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The mesentery of the jejunum (MJ) of the Roux limb is conventionally divided when Roux-en-Y reconstruction is performed after total gastrectomy for gastric cancer (GC). However, the impact of dividing or preserving the MJ on anastomotic leakage (AL) at the esophagojejunostomy (EJS) site after minimally invasive total gastrectomy for GC is unclear.This retrospective cohort study enrolled 226 patients with GC who underwent EJS after laparoscopic or robotic total gastrectomy, including preservation of the MJ (n = 87) and division of the MJ (n = 137). The prevalence of anastomotic complications at the EJS and short-term outcomes were compared between groups using propensity score (PS) matching.After PS matching, 69 patients were selected for the preserving and dividing MJ groups. There were no significant intergroup differences in patient backgrounds, including oncological stage, body mass index, and gender ratio. After PS matching, overall and severe complications after surgery were compared between the preserving and dividing MJ groups (21.7% vs. 27.5%, p = 0.554 and 8.7% vs. 13.8%, p = 0.137, respectively). However, the rate of AL at the EJS was significantly lower in the preserving than that in the dividing MJ group (1.4% vs. 13.0%, p = 0.017). In addition, the median postoperative hospital stay was significantly shorter in the preserving than that in the dividing MJ group (13.0 days vs. 16.0 days, p = 0.005).Preserving the MJ significantly reduced AL at the EJS after minimally invasive total gastrectomy for GC.

In Japan, the actual number of stoma constructions and stoma closures is not known. The aim of this study was to conduct a survey to determine the number of gastrointestinal stoma constructions and closures in Japan.Enrolled participants comprised patients undergoing selected gastrointestinal surgeries who were recorded in the National Clinical Database. This database uses the "Common Items for Gastrointestinal Surgeons." These procedures were formulated by the Japanese Society of Gastroenterological Surgery during 2013-2018.According to the National Clinical Database, a total of 154,323 gastrointestinal stomas were constructed between January 1, 2013 and December 31, 2018. By procedure, there were 78,723 cases of stoma construction, 39,653 of abdominoperineal resection, 2470 total pelvic exenteration procedures, and 33,572 Hartmann's procedures. The ratio of stoma closures to stoma constructions increased annually in patients under 70 y of age but not in older patients. Approximately 35% of total colectomies, 60% of proctocolectomies, and 20% of low anterior resections were accompanied by stoma construction. The number of patients with rectal cancer who underwent colostomy increased gradually during the study period and the number who underwent stoma construction increased among older patients.The number of cases of gastrointestinal stoma construction has increased gradually in Japan, and the proportion of older patients is increasing each year. The purposes and surgical techniques for stoma construction are diverse and are expected to increase in Japan, a super-aged society.

Objective. The aim of this study was to elucidate treatment outcomes for frail patients with gastric cancer (GC) who undergo gastrectomy.Methods. Frailty was assessed preoperatively by frailty index (FI) in 209 patients aged 65 and over undergoing gastrectomy for GC. Patients were assigned into two groups (frail vs. non-frail). Short-term outcomes and loss of independence (LOI) after discharge were compared. Results. Frail patients undergoing gastrectomy had more intraoperative blood transfusions, longer hospital stays, and higher medical costs. The overall complication rate was significantly higher in frail patients. Pneumonia and urinary tract infections were more frequent in the frail patients. In multivariate analysis for LOI after discharge, frailty, older age (≧ 75 years), and open surgery were independent risk factors. A risk score assigning 1 point for each of these variables was useful in predicting postoperative LOI (LOI: score 0, 6.8%; score 1, 26.1%; score 2, 47.6%; score 3, 100%; area under the curve [AUC]=0.748.) Conclusions. Frailty is associated with LOI after gastrectomy in elderly GC patients. A simple risk score assigning points for frailty, age ≧75, and open surgery was an accurate predictor of postoperative LOI. We propose that frailty screening should be applied for all elderly GC patients before surgery.

