Preoperative diagnosis of tumor depth in gastric cancer using transabdominal ultrasonography compared to using endoscopy and computed tomography.

BACKGROUND: An accurate evaluation method for preoperative diagnosis has not yet been established in patients with gastric cancer (GC), though it is essential for optimal treatment. Current standard modalities are endoscopy and contrast computed tomography (CT). In this study, we investigated the efficacy and limitations of transabdominal ultrasonography (TUS) for the assessment of tumor invasion. METHODS: We enrolled 178 consecutive patients with GC evaluated by TUS, endoscopy, and contrast CT before gastrectomy. For the TUS examination, patients ingested water to fill their stomachs. The clinical staging determined using these modalities was compared to the pathological staging. RESULTS: The overall accuracy of clinical T staging using TUS was 47.8% (pT1a: 5.8% (2/35); pT1b: 58.8% (20/35); pT2: 69.6% (16/23); pT3: 66.7% (22/33); pT4a: 46% (23/50); pT4b: 100% (2/2)). Using endoscopy, contrast CT, and TUS, the overall accuracy was 60.7%. The accuracy of TUS was associated with the tumor region (U region: 50% (14/28); M: 31.8% (14/44); L: 53.7% (57/106); P = 0.048), but not with the cross-sectional parts (P = 0.49). Multivariate analysis identified inaccurate TUS as independently correlating with tumor region (M vs. U/L, odds ratio (OR) = 3.11, 95% confidence interval (CI) 1.41-6.87; P = 0.005) and pT (pT1 vs. pT2-4, OR = 3.00, 95%CI 1.31-6.87; P = 0.009). CONCLUSIONS: The present study demonstrated the importance of TUS in evaluating GC. Thus, TUS may be useful for clinical T staging in certain circumstances, leading to treatment optimization.

[A Case of Cecal Cancer Diagnosed from Sister Mary Joseph's Nodule].

A metastatic tumor of the umbilicus is called"Sister Mary Joseph's nodule", and patients with this tumor show a poor prognosis. Sister Mary Joseph's nodule is a rare occurrence, and there are few case reports. We report a case of cecal cancer first presented with the metastatic tumor in the umbilicus. A 90-year-old woman, complained umbilical induration and foul-smelling discharge, had been treated as omphalitis for 2 months. Because her symptom didn't improve, biopsy of the umbilical tumor was performed, and the findings revealed an adenocarcinoma. She was referred to our hospital. Abdominal CT showed wall thickening in the cecum, and multiple liver metastases. Therefore, we performed lower gastrointestinal endoscopy, which revealed a cecal tumor. We performed biopsy of the tumor and the findings were consistent with adenocarcinoma. Based on these results, we diagnosed the umbilical tumor as a metastasis from the colorectal cancer. Umbilical resection and ileocecal resection were performed, and multiple peritoneal metastases was detected. Post operative course was uneventful, she died 11 months after surgery. Umbilical metastases may worsen the patient's quality of life; thus, the local resection of umbilicus was recommended positively.

Indirect cholecystoduodenal fistula via hepatoduodenal ligament secondary to gangrenous cholecystitis: a case report.

BACKGROUND: Cholecystoduodenal fistula is an infrequent complication of gallbladder diseases. In the majority of cases, the fistula is formed by direct communication between the gallbladder and duodenum due to gallstone impaction in the gallbladder neck. We herein report a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis. CASE PRESENTATION: An 80-year-old woman suspected of having emphysematous cholecystitis by a previous doctor was referred to our hospital for urgent surgery. The initial diagnosis based on additional examinations was gangrenous cholecystitis penetrating the hepatoduodenal ligament. Since she did not complain of signs of peritonitis and was taking an anticoagulant medicine, we avoided surgery and selected percutaneous gallbladder drainage (PTGBD) instead. Contrast imaging of the PTGBD tube and upper endoscopy identified the indirect cholecystoduodenal fistula via the hepatoduodenal ligament. Despite repeated attempts at endoscopic fistula closure using clips, the fistula did not close successfully. We therefore performed laparoscopic cholecystectomy and fistula closure. The postoperative clinical course was uneventful, and she left the hospital on postoperative day 15. The resected gallbladder contained small black stones, and a histological examination revealed gangrenous cholecystitis with no malignant signatures. CONCLUSION: We encountered a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis that was successfully treated by laparoscopic cholecystectomy and fistula closure. It is important to recognize the possible formation of indirect cholecystoduodenal fistula in cases of gangrenous cholecystitis penetrating the hepatoduodenal ligament.

