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Pancreatic fistula is one of the most common and potentially fatal surgical complications after radical gastrectomy. The purpose of this study was to assess the validity of extrapolating the definition of pancreatic fistula by the International Study Group on Pancreatic Surgery to include situations surrounding gastric cancer surgery.The clinicopathological data of 443 patients who underwent elective gastrectomy with suprapancreatic lymph node dissection (D1+, D2, or D2+ dissection) without pancreatic resection were reviewed. The relationship between postoperative pancreas-related complications (PPRC) and laboratory data, including drain fluid amylase levels on postoperative day 1 (dAmy1) and day 3 (dAmy3), were investigated.Twenty-four patients (5.4%) developed PPRC of ≥ grade II according to Clavien-Dindo classification. Among them, 15 patients had dAmy3 levels ≥ 375 IU/L, while all 24 patients had dAmy1 levels ≥ 375 IU/L. None of the patients with dAmy1 levels 375 IU/L developed PPRC. The area under the curve of dAmy1 and dAmy3, calculated by drawing receiver operating characteristic curves, were 0.896 and 0.791, respectively. Univariate and multivariate analyses demonstrated that both dAmy1 and dAmy3 were significant predictors of PPRC; however, dAmy1 (p 0.001) was more strongly correlated with PPRC than dAmy3 (p = 0.049).DAmy1 is more sensitive than dAmy3 as an indicator of pancreatic fistula after gastric cancer surgery.

A 58-year-old man who underwent lower lobectomy of the right lung for primary pulmonary leiomyosarcoma (PPL) 4 years ago presented with epigastric pain and was diagnosed with small bowel intussusception caused by an intestinal mass. Partial resection of the small intestine was performed, and pathological examination revealed metastatic leiomyosarcoma. Masses in the left adrenal gland, subcutaneous tissue of the left upper arm, right pleura, jejunum, right trapezius muscle, and right adrenal gland were subsequently detected in the following 4 years. Resection was performed for each tumor, which was histologically confirmed as metastatic leiomyosarcoma. However, 1 month after the last surgery, multiple systemic metastases were found, thus, he is currently undergoing chemotherapy. The patient has been alive for 8 years and 4 months after the first operation for PPL. PPL is an extremely rare disease with no established treatment strategy for recurrences. Aggressive metastasectomy may be beneficial in selected cases.

Introduction: The drain amylase concentration (dAmy-C) is a useful marker for predicting pancreatic fistula after gastric cancer surgery. However, dAmy-C might be reduced in cases of high drainage volume. Therefore, we hypothesized that we could accurately assess the amount of amylase leaked from the pancreas by multiplying dAmy-C by the daily drainage volume. In this study, we investigated the clinical utility of the amount of drain amylase (A-dAmy: concentration × volume) for predicting pancreatic fistula. We investigated the clinical utility of the combination of dAmy-C and A-dAmy for predicting pancreatic fistula. Methods: We investigated patients who underwent gastrectomy for gastric cancer at Yodogawa Christian Hospital between 2012 and 2020. The optimal cutoff levels of dAmy-C and A-dAmy on postoperative day 1 for predicting Clavien-Dindo (CD) grade II or higher pancreatic fistula was calculated using receiver operating characteristic (ROC) curves. We calculate the positive predictive value and negative predictive value for predicting pancreatic fistula using these cutoff levels. Results: A total of 448 patients were eligible for analysis. Twenty-two patients experienced CD grade II or higher pancreatic fistula. ROC curves identified 1,615 IU/L as the optimal cutoff level of dAmy-C, predicting pancreatic fistula. When the simple cutoff level of dAmy-C was 1,600 IU/L, the positive predictive value for was 22.8%, and the negative predictive value was 99.7%. ROC curves identified 177.52 IU as the optimal cutoff level of A-dAmy predicting pancreatic fistula. When the simple cutoff level of A-dAmy was 177 IU, the positive predictive value was 21.2%, and the negative predictive value was 99.7%. Using these two cutoff levels together, the positive predictive value was 34.4%, and the negative predictive value was 99.7%. Conclusion: A-dAmy could predict and exclude pancreatic fistula after gastrectomy as with dAmy-C. The combination of dAmy-C and A-dAmy predict pancreatic fistula more accurately than dAmy-C alone.

A 43-year-old woman was suffering from epigastric pain. Her gastroscopy revealed polyposis of the stomach, and her biopsy revealed a hyperplastic polyp. During the 18-month follow-up, the polyps proliferated, and the patient was referred to our institute for further investigation and treatment. A juvenile gastric polyposis diagnosis was made. She refused to have the surgery despite the fact that it was necessary due to the anemia and hypoalbuminemia she was experiencing. Endoscopic biopsy results revealed gastric cancer at a follow-up visit 2 years and 3 months later; thus, a laparoscopic total gastrectomy was performed. Pathological examination revealed adenocarcinomas that were scattered and well-differentiated, with hyperplastic polyps in the background. No lymph node metastasis was found. Despite the fact that juvenile gastric polyposis is a pathologically benign disease, there have been numerous case reports of surgery being performed due to anemia, hypoalbuminemia, or gastric cancer associated with the disease. When gastric cancers are discovered in cases of juvenile gastric polyposis, they are usually in an early stage, making them a good candidate for laparoscopic total gastrectomy.

