A 67-year-old male presented with severe epigastric pain in May 2023 and was diagnosed with Stage Ⅲ advanced gastric cancer(cStage Ⅲ)in June. Due to indistinct boundaries between lymph node #8a and the pancreas, non-resectional chemotherapy and enterostomy were performed during a diagnostic laparotomy. The diagnosis was updated to sStage Ⅳ with cy1. Beginning in July, the patient was administered SOX and nivolumab. Following 6 courses, CT scans in December revealed clearer boundaries, allowing for conversion surgery in January 2024. This surgery resulted in a pathological complete response(pCR), with no detectable malignant cells. Despite postoperative complications, the patient was discharged on day 34 and is currently receiving outpatient S-1 therapy. This case suggests that enterostomy may facilitate conversion surgery to achieve pCR, thereby providing a new treatment strategy for advanced gastric cancer.

BACKGROUND:Preoperative chemotherapy for gastric cancer with obstructive symptoms traditionally requires bypass surgery. OBJECTIVE:To investigate the feasibility of preoperative enterostomy chemotherapy in patients with advanced gastric cancer who present with obstructive symptoms. METHODS:A total of 47 patients with cStage Ⅲ gastric cancer who underwent preoperative chemotherapy between April 2013 and May 2024 were included. Patients with circumferential lesions underwent enterostomy during diagnostic laparoscopy, which was followed by chemotherapy. RESULTS:The enterostomy and non-enterostomy groups included 20 and 27 patients, respectively. The chemotherapy regimens included SOX, SOX+nivolumab, SP, biweekly NAC-DCS, and XP+trastuzumab. Grade 3 or higher adverse events, including neutropenia, malaise, and diarrhea, were more common in the no-enterostomy group. The completion rates of at least 2 chemotherapy courses were similar between groups. Grade Ⅲa or higher complications during gastrectomy were slightly higher in the enterostomy group. The pathological responses were comparable between groups. CONCLUSION:Preoperative chemotherapy using enterostomy for advanced gastric cancer with obstructive symptoms showed efficacy and safety comparable to those of traditional methods, suggesting that it is a viable treatment option.

Small bowel adenocarcinoma (SBA) is a relatively rare disease that is difficult to detect in the early stages; therefore, it often has a poor prognosis. We present a rare case of SBA and multiple liver metastases in a patient who underwent curative resection combined with neoadjuvant chemotherapy (NAC). A 70-year-old woman presented to the emergency department complaining of abdominal pain and bloating. She was diagnosed with bowel obstruction due to a primary jejunal tumor and was admitted to the hospital. After further imaging and histopathological examination, the patient was diagnosed with primary jejunal adenocarcinoma with multiple liver metastases, all of which were considered resectable. Since she had developed bowel obstruction due to the primary tumor, jejunal resection with draining lymph node removal was initially performed. The remaining multiple liver metastases were treated with four courses of capecitabine and oxaliplatin (CAPEOX) with bevacizumab as NAC, followed by hepatectomy. After NAC, the patient underwent radical liver resection. Based on a pathological examination, the five liver tumors were all diagnosed as liver metastases from jejunal adenocarcinoma. Six months after the liver resection, a single recurrence was observed in segment V of the liver. Therefore, four courses of CAPEOX with bevacizumab were administered again as NAC, and liver resection was performed again. At the time of writing this report, she has survived for more than four years after the first surgery, with no apparent recurrence. This is a rare case of a patient who underwent radical resection of SBA with multiple liver metastases following CAPEOX and bevacizumab as NAC.

The high recurrence rate of colorectal cancer liver metastasis (CRCLM) after surgery remains a crucial problem. However, adjuvant chemotherapy after hepatectomy for CRCLM has not yet been established. This study evaluated the efficacy of adjuvant therapy with S-1 and oxaliplatin (SOX). In a multicenter, randomized, phase II study, patients undergoing curative resection of CRCLM were randomly enrolled in a 1:1 ratio to either the low- or high-dose group. S-1 and oxaliplatin were administered from days 1 to 14 of a 3-week cycle as a 2-h infusion every 3 weeks. The dose of S-1 was fixed at 80 mg/m2. The doses in the low- and high-dose oxaliplatin groups were 100 mg/m2 (low-dose group) and 130 mg/m2 (high-dose group), respectively. This treatment was repeated eight times. The primary endpoint was the rate of discontinuation owing to toxicity. The secondary endpoints were the relapse-free survival (RFS) and frequency of adverse events (AEs). Between August 2010 and March 2015, 44 patients (low-dose group: 31 patients and high-dose group: 13 patients) were enrolled in the study. Of these, one patient was excluded from the efficacy analysis. In the high-dose group, five of nine patients were unable to continue the study due to toxicity in February 2013. At that time, recruitment to the high-dose group was stopped from the protocol. The relative dose intensity (RDI) for S-1 in the low- and high-dose groups were 49.8 and 48.7

