Purpose: Postoperative aspiration pneumoniae in elderly patients leads to an extended hospital stay and reduction of QOL. This study was designed to evaluate the usefulness of a perioperative intervention, which we refer to as the “Preventative Program of Aspiration Pneumoniae” (PPAP), for prevention of postoperative aspiration pneumoniae in elderly patients with gastrointestinal cancer. Materials and Methods: The PPAP consists of (1) identification of patients aged ≥80 years old with PS 1 or higher and those aged 75–79 years old with suspected swallowing dysfunction based on a questionnaire to screen for dysphagia, (2) evaluation of swallowing function using the Hyodo score, (3) identification of patients requiring postoperative swallowing rehabilitation, and (4) postoperative swallowing rehabilitation. A total of 262 patients aged ≥75 years old who underwent radical surgery for gastrointestinal cancer excluding esophageal cancer between January 2020 and April 2021 were evaluated retrospectively. The patient backgrounds and incidence of postoperative aspiration pneumoniae in 52 patients with PPAP intervention were compared with those for 210 patients without PPAP intervention. Result: Patients with PPAP intervention were significantly older (P<0.01) and had significantly lower preoperative albumin (P<0.01) and preoperative PNI (P=0.03) compared with patients without PPAP intervention. Of the 52 PPAP patients, 10 underwent postoperative swallowing rehabilitation and 42 were evaluated for aspiration at the start of meals. The incidence of postoperative aspiration pneumoniae was 0/52 (0%) in patients with PPAP intervention and 5/210 (2.4%) in those without PPAP intervention, but did not differ significantly (P=0.26). Conclusion: Perioperative intervention with PPAP was useful for prevention of postoperative aspiration pneumoniae. Preoperative screening of high-risk patients and aggressive postoperative intervention are useful for prevention of postoperative aspiration pneumoniae in elderly patients.

A 61-year-old man visited his primary care physician with postprandial tightness and was referred to our hospital for further evaluation. A type 1 tumor was detected at the esophagogastric junction, and biopsy revealed a moderately differentiated adenocarcinoma. Total gastrectomy and abdominal esophagectomy were performed. Histopathological examination of the resected specimen revealed a well-differentiated adenocarcinoma with a papillary pattern of atypical columnar epithelial cells with pale cytoplasm and severe nuclear atypia. Immunohistochemical analysis showed tumor cells with immunopositivity for alpha-fetoprotein and glypican3. The patient was diagnosed with adenocarcinoma with enteroblastic differentiation. We did not detect lymph node metastasis; therefore, adjuvant chemotherapy was not administered and the patient was placed under observation. CT at 2 years postoperatively revealed right lung metastasis and right lower lobectomy was performed. Histopathological findings were consistent with metastasis from esophagogastric junction carcinoma. The patient refused postoperative adjuvant chemotherapy and was recurrence-free for 1 year and 10 months after resection of lung metastases. We report this case as an extremely rare histopathological type of adenocarcinoma with enteroblastic differentiation that originated at the esophagogastric junction.

Primary aortoenteric fistula is an extremely rare condition that occurs in approximately 0.91% of abdominal aortic aneurysms, but has a high mortality rate of 40–87%. We report a case of ruptured abdominal aortic aneurysm with primary aortoduodenal fistula. An 83-year-old man was urgently admitted to hospital with hematemesis that had persisted for about one week and transient loss of consciousness. Blood tests showed hemoglobin of 8.7 g/dl. Contrast-enhanced abdominal CT showed an abdominal aortic aneurysm of 90 mm in diameter below the renal artery, and intra-abdominal free air in continuity with the duodenum within the aneurysm. The patient was diagnosed with ruptured abdominal aortic aneurysm with primary aortoduodenal fistula, and underwent emergency artificial vascular replacement and partial duodenectomy. He was transferred to another hospital on postoperative day 47. Treatment of aortoduodenal fistula requires surgery, and various procedures can be used. Early diagnosis is extremely important, and early and appropriate surgical treatment is likely to be lifesaving.

