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Background To date, the optimal surgical strategy for remnant gastric cancer has not been determined. The purpose of this study was to clarify the significance of lymphadenectomy with splenectomy in remnant gastric cancer surgery. Methods This retrospective cohort study was conducted at the Kumamoto Regional Medical Center. The primary endpoint was overall survival after surgery. We retrospectively analyzed the clinicopathologic features, surgical treatments, and long-term prognosis of remnant gastric cancer patients treated with total gastrectomy. Results A total of 80 patients with gastric cancer in the remnant stomach after distal gastrectomy and who underwent total gastrectomy were enrolled in the study. Splenectomy was performed in 38 patients. Lymph node metastasis in the splenic hilum was not observed in the patients with pT1/pT2 tumors, whereas nodal metastasis at the splenic hilum was detected in 30.4% of the patients with pT3/pT4 tumors. The survival rate of the patients with pT3/pT4 tumors who underwent splenectomy was significantly higher than that of the patients who did not undergo splenectomy, although there was no difference in the patients with pT1/pT2 tumors. Among the patients classified as R0, the survival rate of the patients with pT3/pT4 tumors who underwent splenectomy was significantly higher than that of the patients who did not undergo splenectomy. Conclusion Lymphadenectomy with splenectomy in radical surgery is beneficial for patients with advanced (pT3/pT4) remnant gastric cancer.

Background: According to the treatment guidelines for gastric cancer in Japan (3rd edition), D1 lymphadenectomy is recommended for T1a cancer (out of indication for endoscopic resection) and a group of T1b cancer (differentiated type, not larger than 1.5cm and clinically N0). D1+ lymphadenectomy is recommended for T1b cancer other than above group. D2 lymphadenectomy is for clinically N+ early gastric cancer (EGC). Methods: Consecutive 1141 resected EGC cases in our institution from January 1991 to December 2013 were analyzed. The size, depth of wall invasion, presence of ulcer, histological type and distribution of metastasis positive lymph node were evaluated. Results: There were 678 T1a and 463 T1b cancers. Lymph node metastasis positive T1a were 11 cases. All of them were undifferentiated type and the metastasis positive lymph nodes were all confined to the D1 area. Lymph node metastasis positive T1b cancer was 82 cases. Among them, 70 cases were within D1 area, 77 cases were within D1+ area and 79 cases were within D2 area. The other 3 cases had metastasis positive lymph node in beyond the D2 area. Conclusion: D1 lymphadenectomy is enough for T1a EGC that is out of indication of endoscopic resection and D1+ lymphadenectomy is reasonable for T1b EGC. These cases are good indication of laparoscopic surgery. D2 lymphadenectomy is required for T1b undifferentiated cancers which size is larger than 4 cm.

Mesenteric defects are often not closed in laparoscopic colectomy. We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy. A 74-year-old woman was hospitalized for the surgical treatment of double colon cancer. Preoperative colonoscopy demonstrated the presence of ascending colon and transverse colon cancers. A laparoscopic-assisted right hemicolectomy was performed. The mesenteric defect resulting from the colectomy was not closed. Three months after the surgery, the patient developed a bowel obstruction. Under a diagnosis of strangulated bowel obstruction, we performed a laparotomy, and found a necrotic small bowel, which had passed into the bursa omentalis through the mesenteric defect. We removed the necrotic small bowel and closed the mesenteric defect by suturing. The patient’s postoperative course was uneventful. An internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy developed a severe strangulated bowel obstruction.

While statin intake has been proven to reduce the risk of colorectal cancer (CRC), the mechanism of antitumor effects and clinical significance in survival benefits remain unclear. Statin-induced antiproliferative effects and its underlying mechanism were examined using six CRC cell lines. Statins except pravastatin showed antiproliferative effects (simvastatin ≥ fluvastatin > atorvastatin) even though both of simvastatin and pravastatin could activate mevalonate pathways, suggesting the statin-mediated antiproliferative effects depended on non-mevalonate pathway. Indeed, statin induced p27KIP1 expression by downregulation of histone methyltransferase enhancer of zeste homolog 2 (EZH2), which acts as an epigenetic gene silencer. Additionally, the use of simvastatin plus classII histone deacetylase (HDAC) inhibitor (MC1568) induced further overexpression of p27KIP1 by inhibiting HDAC5 induction originated from downregulated EZH2 in CRC cells and synergistically led to considerable antiproliferative effects. In the clinical setting, Statin intake (except pravastatin) displayed the downregulated EZH2 expression and inversely upregulated p27KIP1 expression in the resected CRC by immunohistochemical staining and resulted in the significantly better prognoses both in overall survival (p = 0.02) and disease free survival (p < 0.01) compared to patients without statin intake. Statins may inhibit tumor progression via an EZH2-mediated epigenetic alteration, which results in survival benefits after resected CRC. Furthermore, statin plus classII HDAC inhibitor could be a novel anticancer therapy by their synergistic effects in CRC.