Introduction: Postoperative pancreas-related complications (PPRC) can cause critical conditions, including sepsis and intra-abdominal bleeding. Thus, it is important to identify patients who are at risk of clinically significant PPRC as early as possible in the postoperative period. Some authors have reported the use of amylase concentration of the drainage fluid (dAmy) to predict PPRC. However, the positive predictive value of dAmy alone is not sufficient. Objective: The aim of this study is to evaluate the predictive value of combined use of dAmy and serum C-reactive protein (sCRP) for PPRC. Methods: The clinicopathological data of 327 patients who underwent elective gastrectomy for gastric cancer were reviewed. There were 18 patients who developed PPRC. Univariate and multivariate analyses were conducted to identify the risk factors of PPRC. Receiver operating characteristic curves were used to identify the cut-off values of dAmy and sCRP on postoperative day 3 (dAmy3 and sCRP3) to predict the risk of PPRC. Results: In the multivariate analysis, splenectomy alone correlated with PPRC. The cut-off values of dAmy3 and sCRP3 were 761 IU/L and 15.15 mg/dL, respectively. Among the 17 patients with both dAmy3 and sCRP3 above the thresholds, 10 (58.8%) had PPRC with Clavien-Dindo classification (CD) ≥II and 7 (41.2%) had PPRC with CD ≥III. In contrast, among the 236 patients with both parameters below the thresholds, 233 (98.7%) did not develop PPRC, and only 1 (0.4%) had PPRC with CD ≥III. Conclusions: Splenectomy correlates with PPRC, which is consistent with results from large clinical trials. A combined use of dAmy3 and sCRP3 can be useful in predicting the risks of PPRC.

Highlights • We experienced a case of appendiceal cancer invading the ileum with a fistula. • This is the first case report of appendiceal cancer with an ileal fistula that successfully treated with laparoscopic resection. • Laparoscopic resection can be a feasible, safe and curative procedure in selected cases of appendiceal cancer with a fistula. • Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration., Introduction Primary appendiceal cancer with fistula formation is extremely rare. We report a case of a patient with appendiceal cancer invading the ileum who underwent successful laparoscopic ileocecal resection. Presentation of case A 76-year-old man who presented with fever and abdominal pain was diagnosed with acute appendicitis and received antibiotics at a local hospital. After a few days, he was referred to our hospital because of an abnormality found in the colonoscopy, which was an oozing ulcer in the terminal ileum. Laparoscopic ileocecal resection was performed with a preoperative diagnosis of ileal cancer. The tumor adhered to the right internal inguinal ring. We dissected the right spermatic cord involved in the tumor. The resected specimen revealed a fistula between the appendiceal orifice and ileac ulcer. Histopathological examination revealed a well differentiated tubular adenocarcinoma. We made the diagnosis of appendiceal cancer with an ileal fistula because the ileal ulcer was derived from the appendiceal site. Discussion Most cases of appendiceal cancer with a fistula undergo laparotomy, but in selected cases, laparoscopic resection should be considered a feasible, safe, and curative procedure. Our patient underwent laparoscopic ileocecal resection, whereby the tumor and other organs with invasion were resected successfully with a negative surgical margin. Conclusion This is the first case report of appendiceal cancer with an ileal fistula successfully treated with laparoscopic resection. Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration.

Background The Glasgow prognostic score (GPS) has been reported as a sensitive prognostic marker for gastric cancer. This study aimed to investigate whether the GPS is equally applicable to patients with early-stage and advanced-stage gastric cancers. Methods Patients (n = 544) who underwent elective gastrectomy for gastric cancer between 2007 and 2015 were retrospectively studied. GPSs of 2, 1, and 0 were allocated to patients with both an elevated C-reactive protein level (> 1.0 mg/dL) and hypoalbuminemia (< 3.5 mg/dL), patients with only one of these abnormalities, and patients with neither abnormality, respectively. The prognostic factors relevant to patients with early-stage (pStage I, n = 304) and advanced-stage (pStage II, III, and IV, n = 240) gastric cancer were analyzed through univariate and multivariate analyses. Results In the early-stage group, only the serum carbohydrate antigen (CA) 19-9 level (P = 0.037) was a significant prognostic factor in the multivariate analysis; the GPS was not significant (P = 0.095). In the advanced-stage group, an American Society of Anesthesiologists physical status of 3 or 4 (P = 0.032), elevated carcinoembryonic antigen (CEA) (P = 0.043) and CA19-9 (P = 0.045) levels, a GPS 1 - 2 (P = 0.017), and type 4 tumor (P = 0.020) correlated significantly with worse overall survival. Conclusions GPS is a simple and useful prognostic score for patients with advanced-stage, but is not applicable to early-stage patients.

Objectives: This study aimed to investigate the validity of gastric cancer surgery in elderly patients. Methods: A total of 544 patients who underwent elective gastrectomy for gastric cancer were divided into an elderly group (age ≥75 years, n = 171) and a control group (age n = 373). The clinicopathological data of the patients were reviewed. Results: The overall morbidity rate (26.3 vs. 16.1%, p = 0.005) and the incidence rate of anastomotic leakage (6.4 vs. 1.6%, p = 0.003) were significantly higher in the elderly group. The proportion of patients who had severe complications (≥grade IIIa) was relatively higher in the elderly group (10.5 vs. 5.7%); however, the difference was not significant (p = 0.074). A stage-matched survival analysis revealed no significant differences between the groups (stage I: p = 0.978; stage II: p = 0.964; stage III: p = 0.199). For the pathological stages II and III, the overall survival of the patients in the elderly group who received adjuvant chemotherapy for >3 months was significantly better than that of the patients who received it for ≤3 months or did not receive it (p = 0.023). Conclusions: An aggressive treatment strategy should be adopted in selected elderly patients with gastric cancer.

