A low prognostic nutritional index is associated with increased remote infections within 30 days of colorectal surgery: A retrospective cohort study.

OBJECTIVE: This study aimed to identify risk factors for remote infection (RI) within 30 days after colorectal surgery. METHODS: This retrospective study included 660 patients who underwent colorectal surgery at Yamaguchi University Hospital or Ube Kosan Central Hospital between April 2015 and March 2019. Using electronic medical records, we identified the incidence of surgical site infection and RI within 30 days after surgery and obtained information on associated factors. Univariate and multivariable analyses were performed to identify significant risk factors in 607 (median age, 71 years) patients. RESULTS: Seventy-eight (13%) and 38 (6.3%) patients had surgical site infection and RI, respectively. Of the 38 patients diagnosed with RI, 14 (36.8%) had a bloodstream infection, 13 (34.2%) had a urinary tract infection, 8 (21.1%) had a Clostridioides difficile infection, and 7 (18.4%) had respiratory tract infections. Multivariable analysis showed that a preoperative prognostic nutritional index of ≤40 (OR, 2.30; 95% CI, 1.07-4.92; P = .032), intraoperative blood transfusion (OR (odds ratio), 3.06; 95% CI, 1.25-7.47; P = .014), and concomitant stoma creation (OR, 4.13; 95% CI, 1.93-8.83; P = .0002) were significant RI predictors. CONCLUSIONS: Nutritional interventions prompted by low preoperative prognostic nutritional index in colorectal surgery may lead to decreases in postoperative RI.

[A Case of Advanced Gastric Cancer Accompanied with Skip Lymph Node Metastasis in the Retro Portal Region].

We report a case of advanced gastric cancer accompanied with skip lymph node metastasis in the retro portal region only. An 81-year-old man was referred to our hospital because of epigastric pain. CT examination of the abdomen revealed a gastric tumor and a tumor of 3.5 cm in diameter behind the portal vein and pancreatic head, which had high concentrations of FDG(SUVmax=8.5)on PET-CT examination. Thus, we diagnosed lymph node metastasis of the gastric cancer. We performed distal gastrectomyand en bloc resection of regional lymph nodes(D2 plus retro portal and retro pancreatic head nodes). In pathological examinations, the gastric tumor was diagnosed as poorlydifferentiated adenocarcinoma(por1, T3, INF b, ly1, v0). There were no metastatic nodes in perigastric lymph nodes, but the only metastasis was observed in the bulky lymph node, which was indicated by preoperative examinations. Postoperative course was uneventful. The patient is living recurrence-free without adjuvant chemotherapyfor more than 6 years after the operation.

[A Case of Huge Colon Cancer Accompanied with Severe Hypoproteinemia].

We report a case of huge colon cancer accompanied with severe hypoproteinemia. A7 4-year-old woman was referred to our hospital because of abdominal fullness. Blood examinations revealed anemia(hemoglobin 8.8 g/dL)and sever hypopro- teinemia(total protein 4.5 g/dL, albumin 1.1 g/dL). Computed tomography examination of abdomen revealed ascites and large tumor(12.5×10.5 cm)at the right side colon. By further examinations ascending colon cancer without distant metastasis was diagnosed, then we performed right hemicolectomy and primary intestinal anastomosis by open surgery. Ahuge type 1 tumor(18×12 cm)was observed in the excised specimen, which invaded to terminal ileum directly. The tumor was diagnosed moderately differentiated adenocarcinoma without lymph node metastasis(pT3N0M0, fStage II ). Postoperative course was uneventful and serum protein concentration recovered gradually to normal range. Protein leakage from the tumor cannot be proved by this case, so we can't diagnose as protein-losing enteropathy, but we strongly doubt this etiology from postoperative course in this case.

[A Case of Locally Advanced Gallbladder Cancer That Developed Early Multiple Liver Metastasis after Curative Resection, and Achieved Long-TermPartial Remission Using S-1 and Gemcitabine].

