Diffusion tensor imaging of rectal carcinoma: Clinical evaluation and its correlation with histopathological findings.

OBJECTIVE: This study sought to assess the feasibility of diffusion tensor imaging (DTI) to noninvasively evaluate histological grade and lymph node metastasis in patients with rectal carcinoma (RC). METHODS: Thirty-seven consecutive patients with histologically confirmed RC were examined by 1.5-T MRI. DTI was performed using a single-shot echo-planar imaging sequence with b values of 0 and 1000 s/mm2 and motion-probing gradients in nine noncollinear directions. Fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) maps were compared with histopathological findings. RESULTS: The FA values (0.357 ±â€¯0.047) of the RCs were significantly lower than those of the normal rectal wall, muscle, prostate, and uterus (P < 0.001 for all), while the AD, MD, and RD values (1.221 ±â€¯0.131, 0.804 ±â€¯0.075, and 0.667 ±â€¯0.057 × 10-3 mm2/s, respectively) were also significantly lower than their respective normal values (P < 0.001 for all). The FA, AD, MD, and RD values for RC additionally showed significant inverse correlations with histological grades (r = -0.781, r = -0.750, r = -0.718, and r = -0.682, respectively; P < 0.001 for all). Further, the FA (0.430 vs. 0.611), AD (1.246 vs. 1.608 × 10-3 mm2/s), MD (0.776 vs. 1.036 × 10-3 mm2/s), and RD (0.651 vs. 0.824 × 10-3 mm2/s) (P < 0.001 for all) of the metastatic and nonmetastatic lymph nodes were significantly different. CONCLUSIONS: DTI may be clinically useful for the noninvasive evaluation of histological grade and lymph node metastasis in patients with RC.

A novel mesenchymal-associated transcriptomic signature for risk-stratification and therapeutic response prediction in colorectal cancer.

Risk stratification in Stage II and III colorectal cancer (CRC) patients is critical, as it allows patient selection for adjuvant chemotherapy. In view of the inadequacy of current clinicopathological features for risk-stratification, we undertook a systematic and comprehensive biomarker discovery effort to develop a risk-assessment signature in CRC patients. The biomarker discovery phase examined 853 CRC patients, and identified a gene signature for predicting recurrence-free survival (RFS). This signature was validated in a meta-analysis of 1212 patients from nine independent datasets, and its performance was compared against established prognostic signatures and consensus molecular subtypes (CMS). In addition, a risk-prediction model was trained (n = 142), and subsequently validated in an independent clinical cohort (n = 286). As a result, this mesenchymal-associated transcriptomic signature (MATS) identified high-risk CRC patients with poor RFS in the discovery (hazard ratio [HR]: 1.79), and nine validation cohorts (HR: 1.86). In multivariate analysis, MATS was the most significant predictor of RFS compared to established prognostic signatures and CMS subtypes. Intriguingly, MATS robustly identified CMS4-subtype in multiple CRC cohorts (AUC = 0.92-0.99). In the two clinical cohorts, MATS stratified low and high-risk groups with a 5-year RFS in the training (HR: 4.11) and validation cohorts (HR: 2.55), as well as predicted response to adjuvant therapy in Stage II and III CRC patients. We report a novel prognostic and predictive biomarker signature in CRC, which is superior to currently used approaches and have the potential for clinical translation in near future.

Colorectal cancer risk factors in asymptomatic Chilean population: a survey of international collaboration between Japan and Chile.

In Chile, the mortality from colorectal cancer has been on the rise. A national screening program based on a fecal immunochemical test was started in 2012 as an international collaboration with Japan. This case-control study was designed to identify the risk factors for colorectal cancer, with a goal of increasing the participation rate for colorectal cancer screening. In accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, we conducted a case-control study from 2012 to 2017; 23 845 asymptomatic participants were enrolled in the study. Participants who were fecal immunochemical test-positive or had a family history of colorectal cancer underwent a colonoscopy. We analyzed the odds ratio of the risk factors for colorectal cancer, including sex, age, family history, BMI, hypertension, diabetes, regular use of nonsteroidal anti-inflammatory drugs, alcohol consumption, smoking, physical activity, and daily intake of certain food items. For the screening program, 202 cases of colorectal cancer were detected, and 195 of them were evaluated pathologically after resection. Of these, 173 cases (88.7%) had colorectal cancer stage 0/1, 151 (77.4%) of which were treated with endoscopic resection. In the multivariate analysis, male sex, family history of colorectal cancer, and low intake of cereals or fibers were closely related to a high colorectal cancer incidence. Moreover, participants in their 60s and 70s had a higher incidence of colorectal cancer than those in their 50s. These results suggest that intensive screening of the high-risk population can help in improving the detection of colorectal cancer, whereas higher consumption of cereals or fibers can be effective in preventing its onset.

