[A Case of Colorectal Cancer with Asymptomatic Idiopathic Pneumatosis Intestinalis during Bevacizumab Administration].

We present the case of a 75-year-old woman who received CapeOX plus Bmab therapy(capecitabine, oxaliplatin, and bevacizumab)after primary excision for an unresectable advanced sigmoid colon cancer with remote metastasis. Pneumatosis intestinalis(i.e., the presence of isolated gas in the abdominal cavity)was revealed accidentally during a periodical imaging examination in the small intestine and transverse colon, albeit no subjective symptoms were reported. Owing to the absence of definitive evidence of pneumatosis intestinalis and gastrointestinal perforation, the patient was diagnosed with idiopathic pneumatosis intestinalis. Bmab was discontinued, and CapeOX therapy alone was continued after follow-up. Approximately 4 months later, pneumatosis intestinalis had completely disappeared. Bmab is a vascular endothelial growth factor antibody with well-known side effect of gastrointestinal-perforation. However, there have been few reports on pneumatosis intestinalis; to our knowledge, there have been no reports on pneumatosis intestinalis associated with colorectal cancer in Japan. Further, the report suggests the need for appropriate and immediate management of pneumatosis intestinalis following diagnosis.

Simultaneously Diagnosed and Successfully Treated Rectovaginal and Vesicovaginal Fistulae after Low Anterior Resection with Concomitant Resection of Female Genitalia.

Rectovaginal fistula (RVF) and vesicovaginal fistula (VVF) are infrequent but distressing complications after pelvic surgery. However, their adequate treatment is not well described. Here, we simultaneously encountered and successfully treated RVF and VVF after radical surgery for rectal cancer. A 70-year-old woman underwent low anterior resection (LAR) combined with resection of the uterus, the bilateral adnexa, and the upper side of the vagina, as well as diverted ileostomy for rectal cancer. A month after the surgery, she developed urinary incontinence and underwent medical treatment, but her symptoms did not improve. Evaluation with contrast enema before stoma closure revealed the presence of RVF and VVF. We repaired the VVF and RVF via transabdominal and transperineal approaches. After 6 months, ileostomy was closed and the patient had no recurrence of cancer and fistula. In LAR with hysterectomy and resection of the vaginal wall, there is a risk of RVF and VVF. The excision and closure of the fistula tract and omental flap can be effective to treat both fistulae.

A case of diffuse cavernous hemangioma of the appendix: laparoscopic surgery can facilitate diagnosis and treatment.

BACKGROUND: A cavenous hemangioma of the appendix (CHA) is rare. The clinical pathophysiology and adequate management of a CHA have not been sufficiently explained since reports on CHA are scarce. CASE PRESENTATION: A 56-year-old woman presented with chronic right lower quadrant pain. Abdominal contrast-enhanced computed tomography revealed a thickened appendix (1.5 cm in diameter) and some focal calcifications in the appendiceal wall. No acute inflammatory signs were visible around the appendix. For diagnosis and treatment, we performed a laparoscopic surgery. Intraoperative findings included purple granular lesions that were spread diffusely along the surface of the appendix. Since these lesions were spread to the terminal ileum, laparoscopic ileocecal resection was performed. Upon macroscopic inspection, purple-colored, raspberry-like lesions were found diffusely on the serosal surface of the appendix. No lesions were found on the mucosal surface. Hematoxylin and eosin staining indicated the presence of blood-filled sinus-like spaces largely in the subserosal layer. Immunohistochemistry analysis indicated that CD34-positive cells lined these spaces. Given these findings, we diagnosed the patient with a diffuse cavernous vascular malformation of the appendix. CONCLUSIONS: CHA is difficult to diagnose. A laparoscopic approach may be useful for both the diagnosis and treatment of the disease.

Successful Resection of Isolated Para-Aortic Lymph Node Recurrence from Advanced Sigmoid Colon Cancer following 156 Courses of FOLFIRI Regimen.

