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Upside-down stomach (UDS) is a rare type ( Case presentation: A 57 year-old male patient with hiatal hernia for several years was referred to our institution because of frequent vomiting and UDS. He had no pain and vital signs were stable. Hematological investigations revealed neutrophil dominant elevation of white blood cell count, but CRP was normal in blood biochemistry. An enhanced computed tomography revealed a giant hiatal hernia (Type IV) and whole stomach migrated into posterior mediastinum with organoaxial gastric volvulus, but obviously ischemic signs were not detected. An esophagogastoroduodenoscopy (EGD) showed erosion of gastric mucosa, but no necrotic sign of stomach. From these findings, surgery was thought to be necessary to improve the obstruction of stomach and prevent from necrosis of the incarcerated stomach. However, because of stable general conditions and no ischemic findings, we performed laparoscopic repair of hiatal hernia and Toupet fundopulication. Ischemic change of the stomach was not observed. After stomach withdrawal into the abdominal cavity from the mediastinum, hiatal defect was repaired and fundoplication was performed by Toupet method. After surgery, the symptom and stomach passage obstruction improved and the patient was discharged without no complications. We successfully performed hiatal hernia repair and fundopulication with laparoscopic approach in the case of UDS. If there are no findings obviously indicating gastric ischemia and necrosis on an enhanced computed tomography and an EGD, laparoscopic hiatal hernia repair and fundoplication are considered as a useful method because of its less invasiveness and magnifying effect.

A 59-year-old man was diagnosed with cholecystolithiasis and cholecystitis and underwent cholecystectomy. The pathological findings were moderately differentiated adenocarcinoma(pT2)in the gallbladder fundus. Sixteen days after surgery, he visited our hospital due to jaundice. Abdominal enhanced CT and EOB-MRI revealed multiple liver metastases and lymph node metastases in the hepatoduodenal ligament that we deemed to be unresectable. A metallic stent was inserted for bile duct obstruction, and he underwent chemotherapy with gemcitabine plus cisplatin(GC). After 12 courses of GC, the metastatic lesions disappeared, and the patient showed complete response. FDG-PET/CT showed FDG uptake in the hepatoduodenal ligament and we subsequently decided to perform surgery. He underwent resection of the extrahepatic bile duct and regional lymphadenectomy. The pathological findings revealed no residual carcinomas in the bile duct or lymph nodes. We are continuing chemotherapy at present, and the patient is alive with no signs of recurrence at 1 year and 3 months following the diagnosis of multiple liver metastases.

A 70-year-old woman was brought to our hospital by ambulance because of severe groin pain on the right side. Computed tomography scan revealed a tumor in the ascending colon, intraperitoneal abscess spread to the subcutaneous tissues, and a large amount of pneumoderma. She was diagnosed with necrotizing fasciitis caused by penetration of ascending colon cancer and underwent lavage and drainage, right hemicolectomy, end ileostomy, and debridement of necrotic tissues on emergency. Postoperatively, she underwent debridement and irrigation at the bedside every day, but the necrotizing tissues spread. Debridement under general anesthesia was repeated on postoperative day 8. On postoperative day 20, negative pressure wound therapy(NPWT)was initiated to manage the exudates and wound condition, and healthy granulation tissues formed gradually. After 4 weeks, she underwent split-thickness skin graft implantation. The postoperative course was uneventful, and she was discharged from the hospital. She is currently on chemotherapy and has been alive for 1 year and 3 months after the first operation.

A 69-year-old man was hospitalized for gastric cancer. He underwent total gastrectomy with distal pancreatectomy, splenectomy, and cholecystectomy. Pathological staging was pT3N3aM0 and Stage ⅢB. Adjuvant chemotherapy(S-1)was administered postoperatively. Ten months later, left adrenal metastasis was detected on computed tomography(CT)scans. He was then treated with 4 courses of chemotherapy with SOX therapy and 2 courses of PTX plus RAM therapy for the left adrenal metastasis. However, the tumor size increased. He underwent adrenalectomy with left nephrectomy and partial resection of the transverse colon for the solitary adrenal metastasis. His pathological diagnosis was metastatic carcinoma of the left adrenal gland and lymph nodes, which invaded the left renal vein and originated from gastric carcinoma. Three months after the adrenalectomy, CT scans identified paraaortic, porta hepatis, and left supraclavicular lymph node metastases. The patient was continuously treated with nivolumab, for 20 courses, and is doing well with good PS. Adrenalectomy for solitary adrenal metastasis of gastric cancer very rarely occurs. We report a case of multiple lymph node metastases treated with nivolumab after an adrenalectomy for solitary adrenal metastasis of gastric cancer after a gastrectomy.

