アクセイ フクマク チュウヒシュ ニ タイスル cytoreductive surgery

海外では悪性腹膜中皮腫に対してcytoreductive surgery (CRS)と腹腔内温熱化学療法を含めた周術期化学療法が普及しているものの、本邦では悪性腹膜中皮腫に対する外科的治療の報告は乏しい。今回我々は当院でのCRSと周術期化学療法による悪性腹膜中皮腫に対する治療成績を報告する。2013年2月から2022年4月までの期間において、15例の悪性腹膜中皮腫に対してCRSを施行した。患者年齢の中央値は58歳(42-67)で、男性5例と女性10例であった。CRSは病変の存在する壁側腹膜と臓器切除を組み合わせて施行した。10例に対して術前化学療法を施行し、12例に対して術後化学療法を施行した。腹腔内温熱化学療法を8例に対して施行した。全生存期間の中央値は41か月であった。3年生存率57.7%で、5年生存率は34.6%であった。上皮型でperitoneal cancer index≦22であった6例については全例生存中であり、今後の長期生存が期待される結果であった。2.5cmより大きな腫瘍が遺残した場合でも術後化学療法の奏功により3年以上の生存が得られる症例も存在していた。単変量解析をおこなうも、生存に関する統計学的に有意な因子は認めなかった。手術合併症（Clavien-Dindo分類3以上）はGrade 3aが2例、Grade 3bが1例、Grade 4aが2例であった。悪性腹膜中皮腫に対して、これまで日本で施行されてきた化学療法単独療法では予後不良であることが知られている。一方、今回の我々が施行したCRSと周術期化学療法の治療成績は比較的予後良好であり、合併症も許容範囲内であると考えられた。悪性腹膜中皮腫に対する海外におけるCRSと化学療法による良好な治療成績の報告があることからも、本邦でのCRSと周術期化学療法の継続と症例の集積により、体系的な治療法確立と治療成績向上が期待できるであろう。Cytoreductive surgery and perioperative chemotherapy, including hyperthermic intraperitoneal chemotherapy, the standard treatments for malignant peritoneal mesothelioma worldwide are not yet widespread in Japan. We report the surgical outcomes of cytoreductive surgery with perioperative chemotherapy for patients with malignant peritoneal mesothelioma at our institution. We encountered 15 patients who required cytoreductive surgery from February 2013 to April 2022. Their median age was 58 (range 42–67) years, and there were 5 men and 10 women. Cytoreductive surgery was performed by combining extensive peritoneal resection and the resection of various organs. Ten patients underwent neoadjuvant chemotherapy. Hyperthermic intraperitoneal chemotherapy was performed in 8 patients, and 12 patients received postoperative systemic chemotherapy. The median overall survival period was 41 months for all patients. After the cytoreductive surgery, the 3- and 5-year survival rates were 57.7% and 34.6%, respectively. All six patients with epithelial-type peritoneal mesothelioma with a peritoneal cancer index of ≤22 are alive, with expected long-term survival. Furthermore, among patients with a cytoreduction completeness of 3, which indicates residual tumors of >2.5 cm in diameter, long-term survival was achieved in those who responded to chemotherapy. In the univariate analysis, no significant factor was identified for overall survival. For malignant peritoneal mesothelioma, the treatment outcome of chemotherapy alone, which is the standard treatment in Japan, is known to be poor. This study demonstrated that cytoreductive surgery with chemotherapy achieved better outcomes than known reports in Japan. The results of cytoreductive surgery with chemotherapy from across the world may improve treatment outcomes in Japan

Laparoscopic Resection of Appendiceal Schwannoma

Background. Schwannoma arises from Schwann’s cell of the neural sheath. Schwannoma of the large intestine, particularly of the appendix, is rare. We report a case of appendiceal schwannoma resected using laparoscopic surgery. Case Presentation. A 75-year-old man was referred to our hospital for abdominal fullness and nausea since 2 months. Abdominal CT revealed a well-demarcated oval mass of 25 mm at the tip of the appendix. Contrast-enhanced CT revealed a lesion with gradually enhanced contrast from the arterial phase to the equilibrium phase. Abdominal US revealed a well-demarcated hypoechoic tumor. Preoperative diagnosis indicated appendiceal mesenchymal or neuroendocrine tumor. Ileocecal resection with D3 lymph node dissection was performed. Pathological and immunohistochemical findings confirmed the diagnosis of appendiceal schwannoma. Conclusions. For determining the surgical procedure of nonepithelial tumor of the appendix, preoperative diagnosis of mesenchymal or neuroendocrine tumors is required. However, appendiceal schwannoma is extremely rare, and its characteristic findings have not yet been established. Accumulating cases of appendiceal schwannomas is necessary for improving imaging diagnosis and surgical treatment