Verrucous squamous cell carcinoma (VSCC) is a rare esophageal tumor histologically defined as a well-differentiated subtype. We present a rare case that was diagnosed as esophageal VSCC preoperatively. A 62-year-old Japanese man was referred to our hospital for further evaluation, presenting with anorexia and postcibal vomiting. An esophagogastroduodenoscopy examination showed esophageal stricture with white-colored papillary nodules in the lower esophagus. We performed repeated superficial endoscopic biopsies of the lesion, but the histologic findings showed nonspecific changes. With an endoscopic boring biopsy, the lesion showed an endophytic growth pattern, well-differentiated SCC with minimal cellular atypia and rare mitosis, and mature squamous epithelium with extensive keratinization. We preoperatively diagnosed the lesion as esophageal VSCC, and we performed a video-assisted thoracoscopic subtotal esophagectomy and cardiectomy with the patient in the prone position. Histologic findings revealed that the invasive well-differentiated SCC extended into the esophageal adventitia and the stomach wall with a pushing border. Regional lymph node metastasis and vascular invasion were negative. The expression of Ki-67 was distributed mainly in the basal cells rather than parabasal cells. Without a conclusive diagnosis, a certain degree of diagnostic prediction is possible by understanding the clinical manifestations, macroscopic form, and histology around the basal cells. It is helpful to obtain the high accuracy provided by an endoscopic biopsy including the basal layer to avoid the diagnostic dilemma that is often presented by esophageal VSCC.

Purpose While the amylase concentration of the drainage fluid (dAmy) has been reported to be a predictor of postoperative pancreas-related complications (PPRC), the optimal timing for its measurement has not been fully investigated. Materials and Methods The clinicopathological data of 387 patients who underwent elective gastrectomy for gastric cancer were reviewed. Laboratory data, including dAmy on postoperative days 1 (dAmy1) and 3 (dAmy3), and serum C-reactive protein (sCRP) concentrations on postoperative days 1 (sCRP1) and 3 (sCRP3) were compared between patients with PPRC and without PPRC. Results Nineteen of the 387 patients (4.9%) developed PPRC. The optimal cutoff values of dAmy1, dAmy3, sCRP1, and sCRP3 were 1514 IU/L, 761 IU/L, 8.32 mg/dL, and 15.15 mg/dL, respectively. The area under the curve of dAmy1 was greater than that of dAmy3 (0.915 vs. 0.826), and that of sCRP3 was greater than that of sCRP1 (0.820 vs. 0.659). In the multivariate analysis, dAmy1 (P

Objectives: This study aimed to investigate the validity of laparoscopic gastric cancer surgery in elderly patients. Methods: A total of 202 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and December 2016 were divided into an elderly group (age ≥75 years, n = 36) and a control group (age < 75 years, n = 166). The patients’ clinicopathological data were reviewed. Results: The overall morbidity rate was relatively higher in the elderly group (16.7 vs. 11.4%, p = 0.389), whereas the incidence of serious complications ≥grade III according to the Clavien-Dindo classification did not increase significantly in the elderly group (8.3 vs. 7.8%, p = 0.920). Univariate and multivariate analyses revealed that age ≥75 years was not a significant predictive factor of postoperative morbidity (p = 0.568). There was no significant difference in the 5-year overall survival rate of patients with pathological stage I gastric cancer between the groups (97.1 vs. 96.1%, p = 0.704; hazard ratio, 0.669; 95% confidence interval, 0.036–3.692). Conclusions: Laparoscopic gastrectomy has an acceptable morbidity rate in elderly patients, and the long-term outcome of patients with stage I gastric cancer was similar to that of the control group.

The present study involved 6 patients who had urgent surgery for acute cholecystitis(AC)complicated with gallbladder cancer(GBC)in our hospital from January 2014 to December 2016. We analyzed the clinical outcome of early surgery for AC complicated with GBC. According to Tokyo Guidelines 2013, the AC severity was classified as Mild 1 case, Moderate 5 cases. Only one patient was diagnosed with GBC before the operation for AC. The others were during or after the laparoscopic cholecystectomy. Histopathologically, all patients had Stage II disease or greater. Two patients had adjunctive radical operation with the wedge resection of the gallbladder bed, lymphadenectomy and bile duct resection, and they survived without recurrence for 28 months and 12 months, respectively. Of the 3 patients without any additional surgery, 2 patients died in several months after the operation. In consideration of the concurrence of GBC, early surgery for AC must be decided carefully.

Background Elderly patients have a high risk of adverse outcomes after surgery. Therefore, it is essential to determine the predictive factors for postoperative morbidity in elderly patients undergoing gastric cancer surgery. Methods A total of 544 patients who underwent elective gastrectomy for gastric cancer at Yodogawa Christian Hospital between January 2007 and December 2015 were divided into the elderly group (age ≥70 years, n=282) and a control group (age

Laparoscopic surgery is a minimally invasive surgery, and the incidence of postoperative small bowel obstruction (SBO) is not high. However, SBO is a disease that detracts from the benefits of laparoscopic surgery due to the need for additional therapies or prolongation of hospital stay. Seprafilm is effective in reducing adhesions and preventing the occurrence of SBO. However, it is very difficult to place the Seprafilm during laparoscopic surgery compared to open surgery. Herein, we report a simple and easy method. The Seprafilm including the holder paper is divided into six pieces; each piece is wound around the end of the forceps and the reduction sleeve is slid over it. The forceps with the reduction sleeve is inserted through a 12-mm trocar and moved closer to the target place. Then, the reduction sleeve is slid down the forceps to expose the Seprafilm. This method does not require any special preparation or training. Based on our experience, this method can easily overcome the problems that the Seprafilm is vulnerable to tear and is difficult to spread out in the abdominal cavity.

No consensus has been reached with regard to the optimal treatment strategy and the prognosis of patients with advanced rectal cancer and inguinal lymph node metastasis. We, therefore, retrospectively analyzed the outcomes of 41 patients with locally advanced rectal cancer who underwent surgery after neoadjuvant chemoradiotherapy(NACRT). Six patients, with clinical inguinal lymph node metastasis determined by pretreatment imaging, underwent inguinal lymph node dissections after NACRT. Five patients survived without a relapse. Only 1 patient, who had been diagnosed with pathological inguinal lymph node metastasis, had a relapse in the right iliac lymph node 6 years after surgery. Surgical treatment after NACRT for rectal adenocarcinoma with inguinal lymph node metastasis contributes to an improvement in outcomes. NACRT plus inguinal lymph node dissection is an effective strategy for patients with inguinal lymph node metastasis from rectal adenocarcinoma.

