Reduced port laparoscopic subtotal cholecystectomy for Mirizzi syndrome with a bilio-biliary fistula: A case report.

A 65-year-old male diagnosed with Mirizzi syndrome with a bilio-biliary fistula was referred to our department and underwent single-incision laparoscopic surgery with an assistant trocar. As typical laparoscopic cholecystectomy could not be performed due to the coexistence of a bilio-biliary fistula, we performed laparoscopic subtotal cholecystectomy as a bail-out procedure according to the recommendation of the recent Tokyo Guidelines (TG18). The neck of the remnant gallbladder could be easily sutured with the effective use of an assistant trocar, and the surgery was completed without any complications. The patient was discharged 5 days after surgery without any complications. While little has been reported on the efficacy of reduced port surgery for Mirizzi syndrome, our surgical approach, i.e. reduced port surgery with an assistant trocar, enabled secure and easy suturing as a bail-out procedure and seemed to be an efficient method that is both less-invasive and safe.

[Two Cases of Lower Rectal Cancer in Which Temporary Ileostomy Could Be Avoided by Using the Pull Through Procedure].

We report 2 cases of lower rectal cancer in which temporary ileostomy was avoided by using the Pull through procedure. Case 1 was a 59-year-old man with a BMI of 29.67 who was diagnosed as having lower rectal cancer after a positive stool occult blood test. He had a strong refusal to use a ileostomy and was obese, so he underwent laparoscopic intersphincteric resection using the Pull through procedure. Reconstruction was performed on the 7th postoperative day. He was discharged from the hospital on the 14th day after the initial surgery. Case 2 was a 65-year-old woman with a BMI of 27.65 who was referred to our department for additional resection after ESD for a lesion in the lower rectum. As in the previous case, she was obese and refused to use a ileostomy, so we chose to perform a laparoscopic intersphincteric resection using the Pull through procedure. Reconstruction was performed on the 7th postoperative day, and she was discharged on the 25th day after the initial surgery. Patient satisfaction was high, and the Pull through procedure may be an option for patients with lower rectal cancer who have difficulty in undergoing temporary ileostomy.

[A Case of Low-Grade Appendiceal Mucinous Neoplasm with Extra-Appendiceal Mucin Extrusion Successfully Treated with Laparoscopic Surgery].

A 49-year-old male patient, who presented with abdominal pain, was suspected of having acute appendicitis. Abdominal computed tomography revealed a swollen appendix, accompanied by a 40 mm low-density mass located behind the appendix. He was diagnosed with an appendiceal mucinous neoplasm, and laparoscopic ileocecal resection was performed. A soft tumor was found proximal to the swollen appendix and was adhered tightly to the iliopsoas muscle. The tumor cells were exfoliated carefully, and the tumor was excised en bloc without any injury. Histopathological examination revealed a low- grade appendiceal mucinous neoplasm(LAMN)accompanied by extra-appendiceal mucin extrusion due to the lack of epithelial lining. Because LAMN is potentially malignant, surgical excision was performed as first-line therapy. In the surgical management of LAMN, preventing intraoperative rupture is essential to avoid pseudomyxoma peritonei. To achieve this, a magnified laparoscopic surgery may be useful. Although no definitive guidelines describing the indications of lymph node dissection or the appropriate extent of resection exist, laparoscopic ileocecal resection may be used to manage cases of LAMN.

Foreign body granulomas mimic peritoneal dissemination caused by incarcerated femoral hernia perforation: A case report.

BACKGROUND: Foreign body granuloma (FBG) is a well-known type of granulomatous formation, and intraabdominal FBG (IFBG) is primarily caused by surgical residues. Multifocal IFBGs caused by gastrointestinal perforation is an extremely rare and interesting clinicopathological condition that resembles peritoneal dissemination. Here, we present a case of IFBGs mimicking peritoneal dissemination caused by bowel perforation and describe the value of intraoperative pathological examinations for rapid IFBG diagnosis. CASE SUMMARY: An 86-year-old woman with an incarcerated femoral hernia was admitted to the hospital and underwent operation. During the operation, the incarcerated ileum was perforated during repair due to hemorrhage necrosis, and a small volume of enteric fluid leaked from the perforation. The incarcerated ileum was resected, and the femoral hernia was repaired without mesh. Four months later, a second operation was performed for an umbilical incisional hernia. During the second operation, multiple small, white nodules were observed throughout the abdominal cavity, resembling peritoneal dissemination. The results of peritoneal washing cytology in Douglas' pouch and the examination of frozen nodule sections were compatible with IFBG diagnosis, and incisional hernia repair was performed. CONCLUSION: IFBGs can mimic malignancy. Intraoperative pathological examinations and operation history are valuable for the rapid diagnosis to avoid excessive treatments.