Highlights • Stent-graft placement is a viable option for treatment of portal vein hemorrhage. • Postoperative hemorrhage was caused by extrahepatic portal vein pseudoaneurysm formation. • Portal vein pseudoaneurysm occurred at the reconstructed portion., Introduction Potential curative therapy for perihilar cholangiocarcinoma requires extensive surgical treatment, which can still be associated with significant morbidity and mortality. Postoperative hemorrhage from the portal vein is a rare but life-threatening complication. We herein report postoperative hemorrhage from an extrahepatic portal vein pseudoaneurysm successfully treated by stent graft placement late after surgical treatment for perihilar cholangiocarcinoma. Presentation of case An 83-year-old man was referred to our hospital with a chief complaint of jaundice. Based on radiological findings, we diagnosed the patient with hilar cholangiocarcinoma. After endoscopic retrograde biliary drainage, resection of the extrahepatic bile duct combined with extended left hemi-hepatectomy, including the caudate lobe, lymphadenectomy of the hepatoduodenal ligament, partial resection and reconstruction of the portal vein, and right hepaticojejunostomy was performed. Fourteen days postoperatively, bleeding through the abdominal drain around the portal vein was observed. Twenty days postoperatively, abdominal computed tomography revealed a portal vein pseudoaneurysm that had formed at the portion of reconstruction. Therefore, 24 days postoperatively, a stent graft placement of the pseudoaneurysm through the ileocolic vein was performed. Subsequently, the portal vein hemorrhage ceased. Discussion Our present postoperative extrahepatic portal vein hemorrhage case was caused by an extrahepatic portal vein pseudoaneurysm that had formed at the reconstructed portion by erosion due to the chemical effect of the leaking bile and mechanical irritation of the surgical drain adjacent to the portal vein. Conclusion Stent-graft placement is a minimally-invasive, safe, and effective treatment option for hemorrhage from postoperative portal vein pseudoaneurysm.

A 78-year-old man without hepatitis virus B or C underwent right hemi-hepatectomy and lymph node dissection for a tumor 5 cm in diameter located in the hepatic hilum of the posterior segment of the liver with portal vein thrombi extending into the main portal trunk and a tumor 1.5 cm in diameter in the peripheral side of segment 5 of the liver. Histopathologically, the former was diagnosed as intrahepatic cholangiocarcinoma and the latter as hepatocellular carcinoma(HCC). Five months after the surgery, intrahepatic and lymph node metastases were diagnosed based on computed tomography(CT); therefore, chemotherapy with S-1 for 3 months and gemcitabine and cisplatin(GC)for 5 months was administered, after which the metastatic lesions were not detected. Nineteen months after the surgery, partial resection of segment 2 of the liver was performed for a tumor 3 cm in diameter, which was diagnosed as HCC histopathologically. Two years after the second surgery, 2 recurrent nodules in the liver in segments 3 and 4 were detected on CT. Platinum-based hepatic arterial infusion chemotherapy(HAIC)and transcatheter arterial chemoembolization(TACE)were performed, and chemotherapy with GC was then administered for 7 months. For a new tumor detected in segment 1 in the liver, TACE was performed 17 months after initial HAIC. Seventy-four months after the initial surgery, 5 new nodules less than 1 cm in diameter were detected, and chemotherapy with sorafenib was administered for 5 months, after which the patient died of coronavirus disease 2019.

A 76-year-old woman had underwent 5-fluorouracil(5-FU), oxaliplatin(L-OHP)combination therapy(mFOLFOX6)as first-line chemotherapy for peritoneal recurrence after resection of sigmoid colon cancer. She showed severe general fatigue and disturbance of consciousness on the second day of the 12th course of chemotherapy. Computed tomography of the head detected no abnormal findings in the central nervous system. The laboratory results revealed a marked hyperammonemia. She was diagnosed as a disturbance of consciousness due to hyperammonemia and treated her with branched- chain amino acid solution. Then the disturbance of consciousness resolved on the following day. After changing the regimen of chemotherapy, the disturbance of consciousness was not found. Recently, it has been reported that high-dose 5-FU regimen such as mFOLFOX6 causes hyperammonemia as a rare adverse event. We should take hyperammonemia into account when disturbance of consciousness occurs during high-dose 5-FU chemotherapy.

