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Background Neoadjuvant chemotherapy (NAC) has been conducted for patients with non-resectable colorectal cancer; however, few reports of a systematic approach to NAC exist. At our hospital, bevacizumab with capecitabine and oxaliplatin (B-mab XELOX) has been used as chemotherapy for Stage IV colorectal cancer since 2014. We aimed to evaluate the efficacy and safety of NAC with a molecular-targeting agent for Stage IV colorectal cancer. Methods A retrospective, single-institute analysis was performed including 27 patients with advanced recurrent cancer following primary tumor resection and 43 patients with non-resectable tumors and remote metastasis. At the time of resection, 17 were receiving chemotherapy. All 70 patients received at least 3 cycles of B-mab XELOX (total: 920 cycles). We determined the 1-year progression-free survival (1Y-PFS), 1-year overall survival (1Y-OS), 3Y-PFS, 3Y-OS, and number of treatment cycles. The objective response rate, clinical benefit rate, and adverse events were assessed. The number of chemotherapy cycles, survival time, and R0 surgery rate were determined for patients who underwent RO conversion surgery. Results The 1Y-PFS was 28.5% [median survival time (MST): 7.4 months], 1Y-OS was 76.6% (MST not reached), 3Y-PFS was 5.5% (MST: 7.4 months), and 3Y-OS was 26.4% (MST: 25.2 months). The mean and median number of cycles of B-mab XELOX was 13.1 and 10.5, respectively. The objective response rate was 28.6%, and the clinical benefit rate was 58.6%. Grade 1 or Grade 2 adverse events occurred in 60 patients (85.7%); however, they all resolved without intervention. A single Grade 4 event (perforation of the primary tumor) occurred in 1 patient (1.4%). RO conversion surgery was performed in 7 patients (10.0%; primary + liver in 2 patients, primary + lung in 1 patient, liver in 3 patients, and primary in 1 patient). These patients received 3 to 10 cycles preoperatively (mean: 7.3; median: 6.5). R0 surgery was achieved in 5 of the 7 patients (71.4%). Postoperative survival ranged from 1 to 26 months (MST: 8 months). Conclusions This modified regimen was safe and effective in Japanese patients, and a high quality of life/quality-adjusted life-year was achieved. To further evaluate PFS and OS, more patients are being investigated.

Aim In the present study, we investigated the relationship between the expressions of two cancer testis antigens (CTA), LY6K (lymphocyte antigen 6 complex locus K) and CDCA1 (cell division cycle associated 1), in esophageal squamous cell carcinoma (ESCC) tumors and the long‐term outcomes of patients with ESCC to clarify the clinical significance of LY6K and CDCA1 expression in ESCC tumors. Methods A total of 175 patients with thoracic ESCC who had undergone a thoracic esophagectomy with three‐field lymphadenectomy without neoadjuvant therapy were retrospectively reviewed in this study. LY6K and CDCA1 expressions were evaluated in tumor tissues using immunohistochemical (IH) staining. Results Median patient age was 63 years; 159 patients (90.9%) were men. Ninety‐four patients (55.3%) were LY6K‐positive, and 85 patients (48.6%) were CDCA1‐positive. The LY6K‐positive group had a significantly worse overall survival (OS) than the LY6K‐negative group (P = 0.012), and the CDCA1‐positive group had a significantly worse OS than the CDCA1‐negative group (P = 0.010). A multivariate analysis suggested that pathological N stage, venous invasion, LK6Y‐positive and CDCA1‐positive were independent prognostic factors. The patients were classified into four groups according to the staining pattern combinations of the two CTA. The LY6K‐positive and CDCA1‐positive group was found to have a significantly poorer outcome than the other groups. Conclusion ESCC patients with a combination of LY6K and CDCA1 expression in their tumor tissues had a worse prognosis than all the other ESCC patients and it was an independent factor associated with prognosis for patients with ESCC., In the present study, we suggested that ESCC patients with LY6K expression or diffuse expression of CDCA1 in tumor tissues had respectively poor OS, and also suggested that ESCC patients with LY6K expression and CDCA1 diffuse expression in tumor tissues had worse prognosis than other patients.

