Fumihiko Fujita

Background: Recent advances in multi‐modality treatments (including systemic chemotherapy, endocrine therapy, and radiotherapy) have led to a paradigm shift in the surgical management of breast cancer toward less aggressive approaches. This evolution has established breast‐conserving (or breast‐reconstructive) surgery as the new standard of care, placing a greater emphasis on aesthetic outcomes. Nipple‐sparing mastectomy (NSM) has emerged as an oncologically safe option that is increasingly paired with immediate or delayed breast reconstruction. The NSM approach is also used prophylactically for high‐risk individuals with BRCA gene mutations. Compared with traditional total mastectomy, an NSM with breast reconstruction preserves the nipple‐areolar complex (NAC), offering significant psychosocial and aesthetic advantages that improve patients' cosmetic appearance and body image. However, some breast cancer patients hesitate to undergo the second stage of breast reconstruction after completing the initial NSM. Patients and Methods: We conducted a retrospective cohort study using the BREAST‐Q questionnaire to assess the postoperative satisfaction and quality of life (QOL) among patients with breast cancer who underwent an NSM with or without subsequent breast reconstruction. Results: We analyzed the cases of 73 patients who underwent breast cancer surgery between December 2016 and December 2022 at a single institution. The cohort was divided into two groups: the breast reconstruction (BR) group ( n = 45), that is, the patients who underwent tissue expander or silicone breast implant reconstruction after an NSM, and the non‐breast reconstruction (NBR) group ( n = 28), comprising patients who underwent an NSM with no intent to pursue subsequent reconstruction. We evaluated and compared the post‐NSM overall BREAST‐Q scores between the BR and NBR groups. Conclusions: The results revealed no significant difference in overall postoperative satisfaction or QOL between the BR and NBR groups. However, the BR group demonstrated significantly higher scores in the specific domains of psychosocial and sexual well‐being, a trend that was particularly pronounced among the patients with small‐to‐intermediate breast volumes.

PURPOSE: Limited information is available regarding the characteristics and outcomes of stage IV small bowel adenocarcinoma (SBA) in Japan. This study examined the clinical and pathological characteristics and outcomes according to the treatment strategies in patients with stage IV SBA.METHODS: This retrospective observational study used the data of patients with jejunal or ileal adenocarcinoma collected by the Small Bowel Malignant Tumor Project of the Japanese Society for Cancer of the Colon and Rectum. Descriptive statistics were expressed as the mean (standard deviation) or median (range). Survival analysis was performed using Kaplan-Meier curves and pairwise log-rank tests.RESULTS: Data from 128 patients were analyzed. The treatment strategies were chemotherapy alone (26 of 128, 20.3%), surgery alone (including palliative surgery; 21 of 128, 16.4%), surgery + chemotherapy (74 of 128, 57.8%), and best supportive care (7 of 128, 5.5%). The median (range) overall survival was 16 (0-125) months overall, and 11 (1-38) months, 8 (0-80) months, 18 (0-125) months, and 0 (0-1) months for the chemotherapy, surgery, surgery + chemotherapy, and best supportive care groups, respectively. Three main categories of chemotherapeutic regimen were used: a combination of fluoropyrimidine and oxaliplatin (F + Ox), fluoropyrimidine and irinotecan (F + Iri), and single-agent fluoropyrimidine. Among patients treated with chemotherapy, the median (range) OS was 16 (1-106) months overall, and 17 (1-87) months, 29 (7-39) months, and 16 (1-106) months in patients treated with fluoropyrimidine, F + Iri, and F + Ox, respectively.CONCLUSION: Patients treated with surgery, chemotherapy, or both had a better prognosis than those who received best supportive care. Among patients who received chemotherapy, survival did not differ according to the chemotherapeutic regimen.

Objectives: Adjuvant chemotherapy for stage II colorectal cancer patients with high-risk factors for recurrence can be useful; however, its advantage in prognosis remains to be controversial. Thus, in this study, we aimed to assess whether a combination of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels can predict the prognosis and advantage of adjuvant chemotherapy.Methods: Using a Japanese nationwide database, in total, 3,688 patients with curative resected stage II colorectal cancer were registered retrospectively between 2008 and 2012 in 24 referral institutions. Patients were classified into three groups as follows: Group A (both non-high levels of CEA and CA19-9), Group B (either high levels of CEA or CA19-9), and Group C (both high levels of CEA and CA19-9).Results: Multivariable Cox regression analysis, adjusting the depth of tumor invasion, number of dissected lymph nodes, tumor differentiation, lymphatic and venous invasion, and other covariates, showed that the 5-year disease-free survival and overall survival were shorter in Group C than in Groups A and B. Furthermore, in Group C, the 5-year disease-free survival rate was improved in the surgery-plus-AC group compared to the surgery-alone group.Conclusions: As with existing high-risk factors for recurrence, the combination assessment of preoperative serum CEA and CA19-9 can predict the prognosis for colorectal cancer. Adjuvant chemotherapy may provide a prolonged disease-free survival advantage in stage II colorectal cancer patients with high levels of both tumor markers.