Transcriptomic expression profiling identifies ITGBL1, an epithelial to mesenchymal transition (EMT)-associated gene, is a promising recurrence prediction biomarker in colorectal cancer.

The current histopathological risk-stratification criteria in colorectal cancer (CRC) patients following a curative surgery remain inadequate. In this study, we undertook a systematic, genomewide, biomarker discovery approach to identify and validate key EMT-associated genes that may facilitate recurrence prediction in CRC. Genomewide RNA expression profiling results from two datasets (GSE17538; N = 173 and GSE41258; N = 307) were used for biomarker discovery. These results were independently validated in two, large, clinical cohorts (testing cohort; N = 201 and validation cohort; N = 468). We performed Gene Set Enrichment Analysis (GSEA) for understanding the function of the candidate markers, and evaluated their correlation with the mesenchymal CMS4 subtype. We identified integrin subunit beta like 1 (ITGBL1) as a promising candidate biomarker, and its high expression associated with poor overall survival (OS) in stage I-IV patients and relapse-free survival (RFS) in stage I-III patients. Subgroup validation in multiple independent patient cohorts confirmed these findings, and demonstrated that high ITGBL1 expression correlated with shorter RFS in stage II patients. We developed a RFS prediction model which robustly predicted RFS (the area under the receiver operating curve (AUROC): 0.74; hazard ratio (HR): 2.72) in CRC patients. ITGBL1 is a promising EMT-associated biomarker for recurrence prediction in CRC patients, which may contribute to improved risk-stratification in CRC.

mFOLFOX6 plus bevacizumab to treat liver-only metastases of colorectal cancer that are unsuitable for upfront resection (TRICC0808): a multicenter phase II trial comprising the final analysis for survival.

BACKGROUND: The TRICC0808 trial is a phase II multi-institutional trial that investigated the efficacy of preoperative mFOLFOX6 + bevacizumab (BV) therapy for liver-only metastasis that is unsuitable for upfront resection. The R0 resection rate in the efficacy analysis has been reported to be 44.4%, and the final analysis for survival was conducted (data fixation on February 16, 2015). METHODS: Six cycles of mFOLFOX6 + BV therapy were applied to patients with liver-only metastases, which were > 5 cm in diameter or more than four tumors (H2 and H3), and hepatectomy was performed if possible. Primary and secondary endpoints were the R0 hepatectomy rate and overall survival (OS), respectively. RESULTS: Of 46 patients registered, OS was analyzed for 45 patients in whom the 3-year OS rate from the starting date of chemotherapy was 44.0% with a 33.6-month median survival time (MST). The 3-year OS rate of 31 patients with hepatectomy, including resection after an additional chemotherapy, was 61.3% with a 43.1-month MST, which was significantly better than 0% of the 3-year OS rate with a 21.0-month MST of 14 patients without hepatectomy (p value < 0.0001). In 24 patients who underwent hepatectomy after six cycles of protocol chemotherapy, the 3-year relapse-free survival rate was 8.3%, with a 36.8-month MST. CONCLUSIONS: This final analysis of the TRICC0808 trial revealed a better long-term survival in patients with hepatectomy after mFOLFOX6 + BV therapy, although most examined patients eventually developed recurrence. Thus, hepatectomy after chemotherapy might improve the survival in patients with advanced liver metastases, although cure remains difficult.

Effectiveness of Wound-Edge Protectors for Preventing Surgical Site Infections after Open Surgery for Colorectal Disease: A Prospective Cohort Study with Two Parallel Study Groups.