A 76-year-old woman was referred to our hospital because of an abdominal tumor in September 2009. An irregularly shaped large tumor was detected in the right subcostal abdominal cavity on computed tomography, and was diagnosed as advanced gallbladder cancer without distant metastasis following further examination. We then performed a laparotomy. The tumor had invaded directly into the descending portion of the duodenum and transverse colon. We performed a curative resection of the tumor macroscopically. Pathological findings were moderately differentiated tubular adenocarcinoma derived from gallbladder cancer(T3N0M0, Stage III ). Postoperative antineoplasticc hemotherapy was not administered. At least 4 metastaticregions in the liver(segments 1, 5, 7, and 8)were detected using computed tomography 3 months after the operation, and we then initiated oral administration of S-1. After beginning treatment, we observed partial remission at 3 months and continued treatment. We changed the regimen of chemotherapy to gemcitabine 11 months later because of a drug-induced corneal disorder. One after treatment change also continues advertising, and treatment has ended 5 years after the operation. The patient has not received any treatment for the last 6 years and 7 months, and is now in the follow up period.

[A Case of Anorectal Amelanotic Malignant Melanoma].

We report a case of primary anorectal amelanotic malignant melanoma (MM), treated with a laparoscopic abdominoperineal resection (APR). A 75-year-old woman was referred to our hospital because of anal bleeding and pain. A finger-tip sized, dark reddish tumor, which protruded from her anus, was observed. After a tumor biopsy, the diagnosis was MM. No cutaneous pigmented regions were observed, and distant metastases and regional lymphadenopathy were not detected by computed tomography and magnetic resonance imaging. Therefore, we performed laparoscopic APR in order to relieve her symptoms. The resected specimen showed a partially pigmented tumor with a diameter of 6.0×4.1 cm in the anorectal junction. Histopathological examination of the specimen showed an amelanotic MM (negative for melanin pigmentation, and positive for HMB-45, Melan-A, and S-100). The post-operative course was uneventful, and we could not find any obvious evidence of recurrence of the disease 11 months after surgery. The prognosis of anorectal MM is extremely poor, thus a less invasive surgical procedure is recommended for treatment of anorectal MM. Laparoscopic APR is useful for treating anorectal MM due to its minimally invasive nature.

Predictors of prolonged laparoscopic cholecystectomy in the treatment of low-grade acute cholecystitis: a single-center, retrospective, observational study.

Aim: Laparoscopic cholecystectomy is frequently used to treat low-grade acute cholecystitis. Improvements in technical skills have reduced the rate of conversion from laparoscopic to open surgery. In this study, we sought to identify factors that might predict the surgical time of laparoscopic cholecystectomy as possible markers for surgical difficulty. Methods: We carried out a single-center retrospective analysis of a Japanese medical insurance database. Data were retrieved for 87 patients with acute cholecystitis. The analyzed factors included age, sex, body mass index, medical history, blood laboratory data, computed tomography findings, and time from disease onset to surgery. Multiple regression analysis was used to identify factors associated with surgical time. Results: Edema of the gallbladder wall on computed tomography, neutrophil sequestration, body mass index, and history of acute cholangitis were significantly associated with surgical time (P = 0.014, 0.027, 0.043, and 0.047, respectively). The conversion rate from laparoscopic surgery to open surgery was 2%. Conclusions: Our results suggest that edema of the gallbladder wall on computed tomography, neutrophil sequestration, body mass index, and history of acute cholangitis are associated with surgical time of laparoscopic cholecystectomy in the treatment of acute cholecystitis in our hospital.

[A case of multiple intestinal lymphomas accompanied by rapid growth of cutaneous infiltration after surgery].

We report a case of multiple intestinal lymphomas accompanied by rapid growth of cutaneous infiltration after surgery. An 86-year-old woman visited our hospital complaining of lower abdominal pain. Multiple tumors in the sigmoidal and ascending colon were detected by using colonoscopy and computed tomography; therefore, we performed surgery. Postoperative pathological examination identified the sigmoidal colon tumor as an adenocarcinoma and the ascending colon tumor as a B cell lymphoma. The tumors in the ileum and the ileal diverticulum, which were simultaneously excised, were also diagnosed as B-cell lymphomas. After surgery, rapid appearance of multiple light purple nodules on the skin of the right thigh was observed. Histological examination of biopsied skin nodules led to a diagnosis of B-cell lymphoma, similar to the previously removed tumors. Although radiotherapy and chemotherapy were administered to the dermatological lesion that reached an advanced stage, the disease condition was progressive. The patient was transferred to another hospital to receive medical treatment 3 months postoperatively. We consider these dermatological lesions to be dermal infiltration of B-cell lymphomas originating from tumors in the intestinal tract.

