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The outcome of the stomach-partitioning gastrojejunostomy (SPGJ) procedure is superior to that of stenting procedures.Data from patients who underwent an SPGJ were collected retrospectively from hospital medical records (body weight, hemoglobin and albumin levels, assessment of food intake, duration of hospitalization, complications, and survival rates), and we compared the results with those obtained from patients treated with stenting.Departments of Gastrointestinal Surgery and Gastroenterology, Tokyo University Hospital, Tokyo, Japan.A series of 16 consecutive patients with gastroduodenal outlet obstruction who underwent an SPGJ and 9 patients who were treated with stenting between January 5, 1998, and August 18, 2004.Mann-Whitney, Fisher exact, and generalized Wilcoxon tests were used for statistical analyses.There were no differences between the 2 groups concerning background data, physiological status, or laboratory data. The starting point of food intake by patients treated with stenting was significantly earlier (at 4.2 days in the stent group vs at 6.0 days in the SPGJ group, P.004). The numbers of patients taking a regular meal at 2 weeks after treatment were 12 of 16 patients in the SPGJ group and 1 of 9 patients in the stent group (P.001). There was no significant difference between the 2 groups regarding the duration of hospitalization. The complication rates were significantly different between the 2 groups (P = .48). The median survival was 7.3 months in the SPGJ group and 2.8 months in the stent group (P = .008), and the mean 6-month survival rates were 81% (13 of 16) and 33% (3 of 9), respectively (P.04).Stomach-partitioning gastrojejunostomy achieved improved quality of life and a better prognosis compared with stenting procedures, and it is the treatment of choice for gastroduodenal outlet obstruction.

14140 Background: We investigated the combination of docetaxel, 5-fluorouracil (5FU) and cisplatin analog, nedaplatin (CDGP) as second-line chemotherapy after esophagectomy. Methods: Eight patients with recurrent esophageal cancer who had undergone adjuvant 5FU/cisplatin after esophagectomy were included this study (7 male, 1 female; median ECOG performance status: 1). Histologic type of all esophageal cancer was squamous cell carcinoma. Patients received docetaxel 60 mg/m2 on day 1, 5FU 600 mg/m2 on days 1–5, and CDGP60 mg/m2 on day 4 every 3 weeks. A total of 17 chemotherapy cycles was administered. The median number of cycles was 2 (range 1–5). Results: The overall response rate was 62.5%. The median overall survival was 42 weeks, and the median progression-free survival was 26 weeks. Hematological and non-hematological toxicities were moderate (neutropenia WHO grade III/IV: 62.5%, alopecia grade II/III: 75%, nausea/vomiting grade II/III: 50%, neurotoxicity grade II: 12.5%). Conclusions: The combination of docetaxel, 5FU and CDGP is an active regimen with moderate toxicity in the treatment of patients with recurrent esophageal cancer. This pilot study suggests the feasibility of a combination treatment containing a taxan, 5FU and cisplatin or its analog in esophageal squmaous cell carcinoma. No significant financial relationships to disclose.

Background: During endoscopic retrograde cholangiopancreatography (ERCP), hyoscine-N-butylbromide (Buscopan) or glucagon is used to inhibit duodenal motility. However, they may cause adverse effects. Peppermint oil has an antispasmodic effect and is used as a less hazardous antispasmodic during colonoscopy and upper gastrointestinal endoscopy. The purpose of the present paper was therefore to investigate peppermint as an antispasmodic for ERCP. Methods: Forty patients were enrolled prospectively. They were assigned to four groups according to the peppermint oil concentration and site of administration: group 1, 20 mL of 1.6% solution around duodenal papilla; group 2, 20 mL of 1.6% solution both to the antrum of the stomach and around the duodenal papilla; group 3, 20 mL of 3.2% solution around the duodenal papilla; and group 4, 3.2% solution both to the antrum and around the duodenal papilla. Glucagon or hyoscine-N-butylbromide was added when duodenal peristalsis was not adequately diminished. Sixteen patients undergoing ERCP with glucagon were employed as historical controls. Results: The ERCP was attempted in all except one patient in group 2 who had bleeding from invaded tumor to the duodenum. Peppermint administration equally reduced duodenal motility in the groups. Duodenal movement was none or mild in 69.2% of patients. The ERCP was successfully performed with peppermint alone in 91.4% of patients (37/39). Glucagon or hyoscine-N-butylbromide was needed in one patient each in groups 1 and 4. Serious complications related to peppermint oil did not occur. Inhibitory effect of peppermint appears to be identical to that of glucagon. Conclusion: Duodenal relaxation was obtained with 20 mL of 1.6% peppermint oil solution in the duodenum, but additional administration may be required. Peppermint oil is useful as an antispasmodic agent for ERCP.