Objective: To determine if a subcutaneous closed suction drain decreases the incidence of wound complications in patients undergoing emergency surgery for colorectal perforation. Materials and Methods: Data on 47 patients who underwent emergency operations for colorectal perforation were examined retrospectively. The clinical features of these cases with or without the use of the J-VACTM Drainage System were examined, and statistical analysis was performed. Results: In these high-risk cases, the overall incidence of incisional surgical site infection (SSI) was 36.2%. The incidence of incisional SSI in these cases with and without the J-VACTM Drainage System was 16.7% and 56.5%, respectively. Conclusion: Our results suggest that a subcutaneous closed suction drain is effective for preventing incisional SSI in patients who have undergone emergency operations for colorectal perforation.

A 71-year-old female presented to our hospital due to pain from the right hip joint to the lower abdomen. The pain had suddenly appeared and spontaneously disappeared more than 10 times during the past 2 years. She had visited many hospitals, but remained undiagnosed. The patient underwent a computed tomography (CT) scan of the pelvis, and a soft tissue shadow was seen between the external obturator and pectineal muscles. She was diagnosed with a right obturator hernia and underwent elective repair by laparoscopic trans-peritoneal hernioplasty (TAPP). 1 year has passed since the surgery, without any recurrence of the abdominal pain. Obturator hernias are rare, and most cases are found as incarcerated hernias. It is rare to find an obturator hernia without intestinal obstruction, or with the recurrent pain as in our case. We herein report a case in which an obturator hernia was undiagnosed and intermittent pain was experienced for 2 years prior to TAPP, which appears to have successfully treated the hernia.

Background Surgical meshes are widely used in incisional hernia repair. However, there are no reports of pregnancies complicated by infection of surgical meshes used for hernia repair. This is the first case report of a pregnant woman who experienced surgical site infection associated with surgical mesh used for repair of an abdominal wall incisional hernia. Case presentation We report a case of a 41-year-old pregnant Japanese woman with surgical site infection after mesh repair of an abdominal wall incisional hernia. She was diagnosed with an abdominal wall incisional hernia at 3 months after her third cesarean section, and she underwent an operation of hernia repair with use of monofilament polypropylene mesh 7 months after the third cesarean section. However, a surgical site infection associated with surgical mesh occurred. During antibiotic treatment, she was found to be pregnant. She was referred to our hospital at 13 weeks and 2 days of gestation. The surgeons removed the infected mesh at 16 weeks and 3 days of gestation. Neither the hernia nor infection at the surgical site recurred throughout pregnancy. We planned a cesarean section using a transverse uterine fundal incision method with an upper abdominal incision. The patient delivered a 2478-g healthy female infant. Conclusions The present report shows that removal of mesh can safely control surgical site infection during pregnancy.

BACKGROUND It is debatable whether laparoscopic surgery is suitable for obstructive colorectal cancer. MATERIALS AND METHODS We retrospectively reviewed the clinical and oncological effectiveness of laparoscopic surgery after tube decompression for obstructive colorectal cancer in 54 patients (18 laparoscopic resections, 36 open resections). RESULTS There were no significant differences between groups with respect to mean size, location, depth, and stage of tumor, median operating times, or median number of lymph nodes retrieved. Abdominal wound infection rate was significantly lower in the laparoscopic than in the open group (0%:22%, P=0.02), as were mean times to first gas passage after surgery (2.3:3.4 d, P=0.002) and mean postoperative hospital stays (16:24.3 d, P=0.03). The 3-year disease-free survival rate of curative resection cases in the laparoscopic (85%) and open (72%) groups were not significantly different. CONCLUSIONS Laparoscopic surgery after tube decompression achieves faster recovery and equal oncological outcome as open surgery and should be a treatment of choice for obstructive colorectal cancer.

While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest. A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis. Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P. The findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.

We report a case of regional recurrence of esophageal cancer after curative esophagectomy. The patient has experienced long-term survival after treatment with salvage chemoradiotherapy (CRT). A 69-year-old woman had received esophagectomy for advanced thoracic esophageal cancer (pathological T3N1M0, Stage Ⅲ). Recurrence in the cervical regional lymph nodes was diagnosed 1 year 4 months after surgery. She was treated with salvage chemoradiotherapy consisting of 60 Gy radiation and cisplatin/5-fluorouracil. The metastatic lymph nodes disappeared(a complete response). She has been alive without recurrence for 7 years and 5 months since completing salvage CRT. Approximately 30-50% of patients develop recurrences of esophageal cancer after curative esophagectomy, and these patients rarely survive longer than a year. Therefore, it is important that we examine this rare case of long-term survival after recurrence of esophageal cancer.

A 43-year-old man with a 23-year history of remission for Crohn's disease was admitted to our hospital because of stomachache and anal pain. Computed tomography showed fistula formation between the ileum and the sigmoid colon. Colonoscopy revealed two elevated tumors in the rectosigmoid and lower rectum. Synchronous double colitic cancer with Crohn's disease was diagnosed. We performed an abdominoperineal resection and an ileocecal resection. Histopathological examination revealed a rectosigmoid tumor invading the ileum and bladder with intestinal mesenteric and lateral lymph node metastasis, Stage Ⅳ. Postoperatively, the patient received adjuvant chemotherapy with mFOLFOX6 plus bevacizumab. Nine months after the operation, he was diagnosed with right pleural dissemination and effusion. He died after 13 months. Synchronous double colitic cancer in Crohn's disease is very rare and is often advanced at the time of diagnosis. These findings suggest that patients with Crohn's disease need periodic surveillance.