A 25-year-old male received palliative total gastrectomy plus D1 dissection plus Roux-en-Y reconstruction for hemorrhagic gastric cancer with left Virchow lymph node metastasis in 2013. The final diagnosis was Type 2, pT4a(se), pap>tub2 >hepatoid adenocarcinoma, pN3b, sM1, fStage Ⅳ. Because AFP was as high as 11,000 ng/mL, he was diagnosed with AFP-producing gastric cancer and started S-1 plus CDDP therapy. Left adrenal gland metastasis and #106pre, #16b1int lymph node metastasis were observed after 9 courses, and the therapy was changed to irinotecan plus CDDP therapy. After 17 courses, the patient was diagnosed with CR, and the drug was discontinued. Recurrence of the left adrenal gland and an increase in AFP were confirmed by CT after 8 months of suspension, and the drug was resumed. After 8 courses of resumption, PET-CT showed mediastinal and #16b1lat lymph node metastasis and changed to weekly PTX plus Ram therapy. After 2 courses, enlargement of lymph nodes and elevation of AFP was observed, and CapeOX therapy was changed. Diagnosis of left adrenal metastasis recurrence by PET-CT after 21 courses. Nivolumab was used, and radiotherapy(total 39 Gy)was performed locally. After the continuation of nivolumab for 3 years, no findings of recurrent metastasis were observed on imaging, and it was judged as CR, and nivolumab was terminated. As of June 2023, he is alive without recurrence. AFP-producing gastric cancer in the young is rare, and no cases with Virchow metastasis or para-aortic lymph node metastasis have been reported. We report a case of long-term survival in which CR was obtained with combined modality therapy.

Background: Spontaneous regression (SR) of cancer is a rare condition in which the cancer partially or completely disappears without treatment. We report a case of breast cancer with tumor regression and spontaneously induced T-cell-mediated immunological responses in a surgical specimen obtained after core needle biopsy (CNB). Case Description: A 52-year-old woman presented with a mass in the right breast. Mammography showed a high-density mass with fine serrated margins in the right lower outer quadrant. Breast ultrasonography showed an irregular hypoechoic mass with a maximum diameter of 22 mm. CNB was performed and revealed an invasive ductal carcinoma with negative estrogen receptors, positive progesterone receptors, and negative HER2 (1+). The Ki67 index was 70% to 80%. Luminal B cT2N1M0 stage IIB right breast cancer was diagnosed. Although preoperative chemotherapy was considered, surgery was selected because of her history of schizophrenia. She underwent right mastectomy and axillary lymph node dissection. A postoperative pathological analysis revealed a 20 mm × 10 mm × 10 mm mass. However, most areas of the mass regressed and appeared as necrotic tissue with no obvious invasive areas. Only intraductal extension was observed in one glandular duct. Axillary lymph node metastases were not observed. These results suggest that the tumor may have spontaneously regressed, possibly because of the CNB procedure. Follow-up without treatment was performed, and no recurrence occurred during 2 years after surgery. Conclusions: Invasive ductal carcinoma may spontaneously regress after preoperative CNB.

The patient was a 57-year-old woman. She was referred to our hospital because severe anemia. Upper gastrointestinal endoscopy revealed polyposis throughout the stomach and lobulated polyps in cardia, greater curve of middle body of the stomach, and angulus. Colonoscopy and small bowel endoscopy showed no obvious abnormal findings. Based on these findings, a laparoscopic total gastrectomy with D1 lymph node dissection was performed for suspected juvenile polyposis of stomach with severe anemia. The gross examination of the resection specimen revealed diffuse polyposis throughout the stomach, and histopathological examination revealed hyperplasia of the orbital epithelium throughout the stomach and lack of edema in lamina propria of mucous and eosinophil leukocytic infiltration, leading to the diagnosis of juvenile polyposis of stomach. Two well differentiated adenocarcinomas were found in 2 locations, which remained within the mucosa. We report a case of laparoscopic total gastrectomy for juvenile polyposis of the stomach with gastric cancer, with some discussion of the literature.