[A Case of Initially Unresectable Advanced Gastric Cancer Radically Resected by Conversion Surgery after Nivolumab Immunotherapy].

A 77-year-old man was admitted to our hospital with symptoms of epigastralgia and vomiting. Detailed investigation revealed unresectable advanced gastric cancer accompanied by multiple lymph node metastases and invasion of the pancreas(UM, type 3, cT4b, N3, M0, Stage ⅢC). The patient received nivolumab immunotherapy after first-line S-1 plus oxaliplatin(SOX)chemotherapy and second-line nab-paclitaxel(PTX)plus ramucirumab(RAM)chemotherapy. Remarkable tumor reduction was observed after 3 courses of nivolumab immunotherapy, and the patient subsequently underwent radical total gastrectomy with splenectomy and D2 lymphadenectomy. Histopathological examination of the resected stomach showed a near complete response, and only small metastatic foci remained in No. 2 lymph nodes, resulting in R0 resection. The patient was followed up without adjuvant therapy, and he is alive 6 months after the treatment without any symptoms of recurrence. The mechanism of action of immune checkpoint inhibitors is fundamentally different from that of conventional cytotoxic chemotherapeutic agents. Recently, several reports have described good responses to immune checkpoint inhibitors in cases where conventional chemotherapy has been unsuccessful. When predictive biomarkers of response to immune checkpoint inhibitors are identified, a combination therapy of preceding immunotherapy and subsequent surgery might provide an efficient radical therapeutic effect even in cases of unresectable advanced gastric cancer.

[A Case of Local Recurrence of Transverse Colon Cancer Radically Resected by Extended Surgery].

A 71-year-old male with a past history of Stage Ⅱb transverse colon cancer was pointed out a mass lesion penetrating into the stomach on abdominal computed tomography 1 year after surgery. The mass lesion was pathologically diagnosed as local recurrence of the previous colon cancer by upper gastrointestinal endoscopy. As he presented progressive anemia due to persistent tumor bleeding and no other recurrent lesion was recognized, surgical treatment was performed. Since intraoperative inspection suspected direct invasion to the pancreas, the patient underwent tumor resection in combination with distal pancreatectomy and partial resection of the stomach. Histopathological examination revealed negative surgical margins, resulting in R0 resection. Loco-regional therapies such as surgery and radiotherapy are considered appropriate for the treatment of local recurrence since pathogenesis of local recurrence is different from that of distant metastasis. As local recurrence may show various symptoms, we should aggressively consider surgical resection. Especially, complete resection of recurrent lesion is the only therapeutic strategy which can achieve radical cure. Although worsening of QOL might be a matter of concern depending on the site of recurrence, extended surgery with secure surgical margins is encouraged in cases of solitary recurrence.

[A Case of Primary Gastrointestinal Stromal Tumor with First Recurrence 13 Years after Surgery and Second Recurrence in the Omentum 6 Years Later].

A 63-year-old man underwent proximal gastrectomy for gastrointestinal stromal tumor(GIST)of the stomach 19 years ago. Local recurrence of GIST of the stomach occurred 13 years later, and the tumor was resected. Since then, he had adjuvant chemotherapy. Six years later, computed tomography revealed a soft-tissue shadow at the left lateral side of the stomach, and positron emission tomography also revealed fluorodeoxyglucose uptake at the same site. The recurrence of GIST was suspected, and therefore laparoscopic resection was performed. The operative time was 70 minutes. Blood loss was 10 g. Immunohistochemical examination showed positivity for c-kit and CD34, leading to a diagnosis of recurrence of GIST. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. At present, the patient is alive without adjuvant chemotherapy 13 months since surgery. GIST may recur 10 years or more after surgery. Therefore, long-term surveillance seems to be mandatory.

Radiosensitizing effect of 5-aminolevulinic acid in colorectal cancer in vitro and in vivo.

