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Aim Severe postoperative pleural effusion (sPOPE) after hepatectomy can lead to respiratory distress and may require thoracic drainage, leading to prolonged hospitalization. Preventive chest tube insertion may be useful for patients at high risk for sPOPE. We aimed to develop a predictive model for sPOPE after hepatectomy and evaluate indications for preventive chest tube insertion using our model. Methods We evaluated all patients who underwent hepatectomy from 2013 to 2020. Risk factors for sPOPE were used to develop a predictive model for sPOPE, which was validated in a cohort that received preventative chest tube placement postoperatively. Results A total of 325 patients were analyzed. Thirty‐one (9.5%) patients had a preventive chest tube placed at the end of their operation. Twenty‐one patients out of the remaining 294 patients developed sPOPE. Multivariate analysis identified resection containing segment 8 [relative risk (RR) 3.24, P = .022], intraoperative bleeding ≥ 500 g (RR 4.02, P = .008), intraoperative diaphragmatic incision (RR 6.96, P = .042) and open hepatectomy (RR 7.51, P = .016) as independently associated with sPOPE. The estimated probability of sPOPE ranged from 0.4% in patients with none of these factors to 73.4% in the presence of all factors. Among the 31 patients who received a preventive chest tube, more patients in the high‐risk group defined by the model had postoperative pleural effusions compared to the low‐risk group (P = .012). Conclusion Our predictive model for sPOPE using four risk factors allows for reliable prediction and may be useful for selection of preventive chest tube in patients undergoing hepatectomy., We established a predictive model for severe posthepatectomy pleural effusion (sPOPE). Our predictive model of sPOPE using four risk factors allows for reliable prediction and may be useful for selection of preventive chest tube in patients undergoing hepatectomy.

Highlights • Neuroendocrine carcinoma of the esophagus is a rare and highly aggressive disease. • A case of large-cell neuroendocrine carcinoma of the esophagus in a 73-year-old male patient with aggressive surgical treatment. • We performed subtotal esophagectomy, partial hepatectomy, radiotherapy and chemotherapy using cisplatin and irinotecan. • We believe that aggressive treatment can become one treatment option with the aim of extending survival., Introduction Neuroendocrine carcinoma of the esophagus is a rare and highly aggressive disease, and the biological features are poorly understood. Presentation of case We report a case of large-cell neuroendocrine carcinoma of the esophagus in a 73-year-old male patient with aggressive surgical treatment. Upper gastrointestinal endoscopy revealed an esophageal large mass. Histological examination of biopsy specimens indicated a neuroendocrine carcinoma. First, we performed subtotal esophagectomy with lymphadenectomy, but he experienced metastasis at the liver and rib 5 months later. Next, we performed partial hepatectomy and radiotherapy for rib metastasis, but he experienced metastasis at the left pulmonary hilar lymph node and sacral bone. Finally, we performed chemotherapy using cisplatin and irinotecan. Discussion The therapeutic strategy for large-cell NEC of the esophagus is unestablished. Thus, accumulating the therapeutic results garnered from various treatment tools is considerably important. Conclusion Aggressive multimodal treatments including surgery have a possibility to gain better survival in patients with large-cell NEC of the esophagus.

Background Subtotal cholecystectomy in patients with severe acute cholecystitis is considered a “bailout” option when the safety of the bile duct cannot be guaranteed. However, subtotal cholecystectomy has a long-term risk of remnant cholecystitis. The appropriate management of remnant cholecystitis has not been fully elucidated. Case presentation Case 1 was a 66-year-old man who had undergone subtotal cholecystectomy 14 years prior to the development of remnant cholecystitis. We first performed endoscopic gallbladder drainage to minimize inflammation, and then proceeded with elective surgery. We performed a reconstituting procedure for the residual gallbladder due to significant adhesions between the cystic and common bile ducts. Case 2 was a 56-year-old man who had undergone subtotal cholecystectomy for abscess-forming perforated cholecystitis 2 years prior to the development of remnant cholecystitis. He underwent endoscopic drainage followed by complete remnant cholecystectomy 4 months later. Conclusion Endoscopic gallbladder drainage is a useful strategy to improve inflammation and reduce the risk of bile duct injury during remnant cholecystectomy.