A 75-year-old woman underwent transcatheter chemoembolization(TACE)for 2 small hepatocellular carcinoma(HCC) lesions associated with severe alcoholic liver cirrhosis that necessitated management for ascites. Over 5 years after the initial TACE, she received multidisciplinary therapies with TACE, transcatheter arterial infusion of anticancer agents, percutaneous ethanol injections, or percutaneous radiofrequency ablation performed on 5 occasions for small recurrent HCC lesions. Computed tomography performed after the last therapy for HCC revealed a solitary lymph node swelling(39 mm in diameter) around the common hepatic artery. Magnetic resonance imaging performed 3 months later revealed that the lymph node had enlarged to 45 mm, without recurrence of the primary HCC, and after 4 months, to 60 mm; she then underwent laparoscopic lymph node resection. Histopathological examination of the resected specimen showed HCC metastasis. A recurrent metastatic lymph node(30 mm in diameter)was detected around the common hepatic artery and was resected laparoscopically 17 months postoperatively. Pancreatic head cancer was diagnosed 22 months after the second surgery; however, the patient refused cancer therapy and died 16 months after this diagnosis. No recurrence of the primary HCC or lymph node metastasis was observed over the 38 months after the second surgery.

A 45-year-old man with unresectable locally advanced pancreas head cancer with multiple synchronous liver metastases was treated with gemcitabine plus nab-paclitaxel therapy as a first-line chemotherapy. During 24 months of 30 courses of this therapy, the primary lesion remained stable and liver metastases were completely disappeared on CT. Three months later, however, solitary relapse of liver metastasis occurred in segment 2. Therefore, we changed the chemotherapy regimen to the second-line treatment, FOLFIRINOX. After 3 courses of FOLFIRINOX, the primary lesion was kept well-controlled, but the solitary metastatic liver lesion was enlarged. An interdisciplinary team suggested surgical resection of the liver metastasis to control disease progress. We performed laparoscopic lateral segmentectomy of the liver. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. The patient underwent another round of gemcitabine therapy owing to the good response of the primary pancreatic lesion to this drug. Three years after starting the first-line chemotherapy, the patient is still alive with well-controlled PDAC without distant metastasis. Surgical intervention for liver metastases may be a promising treatment option when unresectable primary PDAC is well controlled by chemotherapy.

Background Anastomotic leakage is a serious, sometimes critical complication of upper gastrointestinal (GI) surgery. The cavity and target drainage tubes are difficult to reach; therefore, a nasogastric tube (NGT) and fasting are required for an extended period. We successfully treated and managed two patients with anastomotic leakage using percutaneous transesophageal gastro-tubing (PTEG). Case presentation In case 1, a 79-year-old man with gastric cancer underwent total gastrectomy; 1 week later, he underwent emergent open laparotomy due to panperitonitis attributed to anastomotic leakage-related jejunojejunostomy. We resected the portion between esophagojejunostomy and jejunojejunostomy and reconstructed it using the Roux-en-Y technique. On postoperative day (POD) 9, anastomotic leakage was diagnosed at the esophagojejunostomy site and jejunotomy staple line. After using a circular stapler for jejunojejunostomy, a stapled jejunal closure was added. We inserted an NGT and performed aspiration for bowel decompression. As he did not improve within 2 weeks, we decided to perform PTEG to free him of the NGT. We kept performing intermittent aspiration; leakage stopped shortly after, due to effective inner drainage. The PTEG catheter was removed after oral intake was restarted. In case 2, an 81-year-old man with esophagogastric junction cancer underwent resection of the distal esophagus and proximal stomach. After shaping the remnant stomach, esophagogastrostomy was performed under the right thoracotomy. On POD 11, anastomotic leakage was identified, along with a mediastinal abscess. We inserted an NGT into the abscess cavity through the anastomotic leakage site. On POD 25, we performed PTEG and inserted a drainage tube, instead of an NGT. Although the abscess cavity disappeared, anastomotic leakage persisted as a fistula. We exchanged the PTEG with a double elementary diet (W-ED) tube with jejunal extension, with the side hole located near the anastomosis. The anastomotic fistula disappeared after treatment. Dysphagia persisted due to disuse atrophy of swallowing musculature; PTEG was useful for enteral feeding, even after the leakage occurred. Conclusion Patients are sometimes forced to endure pain for a long time for transnasal inner drainage. Using PTEG, patients will be free of sinus pain and discomfort; PTEG should be helpful for patients withstanding NGT.

