[A Case of Overwhelming Post Splenectomy Infection(OPSI)after Operation for Sigmoid Colon Cancer].

A 64-year-old woman was diagnosed with hereditary spherocytosis 30 years ago and underwent splenectomy. She presented to the hospital with lower abdominal pain and was diagnosed with sigmoid colon cancer(cT3N3M1[LYM], H1, Stage Ⅳ)for which sigmoidectomy was performed. On the 7th postoperative day, a fever of 40℃ and an inflammatory reaction were observed. She developed a consciousness disorder the next day, and her condition rapidly deteriorated along with the development of septic shock and disseminated intravascular coagulation(DIC). With the aid of a ventilator, immediate treatment for DIC was started, but reversion of septic shock and DIC was not possible, and the patient died of multiple organ dysfunction on the 17th postoperative day. Computed tomography and urinalysis performed during the course of treatment showed no infected lesion, but Citrobacter spp. was detected thrice in venous blood culture. Hence, the patient was diagnosed as a case of Citrobacter overwhelming post splenectomy infection(OPSI). To our knowledge, this is the first report of Citrobacter spp. infection following an abrupt course of OPSI.

[A Case Survived Long Period after Repeated Operation against the Small Intestinal GIST with Perforation].

A patient was 60-year-old man. In March 2011, the small bowel tumor with perforation was found and the partial resection of small intestine was urgently performed. KIT of resected specimen was positive. Then, diagnosis as GIST was defined. Oral administration of imatinib was started, but it was finished in 5 months because of development of the systemic edema. In February 2013, the abdominal CT revealed a tumor of 20 cm in size in the pelvis. Upon laparotomy, we detected the GIST recurrence generated at the region of small intestine anastomosis where manipulated previously, then resected all of tumor and partially small intestine. Afterward, we diagnosed as a recurrence of GIST. In March 2014, the abdominal CT found 4 cm sized mesenteric tumor and 2 cm sized abdominal wall tumor. The laparotomy was performed and we found 5 disseminated nodules intraperitoneally. We confirmed that all of these disseminated nodules were successfully removed. We defined them as re-recurrence of GIST. Six years and 5 months have elapsed since the first operation was performed, but there is no sign of three times recurrence.

[Long-Term Survival after Resection for Repeated Abdominal Wall Recurrence of Gallbladder Cancer].

We report the case of a 79-year-old woman with repeated abdominal wall recurrence of gallbladder cancer. The original diagnosis was gallbladder carcinoma. She underwent open liver bed dissection and lymph node dissection. Postoperative pathological examination indicated T2N1M0, Stage III disease. She received 6 courses of postoperative chemotherapy with gemcitabine. Two years and 2 months after the surgery, we detected a 13 mm mass under the abdominal wall scar on CT, and we resected this tumor. Pathological findings indicated adenocarcinoma, which was found to be metastasis of the gallbladder cancer. She was treated with S-1 for 8 courses postoperatively. However, 3 years 4 months after the first surgery, a tumor of 22mm was detected in the abdominal wall on the caudal side away from the previous tumor excision site. We resected the abdominal wall including the tumor. The pathological examination revealed adenocarcinoma, which was again metastasis from gallbladder cancer. The increase of CA19-9 was confirmed around 4 years and 7months after the first operation. An abdominal wall tumor of 45mm was detected in contact with the iliac bone near the last excision site and it proved to be a recurrence of gallbladder carcinoma. We performed abdominal wall tumor resection, again identifying adenocarcinoma, which was the third recurrence of gallbladder cancer. Despite continued abdominal wall recurrence, she is alive and well without metastasis for more than 5 years.

[Evaluation of Complications after Gastrectomy with Clavien-Dindo Classification in Patients Aged Over 85 Years].

