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Hepatic resection has been regarded as the only curative treatment for colorectal liver metastases. After a first hepatectomy, 30% to 70% of patients develop intrahepatic recurrence. In this study, we retrospectively analyzed risk factors for intrahepatic recurrence.From April 1990 to December 2006, 86 patients with colorectal liver metastases underwent curative hepatic resection at Kanagawa Cancer Center. Clinicopathological characteristics of 35 patients in the intrahepatic recurrence group were compared with those of 30 patients in the no recurrence group.The 5-year survival rate was 18.7% for patients in the intrahepatic recurrence group. Lymph node metastases of primary colorectal cancer and synchronous liver metastases were found to be independently associated with intrahepatic recurrence.We suggest that neoadjuvant chemotherapy before hepatectomy should be considered as feasible treatment for reducing intrahepatic recurrence in two cases; One case is resectable synchronous liver metastases from colorectal cancer, and the other is resectable metachronous liver metastases with primary regional lymph node metastases from colorectal cancer.

We investigated whether or not there are cancer cells in the blue node (BN) and the sentinel lymphaticus (SL), which is detected using sentinel node biopsy (SNB).Patent blue (1%) is injected submucosally into 4 to 5 different sites at 1 mL per site around the primary tumor. Blue-stained lymphatics and lymph nodes can be seen by turning over the greater omentum and lesser omentum extraperitoneally. If blue nodes or lymphaticus are found, biopsy is performed at this point. The study was conducted in 14 patients (11 males and 3 females, mean age 65.7 y/o) with a preoperative diagnosis of T1 tumor invasion and NO that there is no lymph node metastasis. Informed consent was obtained from the patients for SNB after patent blue staining and investigation of CEAmRNA and CK20mRNA.Of the 14 patients in whom BN and SL were identified, 1 (7.1%) had positive CEAmRNA and positive CK20mRNA of SL.Our present study shows the possibility for the existence of cancer cells in the lymphaticus from the tumor to BN. We should avoid the cut of lymphaticus when we perform gastrectomy.

We studied food intake in 107 patients undergoing gastric surgery, with emphasis on postoperative quality of life (QOL). The time course of food intake after surgery, sex- and age-related differences in food intake, and the relation of food intake to surgical procedure were evaluated retrospectively.The following variables were studied: 1) the time required for stabilization of food intake, assessed on the basis of the time course of food intake after operation; 2) the relations of sex and age to postoperative food intake, assessed by comparing food intake according to sex and age; and 3) postoperative food intake according to surgical procedure, evaluated by calculating the ratio of postoperative food intake to the food intake of healthy individuals matched for sex and age.At 6, 12, and 24 months after operation, there was no difference in food intake among the three operative procedures; food intake was stable from 6 months onward. When food intake was analyzed according to age, similar trends were seen in men and women, and there were no significant differences in food intake among patients in their 40s, 50s, or 60s. Food intake was significantly lower in patients in their 70s than in patients in the other age groups. Food intake even in women with significantly decreased food intake or in patients 70 years or older was not necessarily low as compared with food intake levels in healthy individuals.Food intake is substantially affected by the period of time after surgery, as well as by sex, and age at the time of surgery.

In order to clarify vitamin E malabsorption after gastric surgery, we evaluated serum vitamin E level and neurological consequences in patients who had undergone gastrectomy for gastric cancer.We studied forty-eight patients (30 men, 18 women) with a mean age of 68.0 years, who had previously undergone gastrectomy for gastric cancer and had no evidence of recurrence. The types of operation consisted of subtotal gastrectomy in 26 patients and total gastrectomy in 22 patients. We measured postoperative body weight, white blood cells, red blood cells, hemoglobin, hematocrit, platelets, and serum levels of vitamins E, vitamin B12, folic acid, total cholesterol, triglycerides, total protein, and albumin.Serum vitamin E level was decreased in 7 (14.6%) of the 48 patients. The occurrence of low vitamin E level was significantly more frequent in the total gastrectomy group than in the subtotal gastrectomy group. In relation to reconstruction procedures, the incidence of low vitamin E level was significantly higher in patients without food passage through the duodenum. The low vitamin E level was significantly associated with low total cholesterol level. The incidence of neuropathy was significantly higher in patients with low vitamin E level.We assume that vitamin E deficiency more likely occurs after the reconstruction procedure in which food does not pass through the duodenum. Transport disturbance with loss of passage through the duodenum consequently may be the major cause of malabsorption. Differential diagnosis of neurological symptoms in post-gastrectomy patients should include hypovitaminosis E.