BACKGROUND: Standard procedures to reduce the surgical site infection (SSI) rate after colorectal surgery have not been established. A prospective cohort study with 2 parallel study groups was performed to clarify the SSI rate after open surgery with and without a wound-edge protector (WEP) for colorectal disease. METHODS: A total of 102 patients who underwent elective open surgery for colorectal disease between October 2012 and August 2014 were randomly assigned to a WEP group and a WEP (-) group. The primary endpoint was the SSI rate in both groups. RESULTS: Fifty-one patients were assigned to the WEP group and 51 to the WEP (-) group. Two patients were excluded from this study. The rate of SSI with and without a WEP was 16 and 36% respectively (p = 0.021). Older age (p = 0.0073) and no WEP (p = 0.021) were risk factors for SSI after open surgery for colorectal diseases on univariate analysis. On multivariate analysis, both older age (p = 0.016) and no WEP (p = 0.012) were independent risk factors for SSI. CONCLUSION: The present randomized, phase II trial found an SSI rate of 16% with use of a WEP. The SSI rate was lower in the WEP group than in the WEP (-) group. A WEP may reduce the SSI rate after open surgery for colorectal disease in Japanese patients.

Colorectal carcinoma: Ex vivo evaluation using q-space imaging; Correlation with histopathologic findings.

BACKGROUND: Although the prognosis of colorectal carcinoma (CRC) patients depends on the histologic grade (HG) and lymph node metastasis (LNM), accurate preoperative assessment of these prognostic factors is often difficult. PURPOSE: To assess the HG and extent of LNM by q-space imaging (QSI) for preoperative diagnosis of CRC. STUDY TYPE: Prospective. SPECIMEN: A total of 20 colorectal tissue samples containing adenocarcinomas and resected lymph nodes (LNs). FIELD STRENGTH/SEQUENCE: QSI was performed with a 3T MRI system using a diffusion-weighted echo-planar imaging sequence: repetition time, 10,000 msec; echo time, 216 or 210 msec; field of view, 113 × 73.45 mm; matrix, 120 × 78; section thickness, 4 mm; and 11 b values ranging from 0 to 9000 s/mm2 . ASSESSMENT: The mean displacement (MDP; µm), zero-displacement probability (ZDP; arbitrary unit [a.u.]), kurtosis (K; a.u.), and apparent diffusion coefficient (ADC) were analyzed by two observers and compared with histopathologic findings. STATISTICAL TESTS: Spearman's rank correlation coefficient, Mann-Whitney U-test, and ROC curve analyses. RESULTS: For all 20 carcinomas, the MDP, ZDP, K, and ADC were 8.87 ± 0.37 µm, 82.0 ± 6.2 a.u., 74.3 ± 3.0 a.u., and 0.219 ± 0.040 × 10-3 mm2 /s, respectively. The MDP (r = -0.768; P < 0.001), ZDP (r = 0.768; P < 0.001), and K (r = 0.785; P < 0.001) were significantly correlated with the HG of CRC, but not the ADC (r = 0.088; P = 0.712). There were also significant differences in the MDP, ZDP, and K between metastatic and nonmetastatic LNs (all, P < 0.001), but not the ADC (P = 0.082). In the HG of CRC and LNM, the area under the curve was significantly greater for MDP, ZDP, and K than for ADC. DATA CONCLUSION: QSI provides useful diagnostic information to assess the HG and extent of LNM in CRC. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1059-1068.

Expression of ATF6 as a marker of pre-cancerous atypical change in ulcerative colitis-associated colorectal cancer: a potential role in the management of dysplasia.

BACKGROUND: Diagnosis of low-grade dysplasia (LGD) is important in the management of ulcerative colitis (UC), but it is often difficult to distinguish LGD from inflammatory regenerative epithelium. The unfolded protein response (UPR) is activated in inflammatory bowel disease and malignancies. We aimed to identify a UPR-related gene that is involved in the development of non-UC and UC-associated colorectal cancer (CRC), and to investigate whether the target gene is useful for the diagnosis of LGD. METHODS: Using our microarray gene expression database of 152 CRCs, we identified activating transcription factor 6 (ATF6) as a target gene. Immunohistochemistry (IHC) of ATF6 were analyzed in 137 surgically resected CRCs, 95 endoscopically resected adenomas and pTis cancers, and 136 samples from 51 UC patients (93 colitis without neoplasia, 31 dysplasia, and 12 UC-associated CRC). The diagnostic accuracy of ATF6 and p53 as markers of LGD was assessed. RESULTS: ATF6 expression was detectable in all CRCs but not in normal colonic mucosa, was elevated with increase in cellular atypia (adenoma with moderate atypia < severe atypia < pTis CRC, p < 0.001), and higher in dysplasia and CRC than in non-neoplastic colitis (p < 0.001). Notably, the difference between colitis and LGD was significant. Compared to p53-IHC, ATF6-IHC had better diagnostic accuracy for distinguishing LGD from background inflammatory mucosa (sensitivity 70.8 vs. 16.7%, specificity 78.5 vs.71.0%, respectively). CONCLUSIONS: ATF6 was expressed in lesions undergoing pre-cancerous atypical change in both non-UC and UC-associated CRC and may be used to distinguish LGD from inflammatory regenerative epithelium in UC patients.

