Preoperative High C-Reactive Protein to Albumin Ratio Predicts Short- and Long-Term Postoperative Outcomes in Elderly Gastric Cancer Patients.

Individualized preoperative assessment of the general condition of elderly patients with gastric cancer is necessary for appropriate surgical treatment planning. This study investigated the efficacy of preoperative markers that could be easily calculated from preoperative peripheral blood to predict the short- and long-term postoperative outcomes of gastrectomy. In total, 571 patients who underwent R0 surgical resection for gastric cancer were enrolled. In the elderly patient group (≥65 years old), univariate analyses revealed that the incidence of postoperative complications was associated with poor performance status (p = 0.012), more comorbidities (p = 0.020), high C-reactive protein to albumin ratio (CAR, p = 0.003), total gastrectomy (p = 0.003), open approach (p = 0.034), blood transfusion (p = 0.002), and advanced cancer (p = 0.003). Multivariate analysis showed that a high CAR was associated with a high incidence of postoperative complications (p = 0.046). High CAR was also associated with poor OS (p = 0.015) and RFS (p = 0.035). However, these trends were not observed among younger patients (<65 years old). Preoperative CAR may play a significant role in predicting short- and long-term surgical outcomes, particularly in elderly patients with gastric cancer.

Intraoesophageal pressure in patients receiving proximal gastrectomy with hinged double flap method for gastric cancer: a retrospective cohort study.

Background: Objective functional assessment of esophagogastric anastomosis in patients who underwent proximal gastrectomy with the hinged double flap method for gastric cancer has not been well investigated. This study aimed to perform a functional analysis of reconstruction using high-resolution impedance manometry (HRIM). Materials and methods: The authors enroled 25 patients who underwent proximal gastrectomy for gastric cancer between May 2015 and April 2020 and subsequently underwent HRIM postoperatively. Eligible questionnaires [Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37)] were retrieved from 16 patients. The association between HRIM data and PGSAS-37 was analyzed. Results: The amplitudes of distal oesophageal peristaltic waves, contractile front velocity, and distal latency assessed by HRIM were almost normal after surgery. Most patient's lower oesophageal sphincter (LES) resting pressure created by the hinged double flap was within normal limits. Conversely, LES residual pressure values during swallowing-induced relaxation were abnormally high in most patients, and the lower the values, the more severe the reflux and diarrhoea symptoms (P=0.038, P=0.041, respectively). In addition, even when the integrated relaxation pressure (IRP) was normal, lower values corresponded to more severe reflux symptoms (P=0.020). The required LES pressure may be higher after proximal gastrectomy because of the relatively higher intragastric pressure due to the reduced volume of the remnant stomach. This also suggests that swallowing-induced relaxation of the LES was considered a trigger for oesophageal reflux in post-proximal gastrectomy patients. Conclusion: LES residual pressure and IRP values in HRIM correlated with reflux symptoms in patients after proximal gastrectomy.

Primary Small Intestinal Sarcomatoid Carcinoma: Report of a Rare Case and Literature Review.

Sarcomatoid carcinoma (SC) is a rare malignant tumor with properties of both epithelial and mesenchymal carcinomas. SC has been reported in various organs, but the number of reports for each type is small. Small intestinal tumors make up about 3-6% of gastrointestinal malignancies. Discovering them in the early stage is rare and difficult, with anemia and/or abdominal pain as the major symptoms of small intestinal tumors. Primary small intestinal SC (SISC) is rare among small intestinal tumors, and currently very few cases have been reported in the literature. Previous studies have reported that neither chemotherapy nor radiotherapy improves the overall survival rate of patients with SISC, and the prognosis is extremely poor. Currently, surgical resection remains the only optimal therapeutic approach for SISC. Here, we present the case of a 90-year-old woman who had acute peritonitis due to perforation of a small intestinal tumor. She underwent emergency exploratory laparotomy and partial resection of the small intestine, including the tumor. The tumor was pathologically identified as a primary SISC with mesenteric lymph node metastasis. Subsequently, she had recurrence in the intra-abdominal area and lymph node metastasis anterior to the inferior vena cava and died 15 months after surgery without any additional treatment.

Inappropriate Secretion of Antidiuretic Hormone after Pancreatoduodenectomy for Pancreatic Head Cancer: A Case Report and Literature Review.

