Purpose: To evaluate whether intraoperative indocyanine green (ICG) fluorescence angiography could decrease the anastomotic leakage (AL) rate of colorectal cancer surgery and assess whether it could influence the construction rate of covering stoma (CS rate) or not with low anterior resection (LAR).

Method: This retrospective study included patients with colorectal cancer who underwent surgery at our institution between May 2020 and July 2023. The patients were divided into two groups: the ICG and no-ICG groups. Additionally, the LAR population was derived from both groups.

Result: A total of 212 patients were included: 100 patients in the ICG group and 112 patients in the no-ICG group. Among them, 13 and 20 patients in the ICG and no-ICG groups, respectively, underwent LAR. The AL rates were 1.7% in the no-ICG group and 0% in the ICG group. Nine (4.25%) patients in the ICG group had a modified resection line after intraoperative ICG fluorescence angiography. On the other hand, CS rates were 60% in the no ICG-LAR group and 15% in the ICG-LAR group.

Conclusion: No significant difference in AL rate was observed. However, the possibility that modification of the resection line prevents AL exists. Furthermore, ICG fluorescence angiography can possibly reduce CS rate with LAR surgery.

A woman in her 50s presented with a 15-mm irregular mass in her left breast and was diagnosed with a left breast cancer (cT1N0M0 stage 1, ER+/PgR+/Her2-, Ki67 index 2%). Left breast-conserving surgery and sentinel lymph node biopsy were performed, and titanium clips were placed on the resection edge of the breast. As postoperative treatment, radiation therapy (50 Gy/25 Fr) and endocrine therapy (TAM to TOR) were administered. Three years after surgery, she presented again with hyperpigmentation, skin rash, and itching near the surgical site. After six months of follow-up, her symptoms did not improve. Suspecting allergy to titanium clips, we performed a titanium patch test, which produced a negative result. However, her symptoms worsened with generalized pruritus. Therefore, we decided to remove the intramammary clips. After marking the location of the clips under CT guidance, we performed an intramammary titanium clip removal. After the surgery, local and general skin symptoms gradually improved and disappeared. We report a case of metal allergy to titanium clips used for breast conservation surgery, occurring 3 years after surgery and resolving after surgical removal of the clips.

A 31-year-old woman presented with masses in her left breast at 12 weeks of gestation. She had a past history of right breast cancer and underwent breast-conserving surgery with sentinel lymph node biopsy. Histological diagnosis confirmed pT2pN0cM0 pStage ⅡA triple-negative breast cancer. She received four courses of doxorubicin and cyclophosphamide (AC) followed by weekly doses of paclitaxel (wPTX) as adjuvant chemotherapy, as well as radiation therapy. The tumor was an invasive triple-negative ductal carcinoma, and the stage was cT2cN1cM0 cStage ⅡB. We performed total mastectomy with axillary dissection at 15 weeks of gestation, and the pathological diagnosis was determined to be pT2pN0cM0 pStage ⅡA. At 21 weeks of gestation, the patient received four courses of AC while being monitored by cardiologists and gynecologists. She delivered vaginally at 37 weeks and 3 days of gestation without any fetal abnormalities. Three weeks after delivery, she received wPTX. Perioperative chemotherapy, including administration of anthracycline, was successfully performed without any cardiac dysfunction. The patient received appropriate treatment through a multi-professional collaboration that included cardiologists and gynecologists.

A 70-year-old man underwent laparoscopic gastrectomy and double-tract reconstruction for gastric cancer. About 3 months after surgery, he had heartburns. An upper gastrointestinal endoscopy revealed LA classification Grade C reflux esophagitis. His symptoms did not improve with medical therapy. His food intake decreased, resulting in a weight loss of 31 kg (72 kg preoperatively). His symptoms did not improve 5 years after surgery; therefore, he was referred for surgery. Preoperative esophageal impedance pH monitoring (MⅡ/pH) showed no decrease in pH of the liquid reflux component. Therefore, duodenal fluid was considered to be the cause of the reflux esophagitis. A total resection of the remaining stomach and anastomosis of the Y-leg (20 cm anorectal side from the anastomosis of the previous surgery) were performed. Postoperatively, his symptoms disappeared, and he observed a weight gain of 8 kg. Furthermore, an upper gastrointestinal endoscopy confirmed the cure of reflux esophagitis. In this report, we describe a case of refractory reflux esophagitis after gastrectomy with gastric resection of the volvulus, which was cured by reoperation. Reoperation is one of the treatment options for refractory reflux esophagitis after gastrectomy. The MⅡ/pH test may be useful in the diagnosis of such patients and in determining the indication for surgery.