To investigate the factors predictive of anastomotic leakage in patients undergoing elective right-sided colectomy. The subjects of this retrospective study were 247 patients who underwent elective right hemicolectomy or ileocecal resection with ileocolic anastomosis between April 2012 and March 2019, at our institution. Anastomotic leakage occurred in 9 of the 247 patients (3.6%) and was diagnosed on median postoperative day (POD) 7 (range POD 3–12). There were no significant differences in the background factors or preoperative laboratory data between the patients with anastomotic leakage (anastomotic leakage group) and those without anastomotic leakage (no anastomotic leakage group). Open surgery was significantly more common than laparoscopic surgery (P = 0.027), and end-to-side anastomosis was less common (P = 0.025) in the anastomotic leakage group. The C-reactive protein (CRP) level in the anastomotic leakage group was higher than that in the no anastomotic leakage group on PODs 3 (P

Aim Surgical‐site infections (SSIs) often occur after surgery for colorectal perforation. We introduced delayed primary closure (DPC) after intrawound continuous negative pressure and irrigation treatment (IW‐CONPIT) to prevent SSIs. We aimed to evaluate the efficacy of DPC after IW‐CONPIT compared with primary closure (PC) after surgery for colorectal perforation. Methods We undertook a retrospective study including 22 patients who underwent DPC (DPC group) and 18 patients who underwent PC (PC group) at our hospital between April 2015 and January 2017. The primary outcome was the SSI rate. The secondary outcomes were other complications (, We undertook a logistic regression analysis to determine predictors of surgical‐site infections. In the univariate analysis, the amount of incisional wound irrigation ≥1,000 nonbreakingspace mL (odds ratio 0.14; 95% confidence interval, 0.03–0.58) and delayed primary closure (odds ratio 0.04; 95% confidence interval, 0.002–0.25) were significant factors.

A 72-year-old woman was referred to our hospital with the diagnosis of peritonitis due to the rupture of a huge abdominal cystic tumor, 27 cm in diameter. Abdominal computed tomography 14 years before revealed the tumor, which was 18 cm in diameter. She had undergone no examinations or treatment in the interim. She was in shock upon presentation to our hospital. She was intubated immediately and underwent an emergent laparotomy. The huge ruptured tumor with adherent small intestine was resected. The tumor weighed 6 kg and consisted of solid and cystic components filled with 4 kg of brown feces-like fluid. Bacteroides fragilis was detected in a fluid specimen. The cystic component of the tumor was filled with old blood clots, and a portion of the tumor wall was highly calcified. Old blood and fibrin with blood vessels of various sizes inside the tumor were observed during the pathologic evaluation; there were no malignant features. The final pathologic diagnosis was a chronic expanding hematoma (CEH). The patient had an uneventful recovery and was discharged 16 days post-operatively. She was involved in a traffic accident approximately 30 years before the current hospital admission; however, she did not recall if she had abdominal pain at that time. A CEH is a benign lesion, but rupture of a CEH can be life-threatening.

A 92-year-old Japanese woman presented with a mass in the left breast, and sparganosis was suspected by biopsy of the mass. The mass disappeared once, but it reappeared at the same site one year later. For a definitive diagnosis, the mass was surgically removed, and a sparganum-like worm was detected. The causative agent was confirmed as Spirometra Type I (most probably Spirometra mansoni) by mitochondrial DNA analysis. The serological examination also proved the case as sparganosis. Considering the presence of two Spirometra species (Type I and II) in Asia, particularly Japan, molecular analysis of the causative agents is highly recommended to understand the epidemiology, infection sources, and pathogenicity in humans in both species, if the parasite specimens are available.

A 37-year-old Nepalese man was admitted to Showa University Hospital because of a loss of consciousness and seizures. He had lived in Nepal, Qatar, Singapore, and India before the age of 34 years. He had no history of having eaten raw pork. His physical findings were normal excluding an abnormal visual field, and a positive serum antibody test result for Taenia solium, CT and MRI examinations showed multiple nodular lesions in his brain and thigh. We resected a cyst from his left thigh and diagnosed him as having cysticercosis based on the presence of characteristic hooklets and suckers on a pathological examination. Later, the Asian type of Cysticercus cellulosa was identified using a mitochondrial DNA test. Albendazole (800 mg/day) and prednisolone (60 mg/day) were administered for 14 days. All cysticercus were smaller on Day7 and had almost disappeared on Day 14. No adverse effects from the treatment occurred. Cysticercosis is rare in Japan, and cases requiring treatment for a large number of cysticercus in the brain and thigh are rare. We report a case of neurocysticercosis that had a good clinical course.