Hypothesis Our previous demonstrations of the feasibility of a pylorus-preserving gastrectomy with a wider-scope lymphadenectomy for early gastric cancer (GC) have raised the possibility of applying pylorus-preserving gastrectomy to a broader segment of GC patients, such as those having GC with invasion extending into the proper muscle layer (GCpm). Design Case series. Setting Tertiary care center. Patients This study comprised 107 patients with solitary primary GCpm located in the middle or lower third of the stomach. Intervention All patients underwent gastrectomy, using at least the former D2 dissection of the American Joint Committee on Cancer. Main Outcome Measures Patterns and sites of nodal involvement were analyzed in relationship to other clinicopathologic characteristics, including preoperative and intraoperative evaluations of tumor depth (cT), nodal involvement (cN), and serosal involvement. The conditions required were serosal negativity and measurements less than or equal to cT2 cN0 with histologic proof of node negativity, or if positive, the positive nodes had to be confined to the first or selective second tier. The selective second-tier nodes were defined as those along the left gastric, common hepatic, and celiac arteries. Results The factors favoring node negativity were serosal negativity, cN0, or both. For tumors that were serosal-negative and less than or equal to cT2 cN0 to meet the above conditions, a tumor in the middle third of the stomach had to be less than or equal to 2 cm in the maximum diameter, and that in the lower third could be any size. No patients with serosal negativity and cT2 cN0 GCpm less than or equal to 2 cm in diameter died of cancer or had positive nodes beyond the selective second tier. Conclusions Considering the required distance between the pyloric ring and distal margin of the tumor to avoid a positive resection margin, pylorus-preserving gastrectomy with a selective second-tier node dissection is optimal for tumors that are serosal negative, less than or equal to cT2 cN0, and less than or equal to 2 cm in maximum diameter when located in the middle or lower third of the stomach.

We have established an experimental model of chronic gastric ulcer, in rats in which transection of the lower horizontal portion of the duodenum and anastomosis of the forestomach to the upper part of the jejunum caused regurgitation of all duodenal juice into the stomach. After 3, 6, 12, and 30 wk, all treated rats developed an ulcer in the prepyloric region on the lesser curvature of the stomach. More than half of the antrum was finally involved in the ulcer. Histologic studies revealed chronic ulcers quite similar to human ones. As a control series, transection at the pylorus failed to produce an ulcer. Although many papers have appeared regarding the experimental production of chronic gastric ulcer, most of the studies reported have applied chemicals, drugs, or mechanical injury to the gastric mucosa. Our model produced chronic regurgitation of duodenal juice as a natural phenomenon, and uniformly resulted in ulcer formation. Intragastric total bile acid concentrations were significantly elevated in the reflux group. Serum gastrin levels, the thickness of the fundic mucosa, and the height of fundic gland were also significantly increased. Thus, the detergent action of bile acids and the increased acid secretion were assumed to play an important role in ulcer formation. Further studies using this model are warranted on the pathogenesis of chronic peptic ulceration.