[A case of far-advanced colon cancer with extraluminal progression that required urgent surgical treatment].

A 60-year-old man was admitted to our hospital because of right flank pain. An irregular cystic mass region with calcification was detected in his right abdomen on computed tomography( CT). On the fifth day after admission, the patient's abdominal pain suddenly worsened. Based on a diagnosis of panperitonitis, we performed an urgent laparotomy on the same day. A bulky tumor involving the right colon, duodenum, and retroperitoneum was found in his abdominal cavity. We performed right hemicolectomy and partial resection of the duodenum but could not completely excise the tumor. The manipulation caused a serious duodenal injury; and therefore, pyloric antrum transection, gastrojejunostomy, and cholecystostomy were performed to reduce the inflow of gastric content and bile. Histological examination of the surgical specimens revealed a moderately differentiated adenocarcinoma that originated from the ascending colon. Many cancer cells were detected in the excised margin; thus, the surgical maneuver of choice was absolute noncurative resection. If peritonitis had not been observed, preoperative chemotherapy would have been more appropriate.

[A case of locally advanced rectal cancer successfully resected after preoperative chemotherapy].

We present the case of a patient who was admitted because of acute pan-peritonitis but was found to have locally advanced rectal cancer that was successfully excised after preoperative chemotherapy. A 68-year-old man was transferred to our hospital via an ambulance because of severe lower abdominal pain. His abdominal computed tomography scan showed a huge tumor in the pelvis. An emergency sigmoid colostomy was performed because of panperitonitis. However, his postoperative examinations indicated locally advanced rectal cancer accompanied with extensive urinary bladder invasion but without distant metastasis, and chemotherapy was started. Eventually, the tumor reduced to 47% of its maximum size after 4 courses of FOLFOX6 and 2 courses of FOLFOX6+panitumumab, and radical excision( low anterior rectal resection, partial urinary bladder resection, D3 lymph node dissection, and total mesorectal excision) was performed on the 154th day since the first operation. No cancer cells were detected on microscopic analysis of the margins of the excised specimen. Thus, preoperative chemotherapy is useful for treating locally advanced rectal cancer.

[A case of remnant gastric cancer with afferent loop syndrome treated by left upper exenteration].

A 64-year-old man with sudden upper abdominal pain and emesis was admitted to our hospital. Forty years ago, he had undergone distal gastrectomy and reconstruction by Billroth II anastomosis for gastric cancer. Abdominal computed tomography revealed a dilated afferent loop and anastomotic tumor. Gastrofiberscopy showed crookedness and edematization of the afferent loop anastomosis. A biopsy revealed a poorly differentiated adenocarcinoma. He was operated on under the diagnosis of remnant gastric cancer. Left upper exenteration was performed because the transverse colon, lateral segment of the liver, pancreas, and left renal hilus were involved. Liver metastasis and abdominal dissemination were not observed. Histopathological findings revealed severe invasion of poorly differentiated adenocarcinoma to other organs, and intraoperative peritoneal lavage cytology was positive. He was discharged from our hospital; however, adjuvant chemotherapy was impossible because of his poor condition. Four months after the operation, he died from peritoneal carcinomatosis. Remnant gastric cancer with afferent loop syndrome has a poor prognosis. Therefore, it is necessary to select surgical resection or palliative care after immediate chemotherapy, considering each patient's condition and cancer stage.

[Two cases of asymptomatic ruptured hepatocellular carcinoma].