症例は74歳の女性で，肝浸潤を伴う胃癌にて胃全摘＋肝外側区域切除を施行した．第1病日，突然頻脈と呼吸促拍が出現し，胸痛はないものの胸部違和感を訴えた．トロポニンTとbrain natriuretic peptide（以下，BNP）は上昇を示したが，心筋逸脱酵素は正常であった．胸部写真で心拡大と，心電図の前胸部誘導でST上昇を認めた．心エコーで心基部の過収縮と，広範囲の壁運動低下を認め，蛸壺様の特徴的な所見からたこつぼ型心筋症と診断した．第6病日，著明な低酸素血症とショック状態となり人工呼吸管理を要した．胸部写真でうっ血と肺炎像を認め，肺炎による増悪が考えられた．肺炎の改善につれ全身状態は改善し，術後3週間で左室壁運動も正常化した．たこつぼ型心筋症は非心臓疾患が誘因となり手術以外でも麻酔，内視鏡検査，その他外科的処置などで発症するとされ，外科医が日常臨床の身近なところで経験する疾患であるとの認識が重要であると考えられた．

1996年から2006年に当院で行った早期胃癌に対する噴門側胃切除後の食道残胃吻合法22例（EG群）と，空腸嚢間置法14例（JPI群）を対象とし比較検討した．手術時間はEG群が有意に短く（EG群:JPI群=133分:161分），出血量，術後在院日数は両群で有意差はなかった．縫合不全，狭窄，膵炎，腸閉塞，肺炎等の術後合併症や，胸やけ，つかえ感，嘔吐，下痢，ダンピング症状等の術後愁訴，また食事摂取量，術後体重減少，術後栄養指標変動においても両群間に有意差はなかった．術後１年目の内視鏡検査では食道炎，残胃炎，狭窄，胆汁逆流において両群に有意差はなかったが，食物残渣の残存はEG群が有意に少なく（EG群:JPI群=14.3％:80.0％），JPI群の食物残渣は大部分が間置空腸嚢内に認められた．今回の検討ではEG群と比べJPI群に良好な成績は得られず，手術時間，食物残渣量の点でEG群の成績が良好であり，噴門側胃切除後の再建には簡便で従来の食道残胃吻合法が望ましいと考えられる．

症例は79歳, 男性で上腹部痛, 悪心を主訴に近医受診し, 胆石症の診断で当科紹介. 腹部US, CTにて胆嚢炎, 胆嚢結石, 総胆管結石の診断となる. EST施行し総胆管結石載石した際, 総肝管狭窄を認めた. CA19-9は245.9U/mlと高値を示しており, 総肝管狭窄は胆嚢癌による胆管浸潤も否定できなかったが, 胆嚢炎症状を繰り返していたため, 開腹胆嚢摘出術を施行. 術中, 高度な胆嚢周囲の炎症, 癒着を認めたが, 肉眼的に悪性を疑わせる所見はなく, 切除標本の病理学的検査所見は黄色肉芽腫性胆嚢炎であった. 術後総肝管狭窄部は改善していた.黄色肉芽腫性胆嚢炎は胆嚢壁の著明な肥厚を伴い術前に胆嚢癌との鑑別がきわめて困難な疾患であり, Mirizzi症候群をきたした症例は自験例も含め4例しか報告されていない. われわれは, 黄色肉芽腫性胆嚢炎よりMirizzi症候群をきたした稀な症例を経験したので若干の文献的考察を加え報告する.