We investigated whether sentinel lymph node biopsy using dye technique alone is useful or not in decision-making for less invasive surgery in patients with gastric cancer.The subjects were 43 patients who had undergone laparotomy for gastric cancer and consented to undergo sentinel lymph node biopsy using patent blue dye. The patients enrolled were 26 males and 17 females, with a mean age of 62.5 years. The tumor sites were upper third of the stomach in 14, middle third in 16, and lower third in 13 patients. The depth of invasion was mucosa in eight, submucosa in 19, muscularis propria in five, subserosa in five, and serosa in six patients. Total gastrectomy was performed in 12, subtotal gastrectomy in 28, and proximal gastrectomy in three patients.The mean number of sentinel lymph node biopsies per surgery was 3.5 +/- 4.1. We were able to perform blue node biopsy in 40 out of 43 patients, but could not find any blue nodes in three patients. Among the 40 patients in whom blue nodes were identified, 29 patients with no metastasis in blue nodes had no evidence of lymph node metastasis (NO). The depth of invasion was not deeper than subserosa in all these patients. Metastasis was observed in one out of the three patients in whom no blue nodes were found.When the depth of invasion was not deeper than the subserosa and blue nodes were identified, no metastases in either non-blue nodes or blue nodes could be found in the absence of metastatic blue nodes. Therefore, if the depth of invasion is not deeper than the subserosa in gastric cancer, metastatic search in blue nodes seems sufficient and less invasive surgery can be performed safely. Even when the invasion depth is not deeper than the submucosa, the tumor could be metastatic to Group 2 lymph nodes in patients in whom blue node biopsy revealed metastases. When metastasis is found in lymph nodes by intraoperative frozen section diagnosis, less invasive surgery for gastric cancer is not indicated.

The present study was conducted to investigate the relationship between bone metabolic disorder after gastrectomy for gastric cancer and vitamin D metabolites or the hormones involved in calcium metabolism.Twenty-one patients who had undergone gastrectomy for gastric cancer and had been followed for less than 10 years were assessed for bone disorder by microdensitometry. The levels of 1,25-dihydroxy vitamin D (1,25(OH)2VD), 25-hydroxy vitamin D (25(OH)VD), 24,25-dihydroxy vitamin D (24,25(OH)2VD), N-PTH, calcitonin, estradiol, osteocalcin, and ALP were measured and assessed for correlations with clinicopathological factors, including the operative procedure and the number of years since surgery.Bone disorder was found in 9 out of 21 patients (42.9%). The prevalence was significantly higher in patients who had undergone surgery more than 2 years before assessment, so there was a relationship between the period after surgery and bone disorder. Among the vitamin D metabolites, the level of 1,25(OH)2VD was normal in all patients, whereas 25(OH)VD was reduced in 6 out of 21 patients (28.6%) and 24,25(OH)2VD was reduced in 17 patients (81.0%). The 1,25(OH)2VD was significantly higher in the patients with Grade I to III bone disorder compared to the patients with normal bones or early bone disease. The 1,25(OH)2VD/25(OH)VD ratio was significantly higher in the patients without passage of food through the duodenum due to the reconstructive method, while the 25(OH)VD/24,25(OH)2VD ratio was significantly higher in the patients with remaining of duodenal food passage. PTH was decreased in about 50% of the patients, while calcitonin was normal in all patients. Estradiol was decreased in one female patient, while it was elevated in 10 of the 17 men (58.8%). The osteocalcin level was high in all patients irrespective of the period after surgery.After gastrectomy, the incidence of bone metabolic disorder increases with time. Changes of vitamin D metabolites, particularly 25(OH)VD and 24,25(OH)2VD, seem to be closely associated with post-gastrectomy bone disease.

In this study, we performed 13C-urea breath test in patients who had undergone total gastrectomy and investigated the content of (13)CO2 in the CO2 gas expired after direct influx of 13C-urea into the small intestine.13C-Urea breath test was performed in 31 patients who had undergone total gastrectomy at this department for the treatment of stomach cancer and consented to participate in this study. The test was performed in two ways, i.e. with and without mouth washing (gargling) on taking 13C-urea.Among 41 measurements, the delta13C was less than 2.5% per hundred in 9 measurements (22.2%) and less than 2.0% per hundred in 6 measurements (14.6%). The delta13C exceeded 50% per hundred, in 4 subjects (9.8%). There were no differences between the methods with and without gargling.The results of this study suggested the possibility that 13C-urea is decomposed even in the jejunum or the lower part of intestine resulting in absorption of H(13)CO3 and another possibility that 13C-urea is directly absorbed from the intestine and decomposed in the blood.