A 77-year-old man presented with biliary colic and was diagnosed with descending colon cancer and cholelithiasis.During the surgery, a mass was detected in the upper jejunum, located 5 cm from the Treitz ligament on the anal side.Open left hemicolectomy with partial jejunal resection was performed.The mass in the small intestine was diagnosed as solitary small intestinal metastasis of colon cancer through immunohistopathological examination.Isolated intestinal metastases of colorectal cancers are rare.Furthermore, synchronous metastases are rare among these cases.A previous study reported poor prognosis in patients with small intestinal metastasis; therefore, more studies on the small intestinal metastasis of colorectal cancer are necessary.

The patient was a 67-year-old man with multiple liver metastases from sigmoid colon cancer and had received capecitabine, oxaliplatin, and bevacizumab(CAPOX plus Bev)combination chemotherapy. After 11 courses of this therapy, he had a rupture of esophageal varices and was treated with endoscopic variceal ligation(EVL). Esophageal varices are rare during the course of oxaliplatin-based chemotherapy. More studies are necessary for early detection of esophageal varices during this therapy.

A 71-year-old man underwent right hemi-hepatectomyfor a hepatocellular carcinoma(HCC)measuring 18 cm in diameter. The pathological diagnosis was poorlydifferentiated HCC. Ten months after the surgery, computed tomographyrevealed a nodule 12mm in diameter in the right lung as well as 2 nodules measuring 19 and 11mm in diameter in the retroperitoneum at the cranial aspect of the left kidney. Four months later, the nodule in the right lung had enlarged to 44 mm, while the 2 nodules in the retroperitoneum had enlarged to 68mm and 34 mm. These nodules were resected and histopathologicallydiagnosed as metastasis from HCC. Twenty-one months after liver resection, computed tomographyrevealed nodules 16 and 25mm in diameter in the retroperitoneum around the urinarybladder and jejunum, respectively. One month later, intussusception resulted from the jejunal tumor. Laparoscopic surgerywas performed for both tumors, which were diagnosed as metastases from HCC. Twenty-five months after liver resection, metastasis from the HCC appeared in the left adrenal grand, at the site of the jejunal anastomosis, and in the fattytissue around the right scapula. Twenty-nine months after liver resection, the patient died of respiratoryfailure from multiple metastases in the left lung.

Introduction and importance Endoscopic intervention is considered first-line therapy for common bile duct (CBD) stones, in recent times. However, surgically altered anatomy and consequent inaccessibility of the duodenal papilla necessitate surgery in some patients. Case presentation A 61-year-old woman presented with fever and right subcostal pain. She underwent total gastrectomy and Roux-en-Y reconstruction for gastric ulcer, 4 years prior to presentation. Based on the clinical findings, she was diagnosed with acute obstructive cholangitis secondary to a CBD stone. Endoscopic retrograde biliary drainage was attempted; however, the duodenal papilla was endoscopically inaccessible owing to the previous Roux-en-Y reconstruction, and we performed percutaneous transhepatic gallbladder drainage (PTGBD). She underwent laparoscopic cholecystectomy and choledocholithotomy, 6 days after the PTGBD. Choledocholithotomy was attempted using basket forceps under choledochoscopic guidance; however, this procedure was unsuccessful, and we performed laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon. Clinical discussion Usually, laparoscopic cholecystectomy concomitant with CBD exploration is performed in patients with an endoscopically inaccessible duodenal papilla. However, an inadequately opened basket may not capture large impacted stones at the duodenal end of the CBD. Intraductal shock wave lithotripsy (electrohydraulic or laser lithotripsy) is considered in such cases; however, the specialized instruments required for this procedure are unavailable at all centers. Laparoscopic choledocholithotomy using a laparotomy biliary lithotomy spoon may be useful to overcome this surgically challenging situation. Conclusion A laparotomy biliary lithotomy spoon is a simple, user-friendly, and economical device that may be useful for laparoscopic lithotripsy and lithotomy of impacted stones., Highlights • Endoscopy did not show the duodenal papilla owing to surgically altered anatomy. • Stone impaction was observed at the terminal portion of the common bile duct. • Choledochoscopic basket lithotomy could not be performed. • Laparoscopic lithotomy was performed using a laparotomy biliary lithotomy spoon.

