Fit elderly patients with cancer can tolerate standard therapy with anticipated efficacy similar to non-elderly patients; however, frail patients are unlikely to tolerate such toxic treatment due to poor general condition, in which case only the best supportive care is indicated. Prefrail patients, in a condition between fit and frail, can tolerate only less-intensive cancer therapy due to their reduced general condition, and managing these patients with confidence is difficult as no guideline is available due to the paucity of evidence. Here, provisional clinical opinions recommended by the Supportive and Palliative Care Working Group are provided for vulnerable elderly patients with colorectal cancer. We have focused on bowel obstruction and chemotherapy-induced peripheral neuropathy and provided answers to questions on important topics such as the following recommendations from multi-occupational teams, including physicians and nurses, occupational therapists and patients' family. For bowel obstruction, “Should insertion of a mechanical stent be prioritized for patients who are poor candidates for surgical procedure?”, “What kind of issues exist for colostomy placement in prefrail elderly patients with colorectal cancer?” and “What should be considered for prefrail elderly patients with colorectal cancer who receive oxaliplatin-based chemotherapy?”

Aims: We evaluated the efficacy of MMX mesalazine for the induction of remission in patients with UC who insufficiently respond to pH- or time-dependent mesalazine.

Methods: Retrospective data were collected from active UC patients who switched to MMX mesalazine 4.8 g/day because of an insufficient response to 3.6 g/day of pH- or 4.0 g/day of time-dependent mesalazine between December 2016 and January 2019. The efficacy of switching to MMX mesalazine was evaluated by the decrease in partial Mayo Score (pMS), which was calculated at baseline, 2, 4, 6, and 8 weeks.

Remission was defined as a decrease in pMS to ≤2. Prognostic factors related to the remission rate at 8 weeks were evaluated using univariate analysis.

Results: 111 patients were included in this study. Previous treatment included pH- and time-dependent mesalazine in 72 and 39 patients, respectively. The remission rate at 8 weeks was 57.7%. Concomitant local mesalazine was identified as a significant prognostic factor related to the remission rate in the univariate analysis. The incidence of side effects was 7.2%.

Conclusion: Switching to MMX mesalazine 4.8 g/day in UC patients insufficiently responding to 3.6 g/day of pH- or 4.0 g/day of time-dependent mesalazine is effective and should be considered.

A 53-year-old man was brought to our hospital because of high fever and disturbance of consciousness with right lower abdominal pain. Enhanced CT scan revealed swelling of the appendix, with no findings of ascites or abscess, and so he was diagnosed as acute non-perforating appendicitis. Furthermore, he was diagnosed as sepsis and DIC by biochemical findings and several examinations. Because we could not completely conclude that the cause of severe sepsis was appendicitis, we started conservative treatment for him. As a result of intensive therapy, he recovered from DIC on the third hospital day. He was discharged from the hospital on the eighth hospital day and received elective laparoscopic appendectomy three months later. The histopathological diagnosis was catarrhal appendicitis. Several non-perforating acute appendicitis cases with sepsis and DIC have been reported until now, but all of those cases had received emergency operation. Therefore, this is the first case in which elective surgery was performed for non-perforating acute appendicitis associated with sepsis and DIC.

Case: A 91-year-old female patient. Chief complaint: Abdominal pain. History of presenting illness: She visited her previous doctor with severe abdominal pain, and general peritonitis with digestive tract perforation was suspected. She was therefore referred to our hospital for surgery. Previous medical history: Rectal cancer (Hartmann surgery at age 72 years). Her consciousness was clear; blood pressure was 116/58 mmHg and heart rate was 68 beats/min. She had severe tenderness with recoil pain around the stoma. Abdominal CT: Fecal masses and extraintestinal gas were observed in the abdominal wall around the stoma. Stercoral perforation in the stoma limb was diagnosed and emergency surgery performed. Perioperative findings revealed perforation of approximately 20 mm in diameter in the sigmoid colon mesentery; however, the feces were confined to the mesentery, with no stool outflow in the abdominal wall. The perforation was excised and a new transverse colon stoma was constructed. The postoperative course was good, and she transferred hospitals on day 22. Idiopathic stercoral perforation in the stoma limb was diagnosed histopathologically. In Japan, seven cases, including ours, of idiopathic colorectal perforation in colostomy patients have been reported. However, no other reports of late-onset post-colostomy exist. We report our findings with a brief literature review.

Gangrenous ischemic colitis is often a fatal disease. There are multiple comorbidities, and the preoperative general condition is also unfavorable, but we report on a case in which we were able to save the patient. We encountered a 63-year-old woman presenting with abdominal pain that had been going on for a week. Significant metabolic acidosis, renal failure, and abnormal coagulation were present. Free air was found on the abdominal CT, and peritonitis was diagnosed. She had been taking steroids for SLE, and warfarin for venous thrombosis. Previously she had received radiation chemotherapy for cervical cancer and an ileostomy for bladder-vaginal-rectal fistula.

During surgery, ischemic colitis was seen from the descending colon to the sigmoid colon, so a total colectomy was performed. Postoperative complications such as sepsis, acute renal failure and residual rectal anastomosis leakage were observed. She improved with intensive care that included endotoxin adsorption therapy and continuous hemodialysis. The patient was discharged on day 53.

Case 1. A 75-year-old woman presented with hoarseness and right submandibular swelling. She had previously undergone surgery for rectal cancer, before having surgery for lung metastasis 6 years and 1 month ago. Primary thyroid cancer was suspected from fine needle aspiration cytology (FNA). She had a thyroidectomy, and thyroid metastasis from rectal cancer was pathologically diagnosed. Case 2. An asymptomatic 71-year-old woman was found to have a tumor in the right lobe of the thyroid by computed tomography (CT) conducted at a postoperative periodic examination. She had previously undergone surgery for rectal cancer, before having surgery for lung metastasis 11 months ago. Primary thyroid cancer was suspected from FNA. She had a thyroidectomy, and thyroid metastasis from rectal cancer was pathologically diagnosed. We experienced two cases of thyroid metastasis from rectal cancer following lung metastasis resection. CT examination including the neck to detect thyroid metastasis should be considered in the follow-up program after resection of lung metastasis.

Seven years prior a 50-year-old man was diagnosed with a fish bone-associated perianal abscess. The abscess was incised and drained twice by his family physician, but the fish bone was not removed and further evaluation was required. The patient came to our outpatient clinic complaining of perianal induration and discomfort, although the perianal abscess had not recurred.

Two anal skin scars were noted, and palpation revealed a subcutaneous induration. Transanal ultrasonography revealed a hypoechoic mass at 10 o'clock and a hyperintense linear shadow within the mass (4 mm in size). Abdominal computed tomography (CT) also demonstrated a linear, highly-resorbable area, thus the fish bone was removed surgically. Under lumbar spine anesthesia, transanal ultrasonography was used to confirm the position of the fishbone, and the mass and fish bone were resected. The histopathologic diagnosis was a 12-mm granuloma containing a fish bone.