A 65-year-old man was hospitalized for gastric cancer. Abdominal computed tomography detected lower gastric cancer and invasion of the liver. Initial laboratory data showed high levels of serum AFP(2,688.6 ng/mL). He underwent distal gastrectomy with left lobectomy of the liver and cholecystectomy. Histology confirmed that the tumor consisted of 2 components: primary gastric choriocarcinoma and AFP-producing carcinoma. The pathological staging was pT4b(liver), N3aM0, Stage ⅢC. After surgery, AFP levels decreased to within the normal limits. Adjuvant chemotherapy(S-1)was administered for 1 year after the operation. Fourteen months later, PET-CT and EOB-MRI detected liver recurrence. He was treated with weekly paclitaxel(PTX)chemotherapy for the liver recurrence. After 12 courses, the tumor had disappeared. The patient was continuously treated with weekly PTX and is doing well without recurrence 24 months after the resection of the liver tumor. Co-existence of primary gastric choriocarcinoma and AFP-producing carcinoma is very rare. We report a case of liver recurrence of choriocarcinoma and AFP-producing carcinoma of the stomach showing a complete histological response after chemotherapy.

A 60's woman had undergone abdominal total hysterectomy due to uterine leiomyoma 17 years previously. She underwent resection of multiple intra-abdominal tumors 9 years previously, and was diagnosed with disseminated peritoneal leiomyomatosis. Because of several recurrences, she was referred to our hospital and treated with GnRH agonist therapy. However, the tumors enlarged gradually and she underwent further resection for multiple intra-abdominal tumors. After surgery, we performed several operations. This is an extremely rare disease and we present this case with a discussion of the literature.

Adjuvant chemotherapy with gemcitabine is the standard treatment in Japan for patients who have undergone resection of pancreatic cancer. However, few reports have described suitable regimens for patients who present cancer relapse following adjuvant chemotherapy. In the present study, we retrospectively evaluated the efficacy and safety of S-1, an oral fluoropyrimidine derivative, as a second-line chemotherapy for patients who had suffered relapse of pancreatic cancer following adjuvant chemotherapy with gemcitabine. A total of 51 patients with pancreatic cancer suffered relapse after curative resection and subsequent adjuvant chemotherapy with gemcitabine at our institution. A group of 26 of these patients were administered S-1 orally twice daily after meals at a dose of 80 mg/m(2) for body surface areas for 14 consecutive days, followed by a 7-day rest (S-1 group). The remaining 25 patients received no additional anticancer drugs other than continuation of gemcitabine (GEM/BSC group). During a median follow-up period of 35 months, a significant difference was observed in overall survival (OAS) between the S-1 group and the control group (median OAS, 20.9 vs. 13.7 months; p=0.0157, log-rank test). Furthermore, there was a significant inter-group difference in survival after relapse (SAR) (median SAR, 11.4 vs. 6.20 months; p=0.0025, log-rank test). No increase in grade 3/4 hematological and non-hematological toxicity was observed in the S-1 group. In conclusion, second-line chemotherapy using a combination of S-1 and adjuvant chemotherapy with gemcitabine may be an efficient and beneficial strategy for patients with relapsed pancreatic cancer.

We report 2 cases of stage IV gastric cancer in which the primary tumor was resected after chemotherapy combined with trastuzumab was administered. Case 1: A 57-year-old man who reported epigastric discomfort was diagnosed as having gastric cancer with Virchow's lymph node metastasis. Because his gastric cancer was human epidermal growth factor receptor( HER)-2-positive, he was treated with trastuzumab+capecitabine and CDDP( XP therapy). After 2 courses of this treatment, he underwent distal gastrectomy because of advanced pyloric stenosis. He was treated postoperatively with capecitabine+trastuzumab, and the residual lymph node shrank. Case 2: A 62-year-old man examined for weight loss was diagnosed as having gastric cancer with peritoneal metastases. Because his gastric cancer was HER2-positive, he was treated with trastuzumab+S-1 and CDDP( SP therapy). After 5 courses of this treatment, he underwent total gastrectomy because of advanced pyloric stenosis. He was treated postoperatively with trastuzumab+SP therapy, and his condition remained stable. Chemotherapy combined with trastuzumab could allow resection of the primary tumor and thereby improve the prognosis.