The radiosensitizing effect of 5-aminolevulinic acid (5-ALA) has been demonstrated in glioma and melanoma in a number of studies. Enhancing the radiosensitivity of colorectal cancer may improve survival rates and lessen adverse effects. The present study assessed the radiosensitizing effect of 5-ALA in colorectal cancer using the human colon cancer cell line HT29 in vitro and in vivo. In vitro, cells were pretreated with 5-ALA and exposed to ionizing radiation. Cells pretreated with or without 5-ALA were compared using a colony formation assay. In vivo, HT29 cells were implanted into mice subcutaneously and subsequently exposed to ionizing radiation. 5-ALA was administrated by intraperitoneal injection. Subcutaneous tumors treated with or without 5-ALA were compared. Single-dose and multi-dose irradiations were applied both in vitro and in vivo. Cells exposed to multi-dose irradiation and pretreated with 5-ALA in vitro had a significantly lower surviving fraction compared with cells without 5-ALA pretreatment. Following multi-dose irradiation in vivo, the volume of the subcutaneous tumors treated with 5-ALA was significantly lower compared with that of tumors without treatment. These results suggest that radiotherapy with 5-ALA may enhance the therapeutic effect in colon cancer.

Early Neuropathy Related to Oxaliplatin Treatment in Advanced and Recurrent Colorectal Cancer.

BACKGROUND/AIM: Chemotherapy dose adjustments in colorectal cancer are usually based on body surface area (BSA). The goal of this study was to investigate patients with nutritional disorder who developed early peripheral neuropathy due to inappropriate dose adjustment of oxaliplatin. PATIENTS AND METHODS: The study subjects were 88 patients with advanced or recurrent colorectal cancer who underwent chemotherapy with oxaliplatin. The psoas muscle area (PMA) was used as a nutritional index. Mild (grades 0-1, MN group) and severe (grades 2-3, SN group) peripheral neuropathy was defined using neurotoxicity criteria of Debiopharm. RESULTS: Severe peripheral neuropathy developed in 29 patients (33.0%). The total oxaliplatin dose/PMA was significantly higher for the SN group (107.6±8.5 mg/cm2) and compared with the MN group (53.8±6.0 mg/cm2) in univariate (p<0.0001) and multivariate (p=0.012) analyses. CONCLUSION: In order to prevent peripheral neuropathy from chemotherapy for colorectal cancer, dose adjustment of oxaliplatin should be based on PMA, in addition to BSA.

Laparoscopic splenectomy for polysplenia with splenic torsion: a case report.

BACKGROUND: Polysplenia refers to the presence of two or more equal-sized spleens. Very rarely, one of the multiple spleens may develop torsion and infarction. CASE PRESENTATION: A 21-year-old woman presented with left upper quadrant pain, the cause of which could not be diagnosed. She returned to our hospital, 2 days later, without any pain improvement. Enhanced computed tomography showed splenic infarction and polysplenia. Initially, we could not identify the cause of the infarction and started conservative therapy, which did not result in any improvement. Hence, we performed a splenectomy, after securing informed consent. Because the patient was a young woman, we opted for a laparoscopic approach. During surgery, we identified the cause of the infarction as spleen pedicle torsion; the infarcted spleen was excised using an automated suturing device. We completed the laparoscopic surgery without converting it to an open laparotomy, and the patient was discharged 4 days later. This was a rare case of polysplenia with splenic torsion. CONCLUSION: Laparoscopic splenectomy is minimally invasive and has cosmetic advantages. Thus, this approach may be considered as a treatment option for this condition.

[Impact of Preoperative Comorbidities on Long-Term Prognosis in Elderly Patients with Gastric and Colorectal Cancer].

BACKGROUND: There has been an increase in the number of elderly cancer patients with preoperative comorbidities, which decrease the safety of surgical therapy. Assessment of comorbidities is useful for prediction of the outcome of treatment in these patients. PATIENTS AND METHODS: The Charlson comorbidity index(CCI)was determined in 83 elderly patients undergo- ing surgery for gastric and colorectal cancer. Relationships of CCI with prognosis were examined in pathological R0/R1 and R2 cases. RESULTS: In the R0/R1 group, CCI was significantly associated with overall survival in univariate(p=0.027)and multivariate( p=0.031)analyses. Mortality from other diseases within a year after surgery for patients with CCIB4 was significantly higher than that for those with CCIC3(11.0% vs 1.4%, p=0.028). CONCLUSION: CCI is an independent prognostic factor after surgery for elderly patients with gastric and colorectal cancer.