A 73‒year‒old man, living in the United States since 1985, visited the University of Minnesota Medical Center with a complaint of upper abdominal pain in December 2019. Gastroendoscopy revealed a depressed lesion in the U area of the stomach, and the biopsy results indicated a diagnosis of por/sig. On further examination, the condition was diagnosed as gastric cancer of cStage II/III. A gastrectomy procedure was planned after treatment with neoadjuvant chemotherapy(NAC). After 1 course of mFOLFOX6, the patient decided to undergo treatment in Japan. He travelled to Japan in February and visited our hospital. In March, he underwent total gastrectomy plus D2 dissection plus Roux‒en‒Y reconstruction. The final diagnosis was gastric cancer, U, Less, ypType 2, ypT3(ss), ypN1, sM0, yfStage IIB, and the therapeutic effect was Grade 2. DS therapy was started as adjuvant chemotherapy in April. After 8 courses, he returned to the United States. After moving to the United States, he personally imported S‒1 and continued adjuvant chemotherapy at the University of Minnesota Hospital. The guidelines in Japan do not recommend NAC. Given that Grade 2 therapeutic effect was obtained even with 1 course of the treatment, FOLFOX therapy could be effective as preoperative chemotherapy for advanced gastric cancer cases.

Anastomotic leakage after intestinal resection is one of the most serious complications of surgical intervention for hollow viscus injury. Adequate vascular perfusion of the anastomotic site is essential to prevent anastomotic leakage. Near-infrared imaging using indocyanine green (NIR-ICG) is useful for the objective assessment of vascular perfusion. The aim of this study was to evaluate the association of NIR-ICG with intestinal and mesenteric injuries. This was a retrospective, single-center study of patients undergoing surgery for intestinal and mesenteric injuries. NIR-ICG was used to evaluate vascular perfusion. Postoperative complications were assessed between NIR-ICG and non-NIR-ICG groups.The use of NIR-ICG was associated with a lower incidence of Clavien-Dindo grade ≥ III complications with a statistical tendency (p = 0.076). When limited to patients that underwent intestinal resection, the use of NIR-ICG was significantly associated with a lower risk of perioperative complications (p = 0.009). The use of NIR-ICG tended to associate with the lower incidence of postoperative complications after intestinal and mesenteric trauma surgery. NIR-ICG was associated with a significantly lower risk of complications in patients undergoing intestinal resection. The NIR-ICG procedure is simple and quick and is expected to be useful for intestinal and mesenteric trauma.

症例は57歳，男性．2019年7月下旬，午前2時頃からの腹痛を主訴に当院救急外来を受診した．腹部造影CTで小腸から連続する嚢胞状構造物内に直径25mm大の結石様の高吸収域を認めた．腸石を伴うMeckel憩室炎が疑われた．腸管壁の造影効果不良があり，虚血性変化が疑われ，経過中に腹部症状の増悪も認めたことから，腹腔鏡下に緊急手術を施行した．腹腔内所見では骨盤内に血性の腹水を認め，回腸末端より80cm口側の回腸に暗赤色の嚢胞状構造物を認めた．腹部の創を4cmへ延長し小開腹し，腹腔外へ引き出し観察すると，Meckel憩室内の腸石が嵌頓し壊死をきたしている状態であった．Meckel憩室を自動縫合機で切除し，手術を終了とした．病理組織学的には，憩室粘膜に異所性胃粘膜が存在した．腸石は，シュウ酸カルシウムによる真性腸石であった．真性腸石を伴う成人の Meckel憩室炎は比較的稀な疾患であり，本邦報告例も少ない．貴重な症例を経験したので，文献的考察を加えて報告する．