Practical method for hydroxyl-group protection using strontium metal and readily available silyl chlorides.

We have found that the etherification of silyl-protected secondary alcohols proceeds smoothly in the presence of strontium metal using silyl chloride instead of the expensive, yet more reactive, and commonly used silyl triflate. The reaction occurred almost completely with various alcohols.

[A Case of Peritoneal Lymphomatosis Diagnosed by Single-Port Laparoscopic Biopsy].

Peritoneal lymphomatosis is an extremely rare presentation of non-Hodgkin lymphoma. We report a case of peritoneal lymphomatosis diagnosed by single-port laparoscopic biopsy. A 70-year-old woman presented to our hospital with a 2-day history of increasing abdominal distension. Abdominal CT and positron emission tomography/CT(PET-CT)demonstrated extensive disseminated disease with marked thickening of the peritoneal surfaces, and a large omental cake with large volume ascites. Under the diagnosis of peritoneal carcinoma, single-port laparoscopic biopsy was performed. Pathological and immunohistochemical examination revealed diffuse large B-cell lymphoma presenting as peritoneal lymphomatosis. She was treated with a combination chemotherapy consisting of rituximab, cyclophosphamide, doxorubicin, and prednisolone(R- CHOP), and no recurrence was reported for 1 year and 6 months. Single-port laparoscopic biopsy was minimally invasive, and helpful for an urgent and accurate diagnosis and treatment of the disseminated peritoneal disease.

[A Case of Ileal Carcinoma Diagnosed under the Examination for Intestinal Obstruction after Gastric Surgery and Performed Laparoscopic Resection].

A 69-year-old man presented to our hospital with chief complaints of epigastral pain and nausea, was diagnosed with intestinal obstruction after gastric surgery. Abdominal CT performed on the admission showed the tumor located on the terminal ileum. On colonoscopy, type 1 cancer was found near the Bauhin valve in the ileum, and suspected primary ileal carcinoma. Laparoscopic ileocecal resection was performed. The pathological diagnosis was moderately differentiated adenocarcinoma, and the pathological stage was T3(SS), N1(3/16), M0, Stage ⅢA. Although superficial surgical site infection was occurred, the patient was discharged 11 days after surgery. He hoped to adopt without adjuvant chemotherapy, so he has been followed as outpatient. Twenty one months since the surgery, there has been no evidence of cancer recurrence.

[Could Preoperative Conditions Be Preserved or Improved by the Support of Preoperative ONS Administration in Patients with Gastric Cancer?]

INTRODUCTION: In our hospital, we measure the body composition of patients undergoing gastrointestinal surgery. For patients who have a skeletal muscle mass(SMM)of less than 90% of the ideal, we provide them with guidance on having oral nutritional supplements(ONS)and self-exercise therapy. Therefore, we perform operations after taking measures on preserving/improving patient's preoperative conditions. This study was aimed to evaluate the effects on body weight, SMM, and fat mass(FM)in the patients scheduled for gastrectomy. PATIENTS AND METHODS: From January 2017 to December 2020, we retrospectively analyzed 64 gastric cancer patients whose body composition changes were measured at the time of initial diagnosis and immediately before surgery. The body composition was measured by a nutritionist using the BIA method, while the self-exercise therapy was instructed by a rehabilitation therapist. RESULTS: A total of 64 patients were divided into 2 groups: ONS group(36 patients)and Non-ONS group(28 patients). The median preoperative ONS administered to the ONS group was 15 packs. Body weight change showed a significant difference between the 2 groups(+0.73% and -0.91%[p<0.01]in the ONS group and Non-ONS group respectively). SMM change showed no significant difference between the 2 groups(+1.18% and +0.64%[p=0.19]in the ONS group and Non-ONS group respectively). Likewise, FM change showed no significant difference between the 2 groups(-1.08% and -3.50%[p=0.39]in the ONS group and Non-ONS group respectively). CONCLUSION: This study suggested that SMM and FM could be preserved, and body weight could be increased by the support of preoperative ONS administration even in patients with gastric cancer close to having sarcopenia.