This study was conducted to evaluate the effects of lateral lymph node dissection (LLD) on overall survival, disease-free survival, and local recurrence for the patients with lower rectal cancer.From 1990 through 2000, 169 consecutive patients with T2 (TNM classification) or more advanced, extended lower rectal cancer (located below the peritoneal reflection) underwent curative resection at Kanagawa Cancer Center were reviewed. One hundred and forty-three patients who underwent LLD and the 26 patients who did not were entered in this study.Cox's multivariate regression analysis showed T stage (TMN classification), N stage (TNM classification), and LLD were found to be significantly related to the rates of both cumulative survival and disease-free survival. That mean LLD was identified as a significant prognostic factor. But disease-free survival did not differ significantly between the patients who underwent LLD and those who did not undergo LLD in stage I, II, or III disease (p = 0.3681, p = 0.1815, and p = 0.0896, respectively). The local recurrence rate was similar in patients who received LLD (17.5 percent) and in those who did not receive LLD (23.1 percent; p = 0.498). But 7 patients with lateral lymph node metastasis (33.3 percent) remained disease free. And these patients had local lateral lymph node metastasis and benefited from LLD.LLD can substantially improve outcomes in selected patients at high risk for lateral lymph node metastasis. A randomized controlled clinical study is necessary to clarify the role of LLD in the treatment of rectal cancer.

In order to predict morbidity after gastrectomy for gastric cancer in aged patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) scoring system was applied.A total of 123 patients who had gastrectomies for gastric cancer at the age of 75 or above, between 1994 and 2002, were enrolled in this study. Postoperative morbidities and mortalities were analyzed and POSSUM scores were calculated.The predicted mortality and morbidity rates according to the POSSUM scores in this series were 47.9% and 14.1% respectively. The observed morbidity and mortality rates were 39.8% and 1.6% respectively. Using these results, we created a modified POSSUM equation to predict the morbidity in this population, expressed as ln[R/(1-R)] = -2.59 + (0.087 x PS) + (0.013 x OS), where PS: Physiological Severity, OS: Operative Severity, R=predicted morbidity rate. We applied this equation prospectively to 26 patients who underwent gastrectomies in 2003. The figures for predicted morbidity and observed morbidity were 37.3% and 38.5% respectively, indicating that our modified equation predicted morbidity more accurately than the POSSUM.The POSSUM over-predicted the morbidity of patients who underwent gastrectomy. However, after creating a modified equation using data from retrospective analysis, a modified POSSUM was found to predict the prospective morbidity rate accurately.

In this study, we performed laparoscopy-assisted distal gastrectomy (LADG) and lymph node dissection with an incision of 3 cm aiming at radical cure and low invasiveness. We introduce and discuss this technique of minilaparotomy and recommend a device for anastomosis. In LADG, a skin incision of 5cm or greater is made in order to pull out the stomach in other institutes. Whether function is distinctly better after laparoscopy-assisted surgery than after abdominal section has not been elucidated so far, so we should seek an aesthetic advantage. We have used a 3-cm abdominal wound to date. If the wound is smaller than this, the body of the SDH25 cannot be inserted, and currently a wound less than 3cm may thus not be possible. The shaft of the SDH is straight, making it easy to confirm the direction even through a laparoscope. The shaft of the anvil head of the PPCEEA is too long, so that when it is connected with the body through the 3-cm incision, it is necessary to draw it through the remnant stomach to a great extent.