Introduction: There are several reports on the use of the over-the-scope clip (OTSC) for gastrointestinal bleeding/fistula and endoscopic iatrogenic perforation. However, there are almost no reports on OTSC use for anastomotic leakage (AL) after colorectal cancer surgery. The purpose of this study was to evaluate the outcome of AL closure using the OTSC.Material and methods: Five patients who had undergone AL after laparoscopic surgery for colorectal cancer from April 2017 to April 2019 were evaluated.Results: The average distance from the anal verge of the anastomosis site was 12 (5-18) cm. The average diameter of the dehiscent part was 10.9 (9.3-14.4) mm. The average number of OTSC days after the occurrence of AL was 11 (5-22). On the contrast examination immediately after OTSC, all cases were completely closed, but in the later contrast examination, only one case remained completely closed. The average incompletely closed diameter was 3.6 (2.9-5.1) mm, and the diameter of the dehiscent part was reduced in all cases. Only one patient ultimately underwent colostomy; the rest were cured with OTSC alone.Conclusion: AL site closure using the OTSC after colorectal cancer surgery is a useful minimally invasive treatment when combined with appropriate drain management.

Purpose This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively. Methods We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5). Results Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups. Conclusions L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

BACKGROUND: From 2004 to 2014, 821 colorectal cancer primary resections were conducted at our institution. Of these, 102 patients (12.4%) were older adults over 80 years old. underwent either the conventional laparotomy group (72 patients) or the hand-assisted laparoscopic surgery (HALS) group (30 patients). METHODS: Data were extracted for 102 patients over 80 years old who underwent primary resection for colorectal cancer and were divided into two groups: conventional laparotomy (CL) (n=72) and hand-assisted laparoscopy (n=30). Pre-operative characteristics and outcomes were compared. RESULTS: Baseline characteristics were similar between groups, except for age: CL group median 83.5 years old (range, 80–92 years old) and hand-assisted laparoscopy (HALS) group median 81.5 years old (range, 80–88 years old) (P=0.027). Pre-operative cardiac and lung function risk, performance status, and pathological classification stage (pStage) were almost similar between groups (P=0.668, P=0.176, P>0.999, P=0.217). No significant differences were found for operation time. The HALS group resulted in less blood loss (median 204 mL in the CL group and median 68 mL in the HALS group, P=0.003), shorter postoperative hospital stay (median was 18 days in the CL group and median was 12 days in the HALS group, P

Background/aim Intracorporeal anastomosis (IA) in laparoscopic colectomy for colon cancer is technically difficult, and there is a lack of consensus on the risk of bacterial contamination and cancer cell dissemination. In this study, short- and long-term outcomes of IA were examined. Patients and methods Short and long-term outcomes of those who underwent IA (n=44) or extracorporeal anastomosis (EA) (n=61) were compared. Results IA was better than EA for blood loss, incision length, and first stool. Maximum temperature and C-reactive protein on postoperative day 1 were higher for the IA group. The rate of positive cultures from intraoperative lavage was higher for IA. The rate of positive cultures improved to an equivalent level by replacing mechanical pretreatment with chemical pretreatment. IA and EA were equivalent for the results of ascites cytology from lavage. Conclusion With the use of appropriate preoperative treatment, IA takes advantage of the minimally invasive nature of laparoscopic surgery.

Background Esophageal cancer is one of the most malignant gastroenterological cancers. To improve the treatment outcomes of patients with esophageal squamous cell carcinoma (ESCC), a biomarker capable of predicting the malignant potential of the cancer cells is needed. The aim of the present study was to investigate the relationship between the expression pattern of insulin-like growth factor II m-RNA-binding protein 3 (IMP3), a promising cancer testis antigen for peptide vaccine therapy, in ESCC tumors and the outcomes of patients with ESCC. Methods One hundred and seventy patients with ESCC who underwent a radical transthoracic esophagectomy between 2003 and 2005 at Tokai University Hospital were investigated. IMP3 expression was immunohistochemically analyzed using sections from surgically resected tumor specimens and metastatic lymph nodes. Results Of the 170 patients, 160 patients (94%) exhibited IMP3 positivity in the cytoplasm of their cancer cells (IMP3-positive group), while 10 patients (6%) were IMP3-negative (IMP3-negative group). No significant difference in the overall survival curves were observed between the IMP3-positive and IMP3-negative groups. When the survival analysis was confined to the 160 IMP3-positive patients, however, an invasive front-type IMP3 expression pattern (IF-type) was seen in 46 patients (29%) and a diffuse-type pattern (D-type) was seen in 114 patients (71%). A multivariate analysis also showed that an IF-type was a prognostic factor (HR =1.618, P=0.049). The overall survival curve for patients with an IF-type was significantly worse than that of D-type patients (P=0.001). Conclusions An IF-type pattern of IMP3 expression might predict a poor outcome in patients with ESCC.