Our aim was to determine factors predictive of long-term post-gastrectomy outcomes in older adults with pathological stage I gastric cancer (GC).A total of 175 patients with resected pathological stage I GC at two institutions were reviewed, each ≥75 years old at the time of gastrectomy and full participants in a 5-year follow-up program. The procedures were undertaken between January 2006 and December 2011. Patients were divided into two groups: survivors and non-survivors at postoperative Year 5. Univariate and multivariate analyses were applied to identify independent predictors of 5-years survival, including preoperative, surgical, and histopathologic variables.Multivariate analysis of overall survival (OS) at 5 years indicated that prognostic nutritional index (PNI)45 and the American Society of Anesthesiologists physical status (ASA-PS) 3 were independently associated with unfavorable outcomes. A clinical score consisting of 1-point each for these two variables proved useful in predicting survival after gastrectomy (5-year OS: 0 point, 86.6%; 1-point, 51.6%; 2-point, 33.3%; p .001, area under the curve [AUC] = 0.757).Long-term survival of older adults with pathological stage I GC is unfavorable in patients displaying both ASA-PS 3 and PNI 45. A simple scoring method, based on combined ASA-PS/PNI determinations, provides an accurate prognostic prediction for these patients.

A 70's man underwent subtotal stomach preserving pancreatoduodenectomy(SSPPD)for pancreatic head cancer. The pathological diagnosis was adenosquamous carcinoma(ASC)of the pancreas. Two months after surgery, a recurrent tumor in the remnant pancreas was confirmed with a CT scan and suspected to be ASC by endoscopic ultrasound-guided fine needle aspiration(EUS-FNA). As the recurrent lesion was limited in the pancreas, total remnant pancreatectomy(TP)was performed 4 months after SSPPD. The final pathological diagnosis was ASC. Two months after TP, liver and para-aortic lymph node metastases were revealed. The patient has been alive for 14 months after SSPPD with chemotherapy. Because of its rarity, it is difficult to implement treatment plans for recurrent ASC in the remnant pancreas.

A 58-year-old man complaining of dysphagia was admitted to our hospital and diagnosed with esophageal cancer.He underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection and reconstruction with a gastric tube created by hand-assisted laparoscopy.The pathological diagnosis was classified as AeLtG, pT3N2M0, pStage III .He was subsequently treated with systemic chemotherapy with 5-fluorouracil and cisplatin.After 2 courses, a single liver metastatic tumor appeared at segment 5.As chemotherapy against the recurrence, weekly-paclitaxel was administered.After 2 courses, the metastatic liver tumor reduced in size.Subsequently, laparoscopic partial liver resection was performed 11 months after first surgery.The pathological finding was negative for malignancy(pathological complete response).

Gastrointestinal stromal tumors (GISTs) of the stomach are found incidentally during gastric cancer screening in Japan. This study investigated whether the Japanese gastric cancer screening system helps to improve treatment outcomes in gastric GIST based on an analysis of the GIST registry conducted by the Kinki GIST Study Group. The registry was designed to collect data on background characteristics, treatment methods, pathologic characteristics, and prognosis of GIST from January 2003 through December 2007 at 40 participating institutions. The study enrolled 672 GIST patients, 482 of whom had gastric GIST. According to the modified National Institutes of Health consensus criteria, 22.6 % of the patients were classified as high risk for recurrence, 18.5 % as intermediate risk, 35.9 % as low risk, and 13.9 % as very low risk. After exclusion of the patients inevaluable for treatment outcome, the study included 137 symptomatic patients (symptomatic group) and 147 asymptomatic patients (asymptomatic group). The diagnosis of the asymptomatic patients was determined through gastric cancer screening. The median tumor size in the asymptomatic group was significantly smaller than in the symptomatic group (3.5 vs. 5.3 cm; P

Previous studies have revealed that an elevated preoperative serum C-reactive protein (CRP) level is associated with a poor prognosis in patients with various malignant tumors. The aim of this study was to determine the clinical significance of the preoperative serum CRP level in patients with stage IV colorectal cancer.We enrolled 144 patients who underwent surgery for stage IV colorectal cancer. A total of 53 patients with a serum CRP level of ≥ 1.0 mg/dl were classified as the high CRP individuals. The association between the preoperative serum CRP level and survival was retrospectively assessed.The cancer-specific survival of the patients with a high CRP level was significantly worse than that of the patients with a low CRP level. A multivariate analysis indicated that the curability (non-curative surgery), the number of organs with metastasis (more than one organ), the tumor diameter (≥ 5 cm), lymphatic involvement, histological differentiation (non-differentiated) and a high CRP level (≥ 1.0 mg/dl) were independent risk factors for a poor survival.A high preoperative serum CRP level is a convenient biomarker for identifying patients with a poor prognosis for stage IV colorectal cancer.