Japanese general rules for the staging of colorectal cancer conventionally classify lymph node metastasis into three groups according to location with respect to the primary tumor. Skip metastasis, in which distant nodes are positive but regional nodes are negative, is often encountered but poorly understood. We studied the clinicopathological features of skip metastasis in colorectal cancer.The location of positive nodes was classified in 323 patients with Dukes' stage C colorectal cancer. Skip n2 lymph node metastasis was defined as positive N2 metastasis without negative N1 or N3 metastasis. Clinicopathological findings and survival were compared between the patients with skip n2 metastasis (skip n2 group) and those with n1 (n1 group) or n2 metastasis (n2 group).There were 211 patients in the n1 group, 91 in the n2 group, and 21 in the skip n2 group. Pathological examination showed that the skip n2 group had fewer positive nodes than the n1 and n2 groups, but was positioned between these groups with respect to the degree of lymphatic invasion. Cumulative survival was significantly poorer in the n2 group than in the skip n2 group (p = 0.039 by log-rank test). Survival was similar in the skip n2 group and n1 group. There was also no difference in survival between patients in the skip n2 group and patients with one, two, or three N1 metastases.Lymph nodes with skip n2 metastasis are most likely sentinel nodes of the primary tumor in patients with colorectal cancer. The prognosis of patients with skip n2 metastasis is therefore better than that of patients with n2 metastasis and similar to that of patients with n1 metastasis.

It is important to clarify the predictive and prognostic factors for chemoradiotherapy (CRT) in patients with inoperable esophageal cancer.Forty-one patients with inoperable advanced esophageal cancer were evaluated. The predictive factors for the response to CRT (low-dose 5-FU and Cisplatin (FP) therapy plus 60 Gy of radiation) and the prognostic factors after CRT were analyzed.Of the 41 patients, seven achieved complete remission, 21 achieved partial remission, nine showed no change and four showed progressive disease. The median survival time was 19 months in patients with a tumor response, compared to 7 months in patients with non-responsive tumors. Only the serum cytokeratin (CYFRA) level independently predicted the responsiveness to treatment. In the multivariate analysis, the serum CYFRA level and the p53 gene mutation independently influenced prognosis.The presence of a p53 mutation in the biopsy specimen or a high serum CYFRA level may be predictive of an adverse therapeutic outcome.

Telomerase is a ribonucleoprotein enzyme that protects erosion of telomeres at the ends of chromosomes and its activity has been detected in immortalized cells and most human cancers.We analyzed telomerase activity in primary esophageal squamous cell carcinomas (SCCs) without any preoperative treatment and lesions unstained with Lugol's solution, using a telomeric repeat amplification protocol (a TRAP) assay.Strong telomerase activities were detected in all resected specimens of esophageal SCCs, and in 33 of 40 endoscopic biopsy specimens of lesions unstained with Lugol's solution. Among lesions unstained with Lugol's solution, 19 of 19 esophageal SCCs, and 13 of 13 dysplasias, which are considered as clinically precancerous lesions had strong telomerase activities.These results indicate that reactivation of telomerase may occur at an early stage in the carcinogenesis of esophageal SCCs, and telomerase activity may be a practically useful molecular biological marker for supporting the diagnosis of early esophageal SCCs.

A 59-year-old man was admitted to our hospital because his serum hepatobiliary enzymes were elevated on the medical check-up in September 2003. In his past history, he had undergone distal gastrectomy for a gastric adenoma 17 years before. Furthermore, he had undergone subtotal esophagectomy with remnant gastrectomy, the right colon and ileum were used for the reconstruction, and a cervical esophago-ileostomy and an abdominal colo-duodenostomy were made in the fashion of an interposition. Duodenoscopy was performed and showed the protruded lesion of the ampulla of Vater, biopsied specimens from this tumor revealed adenocarcinomas. Accordingly, we performed pancreaticoduodenectomy with regional lymph nodes dissection. The problem in this case was that the rt middle colic artery (MCA), and the middle colic vein (MCV) tend to be injured because these vessels are situated near the caudal region of the pancreas. We were able to identify the superior mesenteric vein (SMV) safely due to approaching this vein from the flank and mobilizing the duodenum, dissecting behind the mesenteric trunk from right to left. Double cancer of the ampulla of Vater and the esophagus are extremely rare, with only 4 cases reported. And we recommended the use of the dorsal approach to the SMV to avoid injuring the MCV such as in this case.

We describe a case of primary mesenteric embryonal carcinoma. The patient was a 73-year-old man who presented with a huge mass palpable at the right upper side of the abdomen. Laboratory evaluations showed very high alpha-fetoprotein and PIVKA-II levels, and an abdominal computed tomographic scan demonstrated a mass contiguous with the liver. These findings suggested hepatic cell carcinoma extending beyond the liver. However, angiography showed the mass to be supplied mainly by the middle colic artery and greater omentum artery, suggesting a mesenteric tumor. Gastroscopy demonstrated a IIc lesion in the anterior wall of the antrum. This lesion was histologically diagnosed to be moderately differentiated adenocarcinoma. The large tumor adjacent to the liver was diagnosed to be a primary mesenteric tumor or a metastatic mesenteric tumor from arising gastric cancer. At laparotomy, a huge tumor was found in the gastrocolic ligament. The tumor adhered to the distal part of stomach, the transverse colon, and the gallbladder. En-bloc resection of the tumor was performed, including the distal part of stomach, Part of the transverse colon, and the gall-bladder. The tumor mass measured 26.0 x 21.0 x 9.0 cm, weighted 2750 g, and showed central necrosis and hemorrhage. The histopathological diagnosis was a primary embryonal carcinoma originating in the mesentery. Primary mesenteric embryonal carcinoma is extremely rare. To our knowledge, no other cases have been reported. We describe this case and briefly discuss the related literature.

