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A recent increase in the number of surgeries performed on obese patents has raised several issues. In this study, we examined the effects of obesity on laparoscopic and open distal gastrectomy.A total of 262 patients with gastric cancer (cStage I) who underwent distal gastrectomy were classified into open distal gastrectomy (ODG) (145 patients) and laparoscopic distal gastrectomy (LDG) (117 patients) groups. According to their body mass index (BMI), they were subdivided into obese (BMI ≥ 25) and non-obese patients (BMI25) to examine the duration of surgery, blood loss, the number of lymph node dissections, postoperative hospital stay, and incidence of postoperative complications.The duration of surgery was longer and blood loss was higher for obese patients than for non-obese patients in both groups. The results for these two endpoints were significantly reduced in the LDG group than in the ODG group both in obese and non-obese patients. Furthermore, the number of lymph nodes dissected tended to be higher in the LDG group than in the ODG group in obese patients. Postoperative hospital stay was not significantly different between obese and non-obese patients in both groups, but was significantly shorter in the LDG group than in the ODG group regardless of the body weight. The incidence of postoperative complications was significantly higher in obese patients than in non-obese patients, although the difference between the groups was not significant.These findings indicate that LDG may be useful for obese patients with cStage I gastric cancer.

Since 2005, we have been conducting prospective surgical site infection (SSI) surveillance and infection control according to the U.S. Centers for Disease Control and Prevention guidelines for patients who undergo gastrointestinal surgery at our institution. Surgical site infection occurs with greater frequency in emergency than in elective surgery because of factors such as ill-conceived preoperative preparation and "dirty" operations. A large number of studies have been reported on risk factors for SSI in elective colorectal surgery; however, there are few papers on such factors in emergency colorectal surgery. The aim of this study was to identify risk factors for incisional SSI in emergency colorectal surgery.Using our SSI surveillance database, we analyzed retrospectively 78 patients who underwent emergency colorectal surgery between 2005 and 2010. Univariable and multivariable analyses were used to identify risk factors for incisional SSI. Moreover, we subclassified dirty-infected operations (class IV) by the extent of contamination according to our own definition to study the incidence of incisional SSI at each degree.The incidence of incisional SSI was 32.1% (25/78 patients). By univariable analysis, seven parameters correlated with a higher risk of incisional SSI: Surgical incision class III-IV, obesity (body mass index ≥25 kg/m(2)), American Society of Anesthesiologists score 3 or 4 points, chronic kidney disease (serum creatinine concentration1.2 mg/dL), blood loss ≥200 mL, blood transfusion, and ventilator support. Multivariable analyses showed that surgical incision class III-IV (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.7, 25.2) and obesity (OR 11.9; 95% CI 2.1, 87.8) were independent risk factors for incisional SSI. The incidence of incisional SSI in colon perforation with generalized contamination was statistically higher than that in prepared colon perforation and colon perforation with localized contamination (82.4% vs. 25.0%; p0.001).The risk factors for incisional SSI in emergency colorectal surgery were incision contamination and obesity. Moreover, the incidence of incisional SSI among the incision class IV operations increased significantly with increasing extents of contamination. As a tactic for management of dirty abdominal wounds, we suggest that primary skin closure is suitable in cases of perforation of a prepared colon or colon perforation with localized contamination. On the other hand, in cases of colon perforation with generalized contamination, delayed primary skin closure or leaving an incision open to heal by secondary intention should be considered.