We describe 2 cases of asymptomatic ruptured hepatocellular carcinoma diagnosed for the first time after the start of the operation. The first case is a 62-year-old woman. A tumor with a diameter of 3.6 cm was observed in the liver lateral segment on the abdominal computed tomography(CT) scan. She had not reported any subjective symptoms. Although we started operation using the laparoscope, we recognized a tumor burst and continuous bleeding. Bleeding was reduced by detaching the left hepatic artery from the left gastric artery, and left lateral hepatectomy was completed using the laparoscope. The second case is an 82-year-old man. A tumor with a diameter of 13 cm was observed in the left liver on the abdominal CT scan. He had also not reported any subjective symptoms. At the start of the operation, we observed about 200 mL of blood and a hematoma in the circumference of the liver. We intercepted the left Glisson's pedicle promptly and performed a left hepatectomy. Although it was unclear when these tumors were ruptured in both cases, they were bleeding from the burst part continuously at the time of the operation. The tumors were safely excised by controlling blood inflow as much as possible in the early stages of the operation.

[Two cases of retroperitoneal liposarcoma].

We report 2 cases of retroperitoneal liposarcoma. Case 1: A 53-year-old woman with severe abdominal distension and dyspnea was admitted to our hospital. Abdominal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a large mass that occupied almost the entire abdominal cavity. She underwent surgery under the diagnosis of retroperitoneal liposarcoma. The tumor originated from the left lower pelvis. The tumor weighed 18 kg, and the histopathological diagnosis was well-differentiated liposarcoma. Seven years after the operation, local recurrence was found without any complaints. The operation was performed again. The tumor weighed 750 g, and it originated from the same area as observed in the first operation. The histopathological diagnosis was well-differentiated liposarcoma. Case 2: An 82-year-old woman complained of abdominal distension. A new dumbbell-like solid tumor was identified as retroperitoneal liposarcoma by CT and MRI findings, and it was growing rapidly. The tumor was removed with the cecum and right kidney in a curative operation. The tumor weighed 2.6 kg, and the histopathological diagnosis was dedifferentiated liposarcoma. The best treatment for retroperitoneal liposarcoma is curative resection. However, dedifferentiation occasionally occurs over time and in recurrent cases. It is important to follow-up strictly for retroperitoneal liposarcoma.

[A case of duodenal invasion due to recurrent gastric cancer with obstructive jaundice treated by chemotherapy].

A 64-year-old man was admitted to our hospital with complaints of jaundice, upper abdominal distension and pain. He had a history of laparoscopic-assisted distal gastrectomy for gastric cancer about 11 months ago. The stage was IB and pathological examination was poorly differentiated adenocarcinoma. The upper gastrointestinal fiberscope showed a continuous duodenal stenosis between an anastomotic region and the third portion. The pathological diagnosis was recurrent of gastric cancer. The abdominal CT scan showed a dilatation of bile duct due to duodenal invasion. After percutaneous transhepatic cholangio drainage (PTCD) and jejunotomy, the chemotherapy with low-dose CDDP and 5-FU followed by weekly paclitaxel was performed. The stenosis of duodenum and dilatation of bile duct were improved. The patient lived for 8 months after chemotherapy. It is important to understand that gastric cancer diagnosed poorly differentiated adenocarcinoma pathologically sometimes occurs duodenal invasion and obstructive jaundice.

[A case of cholangiocellular carcinoma accompanied with peripheral blood eosinophilia which improved by removal of the hepatic tumor].

We present a case of cholangiocellular carcinoma accompanied with moderate blood eosinophilia. A 65-year-old man was admitted to our hospital because of widely spread skin eruption like urticaria with severe itching. Laboratory findings on admission showed leukocytosis (WBC 10,600/mm3) with moderate eosinophilia (eosinophils 3,678/mm3). Stool examination for ova and parasites was negative. Bone marrow aspiration revealed almost normal appearance. Chest X-ray was normal. Abdominal CT scan revealed a hepatic tumor (6.8 cm in diameter) in the left hepatic lobe. Needle biopsy of the hepatic tumor revealed an adenocarcinoma. We performed left hepatectomy with lymph node dissection without a bile duct reconstruction. The tumor was mass forming type accompanied with intra bile ductal growth in macroscopically. Pathological diagnosis was cholangiocellular carcinoma. After removal of the hepatic tumor, peripheral blood eosinophil counts fell down and cutaneous lesion disappeared immediately. Since the surgery, the patient had no sign of recurrence for 4 years.