Isolated para-aortic lymph node (PLN) recurrence from colorectal cancer (CRC) is rare, with no currently validated treatments. Few reports have described the successful resection of isolated PLN involvement from CRC following chemotherapy. We report the case of a 63-year-old man who underwent sigmoidectomy for sigmoid colon cancer at our hospital. Pathological examination demonstrated advanced sigmoid colon cancer with metastatic involvement in both of the tested PLNs. Palliative chemotherapy was initiated four weeks after surgical resection, with administration of the FOLFIRI regimen. Four years after the operation, computed tomography (CT) revealed an enlarged PLN below the left renal vein. As PLN enlarged to 15 mm in the minor axis on a CT scan in 2014 after receiving a total of 156 courses of the FOLFIRI regimen, we considered the enlarged PLN to represent an isolated metastasis. Accordingly, lymph node resection was performed with microscopically negative margins. The patient maintained a good quality of life without any side effects throughout the whole course of his treatment and remains disease-free at 24 months without chemotherapy after resection of the isolated PLN. Curative resection following chemotherapy may improve survival of carefully selected advanced CRC patients with locoregional recurrence, such as isolated PLN involvement.

A meta-analysis of the use of a transanal drainage tube to prevent anastomotic leakage after anterior resection by double-stapling technique for rectal cancer.

BACKGROUND: The safety and efficacy of transanal drainage tube (TDT) placement to decrease the risk of postoperative anastomotic leakage after rectal cancer surgery has not been validated. The objective of this meta-analysis was to evaluate the usefulness of a TDT for the prevention of anastomotic leakage after an anterior resection for rectal cancer. METHODS: The PubMed and Cochrane Library databases were searched for studies comparing TDT and non-TDT. The endpoint utilized in this study was defined as the rates of anastomotic leakage and re-operation. The relative effects of these variables were synthesized using Review Manager 5.1 software. RESULTS: Four trials including 909 participants (401 TDT cases and 508 non-TDT cases) met our inclusion criteria. The weighted mean anastomotic leakage rate was 4% [95% confidence interval (CI) 1-6%], and a significantly lower risk of anastomotic leakage was identified in the TDT group compared with the non-TDT group [odds ratio (OR) 0.30; 95% CI 0.16-0.55; p = 0.0001]. Furthermore, there were significant differences between the TDT and non-TDT groups in terms of the re-operation rate (OR 0.18; 95% CI 0.07-0.44; p = 0.0002). No significant covariates related to anastomotic leakage or re-operation were identified in meta-regression analysis. Both the anastomotic leakage and re-operation rates for all studies lay inside the 95% confidence interval boundaries. No visible publication bias was found by visual assessment of the funnel plot (Egger's test; anastomotic leakage: p = 0.056, re-operation: p = 0.681). CONCLUSIONS: Placement of a TDT is an effective and safe procedure that can decrease the rate of anastomotic leakage and re-operation after an anterior resection.

Effects of laparoscopic surgery on the patterns of death in elderly colorectal cancer patients: competing risk analysis compared with open surgery.

PURPOSE: The effects of laparoscopic colorectal surgery (LAC) on the long-term outcomes of elderly patients remain unclear. This study aimed to assess the short- and long-term outcomes of LAC in elderly colorectal cancer patients and to quantify the effects of LAC on the patient death patterns. METHODS: The clinicopathological data of elderly colorectal cancer patients aged ≥80 years old who were treated between 2006 and 2014 were extracted. The relationships between the clinicopathological factors and overall survival (OS) were assessed using the Cox proportional hazards model and Kaplan-Meier analyses. The risk factors for the types of death were estimated using a competing risk analysis. RESULTS: A total of 107 patients were included. Fifty-two patients underwent LAC, whereas 55 underwent open surgery (OC). There were no significant differences in the American Society of Anesthesiologists grade or comorbidity rate between the groups. The postoperative complication rate was significantly lower with LAC than OC (p < 0.001). After adjustment for covariates, laparoscopic surgery was not a significant risk factor for any of the types of death. CONCLUSIONS: LAC is an effective and safe technique for elderly patients with colorectal cancer. Furthermore, there was no significant association between the surgical procedure and the pattern of death.

Outcomes for patients with obstructing colorectal cancers treated with one-stage surgery using transanal drainage tubes.

BACKGROUND: Acute colorectal obstruction requires immediate surgical treatment. Although one-stage surgery with transanal drainage tubes (TDT) is reportedly safe and feasible, the long-term outcome of this procedure remains unclear. AIM: To assess the outcome of one-stage surgery using TDT in the acute left colon or rectal obstructions due to colorectal carcinomas. METHODS: Clinicopathological data were recorded from patients with colorectal cancer with acute obstructions between 2006 and 2013. RESULTS: A total of 43 patients were enrolled including 29 males and 14 females. Among 39 patients, TDT was successful in 33 (84 %) and was incomplete in 6. Thus, 33 patients received one-stage surgery with TDT decompression, and 9 patients, including 6 with incomplete decompression, received one-stage surgery with no decompression. No significant differences in clinicopathological factors were observed between decompression and non-decompression groups. Adjusted analyses revealed that decompression using TDT was significantly associated with OS (hazard ratio 0.24; 95 % confidence interval, 0.08-0.72; p = 0.01). Furthermore, OS in the TDT decompression group was significantly longer than that in the non-decompression group (p = 0.01). CONCLUSIONS: One-stage surgery with decompression using TDT may be effective to avoid stomas and to improve overall survival in patients with obstructing colorectal cancers.