No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years. We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY. Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position. SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.

The prognosis of HCC with vascular invasion is dismal, but surgery is elected when the hepatic reserve is adequate. The case involved a 68-year-old male HCV carrier. A 10 cm diameter tumor occupying the central 2 segments of the liver and liver metastasis in the left lobe were detected. The patient was diagnosed with multiple HCC with severe vascular invasion of Vp2 and Vv3. The tumor shrunk dramatically after starting HAIC therapy with cisplatin and oral administration of sorafenib. A laparoscopic partial hepatectomy was performed for the viable lesion. The tumor showed almost complete coagulative necrosis. Multiple hepatic metastases were found 4 months after surgery, but the tumor was under control at 25 months after the first HAIC due to HAIC, oral administration of sorafenib, and RFA. An improved prognosis for multiple HCC with severe vascular invasion can be expected by performing multidisciplinary treatments including surgery.

We conducted a meta-analysis to evaluate and compare the outcomes of laparoscopic and open surgery for the treatment of patients with acute appendicitis. We searched MEDLINE, EMBASE, Science Citation Index, and the Cochrane Controlled Trial Register for relevant papers published between January 1990 and February 2012. We analyzed 22 outcomes of laparoscopic and open surgery for acute appendicitis. We identified 39 papers reporting results from randomized controlled trials that compared laparoscopic surgery with open surgery for acute appendicitis. Our meta-analysis included 5,896 patients with acute appendicitis; 2,847 had undergone laparoscopic surgery, and 3,049 had undergone open surgery. Compared with open surgery, laparoscopic surgery was associated with longer operative time (by 13.12 min). However, compared with open surgery, laparoscopic surgery for acute appendicitis was associated with earlier resumption of liquid and solid intake; shorter duration of postoperative hospital stay; a reduction in dose numbers of parenteral and oral analgesics; earlier return to normal activity, work, and normal life; decreased occurrence of wound infection; a better cosmesis; and similar hospital charges. Laparoscopic surgery may now be the standard treatment for acute appendicitis.

Purpose: We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopy-assisted colectomy (LAC) and open colectomy (OC) for colon cancer.Methods: We searched MEDLINE, EMBASE, Science Citation Index, and Cochrane Controlled Trial Register for relevant papers published between January 1990 and October 2011 by using the search terms “laparoscopy,” “laparoscopy-assisted,” “surgery,” “colectomy,” “colon cancer,” and “randomized clinical trials (RCTs)”. We analyzed the outcomes of each type of surgery over short- and long-term periods.Results: We selected 12 papers reporting RCTs that compared LAC with OC for colon cancer. Our meta-analysis included 4614 patients with colon cancer; of these, 2444 had undergone LAC and 2170 had undergone OC. In the short-term period, we found that the rates of overall postoperative complications and ileus in LAC were lower than in OC groups. LAC was associated with a reduction in intraoperative blood loss, a shorter duration of time to resumption and hospital stay, and lower rates of overall complication and ileus over the short-term, but with similar long-term oncologic outcomes such as overall and cancer-related mortality, overall recurrence, local recurrence, distant metastasis, and wound-site recurrence, compared to OC.Conclusions: It is suggested that LAC may be preferred to OC for colon cancer.

Purpose: We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopy-assisted colectomy (LAC) and open colectomy (OC) for colon cancer. Methods: We searched MEDLINE, EMBASE, Science Citation Index, and Cochrane Controlled Trial Register for relevant papers published between January 1990 and October 2011 by using the search terms “laparoscopy,” “laparoscopy-assisted,” “surgery,” “colectomy,” “colon cancer,” and “randomized clinical trials (RCTs)”. We analyzed the outcomes of each type of surgery over short- and long-term periods. Results: We selected 12 papers reporting RCTs that compared LAC with OC for colon cancer. Our meta-analysis included 4614 patients with colon cancer; of these, 2444 had undergone LAC and 2170 had undergone OC. In the short-term period, we found that the rates of overall postoperative complications and ileus in LAC were lower than in OC groups. LAC was associated with a reduction in intraoperative blood loss, a shorter duration of time to resumption and hospital stay, and lower rates of overall complication and ileus over the short-term, but with similar long-term oncologic outcomes such as overall and cancer-related mortality, overall recurrence, local recurrence, distant metastasis, and wound-site recurrence, compared to OC. Conclusions: It is suggested that LAC may be preferred to OC for colon cancer.

