Laparoscopic Partial Splenectomy May Be Valuable for the Diagnosis of Malignant Lymphoma: A Case Report.

Background/Aim: Diagnosing primary splenic malignant lymphoma (PSML) is challenging due to the non-specific nature of splenomegaly, necessitating splenic biopsy for confirmation. However, performing partial splenic resection for diagnostic purposes is an elective procedure due to the risk of major hemorrhage. Despite the longstanding practice of splenectomy over the past few decades, it remains invasive and may result in severe early or late complications. Hence, we present laparoscopic partial splenectomy (LPS) in a patient suspicious of PSML for diagnostic purposes in this study. Case Report: An 81-year-old woman presented to our hospital with a one-month history of fever and dry cough. Atypical cells had been detected in her peripheral blood nine months ago. However, at that time, a bone marrow examination did not reveal any atypical cells. The laboratory tests revealed a soluble interleukin receptor-2 levels of 4,667 U/dl and atypical cells were also found in peripheral blood. Abdominal computed tomography showed splenomegaly without any other relevant findings. These findings are suspicious of PSML and LPS without vessel ligation was performed and a small fraction of the spleen from the inferior pole measuring 1.8×1.0 cm was resected. The operation lasted for 63 min with minimal estimated blood loss. Histopathological findings were compatible with the diagnosis of diffuse B-cell lymphoma. The postoperative clinical course was uneventful, and splenomegaly demonstrated improvement six months after the operation. Conclusion: LPS without vessel ligation for biopsy may be valuable for the diagnosis of malignant lymphoma, particularly when there are no swollen lymph nodes, as it offers a less invasive approach.

[A Case of Laparoscopic Gastrectomy for Gastric Cancer Occurring after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery].

We present a case of 72-year-old man who was diagnosed with gastric cancer that occurred after coronary artery bypass grafting(CABG)with the right gastroepiploic artery(RGEA). Gastrointestinal endoscopy revealed a 0-Ⅱc lesion at the posterior wall of gastric angle, and diagnosis was cStage Ⅰ(T2N0M0). Cardiac computed-tomography showed an occlusion of the RGEA graft, suggesting that the RGEA graft could be ligated and dissected. Coronary angiography showed no severe stenosis of the right coronary artery, suggesting that coronary revascularization was not necessary. He underwent laparoscopic distal gastrectomy with D2 lymph node dissection. During the operation, the RGEA graft was dissected after clamp test for 20 minutes to confirm no cardiac event. In such cases, it is crucial to consider whether it is possible or not to dissect the RGEA graft and whether to restore the coronary flow with preoperative meticulous examination.

Current status of function-preserving gastrectomy for gastric cancer.

Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is "function-preserving gastrectomy (FPG)." FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long-term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper-third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus-preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle-third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.

[A Case of Gastric Cancer with Extensive Lymph Node Metastasis Causing Stenosis Symptoms in the Primary pCR after Preoperative Chemotherapy].

A 65‒year‒old man was found with a circumferential type 2 tumor in the gastric antrum by upper gastrointestinal endoscopy, and biopsy revealed poorly a differentiated adenocarcinoma and HER2‒negative results. According to imaging examinations and laparoscopy, he was diagnosed with an advanced gastric cancer, classified as cT4a(SE)N3M0 and cStage Ⅲ. He underwent neoadjuvant chemotherapy(SOX regimen)because of the bulky N finding. After 2 courses of the treatment, marked reductions in the primary gastric lesion and metastatic lymph nodes were observed, although stenosis appeared at the gastric tumor site. The W‒ED tube was used to depressurize the stomach and to manage his nutrition, and the patient's surgery was conducted under good general conditions. We performed a distal gastrectomy(D2 dissection)and cholecystectomy. Histopathological examination showed no viable tumor cells in the primary gastric lesion(Grade 3). Two metastases were found in the dissected lymph nodes, although only a few cancer cells persisted. We report a case of gastric cancer in which pCR was obtained in the primary lesion, although stenosis appeared after the neoadjuvant chemotherapy.

The therapeutic strategy for advanced gastric cancer with pyloric stenosis and liver metastasis; successfully treated by gastro-jejunal bypass and chemotherapy first, followed by curative R0 resection.