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a disease that leads to dilute hyponatremia through excessive secretion of antidiuretic hormone. SIADH has various causes, including ectopic ADH-producing tumors, drug properties, and can be idiopathic. But there have been very few reports of cases in which SIADH has developed after surgery for malignant tumors. In addition, few cases have been reported where this disease has developed after surgery for pancreatic cancer, because the symptoms of hyponatremia are non-specific. These symptoms are particularly gastrointestinal symptoms; therefore, it is difficult to differentiate them, even if SIADH has developed after gastrointestinal surgery. The patient in our case was an 80-year-old woman. She had persistent epigastralgia and left back pain. Imaging studies revealed a tumor in the head of the pancreas, which was diagnosed as pancreatic head cancer. We performed subtotal stomach-preserving pancreatoduodenectomy. After the operation, she complained of appetite loss and general fatigue. Her serum sodium levels decreased to 109 mEq/L on postoperative day 11. She was diagnosed with SIADH using the SIADH diagnostic criteria listed by the Japanese Ministry of Health, Labor and Welfare. We treated the patient with sodium supplementation for hyponatremia, and her symptoms ameliorated. After the event, she did not relapse with hyponatremia. This case is significant in that we performed differential diagnosis after major gastrointestinal surgery for pancreatic cancer and diagnosed SIADH at an early stage.

Alpha-fetoprotein-producing Colon Carcinoma with Rapidly Increasing Liver Metastases That Resulted in Death: A Case Report.

Alpha-fetoprotein (AFP) has been widely used as a tumor marker for detecting hepatocellular carcinoma and yolk sac tumors. Recently, cases of gastrointestinal cancer with elevated serum AFP levels have been reported. However, AFP-producing colon cancer is considered rarer than other AFP-producing gastrointestinal cancers. In this study, we report on a case of a 47-year-old woman who was diagnosed with sigmoid colon cancer and underwent sigmoidectomy and lymph node dissection. Postoperative adjuvant chemotherapy (AC) was performed after the curative surgery. After the seventh course of AC, multiple liver masses and enlarged systemic lymph nodes were detected; these were later diagnosed as liver metastases from sigmoid colon cancer. Laboratory examination revealed high AFP levels (14,657.8 ng/mL). After confirming the recurrence, her condition worsened rapidly, and she eventually died 8 months after the operation. Autopsy and histopathological findings showed that the liver mass was positive for AFP staining, but the sigmoid colon cancer tissue was not. We then determined that liver metastases of the colon cancer were more likely than germ cell carcinoma according to the clinical course and pathological findings. We assumed that colon cancer cells can rapidly expand by dedifferentiation, and we diagnosed AFP-producing colon cancer with liver metastases. Despite curative surgery and AC for AFP-producing colon cancer, the patient died of liver and systemic lymph node metastases.

A safe and reliable technique for fascial closure without special devices after laparoscopic surgery.

INTRODUCTION: To prevent port-site hernia, we established a simple and low-cost closure method that uses a venous catheter needle and suture, without any other special devices. MATERIALS AND SURGICAL TECHNIQUE: We used the inner needle of a 16-G venous catheter and a 2-0 absorbable bladed suture. To evaluate the efficacy of this technique, the procedure time was noted and compared among three operators (an experienced surgeon and two inexperienced surgeons). DISCUSSION: The median suturing time was 60.5 seconds (range, 26-130 seconds) per incision. Even an unexperienced surgeon can close the fascia safely and quickly after some experience with the procedure.

A Case of Peritoneal Dissemination and Splenic Metastasis after Gastric Cancer Surgery That Could Be Controlled with Multidisciplinary Treatment.

Splenic metastasis is known to occur at the terminal stage of cancer. While peritoneal dissemination is the most frequent recurrence of gastric cancer, metastasis to the spleen from gastric cancer is very rare. Splenectomy is currently the most effective probable treatment for solitary splenic metastasis of gastric cancer; it provides a good patient prognosis. However, careful consideration of surgical indications is required, as splenic metastasis is typically accompanied by multi-organ metastasis and dissemination. One of the main cancer treatment methods is the "wait-and-see" approach using chemotherapy. In general, patients with gastric cancer are treated with systemic chemotherapy for distant metastases including peritoneal dissemination. Radiotherapy is not commonly used to prolong life in patients with gastric cancer as gastric cancer is predominantly adenocarcinoma. However, a recent report indicated that chemo-radiotherapy was performed successfully for unresectable gastric cancer, including peritoneal dissemination. Here, we present the case of a 67-year-old patient who was observed to have peritoneal dissemination and splenic metastasis after gastric cancer surgery. Once the peritoneal dissemination was localized, surgical excision and chemo-radiotherapy were performed. We treated the splenic metastasis with the "wait-and-see" strategy with chemotherapy. A complete response on imaging in accordance with the Response Evaluation Criteria in Solid Tumors was achieved using multidisciplinary treatment. Our strategy of intensive multidisciplinary therapy could be a treatment option for cases with peritoneal dissemination or splenic metastasis of gastric cancer.

Clinical Complete Response after Chemotherapy and Palliative Surgery for Unresectable Gastric Cancer.