[A Case of Sigmoid Colon Cancer with Idiopathic Thrombocytopenic Purpura].

An 80-year-old man reported at our hospital with the chiefcomplaint ofconstipation. He was diagnosed with sigmoid colon cancer(T4aN0M0, Stage II). He also had steroid-resistant idiopathic thrombocytopenic purpura(ITP)since 2001. After a high dose g-globulin therapy, he underwent sigmoidectomy and splenectomy simultaneously because ofthe steroidresistant ITP. While some reports suggest that ITP is dominant when it occurs with blood cancer, others suggest that it can be immunologically dominant even when it occurs with solid tumors. ITP has a significant effect on solid tumors.

[A Case of Ischemic Colitis Four Months after Laparoscopic Left Hemicolectomy Preserving Superior Rectal Artery].

The case was for a male at the age of 80. We performed laparoscopic left hemicolectomy and D3 lymph node dissection for descending colon cancer. He had a good postoperative prognosis and was discharged on the 14th day after the operation. Later, he was receiving the treatment on an outpatient basis without postoperative adjuvant chemotherapy during the followup period. He visited the hospital for sudden abdominal pain and melena as chief complaint approximately 4 months after the operation. We found prominent edematous wall thickening and increased surrounding fat concentration in the anal side of colon from the anastomosis site with plain abdominal CT scan. We also found that the anal side of colon from the anastomosis site an edematous change broadly in the lower gastrointestinal endoscopy. We conducted conservative treatment with the diagnosis of ischemic colitis at the anal side of colon from the anastomosis site. He was discharged on the 11th day after the hospitalization. Later, we conducted a follow-up examination for him on an outpatient basis. We recognized the symptom improvement approximately 2 months after the onset of the ischemic colitis.

[A Case of Cancerous Meningitis in Juvenile Onset Gastric Cancer].

A 30-year-old woman was diagnosed with advanced gastric cancer(MUL, Circ, Type 4, por1+2, T4a, N3a, M1[LYM, P1, CY1, H0], Stage Ⅳ)on delivery. Because of unresectable, she underwent chemotherapy(first-line: S-1 plus CDDP, secondline: PTX plus Rmab, and third-line: Nmab); approximately 10 months later, she started complaining of headache. We performed a close examination, because she also developed resistance to chemotherapy. Contrast-enhanced magnetic resonance imaging of the brain revealed intense and diffuse enhancement on the brain surface, leading to the suspicion of meningeal carcinomatosis. However, hydrocephalus did not occur. She was given steroids to alleviate symptoms, but this treatment did not effective. We used neither intrathecal chemotherapy nor radiation therapy. Her symptoms gradually worsened, and she died approximately 4 weeks after the diagnosis of meningeal carcinomatosis. Meningeal carcinomatosis resulting from gastric cancer is very rare and is often difficult to diagnose. Even though this type of disease is diagnosed correctly, rapid disease progression makes the treatment difficult; therefore, patients with this type of disease have a terribly poor prognosis in daily clinical practice.

[A Study of 15 Patients with Colorectal Cancer Perforation, Kyoto Chubu Medical Center].

In colorectal cancer perforation, selecting the appropriate surgical operation while considering the patient's life and radical treatment is important. We divided 15 patients who underwent surgical intervention at our department into 2 groups, namely, free and covering perforation groups, and conducted a retrospective analysis. In the comparison between the 2 groups (free vs covering), there were 11 vs 4 cases with similar morphology, 2 vs 0 cases of perioperative death, and 3 vs 0 cases of recurrence, respectively. For the 2 groups(free vs covering), the SOFA score was 1.72 vs 1.0, postoperative chemotherapy enforcement rate was 55%vs 75%, start time was 59.4 days vs 40.3 days, and postoperative PMX implementation was 6 vs 0, respectively. All cases of recurrence and perioperative deaths were from the free perforation group. In free perforation, patients have a high risk of sepsis before surgery, and postoperative chemotherapy cannot be performed smoothly and completed. This leads to an increase in the relapse rate. It is important to select the appropriate operative method for curability and to perform postoperative chemotherapy without delay, especially in covering perforation.

Photodynamic Diagnosis of Hepatocellular Carcinoma Using 5-Aminolevulinic Acid.