Background Carcinoma of the gastric remnant after partial gastrectomy for benign disease or cancer is unusual but an important cancer model. The Japanese Society for the Study of Postoperative Morbidity after Gastrectomy (JSSPMG) performed a nationwide questionnaire survey to understand the current state of gastric stump carcinoma in Japan. Methods In the questionnaire survey of November 2008, gastric stump carcinoma was defined as an adenocarcinoma of the stomach occurring 10 years or more after Billroth I or Billroth II gastrectomy for benign condition or cancer disease. The survey was conducted at the request of reports on five or more patients with gastric stump carcinoma for each institution. Items for the survey included gender, age, methods of reconstruction in an original gastrectomy, original diseases, time interval between original gastrectomy and first detection of stump carcinomas, locations of stump carcinomas, tumor histology, tumor depth, and extent of lymph node metastasis. The questionnaire was sent to 163 surgical institutions in the JSSPMG. Results Ninety-five institutions (58.3%) responded to the survey, and the data of 887 patients satisfied the required conditions for the survey. A total of 887 patients were composed of 368 patients who received Billroth I distal gastrectomy and 519 who received Billroth II. The Billroth II group has a significantly higher number of original benign lesions than the Billroth I group (P

Highlights • The overall mortality rate reported in the studies in Japan (25%) is considerably higher than that reported in a systematic review conducted of similar studies in other countries (3.3%). • Japan is a low-risk area for amebiasis, and many physicians fail to consider amebiasis in the differential diagnosis of acute appendicitis. In all of the cases, the diagnosis occurred only after surgery. • It is important to conduct further examinations, including those for amebiasis, when appendectomy does not resolve acute appendicitis., INTRODUCTION Outside of these high-risk regions, acute amebic appendicitis is considerably rarer and the mortality rate is much higher than with non-amebic appendicitis. PRESENTATION OF CASE A 31-year-old woman presented with fever and right lower abdominal pain with no history of traveling abroad or sexual infection. Computed tomography revealed a dilated appendix and thickened cecal and ascending colon walls. She underwent an appendectomy for appendicitis. Owing to a lack of symptom resolution, we performed a pathologic examination of the appendix again that revealed multiple Entamoeba histolytica trophozoites; the serum amebic antibody was positive. She was treated postoperatively with metronidazole for amebiasis and discharged on postoperative day 12. DISCUSSION The mortality rate and frequency of severe postoperative intraabdominal complications were higher in the Japanese literature (1995–2013) (25% and 33%, respectively) than in other developed countries (3.3% and 19.4%, respectively). Japan is a low-risk area for amebiasis; many physicians fail to consider amebiasis in the differential diagnosis of acute abdomen. It is important to conduct further examinations, including those for amebiasis, when appendectomy does not resolve acute appendicitis. CONCLUSION We report a case of acute amebic appendicitis in a 31-year-old woman and review the ages at presentation, causative factors, treatments, and outcomes of 11 cases reported in Japan between 1995 and 2013.

We investigated the functional and morphological aspects of acid secretion in 6 patients with post-bulbar duodenal ulcer and compared the findings with the events of 40 patients with the usual chronic duodenal ulcer. The post-bulbar ulcer patients showed a much higher acidity, and a biphasic, prolonged acid secretion pattern, presumably representing an enhanced parietal cell function. Histological study of antrectomized specimens revealed that 4 of those with the post-bulbar ulcer had a small antrum in which the fundic gland area expanded distally. The proximal border of the pyloric gland area was within 4 cm of the pylorus. This would suggest the presence of a large parietal cell mass. On the contrary, however, there was no such instance in those patients with the usual duodenal ulcer. Hyperacidity, due to a large parietal cell mass and an enhanced parietal cell function, may play an important role in the pathogenesis of post-bulbar duodenal ulcer.

Summary By infusing caustic soda (NaOH) into the stomach of rats, the gastric mucosa fell off and regeneration could be induced. In 18 of 26 rats, intestinal metaplasia associated with goblet cells was observed in the regenerative epithelium. Recently, induction of intestinal metaplasia by weak carcinogenic agents are reported with some emphasis on its precancerous meaning. However, our results suggest that, as intestinal metaplasia can be induced by a benign process of regeneration, it is not directly related with carcinogenesis.