Cutaneous metastasis of colorectal cancer is rare. A 70-year-old woman underwent laparoscopic low anterior resection for a rectal adenocarcinoma in 2019.

Fifteen months later, she developed a mass in the right perineal region. The tumor marker CEA level had increased, and a pelvic CT scan detected an enhanced mass in the same region. A diagnosis of local recurrence was made. After 12 courses of chemotherapy with Panitumumab and mFOLFOX6, she had a clinical diagnosis of stable disease. Biopsy of the mass showed metastasis of rectal cancer, requiring a local excision. A pathological assessment revealed an adenocarcinoma-like colorectal cancer and immunohistochemical findings of a CK20, CDX2, and SATB2-positive and CK7-negative lesion. We made a final diagnosis of cutaneous metastasis of rectal cancer. She did not undergo adjuvant chemotherapy, and no recurrence was observed 17 months after excision.

An 87-year-old man with complaints of abdominal distension and nausea was admitted to the emergency department. He had undergone choledochojejunostomy for choledocholithiasis 38 years ago. He was diagnosed with gallstone ileus of the small intestine by contrast-enhanced computed tomography of the abdomen and was hospitalized on the same day. After hospitalization, the patient underwent conservative treatment without any improvement of his condition. Therefore, he later underwent laparoscopic lithectomy. A 4.0-cm yellow clay-like stone was removed from the jejunum. The postoperative course was uneventful, and the patient was discharged from the hospital 12 days after surgery. Three months after discharge, no recurrence of symptoms has been reported. A case of gallstone ileus after choledochojejunostomy, such as our case, is rare. We report this case with some literature considerations.

A 76-year-old woman was referred to the Department of Gynecology of our hospital on account of an enlarging left ovarian tumor. Imaging suggested a tumor of the small intestine. Another tumor was newly found at a site between the perihilar bile duct and distal bile duct, close to a merger of three ducts. Since the bile duct tumor could either be a metastasis or primary bile duct cancer, we referred the patient to the Department of Surgery. CT and MRI suggested that the lesion was a solid tumor, and PET-CT showed accumulation. Based on these findings, surgery was performed for the original lesion (ovarian or small-intestinal tumor) and the newly found lesion (metastasis to the bile duct or primary bile duct cancer). An intraoperative biopsy revealed that the ovarian tumor was benign. However, the bile duct tumor could be a well-differentiated adenocarcinoma because of the increased number of glandular cells. Therefore, the tumor was resected. A histopathological examination of the excised specimen suggested that the biliary mucosa was maintained, leading to a diagnosis of a submucosal tumor. Immunostaining was positive for synaptophysin and negative for chromogranin A. Based on these findings, the final diagnosis was an extrahepatic biliary neuroendocrine tumor (NET, G1). The patient has been followed up as an outpatient and has had no recurrence 7 years after surgery. We report this case with a literature-based discussion as a rare example of primary extrahepatic biliary NET that was diagnosed histopathologically and resected surgically.

A 61-year-old woman who presented with abdominal distension was diagnosed with a large anaplastic pancreatic carcinoma of the pancreatic body and tail and treated by surgical resection. The pancreatic tumor, measuring 190 mm in diameter, was identified by an abdominal CT. Endoscopic ultrasound-guided fine needle aspiration further revealed the tumor to be a non-epithelial sarcomatous tumor. A combined distal pancreatectomy and distal gastrectomy was performed. After histopathological assessment of the resected specimen, the tumor was finally diagnosed to be an anaplastic pancreatic carcinoma. Anaplastic pancreatic carcinoma is reported to be a hyper-vascular tumor that grows rapidly and has an extremely poor prognosis. During surgery, it frequently requires combined resection of surrounding organs of the pancreas because of its tendency to spread. Extensive curative resection is necessary for long-term survival in managing cases of anaplastic pancreatic carcinoma.

A 64-year-old woman presented with a mass in the left lower abdomen. CT scan revealed incarceration of small intestine into the abdominal wall, thickened rectal wall, and lymphadenopathy. Under ultrasound guidance, we repaired the small intestine, which was well perfused. Further assessment of the rectum by colonoscopy detected a rectal adenocarcinoma. We performed surgery. The hernial orifice was the left internal inguinal ring, and the hernial sac was projected anteriorly and into the cranial side, between the internal and external oblique muscles but not into the inguinal canal. After low anterior resection of the rectum was performed, we performed hernioplasty using a uterine flap. Final diagnoses of interparietal hernia and a rectal cancer were made.