[Two Cases of Rectal Cancer with Pelvic Local Recurrence Complicated with Sepsis after Rectal Cancer Surgery Successfully Treated with Radiation Therapy].

Treatment of rectal cancer with postoperative pelvic recurrence may complicate infection and may be difficult to treat. We experienced 2 cases complicated with sepsis due to infection in the pelvic local recurrence in which radiation therapy was performed and they were shifted to outpatient molecular-targeted drug therapy. Case 1 involved a 58-year-old woman. In December 2011, colostomy and chemotherapy were performed for locally advanced rectal cancer. In June 2012, we performed low anterior resection. In January 2014, chemotherapy was started for pelvic recurrence. She discontinued treatment for 4 months due to personal circumstances. Recurrence was worsened, and infection caused sepsis and she was admitted to the hospital in February 2017. Infection was not improved with antibiotic drugs, and radiation therapy(60 Gy/30 times)was performed. Infection was improved, and panitumumab monotherapy was started and she was discharged. Case 2 involved a 61-year-old man. In February 2014, a lower anterior resection for rectal cancer was performed. In September 2015, chemotherapy was started for pelvic recurrence. In November 2016, chemotherapy was discontinued due to esophageal variceal rupture. Recurrence was worsened, and infection caused sepsis and he was admitted to the hospital in May 2017. Radiation therapy(50 Gy/20 times)was performed after colostomy. Infection was improved, and cetuximab monotherapy was started and he was discharged.

Morphologic change of the psoas muscle as a surrogate marker of sarcopenia and predictor of complications after colorectal cancer surgery.

PURPOSE: Sarcopenia is reported to be associated with complications after surgery. However, there is no established optimal parameter to determine sarcopenia affecting surgical outcome. This study investigated whether morphologic change of the psoas muscle (MPM) reflects sarcopenia and could be a predictor of complications after colorectal cancer surgery. METHODS: Colorectal cancer patients who underwent primary tumor resection with anastomosis between 2015 and 2016 were analyzed. MPM score was evaluated as the ratio of the short-to-long axis of the psoas muscle in CT images at the L3 vertebrae and classified into five MPM grades. Then, the impact of MPM grade on development of postoperative complications was investigated. RESULTS: A total of 133 patients were studied. MPM score was significantly correlated to the sectional areas of the psoas muscle at the L3 vertebrae which was evaluated by manual tracing. 21.1% of the subjects were classified into severe MPM (defined as MPM grade 3-4). Overall and infectious complications were noted in 37 (27.8%) and 16 (12.0%) patients. Severe MPM (odds ratio [OR] 2.71, 95% confidence interval [CI] 1.09-6.73), longer operative time (OR 1.01, 95%CI 1.001-1.01), and open surgery (OR 2.73, 95%CI 1.17-6.35) were identified as independent risk factors of overall complications. Severe MPM (OR 4.26,95%CI 1.38-13.10) and open surgery (OR 3.42, 95%CI 1.11-10.48) were identified as independent factors associated with infectious complications. CONCLUSIONS: MPM grade may be used as a simple and convenient marker of sarcopenia and to identify patients at increased risk of complications after colorectal cancer surgery.

Colorectal carcinoma: Ex vivo evaluation using 3-T high-spatial-resolution quantitative T2 mapping and its correlation with histopathologic findings.