Recently, several studies have suggested that near-infrared (NIR) imaging using indocyanine green (ICG) may contribute to the reduction of anastomotic leakage (AL) after colorectal cancer (CRC) surgery. However, few reports have focused on the usefulness of NIR imaging for AL after stapled functional end-to-end anastomosis (stapled FEEA). The purpose of this study was to clarify the frequency of fluorescence abnormalities on NIR imaging, in cases reconstructed with stapled FEEA. This retrospective study included patients with colon or appendiceal cancer who underwent laparoscopic colectomy with stapled FEEA reconstruction between March 2016 and August 2019. A total of 400 patients who were managed at our three institutions were included in the present study. The rate of Clavien-Dindo (CD) grade > III AL was 1.0% (4/400). The median length of postoperative hospital stay was 7 days (IQR 25–75th percentile 6–8 days). In 11 patients (2.8%), the transection line was changed by NIR imaging, due to fluorescence abnormalities. The rate of transverse colon involvement in anastomosis was significantly higher in cases with fluorescence abnormalities than in cases with normal fluorescence (p = 0.035). The frequency of fluorescence abnormalities on NIR was 2.8% in cases of colon resection with reconstruction by using stapled FEEA. There was a probability of abnormal fluorescence on NIR in cases where the transverse colon was involved in the anastomosis. This means that NIR may have potential benefit in such cases. UMIN000039977

PURPOSE:The purpose of this study was to investigate the relationship between the fluorescence on indocyanine green fluorescent imaging (ICG-FI) and the histopathological findings of regional lymph node (LN) metastasis of splenic flexural colon cancer.METHODS:From July 2013 to December 2018, consecutive patients with splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. The distribution of cancer sites in metastatic LNs (completely/not completely occupied by metastatic foci) was evaluated with hematoxylin and eosin-stained preparations. We compared the relationship between the distribution of cancer site and fluorescence of paraffin block in metastatic LNs.RESULTS:Seventy-two patients were enrolled, of whom 13 (18.1%) had metastatic LNs. A total of 25 metastatic LNs were evaluated. The median short axis of the occupied LNs was 4.5 mm, which was significantly larger than that of the non-occupied LNs (3.0 mm; p = 0.036). In the near-infrared observation of the paraffin block, the completely occupied LNs showed no fluorescence, regardless of the LN size, but 8 of 10 non-occupied LNs showed fluorescence (p < 0.001). Even the non-occupied LNs that showed fluorescence, the cancer site did not show fluorescence.CONCLUSIONS:The occupied LNs showed no fluorescence, but 80% of the non-occupied LNs showed fluorescence. Even in non-occupied LNs that showed fluorescence, the cancer site did not show fluorescence. This demonstrated LN dissection should not be omitted, even if no fluorescence is noted on intraoperative ICG-FI.

症例は76歳，男性．2005年8月の検診にて膵腫瘍を指摘され来院．当院にて膵尾部腫瘍に対して膵体尾部切除，脾摘術を施行．病理の結果はガストリノーマ（2017年WHO分類ではPanNET G2）の診断．外来にて経過観察中に，CTで低吸収域を示す腫瘤を認め肝S4転移と診断し，2008年1月に肝S4部分切除術を施行した．病理結果はガストリノーマ肝転移（PanNET G1）の診断．その後10年間再発なく経過していた．突然の腹痛にて来院し，単純CTにて肝に低濃度腫瘤を認めたため，ガストリノーマの再発が疑われた．上部消化管内視鏡検査では，十二指腸下行脚に多発潰瘍を認めた．造影MRIを施行し肝S2・S3・S5・S8にガストリノーマの肝転移の診断で肝部分切除術（4箇所）を施行した．病理組織学的検査で増殖する異型細胞を認め，免疫染色にてガストリン陽性であったため，ガストリノーマ（PanNET G1）と診断した．術後2年，十二指腸潰瘍は改善し，無再発で経過している．今回，ガストリノーマ術後10年以上経過してからの再発症例は稀であり，手術しえた1例を経験したので，文献的考察を踏まえて報告する．

胃原発のMANECは非常に稀な疾患である．症例①は胃体中部前壁の2型病変であり，術中所見にて肝腫瘍を認めた．胃切除・肝部分切除を行い，mixed adenoneuroendocrine carcinoma（MANEC）と診断され，急激な肝転移再発をきたした．症例②は早期病変であり，ESD治療にて切除後，腹腔鏡下にて追加切除とリンパ節郭清を施行した．MANECは術前診断が難しく，腺癌に比較し予後が不良であるとされている．しかし，早期に発見され，良好な予後を得ている症例も散見される．今回，胃原発のMANECの切除例を2例経験したので報告する．