Diaphragmatic hernia following coronary artery bypass surgery with the right gastroepiploic artery: case report and literature review.

We report an unusual case of intrapericardial diaphragmatic hernia 2 years after coronary artery bypass surgery with the right gastroepiploic artery. Herniation through the orifice created for the right gastroepiploic artery caused small bowel strangulation and secondary volvulus requiring extensive small bowel resection due to acute mesenteric ischemia. This case highlights the importance of careful operative management of coronary artery bypass surgery with the right gastroepiploic artery and increases awareness of this rare but potentially fatal complication.

[A case of gastrointestinal stromal tumor of the duodenum with a huge abscess].

A 36-year-old man admitted for upper abdominal pain and fever. Enhanced abdominal computed tomography showed a cystic tumor with an air fluid level, measuring 140mm in size, along the side of the first and second portions of the duodenum. The common bile duct, portal vein, and proper hepatic artery were displaced by the tumor. Upper gastrointestinal endoscopy showed duodenal ulcer, but fistula was not confirmed. Combining all imaging and clinical findings, it was clinically diagnosed as duodenal submucosal tumor with abscess, and elective surgery was performed. There was a huge mass in the Morrison pouch, with severe adhesion to the second portion of the duodenum, gall bladder, common bile duct, and transverse colon. Subtotal stomach-preserving pancreaticoduodenectomy with transverse colectomy was performed. A fistula from the second portion of the duodenum to the tumor was confirmed on the resected specimen. Histological examination showed gastrointestinal stromal tumor originating in the duodenum.

[A case of advanced rectal cancer responding to neoadjuvant chemotherapy with CPT-11, 5-FU and l-LV after coronary artery bypass graft].

A 75-year-old man was referred to our hospital with a diagnosis of lower rectal cancer. Unstable angina attack occurred after admission and cardiac angiography revealed stenosis of three coronary arteries which were treated by percutaneous transluminal coronary angioplasty unsuccessfully. Coronary artery bypass graft was performed after colostomy. It is possible for operative stress, extracorporeal circulation and blood transfusion to diminish immunocompetence and increase the risk of recurrence. Therefore, CPT-11/5-FU/l-LV combination therapy (CPT-11 80 mg/m(2), 5-FU 500 mg/m(2), l-LV 250 mg/m(2) day 1, 8, 15 every 5 weeks) was carried out as neoadjuvant chemotherapy. The tumor decreased in size, and the level of tumor marker was normalized after two courses of the combination therapy. The patient is alive without recurrence three years after abdominoperineal resection.

[A long-term survival case after resection for umbilical metastasis from gastric cancer treated with weekly paclitaxel].

We report a patient with umbilical metastasis of gastric cancer (Sister Mary Joseph' s nodule) who has been treated by weekly paclitaxel for 16 months after resection of an umbilical tumor. A 61-year-old man who underwent total gastrectomy for cytology-positive advanced gastric cancer in March 2002 and received TS-1 after surgery for 2 years, complained of abdominal pain in May 2004. Physical examination and computed tomography showed an umbilical nodule about 20 mm in diameter. An excisional biopsy of umbilical tumor was performed, and the umbilical metastasis and peritoneal dissemination were diagnosed histopathologically. Weekly paclitaxel was administered after resection of umbilical metastasis. The patient has been alive with good performance status and normal level of serum tumor markers after 48 administrations of paclitaxel.

Hepatic resection for colorectal metastases in the caudate lobe of the liver.