UNLABELLED: Backgtound/Aim: Since hepatocellular carcinoma (HCC) has a high recurrence rate, accurate diagnosis of its location and curative resection is important to improve survival. This study evaluated the utility of photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5-ALA) for HCC. MATERIALS AND METHODS: We used two human hepatoma cell lines (HuH-7 and Hep G2). Cells were treated with 5-ALA for 4 h. 5-ALA-induced fluorescence was then examined under a fluorescence microscope. We designed hepatoma mouse models, with mice receiving an intraperitoneal injection of 5-ALA. After 4 h, their liver tumors were removed and examined under a fluorescence microscope. We also analyzed 12 HCC patients who underwent curative liver resection. The patients were administered 5-ALA orally before surgery. The excised livers were sectioned and examined by fluorescence microscopy. RESULTS: In vitro and in vivo, red fluorescence of protoporphyrin IX (PpIX) was observed in tumors. In 11 of 12 patients, red fluorescence was observed in their HCC. The tumor of only one patient did not exhibit red fluorescence because it had been necrosed by transcatheter arterial chemoembolization (TACE). CONCLUSION: Red fluorescence of PpIX was observed in hepatoma cells, tumors of HCC mouse models and HCC of patients. PDD of HCC using 5-ALA is simple and may be useful for real-time diagnosis during liver resection.

Urinary 5-Aminolevulinic Acid Concentrations as a Potential Tumor Marker for Colorectal Cancer Screening and Recurrence.

BACKGROUND/AIM: Tumor biomarkers, such as carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA19-9), are used to screen and monitor tumor recurrence in patients with colorectal cancer (CRC). 5-Aminolevulinic acid (5-ALA) is used in photodynamic diagnosis and therapy. Porphyrins produced by tumor cells are excreted in the urine after 5-ALA administration. In this study, we evaluated the use of porphyrins as novel tumor markers in urine samples from patients with CRC. PATIENTS AND METHODS: Porphyrin metabolite concentrations were measured in urine samples of 33 patients with CRC, 16 patients with benign disease and 8 healthy adults, after 5-ALA administration. RESULTS: The porphyrin metabolite concentrations were significantly increased in the CRC group compared to the control group, while in CRC patients, the porphyrin metabolite concentrations in urine were significantly decreased after surgery. CONCLUSION: These results suggest that the measurement of porphyrin metabolites in urine may potentially serve as a new screening and recurrence marker for CRC.

[Radiosensitizing effect of 5-aminolevulinic acid (5-ALA ) in Colon cancer].

5-aminolevulinic acid (5-ALA) is widely used in clinical practice because it shows tumor-selective accumulation of protoporphyrin IX, a fluorescent substance and a metabolite of 5-ALA. In addition, some studies have reported that 5-ALA increases the radiation sensitivity of glioma and melanoma. In this study, we investigated the radiosensitization effect of 5-ALA on colon cancer. Mice implanted with the human colon cancer cell line HT29 were administered 5-ALA and subsequently X-ray irradiated. These mice were compared with those not administered 5-ALA. Following multiple irradiations, the tumor volume of the 5-ALA group was significantly lower than that of the non-5-ALA group (day 5: p value=0.0489, day 8: p value= 0.0318, day 12: p value=0.0394). Tumor growth was inhibited by multiple irradiations in the 5-ALA group compared with the non-5-ALA group. These results suggest that 5-ALA also exhibits a radiosensitization effect on colon cancer.

[A case of advanced colon cancer resected successfully after neoadjuvant chemotherapy].

This case concerns a 54-year-old male patient who had been identified as having a type 2 tumor in the cecum, which subsequent pathologic examination revealed to be an adenocarcinoma. The results of a computed tomography (CT) scan suggested that the tumor had directly invaded the right iliopsoas. Neoadjuvant chemotherapy was performed to avoid a non-curative resection. CT and positron-emission tomography(PET) findings after the 6th course of chemotherapy revealed a significant reduction in tumor size, at which point a right hemicolectomy with D3 nodal dissection was performed. The changes from neoadjuvant chemotherapy were judged to be Grade 1a. The patient was recurrence-free at his 14- months follow-up examination. Neoadjuvant chemotherapy with a drug that targets a specific molecule is a useful treatment for patients with an unresectable primary cancer.