Paraganglioma is a very rare extraadrenal nonepithelial tumor. The number of cases of laparoscopic surgery in Paraganglioma is small and controversial. This study encountered a case of successful transperitoneal laparoscopic surgery for a 56‐mm paraganglioma in a 53‐year‐old female. Moreover, previous reports on laparoscopic surgery for paraganglioma are reviewed., A round tumor with capsule with a clear boundary was observed, and no necrosis existed on the cut surface. Moreover, yellow consolidation was observed.

The present study investigated the association between the mode of tumor recurrence and prognosis in 123 patients with clinical stage II/III rectal cancer. In the past 10 years, patients received systemic chemotherapy following radical (R0, with no macroscopic residual tumor lesions) resection using total or tumor-specific mesorectal excision. Patients with rectosigmoid cancer and T4 + chemoradiation therapy were excluded from the present study. The 5-year relapse-free survival rate (5Y-RFS), 5-year overall survival rate (5Y-OS), and associations between early post-operative complications, recurrence mode and prognosis, as well as the 5Y-OS of patients with relapsed cancer, were calculated. The overall 5Y-RFS and 5Y-OS were 71.4 and 83.5%, respectively, and the overall recurrence rate was 22.8% (28/123 patients). Among relapses, remote metastases were observed in 17/123 patients (13.8%): The lung in 8 patients (6.5%), the liver in 5 patients (4.1%) and elsewhere in 4 patients (3.3%). A total of 11 patients (8.9%) had pelvic local recurrence as the first relapse, which was located anterior to the sacrum in 7 patients (5.7%), at the anastomosis site in 2 patients (1.6%), and in the inner pelvis in 2 patients (1.6%). Among relapsed patients, the 5Y-OS was 69.3% in those with distant metastases and 27.3% in those with local relapse (P=0.02; no significant differences in patient demographics). The results indicated that advanced rectal cancer and control of pelvic local recurrence are manageable by R0 resection and postoperative chemotherapy. However, for patients whose initial relapse was pelvic local recurrence, the relapsed tumor initiated a new metastatic cascade to organs, such as the lung and liver, and affected prognosis.