Although hepatic resections for colorectal metastases have become established procedures, there is still only a small number of reports of hepatic resections for such metastases in the caudate lobe. From 1993 to 2001, seven patients underwent eight hepatic resections for colorectal metastases in the caudate lobe at our department. The patients were five men and two women, and their ages were from 53 to 73 years. The ratio of synchronous to metachronous liver metastases was 2 : 5. Solitary metastasis was observed in one patient. One patient with a metastasis in the Spiegel lobe and three patients with metastasis in the caudate process underwent partial resection of the site. The other patients underwent resection of the Spiegel lobe (two times), resection of the right-sided caudate lobe, and total caudate lobe resection. The mean (+/-SE) operative time was 315.9 +/- 30.6 min. Mean intraoperative blood loss was 1325.9 +/- 421.1 ml, and mean postoperative hospital stay was 21 +/- 3.7 days. One patient, who underwent sigmoidectomy and hepatectomy as an emergency operation due to ileus, experienced wound infection. No patient died within 12 months after the surgery. Five patients were alive at 24 months, and three at 36 months. The outcome of these patients encourages us to continue performing hepatic resection for colorectal metastases in the caudate lobe, as it is assumed to be a safe and effective procedure.

Hepatectomy following transarterial chemotherapy for a metastasis in the caudate lobe.

We describe a solitary liver metastasis in the caudate lobe from a colon cancer treated with a hepatic resection following transarterial chemotherapy. A 73-year-old male was admitted with a complaint of melena. The findings from endoscopic examination of the colon showed a type 3 cancer at the hepatic flexure. Computed tomography revealed a metastatic lesion in the caudate lobe of the liver, which was three centimeters in diameter and located between the roots of the middle and the left hepatic vein. A right hemicolectomy was performed and the surgical findings revealed extended lymph node metastasis and the serosal exposure of the primary lesion. A transarterial catheterization to the liver for chemotherapy was placed instead of performing a hepatic resection. After six months of the transarterial chemotherapy, the metastatic tumor was decreased to less than one centimeter and no other new lesion was developed in and out of the liver. The patient underwent a resection of the Spiegel lobe 8 months after the first operation. There were small lesions of viable metastatic cells in the tumor histologically. The patient is currently well without any signs of recurrence 28 months after the first operation.

Direct retroperitoneal open drainage via a long posterior oblique incision for infected necrotizing pancreatitis: report of three cases.

Although several surgical approaches have been advocated for patients with infected necrotizing pancreatitis, there is still a high incidence of morbidity and mortality. We used a new approach of direct retroperitoneal open drainage after various other treatments, for three patients with necrotizing pancreatitis and extended infection with multiple-organ failure. Long oblique incisions were made from the root of the 12th rib to the anterior superior spina iliaca on the left or right side of the back, or both, to approach the retroperitoneal area of infected necrosis. The necrotic tissue was removed bluntly and the wound was laid open. Lavage and debridement were done repeatedly after the operation. The patients recovered from multiple-organ failure within 2 weeks, and control of local infection was achieved within 3-4 weeks. All three patients were discharged and are now well. Therefore, we propose that this method is appropriate for patients with spreading infected necroses, who are in poor general condition.

A giant retention cyst of the pancreas (cystic dilatation of dorsal pancreatic duct) associated with pancreas divisum.

We describe a rare case of pancreas divisum associated with a giant retention cyst (cystic dilatation of the dorsal pancreatic duct), presumably formed following obstruction of the minor papilla. The patient was treated by pancreatico(cysto)jejunostomy. A 50-year-old man was admitted with complaints of increasing upper abdominal distension and body weight loss. There was no previous history of pancreatitis, gallstones, drinking, or abdominal injury. An elastic-hard tumor-like resistance was palpable in the upper abdomen. Computed tomography and ultrasound (US) examinations revealed a giant cystic lesion expanding from the pancreas head to the tail. Endoscopic retrograde cholangiopancreatography findings showed a looping pancreatic duct which drained only the head and uncinate process of the pancreas to the main papilla. A US-guided puncture to the cystic lesion revealed that the lesion continued to the main pancreatic duct in the tail of pancreas. The lesion was connected to a small cystic lesion, which was located inside the minor papilla, and ended there. The amylase level in liquid aspirated from the cyst was 37 869 IU/l, and the result of cytological examination of the liquid showed class II. A pancreatico(cysto)jejunostomy was performed, with the diagnosis being pancreas divisum associated with a retention cyst following obstruction of the minor papilla. The histological findings of a specimen from the cyst wall revealed that the wall was a pancreatic duct covered with mildly inflammatory duct epithelium; there was no evidence of neoplasm. The patient is currently well, and a CT examination 2 years after the operation showed disappearance of the cyst and normal appearance of the whole pancreas.