Laparoscopy-assisted distal gastrectomy (LADG) has been widely used to treat early gastric cancer (EGC). The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system predicts the risk of fatal postoperative complications by quantifying the patient’s reserve and degree of surgical stress, but there have been a few reports of use of the E-PASS scoring system to assess the risk of mortality following special types of surgical procedures such as LADG. In this study we assessed the feasibility of LADG versus open distal gastrectomy (ODG) by the E-PASS scoring system. The subjects of this study consisted of 69 stage IA gastric cancer patients who underwent LADG (LADG group) and 69 stage IA gastric cancer patients who underwent ODG (ODG group). The mean age of the patients in the LADG group was 68.6 years, which was significantly higher than the mean age of 63.4 years in the ODG group. There were no statistically significant differences between the groups in operation time or preoperative risk score, but there were statistically significant differences in blood loss, surgical stress score, comprehensive risk score, and duration of postoperative hospital stay. We conclude that using the E-PASS scoring system, LADG appreciates a more beneficial procedure for the treatment of EGC than ODG.

True splenic cysts are uncommon and are associated with elevated serum and intracystic tumor marker CA 19‑9 levels. A 33‑year‑old woman presented to our hospital with a chief complaint of epigastralgia. Computed tomography of the abdomen showed a 10‑cm cystic lesion in the spleen. The serum carbohydrate antigen (CA 19‑9 level was 3347 U mL (normal

Summary Background Spontaneous perforation of the extrahepatic bile duct is very rare. We report a patient with a spontaneous perforation of the left hepatic bile duct who was diagnosed preoperatively. Case Report A 65-year-old woman was admitted to our hospital complaining of a right upper quadrant pain lasting for two days. She was diagnosed as having a perforated bile duct and peritonitis and underwent a laparotomy. After a cholecystectomy, T-tube drainage of the left hepatic duct was performed. The postoperative course was uneventful. The T tube was removed 25 days after the surgery. Conclusions A more noninvasive procedure, such as endoscopic treatment, should play a central role in the management of extra bile duct perforation. For this case, however, we chose to perform a laparotomy based on the patient’s general condition and the presence of peritonitis. T tube decompression is effective and a safe and reliable method. The goal of treatment is to stop the bile leakage, resolve the choledocholithiasis and cholangitis, and reconstruct the bile duct.

An 80-year-old man presented at our hospital with chest oppression and vomiting. An endoscopic examination revealed a tumor in the lower portion of the esophagus, and the patient was diagnosed as possibly having esophageal carcinosarcoma based on a histological examination of endoscopic biopsy specimens. During the initial medical examination, the patient had a high leukocyte count and a high level of serum granulocyte-colony stimulating factor (G-CSF). Moreover, immunohistochemical examination revealed cells that were positive for antibodies against G-CSF. Therefore, we diagnosed the patient as possibly having a G-CSF-producing esophageal carcinosarcoma. The patient died of tumor 4 months after the initial diagnosis.

Chemosensitivity tests have long been discussed but remain a topic of research. In this study, we investigated the correlation between the results of a chemosensitivity test for 5-fluorouracil and 5-chloro-2, 4-dihydroxypyridine and the clinical outcomes of gastric cancer patients treated with S-1, an oral fluoropyrimidine, as adjuvant chemotherapy.For gastric cancer patients, we performed surgical treatment and a lymph node dissection of D2 or more. Afterwards, a chemosensitivity test for 5-fluorouracil and 5-chloro-2, 4-dihydroxypyridine was performed, using the collagen gel droplet embedded culture drug-sensitivity test (CD-DST), in surgical specimens. All the patients received postoperative adjuvant chemotherapy with S-1 for 1 year, and the overall survival (OS), relapse-free survival (RFS), and adverse events were investigated.The chemosensitivity test was performed for 27 patients. The growth inhibition rate (IR) was 50% or more (high-sensitivity group) in 59.3% (16 cases) and it was under 50% (low-sensitivity group) in 40.7% (11 cases). The 3-year OS rate was 100% in the high-sensitivity group and 62.34% in the low-sensitivity group. The 3-year RFS rate was 83.33% in the high-sensitivity group and 24.24% in the low-sensitivity group. Thus, the 3-year OS rate and the 3-year RFS rate were higher in the high-sensitivity group than in the low-sensitivity group. No adverse events of grade 3 or greater severity were observed.The results of the chemosensitivity test were correlated with the patient outcome. Therefore, such results might be useful for individualizing cancer chemotherapy and for determining future indications for postoperative adjuvant chemotherapy.