A 50-year-old man underwent thorough examination for a chief complaint of melena. Gastric cancer and right kidney cancer were diagnosed. The gastric cancer was in the antrum, and poorly differentiated adenocarcinoma was diagnosed by biopsy. The right kidney cancer was diagnosed as clear cell carcinoma by computed tomography-guided biopsy. We performed right nephrectomy and distal gastrectomy. The final diagnosis of the gastric cancer was por2, pT3( ss), pN3b( 46/ 61), M0, pStage IIIB, R0, and that of the kidney cancer was clear cell carcinoma, pT3a, pN0, pM0. The patient reported lower back pain approximately 2 months after surgery. Several examinations revealed that the patient had multiple bone metastases, disseminated carcinomatosis of the bone marrow, and disseminated intravascular coagulation (DIC).We treated the bone metastasis with denosumab and palliative radiation therapy and the gastric cancer with weekly paclitaxel (PTX). The DIC subsided during the first course but recurred during the discontinuation period. We attempted additional trastuzumab treatment but did not achieve a curative effect, and the patient died. It is necessary to provide appropriate medical care while taking into consideration the possibility of disseminated carcinomatosis of the bone marrow in cases with a high likelihood of lymph node metastasis.

We report a case of cancer in the dilated jejunal pouch after total gastrectomy, in which we resected the jejunal pouch. The patient was a man in his 60s and had a history of total gastrectomy with jejunal pouch ρ-interposition for mucosa-associated lymphoid tissue (MALT) lymphoma in 1994. In late July 2012, he presented to the emergency department with a protracted ileus-like symptom and was admitted to the gastroenterological department after the diagnosis of a dilated jejunal pouch. He was managed conservatively; however, the same symptom recurred. Examinations showed a duodenal carcinoma and cancer in the jejunal pouch; therefore, he was referred for digestive surgery in early August. Endoscopic mucosal resection( EMR) was performed on the duodenal carcinoma, and we resected the jejunal pouch with Roux-en-Y reconstruction for the jejunal cancer. He recovered from postoperative wound infection and was discharged 15 days after the second operation.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas exhibit a wide range of histopathological variation. Epithelial cell adhesion molecule (EpCAM) is a 40 kDa type I membrane protein that is known to be highly expressed in epithelial carcinomas. In this study, we examined immunohistochemical expression of EpCAM in the pancreatic IPMNs in order to clarify its clinicopathological significance. We analyzed 51 cases of surgically resected IPMNs: 32 cases of adenoma; 6 cases of non-invasive carcinoma; 8 cases of minimally invasive carcinoma; and 5 cases of invasive carcinoma. Additionally, these 51 cases were classified into four phenotypes (gastric, intestinal, pancreatobiliary and oncocytic). EpCAM overexpression was found in 16 (31.4%) of the tumor samples. We found five predictive factors of malignancy using the univariate analysis as follows; serum CA19-9 level, main pancreatic duct diameter, presence of mural nodule, phenotype and EpCAM overexpression. In the multivariate analysis, only EpCAM overexpression was identified to be independently associated as a predictive factor for malignancy (odds ratio, 11.039; 95% confidence interval, 1.877-64.919; P-value, 0.008). Our study is the first report to demonstrate that EpCAM overexpression is an independent factor for malignancy; therefore, EpCAM overexpression is thought to be a novel predictor of malignant IPMNs.

The aim of this study was to determine whether preoperative radiotherapy had an influence on the anal function of patients having an intersphincteric resection (ISR).We evaluated a long-term outcome and postoperative anal function in 22 patients having undergone ISR for low rectal cancer.There was no significant difference between the irradiated and nonirradiated group in the postoperative complications and oncological outcome. After a median follow-up of 6 .8 years, the number of bowel movements per 24 hours in patients with and without radiation was 4 .5 and 2 .7, respectively. Poor anal function assessed by Wexner incontinence score and Kirwan classification were significantly associated with preoperative radiotherapy.Preoperative radiotherapy was identified as a risk factor with the greatest negative impact on anal function after ISR.

