[A Case of Primary Omental Well-Differentiated Liposarcoma].

A 61-year-old woman was diagnosed with a low-absorption tumor measuring 17×5.5×9 cm with fat density between the stomach and transverse colon by follow-up contrast-enhanced CT after surgery for early rectal cancer. The right gastroepiploic artery and vein flowed into the tumor. The tumor demonstrated high signal intensity on contrast-enhanced T2- weighted MRI images, while the overall signal intensity being suppressed on fat-suppressed T2-weighted images. Thus, the patient was diagnosed with primary omental liposarcoma and underwent surgery. The tumor, mainly located on the right omental wall with the right gastroepiploic artery and vein as feeding vessels, was hanging caudally from the greater omentum to the anterior and posterior lobes of the transverse colon. Due to the absence of peritoneal dissemination and infiltration into the surrounding organs, the transverse mesocolon was hollowed out and the entire tumor excised. Based on the histopathological findings, the patient was diagnosed with well-differentiated liposarcoma. Surgical resection is the first-line treatment for liposarcoma, and postoperative adjuvant chemotherapy is ineffective. Since the tumor was completely resected, the patient has survived without recurrence for 2 years and 6 months after surgery.

[A Case of Unresectable Locally Advanced Descending Colon Cancer with an Extensive Retroperitoneal Abscess Treated by Curative Surgeries after Chemotherapy].

The patient was a 61-year-old man who visited the emergency department of our hospital for the exacerbation of left lower abdominal pain. CT scan revealed a tumor in the descending colon and fluid accumulation and extensive foamy gas in the retroperitoneal space, suggesting that the tumor in the descending colon penetrated the parietal peritoneum and formed an abscess. After percutaneous drainage for the retroperitoneal abscess, a transverse colostomy was performed. After the improvement of the general conditions, the patient underwent an endoscopic biopsy and was diagnosed with well-differentiated adenocarcinoma. After 4 courses of FOLFOX plus panitumumab(PANI), with the drainage and wound care continued, he was discharged and underwent 2 additional courses of chemotherapy. PET-CT revealed marked shrinkage of the descending colon tumor without distant metastasis. Therefore, left colectomy and transverse colostomy closure were performed as curative surgeries. After discharge, the patient underwent 6 courses of chemotherapy and has been followed up without recurrence for 13 months after the curative surgeries.

Prediction of Postoperative Delirium after Gastrointestinal Surgery Using the Mie Constructional Apraxia Scale.

BACKGROUND: Postoperative delirium (POD) is a transient postoperative complication that occurs after surgical procedures. Risk factors reported for POD include dementia and cognitive decline. The purpose of this study was to identify predictors of POD by examining the use of preoperative neuropsychological tests, including the Mie Constructional Apraxia Scale (MCAS), and patient background factors. METHOD: The study was performed as a retrospective cohort study. The subjects were 33 patients (mean age, 75.8 ± 10.9 years; male:female ratio, 26:7) who underwent gastrointestinal surgery at Matsusaka City Hospital between December 2019 and April 2021. Data were collected retrospectively from medical records. The study was started after receiving approval from the institution's ethics committee. The survey items included general patient information, nutritional assessment, surgical information, and neuropsychological tests. Subjects were classified into 2 groups according to the presence or absence of POD. If a significant difference was observed between the 2 groups, the sensitivity, specificity, and area under the curve were calculated using a receiver operating characteristic (ROC) curve. RESULT: There were 10 patients in the POD group (male:female ratio, 6:4) and 23 patients in the non-POD group (20:3). The POD group had a shorter education history (p = 0.047) and significantly higher MCAS scores (p = 0.007) than the non-POD group. The ROC curve showed a sensitivity of 90%, a specificity of 69%, and an area under the curve of 0.798 when the MCAS cutoff value was set at 3 points. CONCLUSION: Preoperative MCAS results were capable of predicting the occurrence of POD after gastrointestinal surgery. In addition, a relatively short education background was also considered a risk factor for POD.

[A Cure Case of Rectal Arteriovenous Malformation with a Large Volume of Melena Caused by Surgery for Rectal Cancer].

This study presents the case of a 52-year-old male suffering from extensive melena. A detailed examination using lower gastrointestinal endoscopy revealed a polyp at the lower rectum; subsequently, endoscopic mucosal resection(EMR)was performed. No other lesion for the melena was observed. Histopathologic findings of the EMR confirmed adenocarcinoma in adenoma, indicating the need for additional surgery. Preoperative contrast-enhanced CT revealed an arteriovenous malformation( AVM)of about 5 cm in the rectal wall at the anal side of the lower rectal cancer. Extensive melena was inferred to be caused by AVM; hence, we performed laparoscopic low anterior resection combined with accessible excision of the AVM and blocked the superior rectal artery, acting as an inflow vessel. Postoperative contrast-enhanced CT confirmed the disappearance of AVM. Thus, we experienced a case in which the block of the inflow vessel, according to the treatment theory of embolism therapy without complete resection of the AVM, enabled the treatment of AVM. Therefore, this case could become a reference for the treatment of lower rectal AVM cases in the future.

[A Case of Choledochoduodenal Fistula and Ruptured Gastroduodenal Arterial Pseudoaneurysm with Penetration to the Duodenum in Invasive Pancreatic Cancer].

The patient was a 76-year-old woman who was referred to our department for jaundice. From further evaluation, resectable cancer of the pancreas head was diagnosed. The patient did not want to undergo surgery, although it had been planned. Thus, we performed biliary stenting and subsequently applied chemoradiotherapy. Then, the patient underwent the best supportive care(BSC). Eleven months after the diagnosis of the pancreatic cancer, she presented with hematemesis while in the hospital for a lumbar compression fracture, and her vital signs showed that she was in shock. Emergency endoscopic examination of the upper gastrointestinal tract revealed bleeding from the duodenal bulb. Endoscopic hemostasis was difficult; therefore, emergency interventional radiology(IVR)was conducted. Owing to the ruptured gastrointestinal pseudoaneurysm in the duodenum, embolization was performed. The 2nd-look endoscopic examination of the upper gastrointestinal tract showed that the biliary stent was exposed to the duodenal bulb, which led to the formation of a choledochoduodenal fistula. As the subsequent course, the patient received conservative treatment and had no onset of retrograde choledochitis; however, the patient died due to the original cancer 15 months after the diagnosis and 4 months after the bleeding.

Postmortem diagnosis of massive gastrointestinal bleeding in a patient with aberrant right subclavian artery-esophageal fistula.

Case: Aberrant right subclavian artery-esophageal fistula is a rare, but fatal, complication. A 55-year-old febrile man with a nasogastric feeding tube developed sudden massive hematemesis and shock. Outcome: Upper endoscopy revealed an intragastric hematoma with no active bleeding observed except for oozing from an esophageal tear. Enhanced computed tomography scan detected aberrant right subclavian artery but was unable to determine the bleeding source. Repeat endoscopy carried out on day 2 confirmed hemostasis and the disappearance of the intragastric hematoma. However, the patient suddenly developed recurrent massive hematemesis with refractory shock on day 4 and died. Postmortem computed tomography revealed endoscopic clips in contiguity with aberrant right subclavian artery; a final diagnosis of aberrant right subclavian artery-esophageal fistula was made. Conclusion: Our case demonstrates aberrant right subclavian artery-esophageal fistula may present with transient spontaneous hematemesis in a state of shock, possibly related to fever of unknown origin, and is challenging to diagnose by repeated endoscopy once hematemesis develops.