[A Case of Rectal Neuroendocrine Tumor with a Major Axis of 10.7 mm with Lymph Node Metastasis].

The case is a 50-year-old woman. Colonoscopy performed by a local doctor for the purpose of stool occult blood positive revealed a 15 mm tumor in the lower rectum, biopsy showed chromogranin positive, synaptophysin positive, and Ki-67 index<1% showed a neuroendocrine tumor(NET), G1 was diagnosed and introduced. Colonoscopy revealed a smooth- surfaced circular hemispherical tumor with a lower edge 30 mm from the anal margin and 20 mm from the dentate line, and EUS showed 10.7×5.2 mm in layers 2 to 3. It was visualized as a well-defined hypoechoic tumor. Contrast-enhanced CT examination showed a 12×5 mm mass showing a contrast-enhancing effect, and no lymphadenopathy or distant metastasis was observed. Contrast-enhanced MRI showed no evidence of pelvic lymphadenopathy. Based on the above, it was diagnosed that NET, G1, and infiltration to the submucosa exceeding 10 mm. Although endoscopic resection as a diagnostic treatment was also an option, we determined surgical resection policy, therefore we performed laparoscopic rectal intersphincteric resection and upper D2 dissection. Histopathological findings showed a tumor of 11×8 mm infiltrating the submucosa( 5,000µm)with metastasis to the pararectal lymph nodes, and the diagnosis was T1b, N1, Ki-67 index 3%, Ly1, V1a, NET G2, pStage ⅢB. Her postoperative course was uneventful, and 6 months later, we performed her artificial anal closure. One year after the operation, there are frequent bowel movements but no fecal incontinence and she is alive without recurrence. For rectal NET with a tumor diameter of 10 mm or more, radical surgery with dissection is recommended because of the high risk of lymph node metastasis. In this case lymph node metastasis was observed surgical resection according to the above reason, but endoscopic resection was possible except that the preoperative size exceeded 10 mm to 0.7 mm and the distance from the anus was short, therefore it took some thought to decide the policy.

The endoluminal pressures during flexible gastrointestinal endoscopy.

In flexible gastrointestinal (GI) endoscopy, endoscopic insufflation is crucial and directly affects visualization. Optimal visualization enables endoscopists to conduct better examinations and administer optimal treatments. However, endoscopic insufflation is typically performed manually and is subjective. We aimed to measure the GI endoluminal pressure during flexible GI endoscopy. Participants underwent esophagogastroduodenoscopy (EGD) at our endoscopy center. Pressure measurement was conducted after completing diagnostic or follow-up EGD. The endoluminal pressure in the esophagus and stomach was measured at 1-s intervals for 1 min while performing EGD for observational and diagnostic purposes. During the measurements, the endoscopists maintained what they subjectively considered to be adequate exposure for screening for lesions by dilating the lumen. Eighty patients were enrolled in this study. The upper GI endoluminal pressure was assessed during EGD without adverse events. The esophageal endoluminal pressure averaged 8.9 (- 3.0 to 20.7) mmHg, and the gastric endoluminal pressure averaged 10.0 (3.0-17.9) mmHg; the upper GI endoluminal pressures were not affected by patient-related factors or the number of endoscopists' postgraduate years. We have successfully obtained the GI endoluminal pressures during EGD. Further accumulation of these data may lead to more stable and reproducible flexible endoscopic diagnosis and intervention.

[A Case of Cytomegalovirus Reactivation after Chemoradiotherapy for Esophageal Cancer].

