pathway.

BACKGROUND: Apoptosis in isolated islets has been implicated in primary nonfunction or early graft failure after islet transplantation. Recently, pancreas preservation by the 2-layer method (TLM) before islet isolation has been proved to improve the islet yield, quality, and transplant results not only in experimental models, but also in clinical settings. We examined the influence of TLM on apoptosis of isolated islets. METHOD: Rat islets freshly isolated and after pancreas preservation by TLM or conventional cold storage in University of Wisconsin solution (UW) were examined and compared. Islet apoptosis was assessed by TUNEL and annexin V assays. The apoptosis pathways involved were investigated by measurement of caspase 3, 8, and 9 activities and by immunoblotting for total and phosphorylated c-Jun NH2-terminal kinase (JNK) and p38. RESULTS: Islet apoptosis in the UW group was significantly increased compared with the fresh and TLM groups. Both caspase 3 and 9 activities in the UW group were higher than in the fresh and TLM groups with an approximate increase of 2- to 3-fold. On the other hand, there was no significant difference in caspase 8 activity among these 3 groups. JNKs were strongly activated both in the TLM and UW groups; although they were not activated in the fresh group, p38 was activated to almost the same levels in these 3 groups. CONCLUSIONS: Pancreas preservation by TLM before islet isolation protects isolated islets against apoptosis mainly through the mitochondrial pathway. Pancreas storage before islet isolation even with TLM triggers activation of JNKs in isolated islets.

Factors influencing hepaticojejunostomy leak following pancreaticoduodenal resection; importance of anastomotic leak test.

BACKGROUND/AIMS: Pancreatic fistula is a common complication after pancreaticoduodenostomy. Prevention of a concomitant bile leak from hepaticojejunostomy is important because it could lead to more serious complications including intraperitoneal abscess, subsequent sepsis and massive hemorrhage by activating pancreatic fistula. This study was designed to determine perioperative risk factors of the hepaticojejunostomy leak for the purpose of decreasing this morbidity. METHODOLOGY: Clinical records of 107 consecutive pancreaticoduodenal resections were reviewed. hepaticojejunostomy anastomoses were performed using absorbable sutures in an end-to-side, single-layer and interrupted fashion. A total of 8 presumed perioperative risk factors were analyzed. They included advanced age, low serum albumin, low serum total cholesterol, impaired glucose tolerance and placement of a biliary drainage catheter as preoperative factors, and dilated common hepatic duct and undone anastomotic leak test as intraoperative factors. In addition, transanastomotic stenting techniques including retrograde transhepatic bile drainage, T-tube and transjejunal drainage were compared with respect to hepaticojejunostomy leak rates. RESULTS: Hepaticojejunostomy leak was demonstrated in 9 patients (8%). Anastomotic leak testing only achieved statistical significance (p = 0.04). It is noteworthy that no hepaticojejunostomy leak developed among 28 patients who underwent this test through a retrograde transhepatic bile drainage catheter. In addition, the frequency of bile leaks (14/107) associated with the transanastomotic stenting techniques urged the necessity of appropriate intraperitoneal drain placement. CONCLUSIONS: Careful anastomotic procedures with a subsequent anastomotic leak test most effectively prevent hepaticojejunostomy leak after pancreaticoduodenal resection.

Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size.

HYPOTHESIS: Selection of proper pancreaticojejunostomy techniques according to pancreatic texture and the main duct size reduces the pancreatic fistula rate. DESIGN AND PATIENTS: Data from 50 consecutive patients undergoing pancreatoduodenectomy with 3 different anastomotic techniques prospectively used according to pancreatic texture and the main duct size were analyzed. Duct-invagination anastomosis was selected for pancreata with a small duct (n = 34 [29 with a soft texture and 5 with a hard texture]). Stitches between the stump parenchyma and the jejunal seromuscular layer were added to this anastomosis procedure only for the hard pancreata. Pancreata with a large duct were reconstructed with a conventional duct-to-mucosa anastomosis (n = 16). SETTING: A university hospital department of digestive surgery. RESULTS: The morbidity was 40% (20 of 50 patients) in this series. Four patients (8%) with a soft pancreas and a small duct developed a pancreatic stump leak after duct-invagination anastomosis, but all of them were removed without sequelae. No pancreatic anastomotic leak was seen in this series, which resulted in no mortality, no remnant pancreatectomy, and only 1 relaparotomy in the consecutive 50 patients. CONCLUSION: The proper selection of pancreatic reconstruction techniques according to our criteria may reduce the pancreatic fistula rate, eliminate risky pancreatic anastomotic leaks, and result in excellent outcomes for those undergoing pancreatoduodenectomy.