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Although indocyanine green (ICG) fluorescence imaging has been reported to be useful for assessing colorectal perfusion, unstable quantification remains an issue. We performed ICG fluorescence observation from the luminal side and examined the usefulness of the transanal approach. A total of 69 patients who underwent left-side colon surgery were enrolled in this cohort study. After the anastomosis had been constructed, ICG 0.2 mg/kg was injected intravenously. The anastomotic site was then observed by a scope inserted transanally. The following items were examined in the areas of the anastomotic site with the highest- and lowest-fluorescence intensity: maximum fluorescence (Fmax), time from ICG injection to Fmax (Tmax), time from start of dyeing to Fmax (ΔT), and the contrast pattern of the mucosa. Anastomotic leakage (AL) occurred in nine cases. Tmax and ΔT values of the lowest-fluorescence area in the distal intestine showed significant differences in the cases with AL (P = 0.015 and P = 0.040, respectively). Regarding the contrast pattern of the mucosa of the lowest-fluorescence area in the proximal and distal intestine, the patients in whom the vessels were not depicted in the area had a significantly higher incidence of AL than those in whom vessels were depicted in the area (P = 0.031 and P = 0.030, respectively). Some of the areas in which vessels were not depicted by ICG fluorescence observation from the luminal side corresponded to the points of leakage. There were heterogeneous changes that might not be grasped by observation from the serosal side. Transanal ICG fluorescence imaging can evaluate perfusion over the entire circumference of the anastomosis in detail and aid in assessing the risk of AL. Therefore, the examination of the detailed low-perfusion area enables us to take measures for AL and to search for safer operative managements.

A 65-year-old man with cT1bN0M0 stage I middle thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the posterior mediastinal route after preoperative carbon-ion radiotherapy and chemotherapy in a clinical trial. Anastomotic leakage occurred, but it spontaneously improved. At six months after the operation, he was rehospitalized with a cough and dysphagia. An esophago-bronchiole fistula and stenosis of the gastric tube were observed. He first underwent stent placement in the gastric tube. Two weeks later, the syringeal epithelium was burned by argon plasma coagulation after stent removal. Endoscopic occlusion was then performed for the fistula with two guidewire-assisted silicone spigots. Two weeks later, he was discharged on an oral diet, and he has not developed recurrence of the fistula or cancer for three years. This is the first report of endoscopic occlusion with a guidewire-assisted silicone spigot through the esophagus.

This is a retrospective study to evaluate the prevention of complications of metallic stent placement in patients with unresectable advanced esophageal cancer. A total of 87 patients were treated with 4 types of metal stents in the esophagus over a period of 18 years. Stent placement was technically successful. The most common prior treatment was chemoradiotherapy. There were no significant differences in the rate of patients with no complications among the prior treatments. Approximately, 30% of patients had the most common chest pain in complications. Stent placement within one month after the completion of chemoradiotherapy should be avoided for the prevention of the chest pain. There was no significant difference in the rate of patients with no complications by lesion location. The rate of no complications was higher for the Niti-S stent than the Gianturco Z-stent or Ultraflex stent. Of note, no complications were noted for the Niti-S ultrathin stent at all. Among cases of stent-related death, the most common type of complication was respiratory disorder caused by the stent that seems to be thick and hard. Therefore, the stent with thin and flexible characteristics like the Niti-S ultrathin stent will solve the various problems of esophageal stent placement.

Background and aims EUS-guided FNA biopsy has been widely performed to aid in the diagnosis of submucosal tumors (SMTs). However, in cases of small tumors, the diagnostic yield of EUS-FNA is poor. Therefore, it is necessary to develop a new needle for the diagnosis. We developed a device with a new mechanism that we refer to as a drill needle aspiration biopsy (DNAB). The aim of this study was to evaluate the use of DNAB in resected gastric SMT specimens. Methods A drill needle with a sharp tip and wide ditch was inserted into a catheter for angiography. Continuous suction is enabled through the catheter at the tip. DNAB was performed with one pass and one stroke in 13 gastric SMTs resected by operation. Similarly, FNA was performed by one pass and ten strokes. These gastric tumors included nine diagnosed gastrointestinal stromal tumors and four undiagnosed SMTs by preoperative examinations. The tissue quantity between DNAB and FNA was macroscopically and microscopically examined. Results All 13 drill biopsy specimens were obtained. Additionally, all 13 gastric SMTs, including 4 undiagnosed tumors, could be diagnosed by DNAB. The quantity of each specimen obtained by DNAB was macroscopically and microscopically much greater than that by FNA. In particular, for tumors