胆嚢管癌根治術後の局所再発に対し，再切除を施行しえた症例を経験したので，若干の文献的考察を加え報告する．症例は81歳の男性で，2005年8月，胆嚢管癌に対し，肝外胆管切除，胆嚢摘出術，D2リンパ節郭清が施行された．術後診断はC-Bm，circ，乳頭膨張型，3.0×2.5 cm，papillary adenocarcinoma＞＞tubular adenocarcinoma，int，INFβ，ly0，v0，pn0，pT2（ss），pN0，H0，P0，M（−），f Stage II，f Cur Aであった．術後，外来にて経過観察中，2007年3月にCA19-9とAlpha-Fetoproteinの上昇を認め，肝ダイナミックCTにて胆嚢床に5 cm大の腫瘤を認めた．胆嚢管癌の局所再発のほか，HCC/CCC混合性腫瘍やHCCの可能性も否定できず，腫瘤は単発であり，局所に限局していたことから，肝S4a，S5亜区域切除および挙上空腸壁部分切除を行った．病理組織学的検査にて胆嚢管癌の局所再発と診断された．また，免疫染色検査にてAFP産生胆嚢管癌と診断された．再切除施行後2年が経過した現在，無再発生存中である．

Maintenance of telomeric ends by the telomerase ribonucleoprotein complex or the telomerase-independent alternative lengthening of telomeres is necessary for the immortalization of human cells. The significance of alternative lengthening of telomeres has been suggested in DNA mismatch repair system-deficient cells; however, much remains unknown in human malignancies. In this study, we investigated the telomere maintenance mechanism in gastric carcinoma. In formalin-fixed and paraffin-embedded sections of the high frequency of microsatellite instability (MSI-H) and non-MSI-H gastric carcinomas, there was no difference in telomere length monitored by telomere intensity ratio using telomere-fluorescent in situ hybridization. Immunoreactivity of hTERT, the catalytic subunit of telomerase, was detected in 48% of MSI-H gastric carcinomas. The frequency was significantly lower than that in non-MSI-H gastric carcinomas (86%, P = 0.02). Conversely, the number of the alternative lengthening of telomeres-associated promyelocytic leukemia bodies (APBs) detected by combined promyelocytic leukemia immunofluorescence and telomere-fluorescent in situ hybridization was statistically higher (57%) in the MSI-H gastric carcinomas compared to that in non-MSI-H gastric carcinomas (19%, P = 0.026). The cases with hTERT(+)APBs(-) were more frequent in non-MSI-H gastric carcinomas (76%) than in MSI-H gastric carcinomas (24%), and the cases with hTERT(-)APBs(+) were more frequent in MSI-H gastric carcinomas (33%) than in non-MSI-H gastric carcinomas (10%). These results suggest that alternative lengthening of telomeres-mediated telomere maintenance plays an important role for microsatellite instability-mediated stomach carcinogenesis, as well as the telomerase ribonucleoprotein complex, although the incidence of MSI-H is low. Defects of the mismatch repair system may lead to homeologous recombination of telomeric ends for the telomerase-independent telomere maintenance in gastric carcinomas.

症例は64歳,女性.便に鮮血が付着したことを主訴に下部消化管内視鏡検査を受けたところ直腸Raに20mm大のIIa+IIc病変を指摘された.pit patternはVI高度不整でsm massiveと判断されたため手術目的で当科に紹介された.20日後の下部消化管内視鏡検査ではIs病変と変化していた.7日後に腹腔鏡下低位前方切除術を施行したところ病変は8mm大のIIa+IIc病変として存在しており,形態および大きさの変化を生じていた. 大腸癌の発育や進展に関してはさまざまな検討がなされており表面型大腸癌においても徐々に自然史が明らかにされてきている.本症例ではポリープ状の隆起部が欠損しており27日間で,形態変化と同時に腫瘍の大きさも明らかに縮小しており,基部のみが残存したものと推測された.大腸腫瘍における発育進展を考えるうえで興味深い症例であり,文献的考察を加え報告する.

The single stapling technique (SST) and the double stapling technique (DST) are common anastomoses for rectal cancer. Although many mechanical devices have been developed, the best choice remains unclear. In this study we examined the strength of anastomoses by determining their bursting pressures using an animal model. The intestines of pigs were used. In experiment 1, we compared the bursting pressures for Endo GIA™ 60 blue, Endo GIA™ 60 green, and GIA™ 60 blue. In experiment 2, the bursting pressures of a buttressed cutting site and a nonbuttressed cutting site were measured. In experiment 3, the SST, DST, and DST with buttress using PCEEA™ were performed and the bursting pressures and points of these anastomoses were examined. The bursting pressure of Endo GIA 60 blue (80.3 ± 10.5 mmHg) was significantly higher than that of Endo GIA 60 green (37.3 ± 4.2 mmHg) and GIA 60 blue (31.7 ± 5.8 mmHg) (p < 0.01). When a cut end was buttressed, the bursting pressure (149.6 ± 37.6 mmHg) was significantly higher than that of the nonbuttressed end (75.3 ± 25.1 mmHg) (p < 0.01). The bursting pressure among SST, DST, and DST with buttress was not significantly different. Only one bursting point was the crossing point of the PCEEA and Endo GIA and the bursting pressure of this point was much lower than that of the others. Endo GIA was most suitable for DST. The SST, DST, and DST with buttress had almost the same strength. The crossing point of PCEEA and Endo GIA may be a dangerous point for DST.