Background Recently, due to increasing reports of stenosis after esophagojejunostomy created using circular staplers and a transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy (LPG) and total gastrectomy (LTG), linear staplers are being used instead. We investigated our preventive procedure for esophagojejunostomy stenosis following use of circular staplers. Methods Since the anastomotic stenosis is considered to be mainly caused by tension in the esophageal and jejunal stumps at the anastomotic site, we have been performing procedures to relieve this tension, by cutting off the rubber band and pushing the shaft of the circular stapler toward the esophageal side, since July 2015. We retrospectively compared the incidence of anastomotic stenosis in cases of LPG and LTG performed before July 2015 (early phase, 30 cases) versus those performed after this period (later phase, 22 cases). Results Comparison of the incidence of anastomotic stenosis according to the type of surgery, LPG or LTG, and between the two time periods versus all cases, indicated a significantly lower incidence in the later phase than in the early phase (4.5 vs. 26.7%, p p Conclusions It is possible to use a circular stapler during laparoscopic esophagojejunostomy, as with open surgery, if steps to reduce tension on the anastomotic site are undertaken. These procedures will contribute to the spread of safe and simple laparoscopic anastomotic techniques.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is a non-tumorous benign lesion that originates in the spleen and It is rare.A 59-year-old man visited his physician for a checkup. Ultrasonography showed a mass in the spleen, and the patient was referred to our hospital. He tested negative for tumor markers and soluble interleukin-2 receptor (sIL-2R). Abdominal computed tomography revealed a 51-mm hypovascular mass that was slowly enhanced from the portal venous to the equilibrium phases, at the inferior extremity of the spleen. Abdominal magnetic resonance imaging showed a spoke-wheel pattern. Fluorodeoxyglucose positron emission tomography indicated a mild tumor accumulation, with a standardized uptake value max of 5.3. These results led to the suspicion of SANT, angioma, and angiosarcoma. Because the onset of malignant diseases could not be excluded, laparoscopic splenectomy was performed. A brown, round mass, without a capsule but with clear boundaries, was macroscopically observed on the cut surface. In addition, white fibrosis was found in the mass. Histopathological examination revealed nodular angioma lesions, and the proliferation of fibrotic interstices and inflammatory cells was observed between the lesions. Immunohistological examination revealed proliferation in the 3 types of narrow capillaries inside angiomatoid nodules;CD31+/CD34+/CD8-, CD31+/CD34-/CD8+, and CD31+/CD34-/CD8- cells; therefore, the patient was diagnosed with SANT.Here, we reported one patient who developed the typical symptoms of SANT. SANT is easily diagnosed by histopathological examination; however, its causes remain unknown. More cases with SANT are required for further analysis.

Background Pancreatic fistula is the most problematic complication in pancreatectomy. Although drainage can be used to relieve this complication, pancreatic surgeons often encounter refractory pancreatic fistula. Fibrin glue injection, with the use of a twofold diluted solution B and a double-lumen tube, was found effective in treating this complicated pancreatic fistula. Case presentation We report the case of a 64-year-old Japanese man who underwent laparoscopic distal pancreatectomy for pancreatic tail cancer. After initial drainage of the pancreatic fistula diagnosed 4 days postoperatively, on day 134, refractory pancreatic fistula was observed using contrast-enhanced computed tomography. We used fibrin glue injection, with a twofold diluted solution containing thrombin and calcium chloride and a double-lumen tube, for treating the refractory fistula; the fluid drainage was almost stopped with no fever or abdominal pain. No recurrence of pancreatic cancer has been observed since the procedure. Conclusions Fibrin glue injection was effective for complicated pancreatic fistula after distal pancreatectomy. Using a twofold diluted solution B containing thrombin and calcium chloride and a double-lumen tube makes possible the thorough injection of fibrin glue.

The patient was a 72-year-old man who consulted with his previous physician for chief complaints of palpitations, fatigue, and blackish feces persisting for 1 month. After confirming the presence of anemia, the patient was referred to our hospital. Blood test findings upon hospital arrival revealed a hemoglobin (Hb) level of 6.0 g/dL. Computed tomography revealed a tumor of 32 mm × 30 mm with a low-density area extending from the bulb to the second part of the duodenum. Magnetic resonance imaging revealed high signal intensity on T1- and T2-weighted imaging and low signal intensity on fat-suppressed T2-weighted imaging, findings consistent with lipoma. Upper gastrointestinal endoscopy revealed a yellowish submucosal tumor that had perforated into the intestinal tract from the external wall extending from the upper corner to the second part of the duodenum. After determining that the tumor was sessile, laparoscopic partial duodenectomy with Roux-en-Y reconstruction was planned and performed. Pathology revealed a yellowish tumor 4 cm × 4 cm in size extending from the pyloric area to the duodenal bulb arising from the tunica muscularis. The present case report details our experience involving a patient who underwent surgical resection for hemorrhagic duodenal lipoma.