Gastric cancer incidence is high in several countries, and management of advanced gastric cancer remains a challenge. Chemotherapy for unresectable gastric cancers is still evolving, and achieving a complete cure is difficult. Although a clinical complete response to chemotherapy has been reported in patients with unresectable gastric cancer, the chemotherapy duration for these patients is unclear. Here, we report the case of a 71-year-old man who presented with abdominal discomfort. Upper endoscopy revealed advanced gastric cancer on the upper gastric body. Histopathological examination revealed a poorly differentiated adenocarcinoma. Computed tomography revealed regional lymph node and multiple bilobar hepatic metastases. Radical surgery was not possible; therefore, palliative resection of the primary lesion was planned for symptomatic improvement. Tegafur, 5-chloro-2,4-dihydro-pyrimidine, and potassium oxonate were administered prior to surgery, and proximal gastrectomy was performed. Tegafur, 5-chloro-2,4-dihydropyrimidine, and potassium oxonate administration was reinitiated after surgery. A clinical complete response was achieved in the 8th postoperative month, with no hepatic metastases noted on radio imaging. Computed tomography performed in the 1st postoperative year revealed ascites; however, the cytological examination findings were negative. The initial chemotherapy was discontinued, and paclitaxel administration was commenced. Computed tomography performed annually thereafter demonstrated no recurrence, and paclitaxel was discontinued in the 9th postoperative year. The patient remained recurrence free at 12 years postoperatively. For elderly patients like the one presented here, it may be necessary to consider ceasing chemotherapy; however, because it is possible for a complete clinical response over the long term, it should be continued if the patient is well.

Drug-Induced Interstitial Pneumonia due to Application of FOLFOX as Adjuvant Chemotherapy after Rectal Cancer Surgery: A Case Report and Literature Review.

The regimen of oxaliplatin with 5-fluorouracil plus l-leucovorin (FOLFOX) has become one of the most commonly used first-line chemotherapy for patients with advanced colorectal cancer and it provides an increase in disease-free survival as well as an overall survival benefit. Although FOLFOX chemotherapy has helped to improve the clinical outcomes in these patients, the regimen is associated with some therapeutic issues or uncontrolled side effects. Gastrointestinal, neurosensory, and hematological toxicities have frequently been observed in patients treated with FOLFOX, and consequently, some palliative treatment has been established to combat such complications. However, pulmonary toxicities including drug-induced interstitial pneumonia (DI-IP) is rarely observed in these patients and a curative treatment is yet to be established. DI-IP due to chemotherapy is most commonly observed in patients treated with mitomycin, paclitaxel, docetaxel, or gemcitabine. Steroid therapy is mostly used to treat DI-IP, although the efficacy of such treatments is not supported with adequate evidence. FOLFOX-induced interstitial pneumonia (FIIP) is rarely observed, and several case reports of FIIP treated with steroids have been published previously that showed the mortality is extremely high. Here, we present a 74-year-old woman who received modified FOLFOX6 as adjuvant chemotherapy after rectal cancer surgery. The patient experienced FIIP, which improved after application of steroid pulse (high-dose methylprednisolone at 1,000 mg/day for 3 days) and tapering (starting with prednisolone at 40 mg/day) therapy. Our data suggest that such a steroid therapy could represent an effective treatment option for FIIP.

Mucinous nonneoplastic cyst of the pancreas penetrates the colon causing infection: a case report.

BACKGROUND: Mucinous nonneoplastic cyst of the pancreas is a rare disease defined as a cystic lesion lined with mucinous epithelium, supported by hypocellular stroma and not communicating with the pancreatic ducts. Mucinous nonneoplastic cyst of the pancreas has no malignant potential and does not require surgical resection or surveillance. However, its preoperative differentiation from other cystic lesions of the pancreas is difficult because of several overlapping clinical, radiological, and biochemical features. We report a rare case of large mucinous nonneoplastic cyst of the pancreas in which surgery was required due to infection and the possibility of malignancy. CASE PRESENTATION: A 75-year-old Japanese man was found to have a pancreatic cyst in 2006 while undergoing postoperative evaluation for colon cancer. In 2015, the cyst ruptured, and it was treated conservatively. In 2017, he fell down on a road with a fever of 40 °C and was transported emergently to a nearby hospital. Enhanced computed tomography revealed a cystic lesion in the body of the pancreas measuring 119 mm × 100 mm and an adjacent left renal cyst measuring 63 mm in diameter. The wall of the pancreatic cyst was thickened. Magnetic resonance imaging demonstrated a liquid surface in the pancreatic cyst. Pancreatic cyst infection was diagnosed as the source of infection. However, identification of the organism was difficult. Furthermore, due to the increase in the size and wall thickness of the cyst, it was unclear whether the cystic mass was neoplastic with malignant potential. For these reasons, the patient underwent distal pancreatectomy and splenectomy with deroofing of the left renal cyst. Intraoperatively, the pancreatic cyst adhered to the descending colon, and partial resection of the colon was added. Pathologic analysis of the resected cyst demonstrated a simple cyst lined by mucinous epithelium. There was no underlying stromal condensation or epithelial dysplasia, and communication with the native pancreatic ducts was not observed. Based on the operative and histological findings, a final diagnosis of mucinous nonneoplastic cyst of the pancreas with colonic communication was made. The colonic fistula was presumed to be the source of infection. CONCLUSION: Mucinous nonneoplastic cyst of the pancreas is generally benign and requires little follow-up, but large cysts may penetrate other organs and cause severe complications.