Reactive fibroinflammatory pseudotumor located in the pancreas is a rare condition. However, we experienced three cases of reactive fibroinflammatory pseudotumor of the pancreas over the previous 2 years. Immunohistochemical staining of immunoglobulin G4 (IgG4) confirmed that Cases 1 and 3 involved IgG4-related disease and that Case 2 did not. In Cases 1 and 3, the masses were formed through autoimmune reaction and were diagnosed as autoimmune pancreatitis (AIP). In Case 2, because only a few IgG4-positive cells were found, it was difficult to diagnose AIP or IgG4-related disease. Reactive fibroinflammatory pseudotumors can develop without the involvement of any autoimmune mechanisms. There seems to be partial overlap between reactive fibroinflammatory pseudotumors and AIP.

症例は34歳の男性で，飲食店で揚げたカレイを摂食した翌日から右下腹部痛が出現した．2日後に近医受診し，虫垂炎疑いで当センター紹介となった．腹部超音波と腹部単純CTで小腸内に線状の異物を認め，腸管壁を穿通していると診断し緊急手術を施行した．回盲部末端から口側約30cmの部位にメッケル憩室を認め，同部位から魚骨が上行結腸の結腸垂に穿通していた．メッケル憩室を含めた小腸切除術を施行した．メッケル憩室の多くは無症状に経過し，一部が穿孔などの合併症により偶然発見される比較的まれな疾患である．また消化管異物はしばしばみられるが，誤飲された異物が消化管穿孔を起こすのは1%以下と報告されている．今回，魚骨によりメッケル憩室穿通を来した極めてまれな症例を経験したので，文献的考察を加え報告する．

The mesh plug technique is one of the most popular procedures for inguinal hernia repair in Japan. This procedure is quick, easy, and low cost with a low recurrence rate. However, some complications associated with the mesh plug have been reported recently. We hereby present a case of an 80-year-old female admitted to our hospital with swelling and pain in the right lower abdomen 5 years after hernia repair with the PerFix plug. Discharge of urine through the route of exploratory needle puncture demonstrated the fistula of skin and the bladder. Computed tomography (CT), magnetic resonance imaging (MRI), abdominal US, and cystoscope examination revealed that the mesh plug had penetrated into the bladder. As far as we know, this is the first report that a mesh plug has migrated into the bladder.

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66歳,男性.上腹部不快感にて近医を受診.上部消化管内視鏡検査にて胃癌の診断であり,手術目的にて紹介受診された.上部消化管内視鏡検査にて胃癌は4型病変であり,生検にて印環細胞癌であった.腹部CT検査,超音波検査にて膵体尾部に腫瘤性病変を認めた. MRCPでは総胆管結石を認めるのみであったが, 3D-CT angiographyでは脾動静脈の途絶像を認めた.以上より胃膵重複癌の診断にて胃全摘+膵体尾脾合併切除術および総胆管切開術を施行した.病理学的検査にて膵病変は腺扁平上皮癌であった.胃癌の他臓器癌重複率は全悪性腫瘍のなかでも高いといわれているが,膵臓の重複率は低く,なかでも膵腺扁平上皮癌の合併は検索しうる限り本症例が初めてである.今回,われわれは極めて稀な症例を経験したので,若干の考察を加えて報告する.

慢性膵炎の経過観察中膵内に腫瘤を認め, F-18-fluorodeoxyglucose positron emission tomography (FDG-PET)にて高集積を示し,膵癌との鑑別が困難であった1例を経験したので報告する.症例は76歳男性,食思不振と体重減少を主訴に来院し,慢性膵炎急性増悪の診断にて経過観察としていた.経過中CT, MRIおよび超音波検査にて膵体部に腫瘤を検出し,腫瘤形成性膵炎と膵癌との鑑別目的でFDG-PETを施行した.同部に異常集積(standardized uptake value: SUV=5.1)を認め,さらに遅延相で増強(SUV=5.4)した.膵癌が強く疑われ,膵体尾部脾合併切除術を施行した.病理組織所見では膵の慢性および急性炎症像に一部膵管上皮の過形成性変化あり,悪性所見は認めなかった. FDG-PETは腫瘤形成性膵炎と膵癌との鑑別に有用であるが,両者の集積レベルにはオーバーラップがあり,今後とも症例を重ね評価法の工夫が必要である.

Trichoblastic carcinoma is a rare skin cancer originating from hair germ cells. We report a case of an 84-year-old man who presented with a tumor on the stoma of the descending colon, which was preoperatively diagnosed as colon cancer. He underwent colectomy with adjacent skin, and the tumor was diagnosed as trichoblastic carcinoma by postoperative pathological examination. We are not aware of any similar cases published in the English literature. Therefore, we report this case because it is quite a rare condition.