An 80-year-old man visited our hospital because of abdominal distension and epigastralgia. He was diagnosed esophageal cancer(Mt, SCC, T3N0M0, Stage Ⅱ). Because he was elderly, he received chemoradiotherapy(CRT)with S-1. At 54 Gy/27 Fr, he was admitted to the hospital because of cough exacerbation, fever, and food intake loss. A chest and abdominal CT showed a pneumonia pattern. First, antibiotics were started for suspected bacterial pneumonia. Nevertheless, elevation of inflammatory reactions and continuous fever were observed. As interstitial pneumonia was suspected, we started to administer an injection of prednisolone 60 mg. His respiratory symptoms were improved. However, we observed that disseminated erythema of the trunk spread throughout the body and liver enzymes further increased. As blood examination revealed elevated CMV-IgG antibody and C7-HRP positive, we diagnosed cytomegalovirus(CMV)reactivation. Administration of ganciclovir improved liver damage and disseminated erythema. He discharged our hospital while the steroid dose was reduced and valganciclovir continued administrating. The therapeutic effect of esophageal cancer was partial response(PR). We are following his symptoms and CT scan while adjusting the steroid dose. This is a rare case of CMV reactivation due to immunosuppression caused by steroids therapy during CRT against esophageal cancer. We should be aware of CMV infection during CRT and steroid therapy.

[Carcinoma of the Ascending Colon Showing Rapid Progression of Disseminated Carcinomatosis of the Bone Marrow-Report of a Case].

A 72-year-old man with ascending colon cancer was admitted to our hospital. Right hemicolectomy and lymph node dissection(D3)were performed. The pathological diagnosis was signet-ring cell carcinoma, T4a(SE), N2b, M1a(LYM), Stage Ⅳ, R0, Cur B. Capecitabine was administered after surgery. Subcutaneous bleeding, thrombocytopenia, and a rapid increase in tumor marker levels occurred 9 months after surgery. He had already developed disseminated intravascular coagulation and was admitted to our hospital immediately. CT scan revealed metastasis in the thoracic vertebrae. Bone scintigraphy demonstrated multiple abnormal areas of uptake in the costal bones and the thoracic and lumber vertebrae. We made a final diagnosis of disseminated carcinomatosis of the bone marrow by histopathological examination. Unfortunately, before starting chemotherapy, his general condition deteriorated, and he died 14 days after hospitalization. We present here a case of colon cancer with disseminated carcinomatosis of the bone marrow.

[Super-Elderly Recurrent Rectal Cancer Effectively Treated with Chemotherapy for Three Years - Report of a Case].

The safety and feasibility of the chemotherapy for super-elderly patients over 85 years old have not been clarified yet. We report an extremely aged patient with recurrent rectal cancer that was successfully treated with chemotherapy. A 85-year-old woman underwent Hartmann procedure for rectal cancer. Nine months after surgery, CT scan revealed liver metastases in S5 and S7. We administered capecitabine plus bevacizumab chemotherapy. Liver metastases were disappeared after 6 courses. Although grade 2 hypertension was appeared, no other adverse event occurred. However, due to lung metastases, we attempted irinotecan plus bevacizumab as second line treatment. After 10 courses, general fatigue was gradually developed, so we changed the frequency of chemotherapy from biweekly to triweekly administration. The patient's performance status score has been kept 0, and she has been under treatment as an outpatient for 3 years. The chemotherapy for extremely aged patients with recurrent colorectal cancer was suggested to be safe and feasible under the adequate dose reduction and interval adjustment.

[An Elderly Colon Cancer Patient with Multiple Liver Metastases Who Was Successfully Treated Using mFOLFOX6 and sLV5FU2 Chemotherapy - A Case Report].

Curative treatment for unresectable colon cancer is difficult, and therefore, chemotherapy is often administered in an attempt to improve the prognosis. However, the safety andfeasibility of chemotherapy for elderly patients over 80-years-old have not yet been clarified. We report an elderly colon cancer patient with multiple liver metastases who was successfully treatedwith mFOLFOX6 andsLV5 FU2 chemotherapy. The patient was an 83-year-old-man who was referredto our hospital. After performing sigmoidectomy, we administered mFOLFOX6 chemotherapy. After 5 courses, the regimen was changed to sLV5FU2 owing to grade 3 neuropathy. Liver metastases disappearedanda complete response was obtained1 year after chemotherapy administration. Twenty-four courses of sLV5FU2 chemotherapy had been safely performed. Although grade 1 neutropenia developed, no other adverse event was observed. Currently, the patient is alive without recurrence. Chemotherapy for elderly patients is both feasible and safe.