Spontaneous regression of transverse colon cancer with high-frequency microsatellite instability: a case report and literature review.

BACKGROUND: Spontaneous regression (SR) of colorectal cancer (CRC) is extremely rare, and only few cases have been reported. Although it is not yet clarified, a plausible mechanism for SR of CRC is an immunological event. CASE PRESENTATION: In this report, we present the case of SR of primary CRC in a 78-year-old man. Preoperative colonoscopy was performed, and a type 2 tumor measuring 30 mm in diameter in the transverse colon was detected. The biopsy revealed a poorly differentiated adenocarcinoma. Colectomy was performed 2 months after initial colonoscopy. During the surgery, only a 10-mm ulcer harboring a polypoid lesion measuring 8.5 mm was detected in the resected tissue; no other masses or carcinoma cells were seen on histological examination. Afterwards, the biopsy specimens were reanalyzed, and immunohistological analysis verified this as adenocarcinoma with stroma-infiltrating lymphocytes. Further analysis revealed a loss of two mismatch repair proteins, suggesting sporadic high-frequency microsatellite instability (MSI-H). CONCLUSION: According to previous literature, a common site of SR in CRC is the proximal colon, which is a feature of MSI-H CRC. However, our report showed a rare case of SR of CRC, which was in the transverse colon, with MSI-H present. This report indicates a relationship between immunological features of MSI-H and the occurrence of SR of CRC. A better understanding of this phenomenon and the mechanisms involved will have significant preventive and therapeutic implications for CRC, including anti-PD-1 immune checkpoint inhibitor therapy.

Hemorrhagic Cholecystitis in a Patient on Maintenance Dialysis.

The present paper describes a case of hemorrhagic cholecystitis in a patient on maintenance dialysis. The patient presented with right upper quadrant abdominal pain. Computed tomography revealed swelling of the gallbladder, high- and isodensity contents of the gallbladder, and high-density stone in the gallbladder neck. He was hospitalized for suspected acute cholecystitis. After hospitalization, his levels of total bilirubin, aspartate aminotransferase, and alanine aminotransferase increased. T2-weighted magnetic resonance imaging showed low-intensity contents expanded to include a wide area from the common bile duct to the cystic duct and gallbladder neck. Endoscopic retrograde cholangiopancreatography revealed clotting from the duodenal papilla. After cannulation of the bile duct, old blood and pus began to flow from the mammary papilla, and an endoscopic nasobiliary drainage tube was placed. After his liver function had improved, the patient underwent laparoscopic cholecystectomy. His sample revealed that the gallbladder was filled with blood clots and stones. His postoperative course was uneventful and he was discharged on day 19 after the procedure. Although hemorrhagic cholecystitis is rare, it should be considered as a differential diagnosis for patients on dialysis who have acute abdominal symptoms.

Prognostic Nutritional Index Predicts Treatment Outcomes following Palliative Surgery for Colorectal Adenocarcinoma.

OBJECTIVES: Palliative surgeries such as stoma creation and bypass are effective for relieving symptoms related to incurable abdominal malignancies; however, these methods are controversial in patients with severe metastatic disease or poor pre-surgical health. The aim of this study was to examine the clinical significance of the prognostic nutritional index (PNI) in evaluations for palliative surgery. METHODS: We retrospectively analyzed data from 37 patients who underwent palliative surgery for histologically-proven colorectal adenocarcinoma from 2009 to 2015. We investigated both risk factors for postoperative complications and prognostic factors. We used a PNI cutoff value of 40, as defined by previous studies. RESULTS: The reason for surgery was stenosis in 18 patients, obstruction in 12, fistula in 5, and bleeding in 2. Bypass was performed in 10 cases, ileostomy in 5, and colostomy in 22. Postoperative morbidity and mortality occurred in 9 and 2 patients, respectively. Median overall survival time was 8.9 months. Only low PNI correlated with postoperative complications at trend-level (p=0.07), and the 2 patients with mortality were classified as PNI-low. The presence of ascites (p=0.003) and PNI (p=0.02) were identified as independent prognostic factors. CONCLUSIONS: PNI could be used as an objective marker for deciding whether to proceed with palliative surgery, independent of the extent of metastatic disease.