BACKGROUND: The indication of surgical resection for liver metastasis from gastric cancer (GC) is still limited and controversial because of its more aggressive oncological characteristics than liver metastasis from colorectal cancer. Pyloric stenosis causes an inadequate oral intake and malnutrition in GC patients. We herein report a case of GC with these two factors that was successfully treated by the combination of gastro-jejunal bypass and chemotherapy, followed by curative R0 resection. CASE PRESENTATION: A 60-year-old man was diagnosed with type 2 GC with liver metastasis and pyloric stenosis, which was confirmed as the HER2-positive type. He underwent gastrojejunostomy and received capecitabine and cisplatin (XP) + trastuzumab chemotherapy. After three courses of the XP + trastuzumab regimen, shrinkage of the primary lesion and liver metastasis was confirmed and his nutritional parameters markedly improved with a stable oral intake after bypass surgery. He underwent curative R0 resection by distal gastrectomy with D2 lymphadenectomy and partial hepatectomy. Histologically, viable tumor cells were observed in less than one-third of the primary lesion, and only scar tissue without viable cancer cells was noted in the resected liver specimen. His postoperative course was uneventful, and recurrence has not been detected in the 30 months after surgery without adjuvant chemotherapy. CONCLUSION: The present case report describes a successful strategy for advanced GC with pyloric stenosis and liver metastasis.

[Preoperative Esophageal Decompression and Enteral Nutrition Using a W-ED Tube in Patients with Esophagogastric Junction Cancer-A Case Report].

The patient was a 67-year-old male diagnosed with adenocarcinoma of the esophagogastric junction. The esophagus was markedly dilated due to severe stenosis, and aspiration pneumonia was observed. Therefore, he was treated with a W- ED tube for simultaneous esophageal decompression and enteral nutrition. Two weeks of W-ED tube placement improved esophageal dilatation and pneumonia while maintaining nutritional status; thus, he underwent proximal gastrectomy, lower esophagectomy and combined resection of distal pancreas, spleen and left crus of diaphragm with jejunal interposition reconstruction. His postoperative course was uneventful, and he was discharged 16 days after surgery without any postoperative infectious complications such as pneumonia, anastomotic leakage, pancreatic fistula and enterocolitis. In the preoperative management for patients with esophagogastric junction cancer with severe stenosis, simultaneous esophageal decompression and enteral nutrition using a W-ED tube is very useful because it can improve aspiration pneumonia, reduce the risk of anastomotic leakage by improving esophageal edema, and prevent disuse atrophy of small intestinal villi.

[A Case of Gastric Carcinoma with Lymphoid Stroma That Was Difficult to Diagnose Preoperatively].

A 71-year-old man was referred to our hospital because of a gastric submucosal tumor. Gastrointestinal stromal tumor (GIST)was diagnosed in the antrum of the stomach and local resection was undergone. At this time, upper gastrointestinal endoscopy found the gastric submucosal tumor with a size of about 5 mm on the posterior wall of the fundus, but it was followed up. The lesion had grown to a size of about 10 mm by endoscopy 2 years later, and a biopsy was performed. Gastric mucosa associated lymphoid tissue(MALT)lymphoma was diagnosed by pathological examination, and Helicobacter pylori eradication therapy was performed. Endoscopy after treatment further increased the size of the lesion to about 20 mm, and ulceration was also observed. A biopsy was performed again, and a diagnosis of poorly differentiated adenocarcinoma was made, and laparoscopic proximal gastrectomy was undergone. It was the diagnosis of gastric carcinoma with lymphoid stroma(GCLS), pT3N0M0, pStage ⅡA in the postoperative pathological examination. GCLS is a rare disease with a frequency of about 1 to 4% of all gastric cancers, and preoperative diagnosis is difficult. From the morphology and histology, the differential diagnosis from submucosal tumors and lymphomas becomes problems.

[A Surgical Case Report of Gastric Cancer Patient with Severe COPD Successfully Controlled by Preoperative Pulmonary Rehabilitation].

A 72-year-old man with a history of chronic obstructive pulmonary disease(COPD)was diagnosed with type 3 gastric cancer at the posterior wall of the gastric body. Although there was no distant metastasis in preoperative imaging tests, pulmonary function test revealed severe obstructive ventilatory impairment, suggesting that the patient had high risks of perioperative pulmonary complications. After treatment for COPD and preoperative pulmonary rehabilitation under hospitalization for 2 weeks, laparoscopic distal gastrectomy plus D2 lymphadenectomy plus Roux-en-Y reconstruction was performed. The patient showed stable respiratory condition postoperatively, and was discharged from hospital on postoperative day 12 without serious postoperative complications. It was suggested that preoperative pulmonary rehabilitation reduced postoperative pulmonary complications and allowed safe surgery in patients with severe COPD.