PURPOSE: In this study, we aimed to evaluate the feasibility of determining the mural invasion depths of colorectal carcinomas using high-spatial-resolution (HSR) quantitative T2 mapping on a 3-T magnetic resonance (MR) scanner. MATERIALS AND METHODS: Twenty colorectal specimens containing adenocarcinomas were imaged on a 3-T MR system equipped with a 4-channel phased-array surface coil. HSR quantitative T2 maps were acquired using a spin-echo sequence with a repetition time/echo time of 7650/22.6-361.6ms (16 echoes), 87×43.5-mm field of view, 2-mm section thickness, 448×224 matrix, and average of 1. HSR fast-spin-echo T2-weighted images were also acquired. Differences between the T2 values (ms) of the tumor tissue, colorectal wall layers, and fibrosis were measured, and the MR images and histopathologic findings were compared. RESULTS: In all specimens (20/20, 100%), the HSR quantitative T2 maps clearly depicted an 8-layer normal colorectal wall in which the T2 values of each layer differed from those of the adjacent layer(s) (P<0.001). Using this technique, fibrosis (73.6±9.4ms) and tumor tissue (104.2±6.4ms) could also be clearly differentiated (P<0.001). In 19 samples (95%), the HSR quantitative T2 maps and histopathologic data yielded the same findings regarding the tumor invasion depth. CONCLUSIONS: Our results indicate that 3-T HSR quantitative T2 mapping is useful for distinguishing colorectal wall layers and differentiating tumor and fibrotic tissues. Accordingly, this technique could be used to determine mural invasion by colorectal carcinomas with a high level of accuracy.

[Long-Term Survival of a Case with Brain and Lung Metastases from Resected Rectal Cancer by Gamma Knife Radiosurgery].

A 69-year-oldfemale hadund ergone low anterior resection for rectal cancer(Rb). Histological examination showedwell differentiated adenocarcinoma with lymph node metastasis. Adjuvant chemotherapy with UFT was performed postoperatively. Nineteen months later, abdominoperineal resection was performedfor anastomotic recurrence andS -1 chemotherapy was made. As 2 left lung metastases appearedat the 44 months after first surgery, capecitabine was performedfor 4 years. At the 101 months after first surgery, sensory difficulty of right lower limb appearedandMRI revealedbrain tumor(single, 18mm) in the left parietal lobe. We performedgamma knife radiosurgery for the brain metastasis andmultiagent chemotherapy for lung metastases. Although the brain metastases have relapsedtwice, gamma knife providedgoodlocal control. She is surviving without symptom of brain metastases 37 months after the detection.

[Two Cases of Colon Cancer with Severe Liver Dysfunction Due to Multiple Liver Metastases Effectively Treated with Hepatic Arterial Infusion Chemotherapy plus CetuximabFollowed by Systemic Chemotherapy].

Case 1: An 80-year-old man was diagnosed with cecal cancer plus multiple liver metastases and peritoneal disseminations. He underwent surgical resection of the primary tumor to prevent bowel obstruction. Initially, hepatic arterial infusion(HAI) plus cetuximab(Cmab)was administered to reduce the size of the metastatic tumors and prevent liver failure. A partial response(PR)was observed in the liver metastases after 12 courses of treatment and S-1 plus oxaliplatin(SOX)plus bevacizumab was started. Case 2: A 44-year-old man was diagnosed with sigmoid colon cancer with multiple liver, lung and bone metastases, and with obstructive jaundice and cholangitis due to severe liver hilum lymph node metastases. His performance status(PS)score was 3 because of severe liver damage. Initially, he underwent endoscopic nasobiliary drainage for obstructive jaundice, and HAI plus Cmab was started to prevent liver dysfunction and to control all metastases. A PR in the metastatic liver tumors was observed after 18 courses. His PS increased to 1 and he was treated with mFOLFOX6 plus Cmab. HAI plus Cmab might be a treatment option for patients who have RAS-wild type tumors with severe liver dysfunction due to multiple liver metastases; HAI is intended to have few side effects and has a high local control rate.

[A Case of Metastasis to the Base of the Skull after Rectal Cancer Operation with Symptom Management via Radiotherapy].

In 2009, A 67-year-old woman underwent high anterior resection for rectal cancer(RS, type 2, pT3, pN1, cM0, pStage III a). U FT/LV was administered for 6 months as adjuvant chemotherapy after the operation. Because peritoneum dissemination and pelvic lymph node metastasis developed 9 months after the operation, CapeOX plus Bmab therapy was started, and we monitored the cancer partial response for the next 6 years. Six years and 9 months after the operation, we detected metastasis to the sacrum; thus, radiotherapy was started. Seven years after the first operation, we detected pulmonary, liver, distant lymph node, and subcutaneous metastasis. Additionally, in the next month, she complained of double vision and dysarthria, and metastasis to the base of the skull was diagnosed via head MRI scanning. We started radiotherapy, and the symptoms gradually improved. Although we started IRIS plus Bmab therapy for pulmonary, liver, distant lymph node, and subcutaneous metastasis, it became a progressive disease(PD). She passed away 7 years and 6 months after the first operation. In this case, radiotherapy was useful for symptom management of metastasis to the base of the skull after surgery for rectal cancer, which is an extremely rare occurrence.