We previously investigated the effects of amoxicillin/omeprazole combined therapy on patients who were Helicobacter pylori (H. pylori) positive after gastrectomy for the treatment of gastric cancer, and we determined the difference in amoxicillin dosage between the therapeutic successes and failures. In the present study, assuming that amoxicillin dosage should be determined on the basis of body weight of each patient, we examined whether the eradication of H. pylori would be improved by using this novel dose-selection method.We have previously reported about eradication of H. pylori of remnant stomach as follows. Patients who underwent gastrectomy for the treatment of gastric cancer were enrolled if H. pylori was detected in their remnant stomach after the operation. Of these patients, 22 were treated with amoxicillin at 750 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks. For the evaluation of H. pylori eradication, endoscopic examination and 13C-urea breath test were performed 12 weeks after the initiation of the treatment. The amoxicillin dosage in the therapeutic successes was compared with that in the therapeutic failures, and we found that the dosage was 14.1 +/- 1.5 and 12.5 +/- 1.5 mg/kg/day in the successes and the failures, respectively. Following these results, another 10 H. pylori-positive patients were treated with amoxicillin greater than 16 mg/kg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks, and H. pylori eradication was evaluated as mentioned above. The efficacy of the drug therapy on H. pylori infection was compared between the two groups that one group (Group A) is treated with amoxicillin 750 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks and the other group (Group B) is treated with 1250 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks.The eradication rate of H. pylori in Group B (84.6%) was higher than that in Group A (42.1%). There was significant difference between the two groups (p = 0.028).We assumed that the optimal dosage of amoxicillin was over 15.6 mg/kg/day for omeprazole-amoxicillin combined therapy for gastrectomized patients who were H. pylori positive, and the favorable therapeutic effects could be obtained by applying this amoxicillin dosage to the eradication of H. pylori.

Platelet-derived endothelial cell growth factor (PD-ECGF) is one of the angiogenic factors. The aim of this study was to examine the PD-ECGF concentrations in hepatocellular carcinoma, background liver, and normal liver tissues, and to elucidate their significance on clinicopathological outcomes.The concentration of PD-ECGF in the tissue extract was determined by enzyme-linked immunosorbent assay.PD-ECGF concentrations were significantly higher in hepatocellular carcinoma and background liver tissues compared with normal control liver (p = 0.003, p = 0.001, respectively). PD-ECGF concentrations in hepatocellular carcinoma tissues were positively correlated with intratumoral arteriole densities (r = 0.667, p = 0.009), and were higher in less differentiated carcinomas (p = 0.039). However, tumor PD-ECGF concentration did not affect the patients' disease-free survival rates. Those in the background liver tissues were positively correlated with histological activity index scores (r = 0.650, p = 0.001) and serum alanine aminotransferase levels (r = 0.0452, p = 0.035).PD-ECGF is up-regulated in hepatocellular carcinoma and the corresponding hepatitis liver. The PD-ECGF concentrations in hepatocellular carcinoma correlated positively with microvessel density, lower differentiation, yet not with patients' prognosis. The concentrations of PD-ECGF in the corresponding hepatitis liver correlated positively with the degree of active hepatitis.