蛋白漏出性胃腸症を伴った, 十二指腸に嵌頓した巨大な胃脂肪腫に対し腹腔鏡補助下切除術を施行し, 低蛋白血症の改善を得た症例を報告する. 症例は34歳の男性で, 平成14年に吐血, 上腹部痛あり, 内視鏡検査にて潰瘍を伴った胃前庭部の粘膜下腫瘍を認めた. 内服加療にて症状軽快し, 以降放置されていた. 平成16年12月, 上腹部痛, 腹部膨満感あり, 内視鏡にて胃腫瘍の増大, 十二指腸嵌頓を認めた. 胃内への還納は不能であった. CT, MRIにて質的診断は脂肪腫であった. また, 著名な低蛋白血症およびα1アンチトリプシンクリアランス高値を認め, 蛋白漏出シンチグラフィにては腫瘍よりの蛋白漏出像を認めた. 蛋白漏出性胃腸症を伴った十二指腸に嵌頓した胃脂肪腫の診断にて, 腹腔鏡補助下切除術を施行した. 腫瘍は65×45×35mm大で胃前庭部に広い基部を有し, 病理診断は脂肪腫であった. 術後経過良好で, 術後1か月には低蛋白血症, 便中α1アンチトリプシン排出の改善も得た.

A 54-year-old man, found to have a submucosal tumor in the stomach by double contrast roentgenography, endoscopy, and endoscopic ultrasonography, underwent a laparoscopic partial gastrectomy. The pathological examination revealed that the lesion, measuring 45 mm x 35 mm, was an inverted hyperplastic polyp (IHP) located in the submucosal layer and consisting mostly of columnar cells resembling foveolar epithelium and pyloric gland cells. Notably, adenocarcinoma with adjacent dysplasia was observed in the submucosal glands. Transition from hyperplasia to dysplasia and from dysplasia to adenocarcinoma was noted. The adenocarcinoma component was intensely and diffusely positive for p53 overexpression, while the dysplasia component showed only weak and focal positivity, suggesting a role of p53 mutation in the dysplasia-carcinoma sequence. Gastric IHP is very rare, and only 31 cases (in 29 patients) have been reported. Five of these IHPs coexisted with gastric adenocarcinomas, which had all developed separately from the IHP lesions. Therefore, this is the first case of adenocarcinoma arising within gastric IHP itself.

Preoperative chemoradiotherapy (CRT) is widely used in the treatment of locally advanced rectal cancer (LARC). Pathological response to CRT has been shown to be a potential prognostic predictor in rectal cancer patients. The aim of this study was to determine the prognostic significance of pathological response to preoperative CRT in LARC patients. Thirty-two patients with LARC were retrospectively analyzed to determine the relationships of pathological response and clinicopathological characteristics to survival outcomes. Patients received CRT with tegafur/uracil and leucovorin. Radiotherapy was administered in fractions of 1.8 Gy/day and 5 days per week. The total dose of radiation delivered was 45 Gy. All patients underwent total mesorectal excision with lymph node dissections after CRT, and resected specimens were examined pathologically. Four patients showed pathological complete response, 14 showed good response, and 14 showed poor response. Pathological complete or good response was associated with longer survival (P = 0.041). Clinicopathological factors excluding gender were not correlated with outcome. No factor was associated with recurrence. Pathological response to preoperative CRT may be a useful prognostic predictor in patients with LARC.

The patient was a 71-year-old man who was diagnosed with anal fistula 50 years previously. He complained of mucous and bloody stools. He was diagnosed with a carcinoma associated with anal fistula after biopsy. Image examination showed that the tumor was filled with mucinous substances and that it had invaded the levator ani muscle, with left external iliac and left inguinal lymph node metastases. Therefore, preoperative chemoradiotherapy for locally advanced cancer was administered. After chemoradiotherapy, the tumor and metastatic lymph nodes reduced in size. We performed laparoscopic abdominoperineal resection. Histopathologically, the tumor was revealed as a mucinous adenocarcinoma, but no cancer cells were present on the surgical margin. This case suggested that preoperative chemoradiotherapy could be effective for locally advanced carcinoma associated with anal fistula.

魚骨による食道穿孔は比較的まれな疾患である. 今回当科では魚骨による食道穿孔から膿胸, 縦隔気腫を生じ開胸ドレナージ術を行った術後, 遅発性に仮性大動脈瘤を合併した症例を経験した. 症例は71歳の女性で, 発熱を主訴に発症, 近医で胸膜炎との診断で入院した. その後, 呼吸状態の悪化を来し食道穿孔との診断で当院へ転送された. 同日, 食道穿孔による膿胸および敗血症の診断のもと緊急手術を施行. 左胸腔内に膿瘍および食道近傍に魚骨の存在を認めたため, 異物除去とドレナージ術を行った. 術後は順調に経過したが, 術後13病日の胸部CTで仮性大動脈瘤形成を認めた. これに対し, 血管造影下でステントを留置した. 本症例は幸い救命できたものの, 治療開始まで時間を要したため, 仮性大動脈瘤という重篤な合併症を生じ, 長期入院を余儀なくされた. 早期に診断し, 治療を開始することが重要であると再認識させられた.

われわれは虫垂炎に合併した盲腸癌の1例を経験したので報告する.症例は74歳,男性.右下腹部痛を主訴に来院した.腹膜刺激症状を伴う圧痛を右下腹部に認め,急性虫垂炎と診断した.抗血小板薬内服中であったため手術は全身麻酔下で施行したところ,触診にて右下腹部に弾性硬な腫瘤を触知したため,回盲部腫瘤の存在を疑い傍腹直筋切開にて開腹した.腫大した虫垂と共に盲腸に径4cmの腫瘤を認め,回盲部切除を施行した.病理組織学的検査の結果はカタル性虫垂炎および盲腸癌であった.盲腸癌は3.8×4.2cm, Borr1型,高分化型腺癌, ss, ly1, v0, n0, H0, P0, stage IIであった.盲腸癌が虫垂炎の原因となることは稀であり,盲腸癌を見落とさないためにも積極的な術中検索が重要であると考えられる.

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.