Malignant fibrous histiocytoma of the liver is an extremely rare tumor. A 43-year-old woman was admitted with an enlargement of the abdomen and a feeling of general fatigue. A clinical examination revealed a right liver giant cystic tumor (18.5 × 22 cm). The cystic tumor, which contained a solid component, occupied almost the entire right lobe of the liver, and a solid S4 tumor was also observed. A blood examination revealed severe anemia and mild liver dysfunction. During hospitalization intratumor bleeding occurred. A right lobectomy of the liver and lymph node dissection was performed after transcatheter arterial embolization. Histopathologically, the tumor was diagnosed as a primary storiform-pleomorphic-type malignant fibrous histiocytoma of the liver. One year after the radical operation, the patient developed recurrences in other organs. She received 17 cycles of chemotherapy with etoposide, ifosfamide, and cisplatin. The recurrent tumors decreased in size, but new recurrences in other organs occurred. The patient died of respiratory failure 4 years and 2 months after the initial operation.

Large vessel invasion is a serious factor determining whether an operation for pancreatic body cancer is feasible. The Appleby operation is a radical operation for the treatment of pancreatic body cancer that has infiltrated the celiac axis. Since this procedure includes a total gastrectomy, the operation is associated with a high morbidity, mortality, and deteriorating postoperative quality of life (QOL). We experienced two cases in which radical operations consisting of a stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric artery were performed. The use of adjuvant chemotherapy in these cases led to a good postoperative QOL.

We report on two patients with gastric tumors (early cancer and adema) and diabetes mellitus who were treated with argon plasma coagulation (APC) therapy. Case 1. A 78-year-old woman visited the Nippon Medical School Musashi Kosugi Hospital because of epigastric pain. An early gastric cancer (IIc) in the anterior wall of the gastric antrum was diagnosed on the basis of the results of a gastric endoscopy examination. The patient had had diabetes mellitus for 18 years and had injected insulin (NovoRapid 30 Mix, 72 units/day) by herself everyday for 10 years. Case 2. A 61-year-old man was referred to our hospital because of a gastric tumor. A gastric adenoma in the anterior of the gastric antrum was diagnosed on the basis of the results of a gastric endoscopy examination. The patient had had diabetes mellitus for 12 years and had been taking oral medication for 2 years. Endoscopic APC was performed in both patients to remove the gastric tumors. These patients have been well for 28 months and 30 months, respectively, after undergoing APC treatment. APC therapy appears to be a safe and useful treatment for patients with diabetes and gastric mucosal lesions.

We conducted a clinicopathological study of cases of gastric carcinoma with pyloric stenosis and examined treatment outcomes and the prognosis of cases of stage IV gastric carcinoma with pyloric stenosis and the validity of gastrectomy as palliative surgery in these cases. The outcomes of 49 surgeries for gastric carcinoma with pyloric stenosis were compared with those of 671 surgeries for gastric carcinoma without pyloric stenosis. The diagnosis of pyloric stenosis was confirmed with both upper gastrointestinal endoscopy and an upper gastrointestinal barium series. The frequency of pyloric stenosis in patients with gastric carcinoma was 7.3%. Serosal invasion was observed in about 70% of all cases. Of these cases, 53.1% were classified as stage IV. The resection rate was 73.5%, and the resection was classified as curative in 44.9% of cases. The incidence of complications after surgery in cases of stage IV gastric carcinoma was 47.1%. The median survival time was significantly greater in patients undergoing resection group than in those not undergoing resection (p=0.025). Most patients with gastric cancer and pyloric stenosis can be considered to have stage IV disease, which is associated with high rates of morbidity and mortality; thus, prevention of complications, and therefore, avoidance of gastrectomy is recommended in such patients. Nonetheless, in this study, gastrectomy was shown to improve prognoses in these patients.