PURPOSE: The aim of this study is to evaluate complications of gastrectomy for gastric cancer in patients aged over 85 years. PATIENTS AND METHODS: Thirteen patients received curative gastrectomy between April 2007 and March 2008. The surgical complications were evaluated using the Clavien-Dindo classification. RESULTS: There were 11 patients aged 85-89 years and 2 who were over 90 years old. The median body mass index was 18. Nine patients underwent distal gastrectomy and 4 underwent total gastrectomy. The median operation time was 142 minutes and the median blood loss was 148 mL. Complications greater than Grade 2 were observed in 5 patients(38.5%). All complications were Grade 2. No surgical mortality was observed. DISCUSSION: The morbidity rate in elderly patients over 85 years of age may be higher than in patients aged 75 and lower. Our results suggest that gastrectomy for patients aged over 85 years is acceptable.

[Evaluation of Postoperative Complications after Gastrectomy in Elderly Patients Aged Over 80 Years].

PURPOSE: The aim of this study was to evaluate the safety and feasibility of gastrectomy in elderly patients aged over 80 years. PATIENTS AND METHODS: A total of 393 patients who underwent gastrectomy for gastric cancer were assigned to 2 groups: those aged over 80 years(n=48; elderly group)and those less than 80 years(n=345).Clinicopathological features, operative factors, post-operative complications(Clavien-Dindo Grade II or higher), and mortality were retrospectively analyzed. RESULTS: Rates of distal gastrectomy(73% vs 59%, p=0.043)and D1 or D1+dissection(73% vs 58%, p=0.046)were significantly higher in the elderly group.There were no significant differences in post-operative complication rates(23% vs 20.3%, p=0.255)or mortality rates(2.1% vs 0.6%). CONCLUSION: Our results indicate that gastrectomy in elderly patients aged over 80 years may be safe and feasible.

[The Safety of Laparoscopic Lower Anterior Resection at Community Hospitals - A Multi Center Retrospective Cohort Study].

There is a high rate of leakage after laparoscopic lower anterior resection(Lap-LAR).We examined the safety of Lap-LAR at community hospitals.We investigated 54 patients who underwent Lap-LAR at the 10 hospitals related to the Department of Surgery at Yokohama City University between April 2013 and March 2014.T he median patient age was 67 years, and 32 patients were men.Forty -eight(88%)cases were higher than pathological Grade T3, and 37(69%)patients had undergone D3 lymph node dissection.A diverting stoma(DS)was created in 13(24%)patients.An anus drain was placed in 23 (40%)patients.The clinical anastomotic leakage rate(13%)is comparable with the rate of the DS study(12.9%).The rate of anastomotic leakage was acceptable.Lap -LAR at a community hospital could be safely performed for rectal cancer by making appropriate case choices and implementing preventive measures against anastomotic leakage.

A propensity score-matching analysis comparing the oncological outcomes of laparoscopic and open surgery in patients with Stage I/II colon and upper rectal cancers.

PURPOSE: Previous studies from Western countries have shown similar survival outcomes after both open and laparoscopic resections. In Japan, radical D3 dissections performed by open resection have been routinely performed for ≥T2- or ≥N1-stage cancers, and relatively favorable survival outcomes were obtained. This study compared the survival in patients with Stage I/II colon and upper rectal cancers undergoing laparoscopic and open resection. METHODS: A total of 145 patients were initially enrolled. Propensity score matching was applied to assemble a study cohort. D2 lymph node dissection for T1 cancer and D3 for ≥T2- and ≥N1-stage cancers were applied. The primary outcome measure was the disease-free survival; the cancer-specific and overall survival rates were secondary outcomes. RESULTS: A total of 64 patients were matched for the analysis. The length of hospitalization, postoperative complication rates, number of lymph nodes removed and surgical margins were similar between the groups. The disease-free survival following laparoscopic surgery was better than that following open surgery, but the difference was not statistically significant. Neither the cancer-specific nor overall survival rates following laparoscopic surgery were inferior to those associated with open surgery. CONCLUSIONS: The outcomes of the laparoscopic approach were comparable to those for open surgeries accompanied by radical lymph node dissection.

Chylorrhea following laparoscopy assisted distal gastrectomy with D1+ dissection for early gastric cancer: A case report.