[A Surgical Case of Solitary Fibrous Tumor Originating from the Greater Omentum].

A36 -year-old man with intellectual disabilities consulted a local physician complaining of a cough, and an abdominal mass was observed on palpation. The patient visited our hospital for close examination. Abdominal contrasting CT revealed a mass with a clear boundary with heterogeneous contrast on the left side of his abdominal cavity. We performed a laparotomy and observed that the tumor originated from the greater omentum. The tumor size was 9×8×6 cm and its weight was 200 g. Histopathologic examination showed hyperplastic spindle-shaped tumor cells with less nuclear fission. Immunohistochemical staining showed that the tumor was positive for CD34, CD99, and bcl-2, slightly positive for p53, and negative for S-100, a- SMA, c-kit, and desmin. Based on the results, a diagnosis of solitary fibrous tumor (SFT) was made. The patient has not shown any recurrence 8 months after surgery.

[A Case of Liver Metastasis of Ampullary Carcinoma That Developed Postoperatively That Was Effectively Treated with Gemcitabine plus Cisplatin].

A 75-year-oldman presenting with obstructive jaundice was referredto our hospital. Basedon a diagnosis of carcinoma of the ampulla of Vater, we performed pancreatoduodenectomy. Postoperative histopathological examination revealed a welldifferentiated papillotubular adenocarcinoma, T3, N0, M0, Stage III . Six months after surgery, an isolatedliver metastasis in S6 was identifiedon CT scan andMRI; therefore, we administeredgemcitabine plus cisplatin chemotherapy. After 6 courses of this regimen, a clinical complete response(CR)was obtained. After 12 courses, the clinical CR continued; however, grade 3 lower-extremity peripheral neuropathy appeared. Therefore, gemcitabine monotherapy was administered as second line chemotherapy. However, multiple liver metastases appearedandthe patient passedaway owing to exacerbation of the disease 2 years after initiating chemotherapy. Although recurrent ampullary carcinoma is difficult to treat, our patient had a long-term survival. Here we report the details of our case and review the relevant literature.

[A Case of Gastric Carcinoid Associated with Hypergastrinemia Treated with LATG].

A 67-year-old man had a gastric polyp diagnosed on screening. Atrophic changes in the upper gastric mucosa were seen on upper gastrointestinal endoscopy. In addition, endoscopy revealed in the middle area of the stomach wall a 10 mm polyp that was diagnosed as a carcinoid tumor through biopsy. Blood serum gastrin was elevated at 2,800 pg/mL.We diagnosed a Rindi Type 1 gastric carcinoid. The patient was planned to be treated with surgical laparoscopy assisted distal gastrectomy (LADG); however, the procedure was changed to intraoperative laparoscopy assisted total gastrectomy (LATG). Chromogranin-positive tumor pathological findings in the mucous membrane submucosa and in the muscularis mucosae endocrine cell micronest (ECM) were widespread. There was no obvious vascular invasion. After the surgery, the serum gastrin level normalized and the patient remains alive.

[A Case of Abdominal Wall Hernia Rupture during Bevacizumab Treatment].

A 78 -year-old man with rectal cancer underwent abdominoperineal resection of the rectum. In the postoperative period, the patient experienced wound infection, leading to an abdominal wall hernia. Two years following surgery, a rise in the serum CEA level was seen. A metastatic tumor was detected in the right lung on chest CT. VATS right lung inferior lobe segmental resection was performed. After lobectomy, the serum CEA level continued to increase. Another metastatic tumor was detected in the right lung on chest CT. Chemotherapy with capecitabine, oxaliplatin, and bevacizumab was commenced. The erosive part of the abdominal wall scar hernia extended during the nine weeks of chemotherapy. The chemotherapy was then discontinued. In the follow-up CT scan, a right pleural recurrence, local recurrence in the pelvis, and a liver metastasis were detected. Chemotherapy was re-introduced 3 years after surgery. The erosive part of the abdominal wall hernia again began to spread with chemotherapy recommencement. Four months after restarting chemotherapy, the hernia ruptured, with a loop of the small intestine protruding out of it. The patient covered this with a sheet of vinyl and was taken by the ambulance to our hospital. The erosive part of the abdominal wall hernia had split by 10 cm, and a loop of the small intestine was protruding. As ischemia of the small intestine was not observed, we replaced it into the abdominal cavity, and performed a temporary suture repair of the hernia sac. Following this, bevacizumab was discontinued, and the erosive part reduced. We performed a radical operation for abdominal wall scar hernia repair 11 weeks after the discontinuation of bevacizumab.