In Japan, surgical therapy is utilized as the main treatment modality for anal squamous cell carcinoma (SCC). Subjects were 6 patients with anal SCC treated at our hospital from 2000-2010, and a study was made on the treatment. In the early 3 cases (Stage IIIA, IIIB, IIIB), chemoradiotherapy (CRT) was used as adjuvant therapy on the premise of surgery. All of them were considered as stable disease, and they all experienced postoperative complications. The average length of the hospital stay was 45 days. Two cases are still surviving without recurrence, but the other one developed a distant metastasis. In contrast, we selected CRT with curative intent in the late 3 cases(Stage II, IIIA, IIIB). Two cases were considered as complete response (CR), and the other one considered as partial response (PR) was performed a salvage operation. Two cases are still surviving without recurrence, but the other case metastasized to the internal iliac lymph nodes. CRT with curative intent for anal SCC demonstrated a good antitumor effect. Salvage operation was safely performed, and showed a good prognosis.

The patient was a 36-year-old female who had undergone Auchincloss operation for left breast cancer at another hospital when 29 years old. Three years ago she was transferred from another hospital to our department complaining of dyspnea. Under the diagnosis of cardiac tamponade, we treated her with pericardial drainage and systemic chemotherapy (intravenous dosage of trastuzumab and vinorelbine: VNR), and then pericardial effusion disappeared. Further medical treatment was continued on an outpatient basis. One year later, cardiac tamponade developed again. We performed echo-guided pericardiocentesis and removed 600 mL of bloody effusion. The cytology of the effusion showed class V. Pericardial effusion recurred, so we instilled OK-432 and mitomycin C (MMC) twice. After that the cytology diagnosis became negative, and the heart shadow in chest X-P reduced. The pericardial effusion has never occurred until now. We also gave her systemic chemotherapy (intravenous dosage of trastuzumab)and endocrine therapy (peroral administration of medroxyprogesterone acetate). She made a remarkable recovery with these treatments and could go back to work.

Background/aim: Pancreatic neuroendocrine tumors (PNETs) are a rare subgroup of tumors, for which the factors predictive of survival and prognosis are not well known. Recently, the European Neuroendocrine Tumors Society (ENETS) proposed the TNM staging and the World Health Organization (WHO) revised its histological classification in 2010. This study aimed to evaluate whether the ENETS staging and the revised WHO classification can predict survival after surgical resection of PNETs. Methods: Twenty consecutive curative resections for PNETs were performed at our institute from 1998 to 2012. The prognostic factors based on the revised WHO histological classification (2010) for survival were retrospectively evaluated using the Kaplan–Meier method. Results: The mean patient age was 60.3 10.9 years. Twelve patients (60%) were diagnosed with functioning tumors and 8 (40%) with nonfunctioning tumors. Surgical methods comprised pancreatoduodenectomy (n 1⁄4 3), distal pancreatectomy (n 1⁄4 5), enucleation (n 1⁄4 9), and central pancreatectomy (n 1⁄4 3). Hepatectomy was performed for 2 patients with synchronous liver metastasis. According to the ENETS staging, 14 (70%), 2 (10%), 2 (10%), and 2 (10%) had stage I, II, III, and IV tumors, respectively. According to the revised WHO histological classification (2010), 13 (65%), 5 (25%), 1 (5%), and 1 (5%) patient was diagnosed with neuroendocrine tumor (NET) G1, NET G2, neuroendocrine carcinoma (NEC), and mixed adenoneuroendocrine carcinoma (MANEC), respectively. Univariate analysis revealed that both the ENETS staging and the revised WHO histological classification (2010) significantly predicted survival after surgical resection for PNETs. Conclusions: The ENETS staging and the revised WHO histological classification (2010) may be useful to predict survival in PNETs. However, because PNETs represent a rare tumor subgroup, more time and a sufficient number of cases are required to confirm its prognostic reliability.