Background The role of elastography for breast tumors is still ambiguous. The purpose of this study was to inquire how effectively elastography can be used in the diagnosis of breast tumors.

症例は68歳，男性．不消化性の下痢，曖気の精査加療目的で入院となった．腹部CTで下行結腸～脾彎曲にかけて13cm大の腫瘤性病変を認めた．下部消化管内視鏡検査では下行結腸に隆起を主体とする5型病変を認め，ファイバーは潰瘍底より容易に胃内へと挿入された．腫瘍からの生検で高分化型腺癌と診断された．胃結腸瘻を形成した進行下行結腸癌と診断し，左半結腸切除術，D3リンパ節郭清，胃全摘，膵尾部・脾臓合併切除術を施行した．最終診断はmuc，si，n0，ly0，v0，ow(－)，aw(－)，stageIIで，手術根治度Aであった．われわれは内視鏡が通過することで診断できた胃結腸瘻を形成した下行結腸癌の1例を経験したので，自験例を加えた本邦報告25例の集計および文献的考察を行った．

症例は41歳，女性．妊娠28週目に腹痛を認めたため，前医を受診した．精査にて横行結腸癌を疑われたため，当科紹介となった．大腸内視鏡検査にて横行結腸腫瘍を認め，生検にてtub2と診断された．明らかな遠隔転移は認めなかったため，産科医および小児科医との相談の上，妊娠29週であることから，帝王切開術および横行結腸切除術を施行した．帝王切開にては1,280gの女児（Apgar score 8/9）を出産した．病理組織検査にて横行結腸癌（tub2，ss，n2，ly0，v1，H0，P0，M0，Stage IIIb）と診断した．妊娠中に消化器癌を合併する頻度は非常に少なく，なかでも大腸癌は妊娠10万例に1～2例といわれ，非常に稀である．治療方針は妊娠時期や患者および家族の意思を考慮する必要がある．今回妊娠中に切除した横行結腸癌の1例を経験したので，若干の文献的考察を加えて報告する．

症例は63歳男性で，急性膵炎を発症し，精査の結果膵体部の主膵管に腫瘍性病変が認められた．膵管内腫瘍または小膵癌の診断のもと膵体尾部切除およびリンパ節郭清を行った．切除標本において，主膵管内に充満するやや白色調の10mm大の腫瘍を認めた．腫瘍内部は異型細胞がスリット状の管腔を有しながら増殖しており，周囲の膵管に乳頭状隆起を伴っていた．膵管内乳頭粘液性腺癌との鑑別に苦慮したが，膵管内管状腺癌と診断した．膵管内管状腫瘍は，2010年に出されたWHO分類ではIntraductal papillary mucinous neoplasm（IPMN）とは別にIntraductal tubulopapillary neoplasm（ITPN）として新しく定義されるようになったが，膵癌取扱い規約第6版では膵管内乳頭粘液性腫瘍に含まれており，その位置づけは明確にされていない．本邦では膵管内管状腺癌は自験例を含め13例の報告をみるにすぎず，臨床病理学的に不明な点が多い．今後さらに症例を蓄積し，病態の検討を重ねていく必要があると考えられた．

症例は58歳，女性．他院にて上行結腸のポリープに対し，大腸内視鏡下ポリープ切除術を施行された．当日夕より腹痛と嘔吐を認めた．間欠的な腹痛の増悪を認めるため，翌日朝に当院救急外来を受診した．来院時の腹部CT検査では明らかなイレウス像を認めなかったが，嘔気と腹痛が持続していたため，経過観察目的にて入院となった．同日夕に腹痛の増悪を認めたため，入院時CT検査より10時間後に腹部CT検査を再度施行した．骨盤内に小腸のループ形成を認め，腹水の貯留も認めたため，内ヘルニアによる絞扼性イレウスの診断にて同日緊急手術を施行した．左子宮広間膜の異常裂孔に小腸が迷入し，終末回腸近傍の小腸が嵌頓しており，虚血性変化をきたしていた．子宮広間膜裂孔を開放し，回盲部切除を行った．大腸内視鏡を契機として発症したと考えられるまれな子宮広間膜ヘルニアの1例を経験したので，若干の文献的考察を交えて報告する．