[Super-Elderly Patient with Recurrent Rectal Cancer with Liver Metastases Effectively Treated with Capecitabine plus Bevacizumab Chemotherapy--Report of a Case].

The safety and feasibility of chemotherapy for super-elderly patients (over 85 years old) has not been clarified yet. We report an extremely aged patient with recurrent rectal cancer that was successfully treated with capecitabine plus bevacizumab chemotherapy. An 85-year-old-woman underwent a Hartmann procedure for rectal cancer. Nine months after surgery, tumor markers were elevated. CT and MRI revealed liver metastases in S5 and S7. We administered capecitabine plus bevacizumab chemotherapy. Tumor makers were normalized after 2 courses, and the liver metastases disappeared after 6 courses. Although Grade 1 hypertension developed, no other adverse event occurred. Chemotherapy has been safely performed for 20 courses. The patient's PS score has been maintained at 0, and she has been under treatment as an outpatient. We suggest that capecitabine plus bevacizumab chemotherapy is an effective regimen for extremely aged patients with recurrent colorectal cancer.

Surgical strategy for the gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm: laparoscopic surgery is feasible, safe, and oncologically acceptable.

BACKGROUND: The efficacy and feasibility of laparoscopic surgery (LAP) for gastric GISTs >5 cm has not been adequately assessed. Here we investigated the clinical outcomes of these patients. PATIENTS AND METHODS: Twenty-seven consecutive patients who underwent resection for gastric GISTs >5 cm were enrolled in this retrospective study. We assessed the tumor characteristics, surgical outcomes, tumor recurrence, and patient survival in the open surgery (OPEN) group and in the LAP group. RESULTS: The tumor size in the OPEN group was larger than that in the LAP group, but there were no differences in the mitotic count. There were no differences in operative complications. Finally, there were no differences in the disease-free and no patients in the LAP group died. CONCLUSIONS: In patients with gastric GISTs >5 cm, LAP can be performed with outcomes equivalent to those of OPEN if patient selection and intraoperative judgment are appropriate.

Esophageal submucosal dissection under steady pressure automatically controlled endoscopy (SPACE): a clinical feasibility study.

BACKGROUND AND STUDY AIMS: Steady pressure automatically controlled endoscopy (SPACE) is a new insufflation system that provides constant carbon dioxide (CO2) insufflation pressure during prolonged procedures. The system consists of an overtube, a surgical insufflator, and a newly developed leak-proof valve. The aims of this study were to validate the feasibility and safety of SPACE for esophageal endoscopic submucosal dissection (ESD). PATIENTS AND METHODS: This was a clinical phase I trial, involving 10 patients who underwent esophageal ESD. The primary end point was the rate of adverse events within 30 days (grade 0 to 4). Secondary end points were changes in partial pressure of carbon dioxide (PaCO2) and vital signs during ESD, completion rate of ESD, and degree of abdominal distension by patient assessment and radiographic grading. RESULTS: All adverse events were Grade 2 or less. Mild PaCO2 elevation after ESD was noted; however, no associated symptoms were reported. The procedure was completed under SPACE alone in 8 of 10 patients. Minimal post-procedural bowel distension was observed. CONCLUSIONS: In this small pilot study, SPACE was feasible and appeared to be safe. Further study with larger case numbers is required to demonstrate efficacy and safety. CLINICAL TRIAL REGISTRATION: UMIN000005434.