[Efficacy of Palliative Radiotherapy for Unresectable Advanced Gastric Cancer with Bleeding].

Bleeding and obstruction negativelyimpact qualityof life for patients with unresectable advanced gastric cancer. There are several choices against bleeding and obstruction such as surgery, endoscopic therapy, radiotherapy and interventional radiology. We report on an 85-year-old woman with StageIV gastric cancer with tumor bleeding. Radiation therapyof 30 Gyin 10 fractions was performed. Anyadverse events were not confirmed. Bleeding or obstruction did not occur for 7 months after radiation therapy. Palliative radiation therapy to gastric cancer can be a reasonable option for patients with unsuitable general conditions for surgical intervention.

[A Case of Laparoscopic Cholecystectomy(TANKO)for Gallbladder Cancer with Torsion].

Gallbladder torsion is comparatively rare. Gallbladder cancer is found in 1.5% of cases of acute cholecystitis. We report a case of laparoscopic cholecystectomy(TANKO)for gallbladder cancer with torsion. CASE: A 54-year-old woman with epigastric pain underwent enhanced computed tomography. Gallbladder torsion and a tumor at the gallbladder neck were suspected, and ascites was observed. She was diagnosed with gallbladder torsion, and surgery was performed the same day. Intraoperative findings: The gallbladder was movable, minimally attached to the liver bed, rotated 360°around the cystic duct and cystic artery, and appeared necrotic. The torsion was relieved and laparoscopic cholecystectomy(TANKO)was performed. We accidentally perforated the gallbladder and bile leaked out. COURSE: The patient did well postoperatively. Pathological diagnosis revealed gallbladder cancer. DISCUSSION: Gallbladder cancer with torsion has been reported in 14 cases, not including ours. Among these, none were performed using laparoscopic cholecystectomy(TANKO). We believe that laparoscopic cholecystectomy is appropriate for such cases, but the approach must be carefully considered because of the risk of perforation.

Treatment with antibodies against primary group A streptococcal peritonitis: A case report and a review of the literature.

RATIONALE: Several reports describe severe group A streptococcal (GAS) infections causing septic shock, soft-tissue necrosis, and multiple organ failure known as streptococcal toxic shock syndrome (STSS). However, primary peritonitis with GAS is rare and most of them were undertaken surgical procedure. PATIENT CONCERNS: We herein reported the case of 26-year-old healthy woman with sudden severe abdominal pain and hypotension. Computed tomography (CT) showed that large amount of free fluid in the peritoneal cavity consist with peritonitis, and no free air. DIAGNOSES: Primary peritonitis with GAS. INTERVENTIONS: Proper antibiotic therapy according to blood culture results. OUTCOMES: After antibiotic therapy, the patient recovered well without complications. LESSONS: An appropriate diagnostic approach and prompt antibiotic therapy is essential in GAS primary peritonitis.

[A Case of Gemcitabine and Nab-Paclitaxel Therapy for Multiple Metastatic Pancreatic Cancer].

Pancreatic cancer is one of the leading causes of cancer-related death in Japan. Nab-paclitaxel(nab-PTX)and gemcitabine( GEM)combination chemotherapysignificantlyimproved overall survival in a phase III trial(MPACT). This combination chemotherapyhas become one of the first-line treatments for patients with metastatic pancreatic cancer since December 2014. We report a case of a patient who underwent this chemotherapyfor recurrence of pancreatic head cancer. A 64-yearold man, who underwent curative resection of pancreatic cancer 2 years ago, relapsed with multiple lung metastases and a para-aortic nodal metastasis. The patient was treated with combination chemotherapyof nab-PTX 125mg/m2 plus GEM 1,000mg/m2. He died from carcinomatous pleurisy1 9 months after starting the chemotherapy. The patient skipped scheduled chemotherapyonly3 times due to Grade 3 neutropenia during his clinical course over 19 months. The combination regimen of nab-paclitaxel and gemcitabine is thought to be a well-tolerated and standard treatment for metastatic pancreatic cancer.

[A Case of Giant Liver Metastasis from Gastric Cancer after Surgery for Which Transcatheter Arterial Embolization and Chemotherapy Made Hepatic Resection Possible].