Laparoscopic Resection of Advanced Colorectal Cancer in a Patient with Lumboperitoneal Shunt

A 78-year-old woman with lumboperitoneal (LP) shunt was diagnosed with advanced cancer of the ascending colon. Laparoscopic right hemicolectomy was performed without manipulating the catheter. The patient’s postoperative course was uneventful, with no shunt-related complications or neurological deficit. The number of patients with cerebrospinal fluid (CSF) shunt who require abdominal surgery has been increasing. There are only few studies on laparoscopic surgery for patients with LP shunt, and the safety of pneumoperitoneum in the CSF shunt remains controversial. Consistent with other studies, we considered that pneumoperitoneum with a pressure of 10 mmHg has few negative effects. Our recommendations are as follows: (1) during colorectal resection, laparoscopic surgery can be performed without routine manipulation of the shunt catheter; (2) altering the location of the port is necessary to prevent both damage to the shunt tube during surgery and wound infection postoperatively; and (3) laparoscopic surgery is superior to laparotomy because it is associated with reduced surgical site infections and postoperative adhesions. However, laparoscopy should be performed at least 3 months after the construction of CSF shunt

Cytoreductive surgery for synchronous and metachronous colorectal peritoneal dissemination: Japanese P classification and peritoneal cancer index

Abstract Aim The outcomes of cytoreductive surgery (CRS) for synchronous and metachronous colorectal peritoneal dissemination were investigated using the Japanese P classification and peritoneal cancer index (PCI). Methods CRS was performed in 111 cases of synchronous peritoneal dissemination and 115 cases of metachronous peritoneal dissemination. The P classification and PCI were determined at the time of laparotomy. Results In the synchronous dissemination group, the 5‐year overall survival rates after CRS in P1/P2 and P3 cases were 51% and 13%, respectively. Even for P3, 51% of the patients achieved macroscopic cytoreductive complete resection (CC‐0), with a 5‐year survival rate of 40%. When P3 cases were classified into PCI 0–9, 10–19, 20–29, and 30–39, CC‐0 was achieved in 93%, 70%, 6%, and 0% of the cases, respectively, and the 5‐year survival rate of PCI 0–9 was 41%. In the metachronous dissemination group, the 5‐year survival rates were 62% for PCI 0–9 and 22% for PCI 10–19; 5‐year survival was not observed in patients with a PCI ≥ 20. CC‐0 was significantly associated with the postoperative prognosis in both synchronous and metachronous peritoneal dissemination. Conclusion In cases of synchronous dissemination, CRS must be performed for P1 and P2 cases or those with a PCI < 10, while detailed examination using PCI is required for P3 cases. In cases of metachronous dissemination, CRS should be considered when the PCI score is <20

Surgical Resection of Anastomotic Stenosis after Rectal Cancer Surgery Using a Circular Stapler and Colostomy with Double Orifice

The double stapling technique has greatly facilitated intestinal reconstruction, particularly for anastomosis after anterior resection. However, anastomotic stenosis may occur, which sometimes requires surgical treatment. Redo surgery with reresection and reanastomosis presents a high risk of complications. Treatment methods need to be selected depending on the degree and location of stenosis. In an effort to propose a new resolution, reporting new cases and sharing valid experiences are necessary. An 82-year-old man diagnosed with rectal cancer had undergone laparoscopic anterior resection. Endoscopic balloon dilation performed for anastomotic stenosis had failed. Therefore, colostomy with double orifice was constructed on the oral side at 10 cm from the stenosis. Approaching from the anal and stoma side, the anastomotic stenosis was resected using a circular stapler. The colostomy was closed 1 month after surgery. Stenosis resection using a circular stapler requires the following steps: (1) passing the center shaft through the stenosis, (2) inserting the anvil head into the oral side of the stenosis, and (3) attaching the anvil head to the center shaft. This method can resect the stenosis using a circular stapler without being affected by postoperative adhesion in the pelvis. Compared to endoscopic balloon dilation, resection of the stricture by the circular stapler is thought to be reliable. This technique is particularly effective for localized stenosis, including anastomotic stenosis. It is considered that this method is minimally invasive and is low risk for complications. This method can contribute to the useful surgical option for refractory anastomotic stenosis after anterior resection