Background: We investigated the correlations between surgery-related factors and the incidence of anastomotic leakage after low anterior resection (LAR) for lower rectal cancer. Methods: A total of 630 patients underwent colorectal surgery between 2011 and 2014 in our department. Of these, 97 patients (15%) underwent LAR and were enrolled in this retrospective study. Temporary ileostomy was performed in each patient. Results: Anastomotic leakage occurred in 21 patients (21.7%). Univariate analysis showed a significant association between operative duration (p = 0.005), transanal hand-sewn anastomosis (p = 0.014), and operation procedure (p = 0.019) and the occurrence of leakage. Multivariate regression reanalysis showed that underlying disease (p = 0.044), transanal hand-sewn anastomosis (p = 0.019) and drain type (p = 0.025) were significantly associated with the occurrence of leakage. The propensity-score analysis showed that closed drainage were 6.3 times more likely to have anastomotic leakage than open drainage in relation to the amount of postoperative drainage (ml), according to the inverse probability of treatment-weighted analysis. Conclusions: Our results indicate that underlying disease, transanal hand-sewn anastomosis, and closed drain may be a risk and predictive factors for anastomotic leakage after LAR for lower rectal cancer. The notable finding was that closed drainage was related to the occurrence of anastomotic leakage and closed drainage was correlated with less volume of postoperative drain discharge than open drain.

Background: Killian-Jamieson diverticulum (KJD) is a rare diverticulum arising from a muscular gap in the anterolateral wall of the proximal cervical esophagus. The first choice of treatment for KJD remains controversial due to its rare incidence. Here, we report two cases of KJD for which we performed different surgery: diverticulectomy in one case and diverticulopexy in the other. Case presentation: Case 1 involved a 58-year-old woman presenting progressive pharyngeal discomfort for the past year. She was diagnosed as KJD using endoscopic and radiographic findings. She underwent diverticulectomy with cricopharyngeal and proximal esophageal myotomy. Staple line leakage developed at 1 month after surgery and was successfully treated conservatively. At 5 months after surgery, she was asymptomatic. Case 2 involved a 77-year-old woman presenting dysphagia for the past 2 years. She had a history of bilateral breast cancer and had hypertension, asthma, and osteoporosis. Taking her age and medical history into account, we selected diverticulopexy with cricopharyngeal and proximal esophageal myotomy. The postoperative course was uneventful. At 2 years after surgery, she remained free of dysphagia. Conclusion: The first choice of surgery for KJD is diverticulectomy. In a high-risk patient, diverticulopexy is a reasonable treatment. We recommend the addition of myotomy as a part of any surgical treatment.

症例は66歳，男性．腹部膨満と血便を自覚し前医を受診し，CTにて回盲部付近に著明な壁肥厚を伴う腫瘤像を指摘された．下部消化管内視鏡を行ったところ回腸末端部に全周性の腫瘍を認め，同部位からの生検でBurkittリンパ腫Stage II2（Lugano病期分類）と診断され，当院血液内科に紹介となった．R-EPOCH療法が導入されたが，4コース終了後にイレウスを発症しイレウスチューブにより減圧処置が行われた．一時的にイレウスは改善したが急激な右下腹部痛が出現し，CTにて腹水と回盲部周囲のfree airを認め，穿孔性腹膜炎の診断で緊急手術となった．術後43日目に化学療法を再開し，治療効果判定はCRとなり現在も経過観察中である． 消化管悪性リンパ腫は化学療法中に消化管穿孔を発症するなど緊急手術が必要になる症例報告が散見され，内科・外科が情報共有しつつ治療に当たることが必要と思われる．

重複腸管に生じた憩室炎の報告は少なく報告する． 症例は62歳の男性．臍周囲痛を主訴に救急外来を受診．白血球増多と腹部CT検査で虫垂様構造物の腫大を認め，虫垂炎あるいは虫垂粘液腫を疑い手術を施行した．術中所見は，回腸腸間膜側に盲端を有する管状の炎症を伴う腸管様腫瘤を認めた．同部が責任病巣と判断し切除した．摘出標本の病理所見は，腸管粘膜および筋層を有していたことから回腸重複症と診断された．また，重複腸管内には憩室が存在し，憩室周囲には炎症性細胞浸潤が認められ，重複腸管に生じた憩室炎と診断した．

Small bowel obstruction (SBO) caused by an internal hernia through a mesocolon after retroperitoneal laparoscopic nephrectomy (RLN) is rare. A 66-year-old man who had undergone RLN with bladder cuff excision for a left renal pelvic cancer. After the surgery, he experienced SBO repeatedly. Contrast-enhanced computed tomography (CT) and gastrografin contract radiography through a long tube showed an internal hernia through the mesocolon to the retroperitoneal space where the resected left kidney had been located. We performed a subsequent surgery for the internal hernia. Postoperative course was uneventful and currently he has no recurrence of herniation 6 months post-operatively. Mesenteric defects that cause an internal hernia can be created inadvertently during RLN when the colon is mobilized medially, and the kidney is being detached from retroperitoneum. The removal of a kidney leads to a potential retroperitoneal space to which small intestine can migrate. While there is no absolute necessity in mobilizing the colon during the retroperitoneal laparoscopic approach, there is still a risk of making mesocolic defects directly in the retroperitoneal space. We need to perform operations with sufficient anatomical knowledge of retroperitoneal fascia and careful surgical techniques. The critical thing to prevent an internal hernia following RLN is to close the mesenteric defects intraoperatively. It is also important to suspect an internal hernia and do proper examinations promptly when patients had the symptoms of SBO after nephrectomy.