症例は, 61歳男性.全身倦怠感,発熱,体重減少を主訴に紹介医を受診.腹部CTにて肝左外側区域を中心に腫瘤像を認めたため,平成10年10月26日精査加療目的に当センター入院となった.腹部CTおよび腹部超音波検査にて肝左外側区域に長径約10cmの肝外に突出する腫瘍を認めた.また, 1番, 8番リンパ節の腫脹も認めた.腹部血管造影検査において,肝左外側区域の腫瘍は濃染像や肝動脈の狭窄は認めなかったが,門脈左枝の閉塞を認めた.以上の所見より胆管細胞癌を疑い,平成10年11月4日,肝左葉切除術を施行した.術後,病理診断にて肉腫様変化を伴った低分化肝細胞癌と診断された. 肉腫様変化を伴った肝細胞癌切除例は比較的稀であり貴重な症例であるので,若干の文献的考察を含めて報告する.

Afferent loop necrosis after Roux-en-Y cholangiojejunostomy biliary reconstruction is rare. We present the case of a 36-year-old woman with acute necrotic afferent loop obstruction. The peripheral area of the Roux-en-Y limb, including the cholangiojejunostomy portion, was twisted just proximal to the cholangiojejunostomy. Cholangiojejunostomy was completely separated due to necrosis of the Roux-en-Y jejunum. In addition to the case report, we discuss features of cholangiojejunostomy that require special attention.

In the past 6 years 14 patients with large nonparasitic liver cysts were treated by intracystic instillation of minocycline hydrochloride or/and carbon dioxide under ultrasonically guided puncture. Six patients were treated with only minocycline hydrochloride and eight patients were treated with both minocycline hydrochloride and carbon dioxide. Four patients treated with minocycline hydrochloride experienced a shrinkage of cysts by more than 80%, but the remaining two showed a decrease in size by less than 70%. On the other hand, all eight patients treated with both minocycline hydrochloride and carbon dioxide obtained a shrinkage of cysts by more than 90%. There were no serious complications in this series, so safety and shortening of hospital stay by this method were confirmed. It is concluded that ultrasonically guided intracystic instillation of minocycline hydrochloride and carbon dioxide is more effective than their use singly. The treated cysts were reducing gradually and they finally obtained obvious shrinkage of the cysts. After all, we have to avoid premature evaluation of therapeutic efficacy, and therefore, have to follow up for at least a year without repeated injections.

We evaluated the indication and problems of percutaneous transhepatic cholangiographic drainage (PTCD) under ultrasonography-guided puncture using the 21G needle with catheter in order to decrease the X-ray radiation to the operator's hands. The catheter of the 21G needle is flexible and we can performed cholangiography and insert guide wires and drainage tubes from outside of X-ray field. By this reason this method of PTCD can decrease X-ray radiation to the hands. These procedures of PTCD were performed in 214 times of 190 patients in our hospital. The punctures of the bile duct were successfully performed in all cases, but insertion of the drainage tube failed in 12 times because of insufficient dilatation under 5mm in diameter and hardness of the bile duct. As a result it is considered that this method is indicated for dilatation of the bile duct over 5mm in diameter and that the suitable angle of puncture and selection of an appropriate catheter are important. The complications in this series were bile duct bleeding in two cases, deviation of the catheter in four cases and serious shock in one case.

In a past 3-year period 15 patients with nonparasitic large cysts were treated by intracystic instillation of carbon dioxide and/or minocycline hydrochloride under ultrsasonically guided puncture. Two of three patients treated with carbon dioxide obtained a shrinkage of the cyst more than 50% in the cyst reduction rate. But the remaining cyst which was over 18cm in diameter decreased in size by less than 25%. Three of four patients treated with minocyline hydrochloride obtained a cyst reduction rate of more than 50%. The remaining cyst decreased in size by less than 50%. Eight patients were treated with both minocycline hydrochloride and carbon dioxide, and a cyst reduction rate of more than 50% was recognized in seven of eight patients. There were no serious complications and the safety of the method was confirmed. It is concluded that the ultrasonically guided intracystic instillation of carbon dioxide and minocycline hydrochloride is more effective than single use of either of them; and can be an alternative to the absolute ethanol injection therapy.