[A case of giant breast cancer performed a radical excision after neoadjuvant chemotherapy].

The patient was a 79-year-old woman with the giant breast cancer accompanied with the invasion to pectoralis major muscle and skin. We worried that we would need a skin grafting for the operation because of a wide skin defect. So we performed FEC regimen (a combination of epirubicin, cyclophosphamide and 5-FU) as neoadjuvant chemotherapy (NAC) to reduce the tumor size. Adverse reaction were stomatitis of grade 2 and leukocytopenia of grade 3. The tumor size was reduced by about 25% and tumor marker decreased after 6-cycle of NAC. Then we performed a radical operation (Bt+Ax with partial resection of invaded part of pectoralis major muscle). It was simply difficult to close the skin, but we could close it without skin grafting by sliding BD area and axial skin flap. The pathological examination of resected specimens revealed scirrhous carcinoma with invasion to pectoralis major and skin, but no cancer cell was seen on the excised margin. There was no lymph node involvement. Her postoperative course was uneventful. On the 17th POD, she went back to her home and she now has been taking paclitaxel weekly as adjuvant chemotherapy at an outpatient clinic.

[A case of pyothorax-associated lymphoma treated by operation following radiation therapy].

A 70-year-old man was admitted to our hospital with complaints of right back to anterior chest pain and fever. He had a history of artificial pneumothorax for tuberculosis when he was 21 years old. The chest CT showed a partial thickness of right pleural cavity. The decortication and fenestration were performed for pyothorax, and a diagnosis of pyothorax-associated lymphoma (PAL) was obtained by pathological examination. After the surgery, chest CT revealed a rapid tumor growth in three months and suspicion of invasion to the ribs. After radiation therapy with a total dose of 40 Gy was performed, right pleuropneumonectomy was carried out. The tumor was not remained in the specimen. Postoperative chemotherapy was not performed. He lived for 5 years after the operation without recurrence. It is important to control local recurrence for PAL with the combined therapy of operation, chemotherapy and radiotherapy.

[A case of regional advanced colon cancer accompanied with right femoral nerve paresis].

The patient is a man in his sixties. A hard tumor that fixed to right iliac bone as big as an adult fist could be palpated in the ileocecal region. He complained a cramp and pain in the right thigh. Computed tomography of the abdomen after the administration of contrast material showed an irregular shape tumor that highly invaded through right iliac muscle, and it widely attached to the right iliac bone. Any distant metastases were not detected. In the abdominal cavity, any peritoneal dissemination nodules were not detected. The tumor was completely removed by excising with periosteum of the iliac bone, iliac muscle, transversus abdominis muscle, and a part of psoas muscle and femoral nerve. The dead space after radical excision was filled with greater omental flap. In the microscopic examination, the tumor was diagnosed moderately differentiated adenocarcinoma with invasion to serosa, muscles, femoral nerve and periosteum and regional lymph nodes involvement. The carcinoma cell was not seen in the excised margin, thus it was judged that it was curative excision. If the colonic cancer obtains the curative excision even if the permeation of the limited part is advanced, an excellent prognosis can often be expected, and the role that the surgical operation plays as limited part treatment is large.

Mesenteric paraganglioma: report of a case.

We report a rare case of a solitary primary paraganglioma arising in the mesentery, found in a 72-year-old woman who presented with abdominal pain and a palpable abdominal mass. This extra-abdominal paraganglioma developed from paraganglionic cells that travelled by vertebral migration from the root of the superior mesenteric artery. Extra-adrenal paraganglia extend anywhere from the neck down to the base of the pelvis. Ultrasonography, computed tomography (CT), and angiography showed a solid and cystic heterogeneously enhanced mass, which was fed by the superior mesenteric artery, without distant metastasis. Exploratory laparotomy revealed a large, dark, brownish-red mass in the mesentery of the ileum, which was distinct from the ileum. The mass consisted of peripherally solid areas with central hemorrhage and cystic degeneration. It was diagnosed as a paraganglioma histologically. The patient is free from recurrence of paraganglioma after 1 year of follow up. To our knowledge, this represents only the seventh case of a paraganglioma arising in the mesentery.