Introduction In recent years, laparoscopic surgery (LS) has been performed for small bowel obstruction (SBO). However, the indications and short-term and long-term outcomes of LS for SBO have not yet been established. Aim To evaluate the usefulness of LS for SBO compared to open surgery (OS), as well as to identify risk factors for poor outcomes after LS. Material and methods A total of 105 patients who underwent surgery for SBO were divided into OS (n = 64) and LS (n = 41) groups, and propensity score-matched analysis was used to compare the short-term and long-term outcomes of the groups. Risk factors for conversion to OS, postoperative complications, and intraoperative bowel injury in LS were also identified. Results The incidences of surgical site infection and postoperative ileus were significantly lower in the LS group. The incidence of recurrent bowel did not differ significantly between the two groups. Prior bowel obstruction was a risk factor for conversion of LS to OS (odds ratio (OR) = 24.79, p = 0.0025). Bowel diameter was a risk factor for postoperative complications (OR = 1.50, 95% CI: 1.01-2.22) and for bowel injury (OR = 1.33, 95% CI: 1.05-1.67). Conclusions LS for SBO had better postoperative short-term outcomes than OS. The outcomes of LS for SBO were significantly affected by prior bowel obstruction and bowel diameter.

Background: The incidence of esophageal adenocarcinoma in Europe and the United States rapidly increased from the latter half of the 1970s and exceeded that of esophageal squamous cell carcinoma in the latter half of the 1990s, currently accounting for approximately 60% of all esophageal carcinomas. Recently, its incidence has also increased in Japan, raising concerns that it will follow a course similar to that in Europe and the United States. Summary: The incidence of esophageal adenocarcinoma in Japan was about 2% until the 1990s, but in recent years, it has risen to 6.5–7.1%. Causes include the increase in the incidence of obesity due to changes in eating habits with resultant increases in the incidence of hiatal hernia and reflux esophagitis, a decrease in the rate of Helicobacter pylori infection, and the increased interest of physicians in the gastroesophageal junction. The number of gastroesophageal reflux disease patients in Japan rapidly increased from the 1990s, which accordingly increased the number of Barrett’s esophageal adenocarcinoma patients from the latter half of the 1990s. Tabulation and analysis of 1,794 reported cases of Barrett’s esophageal adenocarcinoma in Japan showed that superficial cancers accounted for 77.6%, and that the concomitant rates of hiatal hernia and reflux esophagitis were high at 87 and 70% respectively. Key Message: The future trend in the incidence of Barrett’s esophageal adenocarcinoma in Japan will depend on the increase in the incidence of reflux esophagitis, which is essential for the development of Barrett’s esophagus and Barrett’s esophageal carcinoma. The obesity rate is lower in Japan than that in Europe and the United States, and the incidence and severity of reflux esophagitis are low. We expect that the incidence of Barrett’s esophageal adenocarcinoma in Japan will not rise as high as in Europe and the United States, and will remain below 10%.

Background Biliary system anatomical abnormalities can be preoperatively detected on magnetic resonance imaging; therefore, some presume that the number of bile duct injuries should decline. However, once a bile duct injury occurs, repair may be difficult. There are various ways to repair bile duct injuries, but successful repair may be exceptionally difficult. Case presentation A 72-year-old Japanese man underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer. We had a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed. We conducted a drip infusion cholecystocholangiography-computed tomography test to determine the positional relationship between his bile duct and elevated jejunum. To secure the bile duct we punctured the bile duct under computed tomography guidance, and the hepaticojejunal anastomosis site was visualized by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle and verified the vibrations with the endoscope. We observed a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion. We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum. We removed all drains after percutaneously inserting an uncovered metallic stent. Our patient’s subsequent clinical course was unremarkable. He visits our institution as an out-patient and has had no stent occlusion even after 6 months. Conclusions When repairing bile duct injuries, it is important to accurately determine the positional relationships between the injured bile duct and the surrounding organs.

In recent years, the use of laparoscopic surgery has been expanded to include radical curative resection. In a previous study, 212 patients with primary colorectal cancer (stages I–III) underwent radical curative resection by hand-assisted laparoscopic surgery (HALS) (n=98) or conventional laparotomy (CL) (n=114) and were compared with respect to 3-year relapse-free survival (3Y-RFS) and 3-year overall survival (3Y-OS). The study included 210/212 patients who were followed up to 5 years, including 96 patients who underwent HALS and 114 treated with CL. The two groups were matched for stage, clinical background, and postoperative management. Patient characteristics were compared and the 5Y-RFS and 5Y-OS were determined. The 5-year follow-up rate was 97.6%. In stage I–III patients, 5Y-RFS and 5Y-OS showed no significant differences between HALS and CL. The patients with stage I disease accounted for 41.7% (40/96) of the patients undergoing HALS, while stage I patients only accounted for 23.7% (27/114) of the patients undergoing CL, and the difference was significant (P=0.005). Stage II patients undergoing CL were older than those treated with HALS (P=0.017). However, there were no differences in the characteristics of stage III patients undergoing HALS or CL. In conclusion, HALS achieved a similar survival to CL in patients with stage I to III colorectal cancer. Compared with CL, HALS was performed more safely and achieved superior cosmetic results.