Minimally invasive surgery has been used to improve the quality of life after operation in patients with gastric cancer. Sentinel-lymphnode biopsy can help to limit the extent of lymph node dissection, but the diagnostic and therapeutic usefulness of this technique has not been accurately evaluated in gastric cancer. This study was designed to clarify the role of intraoperative sentinel-node biopsy in patients with gastric cancer.We were conducted to evaluate 1) mapping sentinel nodes according to tumor location 2) comparison sentinel node metastases as assessed by frozen section, permanent section (HE stain) and immunohistochemical diagnoses, and 3) comparison non-sentinel node metastases as assessed by permanent section (HE stain) and immunohistochemical diagnosis.All sentinel nodes were identified in the regional perigastric lymph node group close to the tumor. Four of the 43 sentinel lymph nodes were positive for metastasis. Similar diagnostic results were obtained by the 3 different procedures. Lymph node metastasis was found in 10 (4 sentinel nodes and 6 non-sentinel nodes) of 779 lymph nodes (1.28%) on HE staining. Immunohistochemical studies revealed a similar number of positive sentinel nodes as that obtained on HE staining, but identified metastases in 15 in non-sentinel nodes in 2 patients, as compared with only 6 nodes on HE staining. In one patient, sentinel nodes at No. 1 and No. 3 were negative for metastasis, whereas non-sentinel lymph nodes at NO. 3 were positive for metastasis. The other patient had negative sentinel nodes at No. 3 and No. 4d, but positive non-sentinel nodes at No. 4d.The results of this small study do not yet provide a firm basis for recommending that sentinel-node biopsy is used to reduce the extent of lymph node dissection.

To describe and discuss extended abdominoperineal resection with partial prostatectomy using the ultrasonic harmonic scalpel as an alternative to total pelvic exenteration in lower rectal T3 cancer contiguous with the prostate.Extended abdominoperineal resection with partial prostatectomy was performed in 4 patients with lower rectal clinical stage T3 cancer contiguous with the prostate using the ultrasonic harmonic scalpel. The ultrasonic harmonic scalpel permitted en bloc dissection of the rectum and the posterior part of the prostate, removing all tumor and disruption of the normal urinary stream.Blood loss ranged from 600 to 2500 mL. The final pathologic stage was T2 in 1, T3 in 2 and T4 in 1 patient, and the surgical margins were clear in all patients. Urethral injury occurred in 1 patient, and 2 patients had postoperative urinary dysfunction. No patients required a urinary stoma or suffered recurrence.Extended abdominoperineal resection with partial prostatectomy using the ultrasonic harmonic scalpel is an attractive alternative to total pelvic exenteration for patients with lower rectal T3 cancer contiguous with the prostate.

As endoscopic procedures become various and complicated, it becomes necessary to develop alternative techniques for tissue suture and ligation. We have developed a new suture technique intracorporeal knotting.An 8-cm suture material having a knot on the other side of a needle, was used in laparoscopic surgery. Furthermore, a 5-mm2 Vicryl mesh was pierced as a buttress. The Lapra-ty was used to secure the tissue. Under laparotomy, the forestomach of a male Donryu rat at 6 weeks of age was incised and sutured with 3-0 Vicryl. 3-0 Vicryl was secured with the knot substitute (group A) or three-throw knot (group B) under Nembutal anesthesia. The animals were sacrificed 7 days after operation. Specimens were taken from the forestomach. Those were fixed with 10% formalin and stained with hematoxylin eosin and Elastica Wangieson methods. The histological findings were compared between group A and group B. A successful laparoscopic closure using Lapra-ty is reported in a patient with a perforation of the sigmoid colon.Microscopically, in this method, neither erosion, ulcer nor microabscess is evidenced. This method may make an intracorporeal knot easy. Also we treated a patient who had a perforation of the sigmoid colon using Lapra-ty. The patient recovered without any trouble.This method could make ligation technique much easier and the operating time shorter.

This paper reports on buried bumper syndrome that is an early complication of percutaneous endoscopic gastrostomy. The patient, a 69-year-old woman with impaired conversation due to Alzheimer's disease, was unable to swallow safely. She had undergone percutaneous endoscopic gastrostomy in the standard manner, and it had allowed her to be cared for in her own home. The patient's family had followed the instructions accompanying the device without difficulty until 5 days before presentation, when they noticed leakage around the tube. On examination, the stoma site was reddish, and at endoscopy, we were unable to confirm the internal bumper. Instead, there was a raised mound and a central small round concave area of gastric mucosa without ulceration and edema. Fluid under pressure could not be injected through the percutaneous endoscopic gastrostomy tube. The internal bumper had become embedded in the anterior abdominal wall. In this case, the first percutaneous endoscopic gastrostomy was removed with incision of abdominal wall under local anesthesia for a short period, and a second percutaneous endoscopic gastrostomy was created, without difficulty. Therefore, we should take greater care when we carry out percutaneous endoscopic gastrostomy in patients with dementia and without paralysis of the upper extremities.