Lymphangiomas of the large intestine have been reported more frequently since the development and widespread use of the colonic fiberscope. It is possible to endoscopically diangnose lymphangiomas because they are lustrous and smooth on the surface, pliable on compression, and half of them have a stalk or a waist at the base. Lymphangiomas of the colon and rectum under 20 mm in diameter can be safely resected by electrocautery, thereby avoiding unnecessary operation.

Background There were only few case reports in which CTC was performed in patients with colostomy. Case Presentation A 68-year-old man was admitted with right abdominal pain and bloody stool that had been present for 2 weeks prior to admission. His medical history included abdominoperineal rectal resection with permanent sigmoid stoma (Miles operation). Colonoscopy showed a sub-occlusive tumor in the transverse colon but provided no information about the proximal colon. Thus, computed tomographic colonography (CTC) was planned to assist our examination of the proximal colon under sigmoid colostomy. CTC revealed the apple core sign in the hepatic flexure, without any evident tumor in the proximal colon. Therefore, we performed transverse colectomy and lymph node dissection, preserving a part of the ascending colon and Bauhin valve. Conclusion CTC examination can be an effective means of preoperatively evaluating the proximal colon in patients with occlusive tumor. Further, CTC examination was technically feasible through a sigmoid stoma.

Helicobacter pylori (Hp) is thought to be a stomach carcinogen from epidemiological findings. To determine the effects of infection with the bacteria on experimental carcinogenesis, a study of the glandular stomach of Mongolian gerbils (MGs) was performed. Male MGs were treated with N-methyl-N'-nitro-N-nitrosoguanidine followed by inoculation with Hp or infected with Hp followed by N-methyl-N'-nitro-N-nitrosoguanidine administration. Animals were killed at week 50, and their excised stomachs underwent microbiological and histopathological examinations. In addition, a serological investigation was performed. The incidences of adenocarcinomas were significantly higher in animals treated with 60 or 300 p.p.m. N-methyl-N'-nitro-N-nitrosoguanidine for 10 weeks followed by Hp inoculation or Hp followed by 20 p.p.m. N-methyl-N'-nitro-N-nitrosoguanidine for 30 weeks than in the respective controls. Moreover, tumour-bearing animals had higher titres of anti-Hp antibodies than tumour-free animals. Of interest was the finding that a dose of 100 p.p.m. N-methyl-N'-nitro-N-nitrosoguanidine given to infected gerbils eradicated the Hp in about half the animals, with a concomitant reduction in the promoting effect. No tumours were found in animals infected with Hp without N-methyl-N'-nitro-N-nitrosoguanidine or non-treated gerbils. Hp infection enhances glandular stomach carcinogenesis in MGs treated with N-methyl-N'-nitro-N-nitrosoguanidine. Animals with high titres of anti-Hp antibodies are at greatest risk of developing neoplasms.

Background Cecal volvulus is relatively rare. Moreover, to the best of our knowledge, a case of cecal volvulus caused by endometriosis has not yet been reported. Case presentation A 41-year-old woman was admitted to our hospital with a 14-day history of subacute intermittent right lower quadrant abdominal pain. Simple abdominal radiography and abdominal computed tomography findings were suggestive of sigmoid volvulus, and she underwent an emergency colonoscopy. Following colonoscopic reduction, the patient’s symptoms resolved quickly, and elective laparoscopic surgery was scheduled 2 weeks after admission. Intraoperative examination revealed a significantly distended cecum and ascending colon, which was twisted around a short rope-like adhesion that connected the cecum and the mesentery of the transverse colon, whereas the sigmoid colon was neither twisted nor extended. We laparoscopically performed an ileocecal resection. The postsurgery histopathological examination revealed the presence of endometrial tissue in the short rope-like adhesion. This finding confirmed that cecal volvulus in this patient was caused by endometriosis. Conclusion Cecal volvulus should be considered in relatively young women who present with atypical right lower abdominal pain. Whenever possible, secondary factors should be evaluated preoperatively, especially in relatively young patients.