We report the case of a patient with intraductal papillary mucinous neoplasm (IPMN) with pancreas divisum who underwent subtotal distal pancreatectomy. A 74-year-old woman with pancreatitis was found to have pancreas divisum and diffuse dilatation of the Santorini duct on CT and ERCP. Mixed type IPMN localized at the dorsal pancreas was diagnosed and subtotal distal pancreatectomy with transection between the ventral and dorsal pancreas was performed to avoid total pancreatectomy. Postoperative pancreatic fistula was treated conservatively. A histological study revealed low grade IPMN without malignant findings. This case shows the importance of considering the anatomical variant in determining the extent of resection in pancreatectomy for a borderline malignant tumor.

We report a case of two-stage reconstruction after pancreaticoduodenectomy (PD), which was practical and useful for severe intestinal congestion caused by accidental prolonged portal clamping. A 59-year-old man was diagnosed with pancreatic head cancer (cT3N0M0, cStage IIA) and treated with PD. There were wide adhesions between the pancreas and superior mesenteric vein (SMV)/portal vein (PV) due to severe pancreatitis, even in areas distant from the cancer site. Adventitia of SMV/PV peeled off and teared incidentally during dissection from the pancreas, and multiple lacerations of the SMV/PV complicated the procedure and became uncontrollable. For these reasons, we had to clamp the SMV/PV. These difficulties were accompanied by severe intestinal congestion and edema. The damaged SMV/PV was resected and reconstructed with a left renal vein graft using portal vein bypass. However, intestinal congestion and edema continued after reperfusion, and we decided to perform reconstruction in two stages, given the risk of anastomotic failure. The second operation was conducted 12 hours after the first operation, at which time intestinal congestion and edema were significantly improved. This permitted reconstruction with the modified Child method and the patient had a good course. This case suggests that two-stage reconstruction is a practical and useful strategy for severe intestinal congestion and edema after PD.

We report the case of a 62-year-old woman who underwent laparoscopic left hemicolectomy for descending colon cancer. The histopathological diagnosis was pT3pN0pM0, pStage IIa. After 22 months, the serum carcinoembryonic antigen (CEA) level increased. FDG-PET/CT showed a mass around the anastomosis and intense FDG uptake in this region (maximum standardized uptake value [SUVmax]: 5.5). Local recurrence of colon cancer was suspected; therefore, we performed resection of the colon with the tumor. The histopathological diagnosis was well-differentiated adenocarcinoma and local recurrence of colon cancer. Twelve months after this surgery, abdominal enhanced CT showed a mass around the anastomosis and FDG-PET/CT showed intense FDG uptake in the same region (SUVmax: 9.7). Recurrence of colon cancer was once again suspected and surgical resection was performed. During the surgery, a mass was found in the mesentery of the colon anastomosis and had infiltrated into the small intestine. We resected part of the colon with the anastomosis, tumor and small intestine. Histopathological examination revealed a silk thread surrounded by inflammatory cells, but no malignant cells. This led to diagnosis of foreign body granuloma due to a surgical thread. This is the first report of a foreign body granuloma after local recurrence of colon cancer. The case shows the importance of considering foreign body granuloma in similar cases with positive findings on FDG-PET/CT.

A 63-year-old man was diagnosed with coronavirus infection on day 5 after onset of symptoms and treated at home. On day 6, the patient developed moderate oxygenation failure and was admitted to hospital for initiation of treatment with dexamethasone and remdesivir. On day 9, the condition deteriorated critically and a single dose of tocilizumab was administered. On day 19 post-symptom onset, the patient presented with abdominal pain, and abdominal CT indicated a perforated diverticulum in the sigmoid colon and diffuse peritonitis. In emergency surgery, laparoscopic observation revealed a large amount of pus and severe inflammation of the sigmoid colon. Sigmoid colon resection, colostomy, and intraperitoneal lavage and drainage were performed. On day 28 post-symptom onset, there was acute exacerbation of pneumonia in response to the coronavirus infection during steroid dose reduction. The condition subsequently improved with steroid pulse therapy, and transfer to another hospital was possible at 48 days post-symptom onset. We report this case as an example of perforation of the diverticulum in the sigmoid colon following administration of tocilizumab for treatment of coronavirus infection-associated pneumonia.