The advantage of laparoscopic surgery is obvious and has been extended to pancreatic and splenic operations. Since 1994, various laparoscopic pancreatectomy, including pancreatoduodenectomy (Gagner & Pomp, 1994), enucleation (Gagner et al., 1996; Dexter et al., 1999), and distal pancreatectomy (Gagner et al. 1996; Sussman et al., 1996), have been performed. As for laparoscopic splenectomy, nowadays it can be conducted safely even for splenomegaly due to portal hypertension (Hama et al., 2008). Open pancreatic surgery requires a relatively large incision for a small lesion, and therefore the potential benefits of the laparoscopic approach are substantial. The most common indications for laparoscopic pancreatic resection were presumed benign pancreatic diseases, such as insulinoma or localized neuroendocrine neoplasms and branch type intraductal papillary mucinous neoplasms. The most common indication for laparoscopic pancreatic resection appears to be enucleations and distal pancreatectomy. Laparoscopic pancreatectomy, however, is still technically rather difficult because of the retroperitoneal position of the pancreas and the complex anatomical relationship between the pancreas and surrounding vessels. Thus, hand-assisted laparoscopic pancreatectomy is gaining recognition as a new and feasible technique that introduces a surgeon’s hand into the abdominal cavity during laparoscopic surgery (Klingler et al., 1998; Shinchi et al., 2001; Kaneko et al., 2004). As a modification of hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is performed under direct vision extracorporeally (Hirota et al., 2009). Furthermore, laparoscopic assistance is also helpful in no-touch distal pancreatectomy for pancreatic cancer. For invasive pancreatic ductal cancers, the transection of the pancreas, splenic artery and vein, left gastroepiploic vessels, and short gastric vessels is performed at first to prevent the dissemination of cancer cells. Division of the pancreas, splenic artery, and splenic vein is done under direct vision through minilaparotomy at epigastrium. Division of the left gastroepiploic and short gastric vessels is done under laparoscope with left hand assistance. And then, retroperitoneal dissection is performed laparoscopically. In this way, the same no-touch distal pancreatectomy as open operation can be achieved.

Mortality due to acute cholangitis (AC) has been tremendously reduced by the advent of endoscopic sphincterotomy (EST). This study investigates whether EST is really a curative procedure for the treatment of AC, or not. Diagnosis of AC, in 159 out of 1,061 cases in which EST was performed, had been made by infected bile which was recognized as green or pyobile collected during ERCP. Emergency drainage by EST was performed immediately after AC was diagnosed. The causes of AC were attributable to benign diseases in 128 cases (80.5%) and malignant diseases in the remaining 31 cases. Clinical symptoms included abdominal pain, fever, and obstructive jaundice, but Charcot's triad was noticed in 66 cases (43.3%) and Reynolds pentad in only 7 cases (4.6%). As to the relation between clinical symptoms and properties of bile, pyobile was more likely to be recognized in patients with severe symptoms. Four patients treated at our hospital died of AC (2.5%). All were over 80 years old, and their conditions were already complicated by disseminating intravascular coagulation (DIC) syndrome. Compared with the results obtained in patients treated with percutaneous transhepatic biliary drainage (PTBD), the resulting mortality rate was less. Therefore, we feel the best approach for treating AC, which progresses to acute obstructive suppurative cholangitis (AOSC) in the final stage of the disease, is to diagnose early, by ERCP, and to promptly obtain decompression by subsequent EST, or to perform radical surgery.

270 Background: General rules for biliary tract cancer in Japan were revised and Stage of biliary tract cancer was compliant with the seventh UICC. Carcinoma of the Ampulla Vater (CAV) is relatively good prognosis among the biliary tract cancer, such as lymph node metastasis, pancreatic invasion and perineural invasion has been reported to be prognostic factors. We investigated the validity of TNM-Stage by examining the prognostic factors from the outcome of resection experienced. Methods: To evaluate prognostic factors after surgery based on a series of 70 patients of CAV from 1996 to 2014. Twenty-eight patients received pancreatoduodenectomy (PD), 25 patients received pylorus-preserving pancreatoduodenectomy (PPPD) and 17 patients received subtotal stomach-preserving pancreatoduodenectomy (SSPPD). We reviewed and analyzed the clinicopathologic data, surgical outcomes, recurrence and survival. Results: Actuarial disease-specific survival (DSS) was 65 % at five years. In univariate analysis, pancreatic invasion, lymph node metastasis and duodenal invasion are significantly poor prognosis. In multivariate analysis, pancreatic invasion is the only poor prognostic factor (p = 0.0023, hazard ratio (HR) 5.31 [confidence interval (CI) 1.77-18.9 95%]); lymph node metastasis and duodenal invasion are not significantly different (p = 0.0672 and 0.8769, respectively). Also, in the study of relapse risk factors, pancreatic invasion and lymph node metastasis are significantly different. In TNM-Stage II, those of T3N0, 1 are poor prognosis than T1, 2N1 (p = 0.0334). Conclusions: Pancreatic invasion is an independent poor prognostic and recurrence risk factor. The Stage of Japanese Society of Biliary Surgery has reflect prognosis than TNM-Stage in carcinoma of the Ampulla Vater.