残胃全摘後の小腸穿孔に対しT-tube留置が有効であった稀な1例を経験したので報告する. 症例は69歳, 男性. 上腹部痛を主訴に当院受診した. 胃潰瘍にて胃切除術 (Billroth II法) の既往歴あり. 胃内視鏡検査にて胃空腸吻合部に2型腫瘍を認め, 残胃癌の診断で残胃全摘術 (Roux-en-Y法), 脾摘, 胆摘術を施行した. 術後第7病日, 腹腔内に留置したドレーンより混濁した黄色の排液を認め, 縫合不全の診断で再手術となった. 縫合不全は認めず, Y吻合より約3cm十二指腸断端側の空腸に直径15mmの穿孔を認めた. 穿孔部は炎症が強く, Treitz靭帯とY吻合からの距離が短く腸切除, 縫合閉鎖できないため, drainage目的でT-tubeを留置し, 再手術後第50病日に抜去した. 検索した範囲では, 本邦においてT-tube drainageで対処できた小腸穿孔の報告はなかった. 一期的な縫合閉鎖が困難な小腸穿孔においてT-tube留置法は有用な方法であると考えられた.

症例は80歳,男性.2003年11月12日S状結腸癌の診断にて,S状結腸切除術を施行した(中分化型腺癌, S, 2型, 65×22mm,全周性, ss, P0, H0, M(-), ly1, v1, n1, D3, aw(-), ow(-), ew(-), curA, stage III a).術後補助化学療法として, UFT-Eを400mg/day内服していた.術後18カ月目に腹部膨満感が出現し当院に入院となった.高度貧血と低蛋白血症, CEAの上昇が認められた.腹部CTで,門脈塞栓,門脈の拡張および門脈周囲海綿腫状静脈叢,腹水,リンパ節腫大,腸管壁の浮腫が認められた.門脈塞栓は,門脈本幹から門脈臍部,右前区域枝,右後区域枝まで達しており, dynamic CTの門脈相で最も強く造影され,腫瘍塞栓と診断した.全身状態を考慮し化学療法も困難と考え,緩和的治療を行った. 2カ月後のCTで,腫瘍塞栓は増大し脾静脈まで達していたが,肝転移は認められなかった.S状結腸切除術から23カ月後,全身状態の悪化により死亡した.大腸癌由来の肝転移を伴わない門脈腫瘍塞栓の報告は少なく,若干の文献的考察を加えて報告する.

症例は72歳の男性で, 55歳の時に胸腺腫にて胸腺摘出術をうけていた. 1週間前頃から発熱あり, 近医にて投薬治療中, 突然の腹痛あり近医受診した. 汎発性腹膜炎との診断で当科紹介され緊急手術施行した. 回腸末端から30センチの部位に穿孔を認めた. 術後, 肺炎を併発し多臓器不全で永眠された. 切除標本の病理組織学的検査ではサイトメガロウイルス腸炎による穿孔であった. 本症例では胸腺腫術後の低免疫状態から, サイトメガロウイルス腸炎を併発し回腸穿孔を来したものと考えられた. 本症例は残念ながら死亡後に確定診断がついたが, このことを教訓として胸腺摘出後の患者の消化管穿孔では日和見感染的なCMV腸炎による潰瘍穿孔も念頭におくべきであると考えられた. 高齢者のCMV腸炎も増加傾向にあり, 免疫低下状態と考えられる患者だけでなく高齢者の消化管穿孔では, サイトメガロウイルス感染症を考慮して末梢血リンパ球数を測定する必要があると考える.

症例は57歳,男性.自動車の間に腹部を挾まれる交通事故で来院した.受診時,下腹部痛を訴えるのみで特に胸腹部に外傷を認めなかった.腹部CT検査にて肝表面に腹腔内液貯留を認めると同時に,左腎は骨盤内に認め異所性腎であった. 1時間後,腹痛が増強し,ショック症状が出現したため再度腹部CT検査施行し,腹腔内液貯留の増強があった.腹腔内出血による出血性ショックの診断で受傷約2時間後に開腹術を行った.腹腔内に約1,100mlの出血を認め,回腸末端から約60cm口側の小腸間膜が8cmの長さにわたり断裂していた.小腸は一部血流不良のため部分切除した.左腎は骨盤内に確認できた.異所性腎は,ほとんどが無症状で経過するため,認識されずに経過される症例が多い.本邦で転倒による腹部外傷により腎破裂を呈した異所性腎の報告はあるが,腸間膜損傷を契機に異所性腎が発見された報告はされていないため,文献的考察を加え報告した.