Background Synchronous and asynchronous multiple cancers have become more pervasive in recent years despite advances in medical technologies. However, there have been only six cases (including the present case) that underwent pancreaticoduodenectomy (PD) for pancreas head cancer following surgery for esophageal cancer. PD for treating pancreas head cancer is extremely challenging; thus, the confirmation of vessel variation and selection of surgical procedures are vital. Case presentation The patient was a 78-year-old Japanese male who was synchronously diagnosed with esophageal and cecal cancer 7 years previously at our hospital. He was admitted with densely stained and jaundiced urine and presented no remarkable family medical history. Following various examinations, surgery was performed due to the diagnosis of distal cholangiocarcinoma (pancreatic head cancer). Since the tumor was located far from the gastroduodenal artery (GDA) and no significant lymph node metastases could be found, subtotal stomach-preserving PD was performed instead of the resection of GDA with the right gastroepiploic artery (RGEA) for gastric tube blood flow preservation. The common hepatic artery (CHA) and GDA were confirmed, and RGEA diverged from GDA was identified. Subsequently, their respective tapings were preserved. The right gastric artery (RGA) was identified, taped, and preserved considering the gastric tube blood flow. The inflow area of the right gastroepiploic vein (RGEV) through gastric colic vein trunk in the superior mesenteric vein was exposed and preserved as the outflow of gastric tube blood flow. PD was completed without any complications on the shade of the gastric tube. Conclusions This case report describes successfully preserved gastric blood flow without the resection of GDA, RGEA, RGEV, or RGA. To preserve the gastric tube, GDA inflow, RGEA, RGA, and RGEV outflow should be preserved if possible. When performing PD after tube reconstruction, it is essential to confirm the relative positions of the blood vessel, blood flow, and tumor through three-dimensional computed tomography angiography before surgery and to consider the balance between the invasiveness and optimal curability of the surgery.

Background Various body composition indices have been reported as prognostic factors for different cancers. However, whether body composition affects prognosis after lower gastrointestinal tract perforation requiring emergency surgery and multidisciplinary treatment has not been clarified. This study examined whether body composition evaluations that can be measured easily and quickly from computed tomography (CT) are useful for predicting prognosis. Methods Subjects comprised 64 patients diagnosed with perforation at final diagnosis after emergency surgery for a preoperative diagnosis of lower gastrointestinal tract perforation and penetration. They were divided into a survival group and a non-survival (in-hospital mortality) group and compared. Body composition indices (psoas muscle index (PMI); psoas muscle attenuation (PMA); subcutaneous adipose tissue index (SATI); visceral adipose tissue index (VATI); visceral-to-subcutaneous fat area ratio (VSR)) were measured from preoperative CT. Cross-sectional psoas muscle area at the level of the 3rd lumbar vertebra was quantified. Optimal cut-off values were calculated using receiver operating characteristic curve analysis. Poor prognostic factors were investigated from multivariate logistic regression analyses that included patient factors, perioperative factors, intraoperative factors, and body composition indices as explanatory variables. Results The cause of perforation was malignant disease in 12 cases (18.7%), and benign disease in 52 cases (81.2%). The most common cause was diverticulum of the large intestine. Emergency surgery for the 64 patients led to survival in 52 patients and death in 12 patients. On multivariate logistic regression analysis, independent predictors of poor prognosis were Sequential Organ Failure Assessment score (odds ratio 1.908; 95% confidence interval (CI) 1.235–3.681; P = 0.0020) and PMI (odds ratio 13.478; 95%CI 1.342–332.690; P = 0.0252). The cut-off PMI was 4.75 cm2/m2 for males and 2.89 cm2/m2 for females. Among survivors, duration of hospitalization was significantly longer in the low PMI group (29 days) than in the high PMI group (22 days, p = 0.0257). Conclusions PMI is easily determined from CT and allows rapid evaluation of prognosis following lower gastrointestinal perforation.