INTRODUCTION: Chylorrhea is a form of lymphorrhea involving digested lipid products absorbed in the small intestine. Here we report a rare case of chylorrhea after laparoscopy-assisted distal gastrectomy (LADG) with D1+ dissection that resolved following administration of a low-fat diet. PRESENTATION OF CASE: A 35-year-old woman with early gastric cancer underwent LADG with D1+ dissection, and on postoperative day 4, the drain output increased and the fluid with a high triglyceride level (740mg/dL) changed from clear to milky. On postoperative day 6, oral intake of a low-fat diet was initiated after a 2-day fast, and the daily drain output decreased from postoperative day 9. The drain tube was withdrawn on postoperative day 15, and the patient was discharged on postoperative day 17. DISCUSSION: D1+ dissection does not typically cause injury to the lymphatic trunks, cisterna chyli, or thoracic duct. The maximum output of chylous ascites was minimal, and thus, we assumed that chylorrhea occurred from slightly injured lymphatics with anatomical variation. CONCLUSION: Chylorrhea after LADG with D1+ dissection is very rare. The fasting of our case followed by a low-fat diet without TPN would be an effective therapy. As a result, our case recovered favorably without further therapy.

[Weekly paclitaxel therapy leading to complete disappearance of multiple liver metastases and subsequent surgical resection for advanced gastric cancer].

A 59-year-old man visited our hospital. After examination he was diagnosed with advanced gastric cancer with multiple liver metastases. At first, chemotherapy of S-1/CDDP was administered. After two weeks, he had severe diarrhea and anorexia, so the therapy was discontinued. Weekly paclitaxel was selected as the next therapy. Depending on the leukocytopenia, doses and intervals were controlled. After 4 courses, CT and MRI revealed that the liver metastases had disappeared, while the primary lesion remained. Seven months after beginning treatment, distal gastrectomy was performed. After the operation, 6 courses of paclitaxel therapy were given at the same doses and the same intervals as before the operation. Two years have passed since the operation, and no recurrence was seen on CT and MRI. Because of the relatively low frequency of adverse events in the digestive system, continued treatment with paclitaxel is possible. These findings show that paclitaxel is an effective drug for advanced gastric cancer with liver metastasis.

[A case of advanced colon cancer successfully treated with cetuximab diagnosed as EGFR-positive by liver biopsy].

Cetuximab, a monoclonal antibody used to target the epidermal growth factor receptor(EGFR), was approved for refractory and metastatic colon cancer expressing EGFR, and the EGFR expression must be confirmed. But the EGFR expression may become false negative by immunohistochemistry. When we used a past operation specimen for a search in particular, a correct evaluation may be difficult for prolonged formalin fixation. We report a case successfully treated by cetuximab, who was diagnosed as EGFR-negative by the past operation specimen, but as EGFR-positive by the liver biopsy specimen. A 51- year old woman with multiple organ metastases, who had experienced failure with prior oxaliplatin, irinotecan(CPT-11), 5- FU and bevacizumab regimens, was administered cetuximab plus CPT-11 because it was EGFR-positive by liver biopsy, and the tumor was obviously reduced. It is useful to obtain another specimen such as by liver biopsy, when the EGFR expression is negative by a past operation specimen.

[A case of pseudomembranous colitis with febrile neutropenia induced by chemotherapy and effectively treated by vancomycin enemas].

Pseudomembranous colitis, an antibiotic-associated diarrhea, needs early diagnosis and treatment for the high fatality rate in severe cases. We report a case of pseudomembranous colitis following the use of antibiotics in febrile neutropenia (FN). A 74-year-old man with non-curative resected sigmoid colon cancer was treated with cefepime in FN induced by chemotherapy. Complications of diarrhea were seen on day 2. Paralytic ileus and disseminated intravascular coagulation were also complications. He was diagnosed as pseudomembranous colitis for Clostridium difficile toxin-positive. Vancomycin enemas were administered because oral administrations were impossible, and the effect was provided. Vancomycin enemas are an effective therapy for patients with severe pseudomembranous colitis unable to tolerate oral medications because of ileus.