胃癌に対する化学療法のsecond-lineとしてtaxaneの有効性が注目されている. Stage IV進行胃癌に対しdocetaxel化学療法が奏効し, 切除しえた1例を経験したので報告する. 症例は70歳の男性, 内視鏡検査で胃癌の診断となった. 腹部CTで膵体尾部, 脾門部への浸潤を認め切除不能の診断でTS-1 100mg/日を1クール (4週) 投与するもPDのためCPT-11 100mg/日 (3投2休) 施行した. 治療効果はPRだったが2クール終了後PDとなり, TXT療法開始80mg/回を3週間隔で4クール施行後, 内視鏡上腫瘍病変, また腹部CT上膵臓, 脾門部への浸潤もほぼ消失 (PR) した. その後, 胃全摘術, 膵体尾, 脾, 胆. 切除, リンパ節郭清 (D3) を施行し, 術後12か月現在外来通院中である. 組織学的所見では, 癌細胞は胃固有筋層から漿膜下のごく一部とそれに連続した膵体部のみで, 胃粘膜面には認めなかった. 胃癌におけるTXTの化学療法は有効性が期待できると考えられた.

内視鏡的乳頭切開術(EST)により著明な全身性皮下気腫を呈した1例を経験したので報告する.症例は56歳,女性で総胆管結石による急性胆管炎,急性胆嚢炎の診断で入院となった.除石目的のEST後に後腹膜気腫,縦隔気腫および頸部から大腿にわたる著明な皮下気腫を認め,傍乳頭十二指腸の後腹膜への穿孔を疑い緊急手術を行った.しかし癒着が高度であり,穿孔部の同定には至らず,経過観察としたが約1週間で気腫は改善した. 本邦においてESTの偶発症として十二指腸穿孔により全身性皮下気腫にまで進展した症例の報告はない. ERCPおよびESTは侵襲的手技であり,偶発症の発生を予防するためには,膵炎,出血だけでなく十二指腸穿孔の可能性も念頭に置き慎重な操作を心がけることが肝要であると思われた.

Gene therapy could potentially revolutionize the treatment of gastrointestinal (GI) tract cancer. The aim of this study was to establish a practical method of gene transfer which would be applicable to human gastric cancer. Retrovirus or/and adenovirus vectors carrying the lacZ marker gene were transferred in situ by needle through an endoscopic biopsy channel into primary gastric cancer in six male beagle dogs that had been treated with N‐ethyl‐N′‐nitro‐N‐nitrosoguanidine (ENNG). In addition, an adenovirus vector carrying the herpes simplex virus thymidine kinase (Ad.CAGHSV‐TK) gene was introduced in situ into cancer tissues in the stomach of three dog, and the animals were treated with intravenous ganciclovir (GCV). Retrovirus‐producing cells which expressed the lacZ gene were specifically localized to the injection site in the stomach. The lacZ gene was more widely transferred into the tumor by the adenovirus vector than by retrovirus‐producing cells. Improvement of the needle used for gene transfer and the use of multiple injections per tumor led to more diffuse transfer of the vector into the tumor. The Ad.CAG lacZ gene was also transferred into regional lymph nodes of the stomach. Moderate to diffuse degeneration of the primary cancer tissues of the stomach was found after Ad.CAGHSV‐TK/GCV gene therapy. Moreover, almost complete tissue degeneration was observed in the regional lymph nodes of the stomach. An adverse effect of HSV‐TK/GCV gene therapy was acute hepatotoxicity, which was not found after Ad.CAG lacZ gene transfer, but was found after high‐titer Ad.CAGHSV‐TK gene transfer followed by GCV. These findings suggest that in situ gene transfer of a suicide gene followed by prodrug treatment may be applicable not only to primary tumors, but also to lymph node metastases of gastric cancer, though further study of both beneficial and adverse effects is required before clinical usage.

We report herein a case of Echinostoma hortense Asada infection, which is known to derive from eating fresh frogs or loaches, which was discovered during routine gastrointestinal endoscopy. To our knowledge, this is the first report in Japan of E. hortense Asada infection observed by means of magnifying endoscopy.