Intracorporeal anastomosis (IA) in laparoscopic colectomy for colon cancer is technically difficult, and there is a lack of consensus on the risk of bacterial contamination and cancer cell dissemination. In this study, short- and long-term outcomes of IA were examined.Short and long-term outcomes of those who underwent IA (n=44) or extracorporeal anastomosis (EA) (n=61) were compared.IA was better than EA for blood loss, incision length, and first stool. Maximum temperature and C-reactive protein on postoperative day 1 were higher for the IA group. The rate of positive cultures from intraoperative lavage was higher for IA. The rate of positive cultures improved to an equivalent level by replacing mechanical pretreatment with chemical pretreatment. IA and EA were equivalent for the results of ascites cytology from lavage.With the use of appropriate preoperative treatment, IA takes advantage of the minimally invasive nature of laparoscopic surgery.

A 67-year-old woman presented with a chief complaint of umbilical region mass and epigastric pain. Carbohydrate antigen 19-9 (CA19-9) level was 177.5 U/mL; computed tomography (CT) showed a hypovascular mass lesion of 20 mm × 20 mm in the pancreas, infiltration into the superior mesenteric artery and dilation of the main pancreatic duct. Peritoneal dissemination to the omentum and abdominal wall was observed. The patient was diagnosed with T4N0M1, cStage IV unresectable pancreatic body cancer and was started on GEM + nab-PTX therapy. She underwent chemotherapy for 10 months for a total of 10 cycles. The CA19-9 level returned to normal, CT showed reduction in tumor size to 11 mm × 8 mm, and peritoneal dissemination also disappeared. Disappearance of peritoneal dissemination was also observed on Positron emission tomography (PET). Laparoscopic surgery was planned, and rapid pathological examination results of ascites washing cytology and peritoneal mass were negative. Laparoscopic distal pancreatectomy was then performed, which transitioned to hand-assisted laparoscopic surgery; R0 resection was achieved. The patient underwent outpatient postoperative adjuvant chemotherapy with orally administered S-1 and has been recurrence-free for 1 year postoperatively. This case demonstrates that patients with pancreatic body cancer with distant metastasis can undergo R0 resection following GEM + nab-PTX combination therapy.

Background Gastric duplication is a relatively rare congenital malformation, accounting for approximately 2.9–3.8% of gastrointestinal duplications. Gastric duplication cyst is a congenital anomaly that is rarely observed in adults. Accurate diagnosis of these cysts before resection is difficult. In this report, we describe a patient with gastric duplication cysts that were treated by laparoscopic resection. Case presentation A 46-year-old Japanese woman was referred to our institution because a cystic lesion in the pancreatic tail was detected by ultrasonography during a health examination. The lesion had a clearly defined boundary of approximately 40 mm. A thick cystic lesion of the septum was observed in the pancreatic tail, but invasion into the stomach wall was not recognized on a computed tomographic scan. Endoscopic ultrasonography revealed that the tumor appeared smooth with a marginal edge, which was characterized by echo with high homogeneity, and the presence of viscous mucus was suspected. The preoperative diagnosis of mucinous cystic neoplasm was the reason for laparoscopic tumor resection. The resected specimen was a smooth surface tumor, and it was full of mucus. Histopathological study revealed that the mucosa was covered with crypt epithelium, muscularis mucosae, intrinsic muscularis, and serosa, and the wall of the tumor had a structure very similar to that of the stomach wall. The mucosa was partially drained by intrinsic gastric glands, but most of them were denucleated. No pancreatic tissue was present, and the tumor had no continuity with the spleen. These findings indicated a diagnosis of gastric duplication cyst with no continuity with the stomach wall. Conclusions In our experience, it is difficult to differentiate gastric duplication cyst from mucinous cystic neoplasm before laparoscopic resection. Events such as infection, bleeding, perforation, ulceration, fistula formation, obstruction, and compression have been linked to gastric duplication cysts, and malignant transformation of these cysts has been reported. Therefore, we suggest that resection should be the first treatment option for gastric duplication cysts.