Our purpose was to evaluate the perioperative safety of laparoscopic-assisted distal gastrectomy (LADG) in elderly patients with clinical stage I gastric cancer. From 527 consecutive patients who underwent distal gastrectomy for gastric cancer from 2000 to 2011, 38 elderly patients (aged 75 years or older) with clinical stage I disease who underwent LADG were compared with 28 elderly patients who underwent open distal gastrectomy (ODG) and with 41 nonelderly patients (younger than aged 65 years) who underwent LADG. Intraoperative cardiopulmonary changes following pneumoperitoneum and surgical outcomes were analyzed. A significant elevation in mean blood pressure (MAP) (by 44 %) and slight increase in heart rate (HR) (by 13 %) were observed 5 min after the beginning of pneumoperitoneum in the elderly LADG group, although they tended to remain stable since 30 min. The elevation of end-tidal CO2 (ETCO2) in the elderly LADG group remained at 8 % and did not differ from that in the nonelderly LADG group who were 20.5 years (median) younger, whereas percutaneous oxygen saturation (SpO2) did not worsen. Compared with the elderly ODG group, the elderly LADG group did not increase intraoperative cardiopulmonary impairment or complication, had lower incidence of postoperative medical complication (7.9 vs. 32.1 %, p = 0.012) and shortened postoperative recovery course (25 vs. 15 days, p

There are several molecular target therapeutic drugs for colorectal cancer which are used in daily medical practice in Japan. One is bevacizumab which is anti-VEGF antibody, and another is cetuximab and panitumumab which are anti-EGFR antibodies. However, there is not a clear conclusion which drugs should be used in each therapeutic line, and many studies are in progress. The results of the direct competitive examination of anti-VEGF antibody and anti-EGFR antibodies have been reported recently. These drugs are under consideration to differentiate the use not only from the characteristic of the drugs, but also from the pathological condition of the tumor. In this report, we will show the latest findings and the use of each drugs.

A 78-year-old man was admitted for workup for a liver tumor. Both serum AFP and PIVKA-II levels were high (2260ng/ml and 806mAU/ml, respectively). Contrast-enhanced CT scan and MRI using Gd-EOB-DTPA demonstrated a liver tumor in segment 6 resembling the imaging patterns of hepatocellular carcinoma (HCC), while the upper gastrointestinal endoscopy revealed a type 2 gastric cancer in the gastric antrum. Although the liver metastasis of the gastric cancer was undeniable, we performed partial resection of segment 6 of the liver and distal gastrectomy under a preoperative diagnosis of double cancer. Histopathologically, gastric tumor consisted of two components, such as well differentiated adenocarcinoma and hepatoid adenocarcinoma. The histology of the liver tumor was similar to that of the hepatoid component in the stomach lesion. Immunohistochemical staining revealed both the gastric and the liver tumors to be positive for AFP and PIVKA-II, yielding a definite diagnosis of AFP and PIVKA-II producing gastric cancer with liver metastasis. Because many cases of this disease have liver metastases at presentation with confusing images with HCC, the diagnosis of liver tumors should be carefully differentiated in the gastric cancer patients with liver tumors, high serum AFP and PIVKA-II levels.

The creation of a gastrointestinal tract anastomosis is a fundamental and important surgical procedure. The mean incidence of clinically apparent leakage after gastrointestinal tract anastomosis ranges from 2.1% to 14.9%. Although many techniques for successfully producing such anastomoses have been described, the goal of these techniques to be technically feasible and safe. In the 1960s, Steichen and Ravitch introduced stapling instruments. During the subsequent years, automatic stapling instruments have continued to be refined, and many automatic anastomotic techniques have been applied to gastrointestinal surgery. In addition, various instruments and techniques for stapling intestinal anastomoses have been applied to colorectal surgery. Functional end-to-end anastomosis (FETEA), stapled end-to-end anastomosis (ETEA), and stapled side-to-end anastomosis (STEA) are the most common techniques. Moreover, there are two types of stapled ETEA, the single stapling technique (SST) and the double stapling technique (DST). Although these methods have been shown to be reliable and safe, anastomosis leakage remains a major problem. Major leakages affect the long-term quality of life (QOL) of patients. In addition, leakage can cause significant morbidity. Studies have reported that the frequency of leakage ranges from 2.9 to 23%, and that the shorter the distance from the anal verge to the anastomosis the greater the risk of leakage. As mentioned above, automatic stapling instruments have been refined over the years, and many automatic anastomotic techniques have been applied to colorectal surgery; however, the optimal instrument and method remain unclear. Since the mechanical strength of an anastomosis is an important factor affecting leakage during the initial postoperative phase, experimental evaluation of this factor would be useful for clarifying these issues. In this chapter, we examined the pressure required to induce failure (bursting pressure) in various kinds of stapled anastomosis and investigated which stapling technique is most suitable.

This case is a 69-year-old woman. We diagnosed gastric cancer and cholecystolithiasis by close inspection of abdominal pain. Because preoperative diagnosis was T2N0M0, Stage I B, we performed an operation. Many lesser tubercles were shown, and were diagnosed as peritoneal metastases pathologically. The tumor in corpus ventriculi infiltrated out of gastric serosa. We judged that curative resection was impossible and finished the operation after giving an intra-abdominal dosage of cisplatin(CDDP)at 85mg. After operation, 3 courses of performed S-1/CDDP combination chemotherapy were performed. Because we observed contraction of the main lesion and could not point out the peritoneal metastases and ascitis, we performed a second look operation. All the nodules found with peritoneal and rectouterine excavation had disappeared and we performed distal gastrectomy. The postoperative diagnosis was pT2(MP), pN0CY0, Stage I B, Cur A, therapy grade 1a. Chemotherapy does succeed, and this is a valuable case in which a radical operation could be performed.