The diagnostic yield of colonoscopy and the therapeutic value of intraduodenal amidotrizoic acid injection in intestinal diphyllobothrium latum infection: report of a case

Gastrointestinal cancer is the most important clinical target of gene therapy. Suicide gene therapy, such as with the herpes simplex virus type 1 thymidine kinase (HSV-TK) gene, has been shown to exert antitumor efficacy in various cancer models in vitro. We previously reported in situ gene transfer and gene therapy for gastric cancer induced by N-ethyl-N'-nitro-N-nitrosoguanidine (ENNG) in dogs. Here, we describe the sequential histopathological changes after suicide gene therapy of N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-induced gastric cancer in rats. Gastric tumors were induced by MNNG in 38 / 73 (52%) of Wistar strain rats. The suicide gene therapy group (14 rats) was subjected to in situ gene transfer with a recombinant adenovirus vector carrying the HSV-TK gene driven by CAG promoter (Ad.CAGHSV-TK) in gastric tumor, followed by the antiviral drug ganciclovir (GCV). To observe the histopathological changes at various times after HSV-TK / GCV gene therapy, groups of animals were sacrificed at 3, 8, and 30 days after gene transfer. Apoptosis in the gastric tumors was detected by the TUNEL method to assess the efficacy of HSV-TK / GCV gene therapy, and it was marked in the 8- and 30-day treatment groups compared to the sham operation controls (P < 0.001). Various histopathological changes, degeneration of cancer tissue and fibrosis after necrosis and apoptosis were significantly greater in the 30-day treatment group. The HSV-TK gene was detectable in peripheral blood by PCR until 30 days after gene transfer. These results may be useful in devising a method of suicide gene therapy for humans.

Close correlation between mucosal atrophy/intestinal metaplasia (IM) and gastric cancer has been reported. Recently, etiological relation between H. pylori infection and gastric cancer has been elucidated. Aim of this study is to clarify the geographical differences of mucosal atrophy/IM and H. pylori infection in the stomach among different populations in Asia, i.e. Japanese (Tokyo) 4260 cases, Chinese (Beijing) 257 cases, Vietnamese(Ho Chi-ming) 223 cases and Thai (Chaing Mai) 437 cases. Under the endoscopic examination, 3 biopsy specimens were taken from #1 antrum, #2 upper corpus and #3 angulus regions and grading of atrophy, IM and H. pylori infection were undergone by the Sydney System. Results showed most geographical differences in biopsy specimens taken from #3 angulus region. H. pylori infection was most high in Thai population in all generation, followed by Chinese, Japanese and Vietnamese in younger generation; and Japanese, Chinese and Vietnamese in elder generation. Mucosal atrophy was most high in Japanese followed by Vietnamese, Chinese and Thai; and IM was most high in Japanese followed by Chinese, Vietnamese and Thai in all generation. In conclusion, H. pylori infection correlated with mucosal atrophy/IM in Japanese but not in Thai population. These differences of stomach mucosa may attribute to high and low incidence of gastric cancer in Japan and Thai population, respectively.

Background Early gastric cancers with duodenal invasion are rare, and no previous case of multiple early gastric cancer, one invading the duodenal bulb, has been reported. Case presentation A 79-year-old woman was investigated for upper abdominal discomfort. Endoscopic examination revealed an irregular nodulated lesion in the antrum area, and a reddish aggregated-type semi-circumferential nodulated lesion extending from the prepyloric area to the duodenal bulb through the normal mucosa with the antrum lesion. Biopsy revealed a tubular adenoma for the antrum lesion and a well-differentiated tubular adenocarcinoma for the prepyloric lesion. Distal gastrectomy with sufficient duodenal resection was performed. Microscopically, the antrum lesion appeared as a papillary adenocarcinoma, and the prepyloric lesion as a mainly papillary adenocarcinoma which partially invaded the submucosa without any sequential elongation for endoscopic findings. The lesion extended into the duodenal bulb, and was 12 mm in length from the oral end of Brunner's gland's area and limited within the duodenal mucosa. Conclusion Here, we present an unusual case of multiple early gastric cancer, one of which invaded the duodenum with relative wide mucosal spreading. This case illustrates that even early stage cancers located in the gastric antrum, particularly in the prepyloric area can invade the duodenum directly.