SUMMARY The relationship between lymphovascular invasion (LVI) and prognosis in patients with superficial esophageal squamous cell carcinoma (SESCC) is unclear. The aim of this study is to evaluate prognostic factors in patients with lymph node-negative SESCC. A total of 195 patients with pathologically confirmed T1a-MM, T1b, and lymph node-negative SESCC were retrospectively reviewed in this study. Overall, the disease-free survival (DFS) rate was poorer in the lymphatic invasion-positive group than in the lymphatic invasion-negative group (p = 0.002) and a multivariate analysis suggested that lymphatic invasion was the only independent prognostic factor of DFS in patients with lymph node-negative SESCC (HR = 4.075, p = 0.005). Distant organ recurrence occurred in one patient (1/52, 1.9%) in the T1b-SM2 group and in six patients (6/61, 9.7%) in the T1b-SM3 group; all of these patients had LVI. LVI-positive patients had a poorer DFS than invasion-negative patients in the T1b-SM2 and SM3 groups (p = 0.026), and a multivariate analysis suggested that LVI was the only independent prognostic factor of DFS in patients with lymph node-negative SM2 and SM3 SESCC (HR = 5.165, p = 0.031). Lymph node-positive patients had a significantly poorer DFS rate than lymph node negative and LVI positive patients among the SM2 and SM3 SESCC patients (p = 0.018). The present results suggested that LVI was an independent prognostic factor in patients with SM2 and SM3 lymph node-negative SESCC; however their prognosis was not worse than that of patients with lymph node-positive SM2 and SM3 SESCC, for whom adjuvant therapy is indicated as a standard treatment.

Esophagogastric junction (EGJ) carcinoma has attracted considerable attention because of the marked increase in its incidence globally. However, the optimal extent of esophagogastric resection for this tumor entity remains highly controversial. This was a questionnaire-based national retrospective study undertaken in an attempt to define the optimal extent of lymph node dissection for EGJ cancer. Data from patients with EGJ carcinoma, less than 40 mm in diameter, who underwent R0 resection between January 2001 and December 2010 were reviewed. Clinical records of 2807 patients without preoperative therapy were included in the analysis. There are distinct disparities in terms of the nodal dissection rate according to histology and the predominant tumor location. Nodal metastases frequently involved the abdominal nodes, especially those at the right and left cardia, lesser curvature and along the left gastric artery. Nodes along the distal portion of the stomach were much less often metastatic, and their dissection seemed unlikely to be beneficial. Lower mediastinal node dissection might contribute to improving survival for patients with esophagus-predominant EGJ cancer. However, due to low dissection rates for nodes of the middle and upper mediastinum, no conclusive result was obtained regarding the optimal extent of nodal dissection in this region. Complete nodal clearance along the distal portion of the stomach offers marginal survival benefits for patients with EGJ cancers less than 4 cm in diameter. The optimal extent of esophageal resection and the benefits of mediastinal node dissection remain issues to be addressed in managing patients with esophagus-predominant EGJ cancers.

The purpose of the present study was to evaluate the recent trend of diagnosing appendiceal diseases through the analysis of appendectomy materials, stressing the importance of their pathological examination. A clinicopathological assessment of patients undergoing an appendectomy was conducted, based on the pathological examination of resected appendiceal lesions. Using a pathological database of surgical specimens from patients who underwent an appendectomy between March 2002 and September 2014, a retrospective, single-center analysis was performed. Among the 803 patients identified, 752 with appendiceal disease were selected for clinicopathological analysis. The diagnosis was inflammation (i.e. appendicitis) in 97.7% (n=735) and appendiceal neoplasm in 2.3% (n=17) of the patients. The most frequent type of appendiceal neoplasm was an intramucosal neoplasm (23.5%, n=4). In conclusion, the incidence of appendiceal neoplasms has increased in recent years, potentially due to increased and earlier detection by newer imaging modalities.

Background Esophageal malignant melanoma is an extremely rare disease and no scientific society has systematically collected data on it previously.