The validity of sentinel lymph node biopsy using dye technique alone in patients with gastric cancer.

BACKGROUND/AIMS: We investigated whether sentinel lymph node biopsy using dye technique alone is useful or not in decision-making for less invasive surgery in patients with gastric cancer. METHODOLOGY: The subjects were 43 patients who had undergone laparotomy for gastric cancer and consented to undergo sentinel lymph node biopsy using patent blue dye. The patients enrolled were 26 males and 17 females, with a mean age of 62.5 years. The tumor sites were upper third of the stomach in 14, middle third in 16, and lower third in 13 patients. The depth of invasion was mucosa in eight, submucosa in 19, muscularis propria in five, subserosa in five, and serosa in six patients. Total gastrectomy was performed in 12, subtotal gastrectomy in 28, and proximal gastrectomy in three patients. RESULTS: The mean number of sentinel lymph node biopsies per surgery was 3.5 +/- 4.1. We were able to perform blue node biopsy in 40 out of 43 patients, but could not find any blue nodes in three patients. Among the 40 patients in whom blue nodes were identified, 29 patients with no metastasis in blue nodes had no evidence of lymph node metastasis (NO). The depth of invasion was not deeper than subserosa in all these patients. Metastasis was observed in one out of the three patients in whom no blue nodes were found. CONCLUSIONS: When the depth of invasion was not deeper than the subserosa and blue nodes were identified, no metastases in either non-blue nodes or blue nodes could be found in the absence of metastatic blue nodes. Therefore, if the depth of invasion is not deeper than the subserosa in gastric cancer, metastatic search in blue nodes seems sufficient and less invasive surgery can be performed safely. Even when the invasion depth is not deeper than the submucosa, the tumor could be metastatic to Group 2 lymph nodes in patients in whom blue node biopsy revealed metastases. When metastasis is found in lymph nodes by intraoperative frozen section diagnosis, less invasive surgery for gastric cancer is not indicated.

13C-urea breath test in patients having undergone total gastrectomy.

BACKGROUND/AIMS: In this study, we performed 13C-urea breath test in patients who had undergone total gastrectomy and investigated the content of (13)CO2 in the CO2 gas expired after direct influx of 13C-urea into the small intestine. METHODOLOGY: 13C-Urea breath test was performed in 31 patients who had undergone total gastrectomy at this department for the treatment of stomach cancer and consented to participate in this study. The test was performed in two ways, i.e. with and without mouth washing (gargling) on taking 13C-urea. RESULTS: Among 41 measurements, the delta13C was less than 2.5% per hundred in 9 measurements (22.2%) and less than 2.0% per hundred in 6 measurements (14.6%). The delta13C exceeded 50% per hundred, in 4 subjects (9.8%). There were no differences between the methods with and without gargling. CONCLUSIONS: The results of this study suggested the possibility that 13C-urea is decomposed even in the jejunum or the lower part of intestine resulting in absorption of H(13)CO3 and another possibility that 13C-urea is directly absorbed from the intestine and decomposed in the blood.

Successful treatment of multiple small-bowel perforations caused by cytomegalovirus in a patient with malignant lymphoma: report of a case.

We report the successful management of multiple small-bowel perforations caused by cytomegalovirus (CMV) infection in a 60-year-old man, 1 day after CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) therapy induction for malignant lymphoma. Emergency laparotomy was performed for perforative peritonitis, but we did not resect the lesions at this time. Instead, we exteriorized the small bowel and then irrigated the peritoneal cavity and intestinal tract. His white blood cell count was low, at 200 cells/microl, so this therapy was continued until it recovered. The intestine was highly edematous, but it improved after irrigation with peritoneal dialysis solution. In the second-stage procedure, we resected the small bowel with the perforations, and constructed a jejunostomy and colostomy, then closed the abdominal cavity. Although the patient needed central venous hyperalimentation, he had a favorable postoperative course and started treatment again for the malignant lymphoma.