Background We performed endoscopic ultrasound real-time tissue elastography to more accurately diagnose lymph node metastasis of esophageal cancer. The aim of this study was to evaluate the ability of EUS elastography to distinguish benign from malignant lymph nodes in esophageal cancer patients. Methods The present study had two steps. As the first step (study 1), we developed diagnostic criteria for metastatic lymph nodes using elastography and verified the validity of the criteria. Three hundred and twenty-two lymph nodes from 35 patients treated by surgical resection were included in the study. As the second step (study 2), we preoperatively examined the lymph nodes of esophageal cancer patients with EUS elastography and compared its diagnostic performance with that of the conventional B-mode EUS images. A total of 115 lymph nodes from 31 patients were included. Results In study 1, lymph nodes were considered malignant if 50 % or more of the node appeared blue, or if the peripheral part of the lesion was blue and the central part was red/yellow/green. The sensitivity and specificity of the elastography were 79.7 and 97.6 % with an accuracy of 93.8 %, which was significantly higher than the values for conventional B-mode imaging. In study 2, the sensitivity and specificity of the EUS elastography were 91.2 and 94.5 % with an accuracy of 93.9 %, which was also significantly higher than the values for conventional B-mode EUS imaging. Conclusions The present study demonstrated that EUS elastography is useful for diagnosing lymph node metastasis of esophageal cancer.

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic–enteric anastomosis. Laparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012. According to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not. Dunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.

A 62-year-old man underwent subtotal esophagectomy with an extended three-field lymph node dissection for squamous cell carcinoma of the lower thoracic esophagus (histological stage pT3N1M0, pStage III). Computed tomography showed a swollen paraaortic lymph node about 6 years later. Positron emission tomography also indicated lymph node metastasis. The patient was treated with surgery, and the lymph node was diagnosed to be metastasis of esophageal cancer. Surgery was followed by chemotherapy with nedaplatin and 5-fluorouracil. The patient has remained alive more than 5 years after surgery without any evidence of recurrence. Although the optimal treatment for the recurrence region of esophageal cancer remains controversial, the current case suggests the possibility of performing a salvage resection for a lymph node recurrence of esophageal cancer in selected patients.

目的:近年においては重症急性膵炎（severe acute pancreatitis:以下SAP）に対する外科治療は稀と考えられるが，一定の条件を満たす症例においてはその選択を余儀なくされる．今回，外科的治療を要したSAP症例についてその臨床的検討を行った．方法:2008年1月から2010年12月までにSAPと診断され開腹手術を要した7例につき検討を行った．結果:症例の平均年齢59歳，男性6例・女性1例，成因はアルコール3例，特発性2例，胆石，腹部外傷1例，前治療として5例に動注療法が施行されていた．手術までの期間が100日を越える症例が5例，術式は5例で膵体尾部切除が行われていた．1例が術後に播種性血管内凝固症候群をきたし死亡，6例は軽快退院となった．結論:現在，SAPに対する手術適応は非常に限られたものとなったが，保存的治療に対し改善が得られない症例を中心に手術の選択を余儀なくされる症例が依然存在するものと考えられた．

症例は70歳代後半の男性．検診で胃癌が発見され，術前の上部消化管内視鏡検査にて体上部2カ所と幽門部の計3カ所に多発する分化型早期胃癌の診断となり，胃全摘術を施行した．病理組織学的検索にて，術前診断し得なかった2病変を含む5カ所の多発早期胃癌を認めた．全て分化型の粘膜癌で転移はなくfT1N0H0P0CY0M0のfStageIaであった．さらに，粘膜下層から漿膜下層に日本住血吸虫卵が散在し，癌周囲で虫卵数が多い傾向を認めた．一方，背景胃粘膜に萎縮や腸上皮化生変化は少なかったが，免疫染色の結果から腫瘍胃粘膜は腸型形質を有していた．術後3年健在で，再発の兆候を認めない．全て分化型の同時性多発胃粘膜癌は極めてまれである．本症例は腸上皮化生を背景とせず，日本住血吸虫卵の存在が発癌に関与した腸型の多発早期胃癌の可能性が考えられる．稀少性とともに胃発癌機序解明の点からも貴重な症例と思われ，若干の文献的考察を加えて報告する．

症例は72歳，男性．下血・腹部膨満感を主訴に受診．下部内視鏡検査で直腸癌が強く疑われ，下血が著明となり入院となった．入院後，急速な全身状態の悪化と内視鏡検査像の変化により壊死性腸炎の診断のもと緊急手術施行．左半結腸全体が融解壊死を起こしていたため，腹会陰式直腸切断+左半結腸切除術を施行した．術前の内視鏡生検結果で赤痢アメーバ原虫（栄養型）を認めたため，術後第1病日目，劇症型腸アメーバ症の診断となった．診断直後よりメトロニダゾールの投与を開始し救命しえた．劇症型腸アメーバ症につき文献的検討を行い，時期を逸しない薬剤治療の開始が救命治療の鍵となると考えられた．

Alimentary tract duplication is a rare congenital malformation but can occur anywhere along the digestive tract. Most patients become symptomatic in early childhood, and only a few cases of adult patients have been reported in the literature. We herein report a unique case of a giant ileal duplication in an adult, which was successfully treated with laparoscope-assisted surgery. A 60-year-old male was admitted because of abdominal pain. Imaging studies revealed a well-defined cystic mass, measuring 15 cm, in the ileocecal region. We diagnosed it as a duplicated ileum and performed laparoscope-assisted surgery. The duplication was successfully resected with attached normal ileum, and there were no major complications in the postoperative course.