[Adjuvant Chemotherapy for Colorectal Cancer].

The purpose of adjuvant chemotherapy for patients with colorectal cancer treated with curative surgery is to prevent from metachronous recurrences and to improve their prognosis. Because surgical outcomes in Japan are relatively better compared to those in western countries, optimal and personalized treatment based on evidence introduced not only by other countries but by Japan should be chosen. We now focus on a research of identification of biomarker which predict high risk of recurrence in Stage II colorectal cancer.

[A Rare Case of Retroperitoneal Metastasis from Ascending Colon Cancer That Required Multimodal Treatment].

A patient in his 70's underwent a right hemi-colectomy due to an ascending colon cancer in a previous hospital. The tumor had widely infiltrated the retroperitoneal space(pT3, pN0[0/12], pPM0, pDM0, pRM1, Stage II ). He was referred to our institute 1 month after primary surgery to receive chemotherapy for his residual tumor. Abdominal computed tomography (CT)showed a 24mm tumor in his retroperitoneal space before chemotherapy. After 4 cycles of mFOLFOX6 and panitumumab, the tumor partially responded, and after 7 cycles, he achieved a complete response(CR). After an additional 10 cycles, he had maintained the CR, and chemotherapy was discontinued. Two years and 11 months after discontinuation of chemotherapy, an abdominal CT revealed a tumor that gradually grew behind the right kidney. The tumor was resected, and pathological findings showed it was recurrence of the past colon cancer. Seven months after resection of recurrent tumor, CT revealed 2 newly recurrent tumors that gradually grew in the retroperitoneal space again. Therefore, we performed resection of newly recurrent tumors along with the right kidney, Gerota's fascia, diaphragm, and lumbar quadrate muscle for R0 resection. Pathological findings revealed recurrence of the past colon cancer with extensive lymphatic invasion. The recurrent tumor had grown in a retroperitoneal space that was not covered in the primary surgical procedure. Therefore, this is considered a rare case of retroperitoneal metastasis.

Acute and chronic acalculous cholecystitis associated with aortic dissection.

Acalculous cholecystitis is a rare but life-threatening disease, but its pathogenesis is not fully revealed yet. We experienced two acalculous cholecystitis cases associated with aortic dissection. In Case 1, acalculous cholecystitis occurred just after the exacerbation of the aortic dissection. Laparotomy showed necrotized cholecystitis with fresh thrombi formation. Case 2 developed acalculous cholecystitis on the 65th hospital day of aortic dissection. Laparotomy revealed the perforation of the gallbladder. Histological study revealed fibrosis and hemosiderosis in the subserosal layer. The histological findings of these two patients are quite different: Case 1 is acute ischemic and Case 2 is chronic ischemic. While a few cases of acute ischemic cholecystitis have been reported previously, chronic acalculous cholecystitis (CAC) has not been documented. History of aortic dissection could be a risk factor of acute and CAC due to relatively decreased splanchnic blood flow.

Pulmonary edema after laparoscopic hepatectomy in a patient with Budd-Chiari syndrome-associated hepatocellular carcinoma.

An 84-year-old man diagnosed with Budd-Chiari syndrome (BCS) developed a 20-mm hepatocellular carcinoma. We performed laparoscopic hepatectomy without complications, but the patient's percutaneous oxygen saturation gradually worsened and pulmonary edema was detected 50 minutes after extubation. He was subsequently re-intubated and received diuretic therapy. He was discharged on postoperative day 32. Patients with severe BCS have been reported to have an expanded plasma volume. In addition, pneumoperitoneum during laparoscopic surgery has been reported to decrease the venous flow in the portal vein and/or renal vein, the collateral pathways in BCS. The cause of pulmonary edema in the present case may have involved increased venous return following decompression of pneumoperitoneum pressure under the state of an expanded plasma volume. This case suggests that clinicians should pay special attention to achieving volume control in patients with BCS, particularly during laparoscopic surgery and minimizing the duration of pneumoperitoneum.