Solitary metachronous metastasis to the thyroid from renal clear cell carcinoma 19 years after nephrectomy: report of a case.

We report a rare case of a solitary metachronous metastasis of renal clear cell carcinoma (RCC) presenting as a thyroid tumor 19 years after a nephrectomy. Our search of the English-language literature found only sporadic reports of late RCC metastases to the thyroid. Fine-needle aspiration biopsy of the thyroid tumor was not accompanied with thyroglobulin (Tg) staining, leading us to initially suspect a primary follicular thyroid carcinoma. The patient, a 77-year-old man, underwent a total thyroidectomy with modified neck dissection. Histological examination confirmed the tumor to be RCC metastasis, and immunohistochemical analysis revealed that both Tg and thyroid transcription factor-1 (TTF-1) were negative in the tumor cells. Thus, the possibility of late RCC metastasis to the thyroid should be considered, even in a patient with a remote history. Furthermore, TTF-1 is useful for identifying thyroid metastatic carcinomas.

Autologous salvaged blood transfusion in spontaneous hemopneumothorax.

Spontaneous hemopneumothorax (SHP) is a rare clinical entity, and an emergent operation due to continuous bleeding or hypovolemic shock is at times necessary. Although allogeneic blood transfusions are urgently required for significant blood loss, autologous blood transfusions can also be considered in patients with SHP. We herein report two cases of successful autologous blood transfusions using blood in the pleural space, decreasing or obviating the need for allogeneic blood transfusion.

How to eradicate Helicobacter pylori using amoxicillin and omeprazole in the remnant stomach.

BACKGROUND/AIMS: We previously investigated the effects of amoxicillin/omeprazole combined therapy on patients who were Helicobacter pylori (H. pylori) positive after gastrectomy for the treatment of gastric cancer, and we determined the difference in amoxicillin dosage between the therapeutic successes and failures. In the present study, assuming that amoxicillin dosage should be determined on the basis of body weight of each patient, we examined whether the eradication of H. pylori would be improved by using this novel dose-selection method. METHODOLOGY: We have previously reported about eradication of H. pylori of remnant stomach as follows. Patients who underwent gastrectomy for the treatment of gastric cancer were enrolled if H. pylori was detected in their remnant stomach after the operation. Of these patients, 22 were treated with amoxicillin at 750 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks. For the evaluation of H. pylori eradication, endoscopic examination and 13C-urea breath test were performed 12 weeks after the initiation of the treatment. The amoxicillin dosage in the therapeutic successes was compared with that in the therapeutic failures, and we found that the dosage was 14.1 +/- 1.5 and 12.5 +/- 1.5 mg/kg/day in the successes and the failures, respectively. Following these results, another 10 H. pylori-positive patients were treated with amoxicillin greater than 16 mg/kg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks, and H. pylori eradication was evaluated as mentioned above. The efficacy of the drug therapy on H. pylori infection was compared between the two groups that one group (Group A) is treated with amoxicillin 750 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks and the other group (Group B) is treated with 1250 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks. RESULTS: The eradication rate of H. pylori in Group B (84.6%) was higher than that in Group A (42.1%). There was significant difference between the two groups (p = 0.028). CONCLUSIONS: We assumed that the optimal dosage of amoxicillin was over 15.6 mg/kg/day for omeprazole-amoxicillin combined therapy for gastrectomized patients who were H. pylori positive, and the favorable therapeutic effects could be obtained by applying this amoxicillin dosage to the eradication of H. pylori.

[Is sentinel lymph node navigation useful for laparoscopic gastrectomy].

The aim of this paper is to assess the usefulness of sentinel lymph node navigation for laparoscopic gastrectomy. The standard lymph node dissection for gastric cancer is a D2 dissection. D2 dissection and sentinel lymph node biopsy can be performed with laparoscopic gastrectomy as well as with open surgery. Sentinel lymph node navigation surgery for gastric cancer has not yet been established, but once a strong consensus is reached we will be able to perform the laparoscopic gastrectomy safely.