Methods to detect metastases in biopsy specimens with certain rapidity and accuracy are essential to performing tailor-made surgeries for solid malignancies. Reverse transcription loop-mediated isothermal amplification (RT-LAMP) reaction is a novel technique for detecting mRNA expression of target sequences with high sensitivity and rapidity, even from crude samples without RNA purification. Applicability to detect lymph node (LN) micrometastasis of gastric cancer was tested. Total of 26 LNs were retrieved from 10 patients with primary gastric cancer. Each LN was serially sectioned, and every set of three serial sections were tested for routine histopathological (H&E) and immunohistochemical examination with anti-cytokeratin antibodies (IHC), and RT-LAMP analysis targeted cytokeratin 19 mRNA. Results from H&E/IHC and RT-LAMP analysis were compared in each set of sections. All the sections of those containing metastatic lesions equivalent to a volume of overt metastasis (maximum diameter>2 mm), 90% of those containing micrometastasis (between 2 and 0.2 mm) and 83% of those containing isolated tumor cells (

Although endoscopic submucosal dissection (ESD) for patients with gastric tumors under the conditions of unconsciousness is considered to be minimally invasive, no objective assessment of the perioperative stress of ESD has yet been conducted. Today, stress levels can be easily and objectively assessed by monitoring salivary amylase activity (sAMY). We evaluated the perioperative changes in the sAMY in patients undergoing ESD and identified the causes of such changes. A total of 40 patients with gastric cancers/adenomas removed by ESD under general anesthesia (GA; n = 20) and under deep sedation (DS; n = 20) were enrolled. sAMY was measured using the enzyme analysis equipment, sAMY Monitor (NIPRO, Osaka, Japan) during the perioperative period of the ESD. Also, all patients were interviewed to determine their subjective stress level, using a questionnaire asking “How did you feel during ESD?”, with the choice of responses ranging from “did not wake up at all” to “I was awake and ESD was extremely stressful”. The sAMY of the DS group increased soon after the start of ESD. Meanwhile, that of the GA group decreased just after the ESD started and was maintained at a stable level throughout the ESD. In response to the stress level questionnaire, all of the patients in the GA group and a majority of the patients in the DS group responded, “did not wake up at all”. Sympathetic agitation, expressed as an increase of sAMY, was absent in the GA group. Meanwhile, in the DS group, some patients showed high levels of sAMY which went down following the administration of an analgesic agent, thus suggesting that pain caused an elevation in the level of the stress and thereby induced an increase in sAMY. The measurement of sAMY is therefore considered to be useful for the assessment of analgesic status under DS.

The prognosis of patients with alpha-fetoprotein (AFP)-producing pancreatic cancer is generally very poor. We, however, present a case of a 33-year-old man who survived AFP-producing pancreatic cancer and its metachronous liver metastasis. The patient had undergone a curative total pancreatectomy for AFP-producing pancreas head cancer invading to the tail, which was postoperatively confirmed by immunohistochemical staining of the resected specimen. At 1 year and 4 months after the operation, the serum AFP level was elevated to 26 ng/mL, and a 2.6 cm-sized mass was found in the lateral segment of the liver. He underwent lateral segmentectomy, and the tumor was histopathologically diagnosed as having metastasized from the AFP-producing pancreatic cancer removed earlier. The patient is doing well 8 years and 5 months after resecting the liver metastasis, with no signs of recurrence. This case suggests that surgery may also be a treatment of choice for patients with liver metastasis from AFP-producing pancreatic cancer, particularly for those with a metachronous and solitary tumor. It should be remembered that some pancreatic cancers produce AFP and that monitoring of postoperative serum AFP levels in such cases will be useful for early detection of recurrence and selection of appropriate surgical intervention.

The use of minimally invasive surgery has become widely accepted in many gastrointestinal fields, even in patients with malignancy. However, performing laparoscopic resection for the treatment of hilar cholangiocarcinoma is still not universally accepted as an alternative approach to open surgery, and only a limited number of such procedures have been reported due to the difficulty of performing oncologic resection and the lack of consensus regarding the adequacy of this approach. Laparoscopy was initially limited to staging, biopsy and palliation. Recent technological developments and improvements in endoscopic procedures have greatly expanded the applications of laparoscopic liver resection and lymphadenectomy, and some reports have described the use of laparoscopic or robot-assisted laparoscopic resection for hilar cholangiocarcinoma as being feasible and safe in highly selected cases, with the ability to obtain an adequate surgical margin. However, the benefits of major laparoscopic surgery have yet to be conclusively proven, and carefully selecting patients is essential for successfully performing this procedure.