A 52-year-old man underwent distal gastrectomy for gastric cancer in July 2000. In July 2005, abdominal CT and barium study of the colon revealed peritoneal recurrence, and chemotherapy of S-1 was started. Within 2 courses, the serum CEA level increased, so combination chemotherapy of S-1 and cisplatin (CDDP) was begun. After 7 courses, the regimen was switched to S-1+paclitaxel (PTX). However, the patient developed digital numbness within 8 courses and single-agent chemotherapy with S-1 was restarted. In July 2007, he developed abdominal distension, and abdominal CT showed a large amount of ascites. S-1+CDDP was administered again, however, and we had to change the regimen within 3 courses due to fatigue and appetite loss. S-1 was restarted, but soon severe fatigue and appetite loss restricted the use of chemotherapeutic agents, and he died in December. This patient had been alive for 2 years and 5 months since peritoneal recurrence was diagnosed. We concluded that S-1-based sequential chemotherapy was effective for recurrent gastric cancer.

The case is a 66-year-old woman. CT showed multiple metastasis of the liver and lung after operation by colectomy for ascending colon carcinoma. A close inspection showed progressive stomach cancer with lymph node metastasis. Metastasis was considered an effect when it was of colon cancer origin, and treatment by mFOLFOX6 was started. In the results, we confirmed contraction of the liver and lung metastasis and contraction of the regional lymph node metastasis of the stomach by CT. The gastric cancer lesion became only a cicatrix with endoscopic examination. For gastric cancer, the availability of mFOLFOX6 was suggested.

A 50-year-old man undergoing operations for sigmoid colon cancer, small intestine invasion, and liver metastasis was given adjuvant chemotherapy postoperatively. During the course, lung, brain and bone metastasis were found, FOLFIRI therapy was started. Fifth FOLFIRI therapy was performed, but on the night of the next day, he was transported on an emergency basis to our hospital because of a coma. Laboratory examination revealed hyperammonemia, so aminoleban was started for its treatment. After 3 days in the hospital, consciousness and serum ammonia were improved. Cases of hyperammonemia caused by 5-FU have been reported in the literature, and this case was diagnosed with the same. Hyperammonemia should be taken into account as a differential diagnosis in the disturbance of consciousness in chemotherapy.

Various techniques of stapled intestinal anastomoses are performed in gastroenterological surgery. Little is known about which technique is optimal. The intestines of a domestic pig were used in this study. Stapled intestinal anastomoses of three types-functional end-to-end anastomosis (FETEA), stapled side-to-end anastomosis (STEA), and stapled end-to-end anastomosis (EEA)-were constructed using pig intestines. The times for constructing anastomoses, length of the completed anastomosed intestine, strength of anastomoses, and bursting locations were measured and recorded on each group. The times required to construct FETEAs (60 S.D. 1.4 sec) were significantly less than those required for STEAs (191.5 S.D. 46.4 sec) and EEAs (274.5 S.D. 54.5 sec). The mean lengths of the completed anastomosed intestine were significantly different for FETEAs (89 S.D. 8.2 mm), STEAs (135 S.D. 6.1 mm), and EEAs (156 S.D. 6.5 mm). The bursting pressures were not significantly different among the three groups. FETEAs are superior in terms of requiring less surgical time. EEAs are superior in terms of the length of anastomosed intestines. In conclusion, anastomotic techniques should be selected properly in consideration of these features.

A family history of cancer raises the risk of gastric cancer. Microsatellite instability (MSI) is frequently observed in hereditary non-polyposis colorectal cancer (HNPCC), and gastric cancer is the most frequent extra-colonic cancer among HNPCC patients. The relationship between gastric cancer and MSI is controversial. The purpose of this study was to identify the relationship between MSI incidence and gastric cancer in patients with a family history of cancer.MSI incidence was examined at 5 microsatellite loci and hMLH1 and hMSH2 protein expression was examined by immunohistochemical analysis in 30 gastric cancer patients with family histories of cancer (familial group) and 37 gastric cancer patients without any family history of cancer (sporadic group).The incidence of high-frequency MSI (MSI-H) in the familial group was 33.3% (10/30) and in the sporadic group it was 5.4% (2/37) (p0.05). The incidence of lack of at least one mismatch repair (MMR) protein was 66.7% (8/12) in MSI-H cases, which was significantly higher than in low-frequency MSI (MSI-L) cases and microsatellite stable (MSS) cases.MSI may play an important role in the development of gastric cancer in individuals with a family history of cancer and it is induced by a deficiency in MMR protein expression.

Yasunori Otowa, Kimihiro Yamashita, Kiyonori Kanemitsu, Yasuo Sumi, Masashi Yamamoto, Shingo Kanaji, Tatsuya Imanishi, Tetsu Nakamura, Satoshi Suzuki, Kenichi Tanaka, Yoshihiro Kakeji Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Abstract: Preoperative chemoradiotherapy (CRT) and lateral pelvic lymph node (LPLN) dissection (LPLD) based on pretreatment imaging are performed to improve oncological outcomes at our institution. However, the advantage of LPLD following preoperative CRT in advanced rectal cancer remains unclear. The objective of the present study was to assess the validity of this approach. Thirty-two patients with advanced rectal cancer were included in the study. All patients were treated with preoperative CRT and curative operation. Of these, 16patients who were treated between August 2005 and June 2008 underwent LPLD on both sides (LPLD group). Sixteen patients who were treated between July 2008 and January 2013 underwent LPLD only on the side with suspected LPLN metastasis determined by pretreatment imaging; in cases without LPLN metastasis, only total mesorectal excision was performed (limited-LPLD group). The overall survival and relapse-free survival between the LPLD and the limited-LPLD groups were compared. Preoperative CRT was able to lower clinical lymph node status in 50% of the cases. In addition, pathological lymph node status did not exceed the pretreatment clinical lymph node status stage in the LPLD group. There were no differences in the overall survival and relapse-free survival between the two groups (P=0.729 and P=0.874, respectively). We conclude that multi-imaging studies have a very low risk of overlooking pathologically positive LPLN metastases. Therefore, limited LPLD is a feasible strategy for patients with advanced rectal cancer and suspicious LPLN metastases based on pretreatment imaging. Keywords: neoadjuvant treatment, rectal cancer, chemoradiotherapy, lateral pelvic lymph node, MRI, CT