症例は59歳，男性．直腸癌（Rb，cT2N0M0，Stage I）の診断で腹腔鏡下内肛門括約筋切除術（経肛門的全直腸間膜切除術併用），予防的双孔式回腸人工肛門造設術を施行し，経過良好で術後9日目に退院した．術後17日目に人工肛門の出口部狭窄による腸閉塞の診断で再入院した．排液のClostridium difficile（CD）トキシン陽性であり，CD腸炎と診断し保存加療を開始した．入院4日目に急激に全身状態が不良となり，敗血症性ショックと診断しICUに入室した．CT検査で回腸の著明な壁肥厚と浮腫を認め，劇症型CD腸炎と診断し緊急で小腸部分切除術を施行した．術後，バンコマイシンの注腸投与と集学的治療により病状改善し，再手術後22日目に自宅退院した．劇症型CD腸炎が小腸に発症した例は稀であり，今回，集学的治療により救命しえた1例を経験したので報告する．

Introduction: The number of diabetes patients has been increasing all over the world. In Japan the main cause of death for diabetes patients is said to be Hepatocellular carcinoma (HCC), which accounts for 8.6% of the whole number. On the other hand, thanks to the progression of medical treatment against hepatitis B and C virus, the number of patients who have viral hepatitis has been gradually decreasing. Since few studies report about the relation between diabetes and viral hepatitis with HCC, the aim of this study is to analyze these patients clinically and pathologically. Methods: From January.2007 to May.2018, 143 HCC patients underwent liver resection at our hospital. The patients were divided into 4 groups; The Group A has no viral hepatitis nor diabetes (24 patients), The Group B has diabetes but no viral hepatitis (27 patients), The Group C has B or C hepatitis but no diabetes (69 patients), and The Group D has both B or C hepatitis and diabetes (23 patients). A study was conducted analyzing these 4 groups, clinically, and pathologically. Results: The social background, the age and the sex showed no difference among the 4 groups. The blood test showed decreased liver function in the Group C and D (ALT; P=0.044, AST; P=0.043), which indicates that it is caused by liver hepatitis. From the pathological point of view, the maximum size of the tumor was smaller in the Group C and D (P=0.005). According to this result, the Stage of the cancer was lower in the Group C and D. Though the amount of the tumor, the rate of portal vein invasion, hepatic vein invasion, and the bile duct invasion showed no difference in the 4 groups. From the surgical point of view, the operation time, amount of the bleeding during the operation, average length of stay after operation, surgical form, post-operative complications showed no difference among the 4 groups. As a result, the overall survival rate and disease-free survival rate showed no difference among the 4 groups. Conclusion: Through the analysis of HCC patients with diabetes and viral hepatitis, patients who have viral hepatitis have decreased liver function and smaller tumor size which accompanies with lower Stage of the cancer. This result is thought to be caused by the condition that patients with viral hepatitis are closely followed up by doctors. We should keep on following these patients and further study is required about the relation between diabetes and HCC.

後腹膜原発平滑筋肉腫膵転移は稀な病態である．今回，後腹膜原発平滑筋肉腫の術前診断で，膵体尾部切除術を行った症例を経験したので報告する．症例は73歳の男性で原発巣を切除し，その後7回の転移・再発に対し切除術が施行されていた．原発切除から6年後の経過観察中に，膵体部に20mm大の腫瘤性病変を指摘され，転移性膵腫瘍と診断し，膵体尾部切除術を施行した．術後ISGPF gradeAの膵液瘻を認めたものの，術後11日目に退院した．骨軟部腫瘍の膵転移は稀であるが，切除例では長期生存例も認められる．治療の選択肢として外科的切除も考慮されるべき症例が存在することが示唆された．

The effects of subcutaneous closed-suction Blake drain for preventing incisional surgical site infections (SSIs) after colorectal surgery have never been evaluated in a randomized controlled trial (RCT). Thus, we performed a RCT to evaluate the clinical benefits of using a subcutaneous closed-suction Blake drain in patients undergoing colorectal surgery.