The prognosis of liver metastasis from gastric cancer, which often exhibits incurable factors, is dismal, and no effective therapy exists. We report a case of giant liver metastasis from gastric cancer after surgery, for which transcatheter arterial embolism and chemotherapy(G-SOX)made it possible to perform hepatic resection. The patient was a 78-year-old woman who underwent distal gastrectomy combined with D2 lymphadenectomy at our department in August 2014. She complained of abdominal distension, and a liver metastasis measuring more than 16 cm in diameter was found on computed tomography in April 2015. Transcatheter arterial embolization was performed followed by chemotherapy(9 courses of G-SOX were administered). These therapies were effective, enabling partial hepatic resection to be performed. The patient remains alive and free from recurrence 4 months after surgery. Although no effective therapy exists for liver metastasis from gastric cancer, intensive therapies may enable curative resection.

[Metastatic breast cancer with microangiopathic hemolytic anemia successfully treated by using eribulin].

A 48-year-old woman was diagnosed with metastatic breast carcinoma and multiple bone metastases as well as a brain metastasis in 2004. Multiple bone metastases and brain metastases were also diagnosed in 2005, 2006, and 2010, but she remained stable with the use of chemotherapy and hormonal therapy for about 8 years. In 2013, severe anemia occurred, and the patient was diagnosed with microangiopathic hemolytic anemia (MHA). She was treated with eribulin(1.4 mg/m²), and recovered successfully after treatment. Approximately 8 months have elapsed after initiating the therapy, and there has been no recurrence. MHA associated with breast cancer is very rare, and is regarded as a disease with a poor prognosis. However, eribulin could be a valid treatment for prolonging the survival of patients with MHA associated with breast cancer.

[Squamous cell carcinoma of the anal canal showing complete response after concurrent chemoradiotherapy and S-1 plus mitomycin C - a case report].

The patient was a 65-year-old man who underwent colonoscopy for melena. Following a biopsy, the patient was diagnosed with anal canal squamous cell carcinoma. A computed tomography (CT) scan revealed metastasis to the regional lymph nodes. The proposed treatment regimen comprised radiotherapy combined with S-1 and mitomycin C (MMC). Dur- ing radiotherapy (59.6 Gy in 32 fractions), 10mg/m² MMC was administered, as an intravenous bolus injection, on days 1 and 29. S-1 was administered orally, at a dose of 80 mg/m², on days 1-14 and 29-42. No serious adverse events were observed during chemoradiotherapy; the observed adverse events were leukemia (Grade 2), diarrhea (Grade 1), anorexia (Grade 1), and radiation dermatitis (Grade 1). After 8 weeks of treatment, no tumors, only scar tissue could be detected by using colonoscopy, and a CT scan revealed a remarkable reduction in regional lymph node metastases. The patient achieved a complete response.

[Two cases of surgical resection of rectal gastrointestinal stromal tumor after neoadjuvant therapy with imatinib mesylate].

Case 1: A 58-year-old man who initially presented with diarrhea was diagnosed with rectal gastrointestinal stromal tumor (GIST). The patient initially received neoadjuvant therapy with imatinib mesylate. After imatinib therapy( 400 mg/day) for 23 weeks, the patient's abdominal computed tomography (CT) and magnetic resonance imaging (MRI) scans showed a reduction of approximately 67% in tumor size. He underwent sphincter-preserving surgery with intersphincteric resection, and the tumor was resected radically and safely. Case 2: A 66-year-old man with a complaint of hematochezia was diagnosed with rectal GIST during treatment for infective endocarditis. Neoadjuvant imatinib therapy (400 mg/day) was started. However, the treatment was stopped after 11 weeks because of rhabdomyolysis, which was suspected to be an adverse effect of imatinib administration. Abdominal CT and MRI revealed a reduction of approximately 53% in tumor size. A radical operation was considered feasible and sphincter-preserving surgery with intersphincteric resection was performed. Currently, neoadjuvant imatinib mesylate therapy is performed in the setting of clinical trials, but the cases suggest that it can be a promising strategy for locally advanced rectal GIST, improving the complete resection rate and the safety of operations by reducing the size of the tumor.

[Case of laparoscopic cholecystectomy for a double gallbladder].

A case of a double gallbladder, a congenital anomaly of biliary system is reported in a 71-year-old woman presenting with right hypochondrial pain. After a confirmed diagnosis of double gallbladder with gallstones was made by MRCP or ERCP, both gallbladders were removed laparoscopically. Double gallbladder is rare anatomic malformation of the biliary tract with only 88 cases, including ours, reported in the Japanese literature. Detailed preoperative investigations are required for an accurate preoperative diagnosis especially when considering laparoscopic removal to avoid inadvertent damage to biliary ductal system.