Purpose: We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopic colorectal surgery (LCRS) and conventional open surgery (OCRS) for colorectal cancer (CRC).Methods: We searched relevant papers published between January 1990 and May 2011. We analyzed the outcomes of each type of surgery over the short- and long-term periods.Results: In the short-term period, we found no significant differences in overall perioperative complications and anastomotic leakage between LCRS and OCRS groups. We found no significant differences in overall, distant, local and wound-site recurrence, overall mortality, 3 and 5 year disease-free survival rate, and cancer-related mortality between the 2 groups.Conclusions: LCRS has the benefits of reducing intraoperative blood loss, earlier resumption of oral intake, and shorter duration of hospital stay in the short-term. The long-term outcomes of LCRS seem to be similar to those of OCRS.

単孔式のストーマの造設術は，消化器外科手術，とくに大腸外科領域においては基本となる手術手技である．手術手技については施設，術者によって種々報告されているが，明確なエビデンスにもとづいた「標準」といったものはない．現時点での標準と考えられる，単孔式ストーマ造設手術手技について解説する．合併症の少ない，管理しやすい良好な消化管ストーマを造設することは,患者および家族にとってとても重要であり，すべての外科医が会得すべき手技である．

症例は62歳，男性．37年前に十二指腸潰瘍に対して胃切除術の既往がある．1カ月前から嘔気・嘔吐を認めるようになり近医受診した．腹部CTで吻合部に腫瘤影と輸入脚の著明な拡張を認めた．同日の上部消化管内視鏡検査では吻合部に全周性の3型腫瘍を認め，残胃癌による輸入脚閉塞症と診断し緊急手術を施行した．前回手術はBillroth-II法の結腸後経路で再建されており，Treitz靱帯から吻合部の空腸は暗赤色を呈し著明に拡張していた．残胃全摘術，膵尾部・脾臓合併切除術を施行した．治癒切除であったが，術後3カ月で胃癌死された．残胃癌による輸入脚閉塞症の本邦論文報告7例について，集計および文献的考察を行った．

症例は34歳，男性．腹痛を自覚し近医を受診した．腹部超音波検査，腹部CT検査にて膵鈎部尾側に4cm大の腫瘤と多発肝腫瘍を認めた．同病院にて試験開腹術を施行し，術中診断は膵腫瘍及び多発肝転移であった．術中に施行した肝生検の組織診断は高分化型膵内分泌細胞癌であった．術後軽快退院後，当院を紹介受診した．血液検査所見では血中インスリン値，ガストリン値，グルカゴン値は正常範囲内であった．以上より，非機能性膵内分泌細胞癌の多発肝転移と診断し，etoposide（ETP）とcisplatin（CDDP）による化学療法を行った．化学療法後の腹部CT検査では膵腫瘍と肝転移巣の増大はなく，新たな肝転移巣も認めず，肉眼的に切除可能と判断し，幽門輪温存膵頭十二指腸切除術，横行結腸部分切除術及び肝部分切除術を施行した．切除標本の病理組織診断は高分化型膵内分泌癌であり，免疫組織学的にはsynaptophysin（+）， chromograninA（-），glucagon（+），serotonin（-），insulin（-），SSTR2a（+）であった．術後14カ月後の現在，残肝再発を認めるも健存中である．

稀な十二指腸乳頭部神経内分泌細胞癌の1例を経験したので報告する．症例は78歳，女性．肝機能異常を指摘され当院を紹介受診した．腹部CT検査で膵頭部に1.5cm大の腫瘤と肝内胆管の拡張を認め，精査加療目的に入院となった．上部消化管内視鏡検査で十二指腸乳頭部の粘膜の不整を認めた．同部の生検組織の免疫染色でCD56，synaptophysin，chromogranin Aが陽性で，神経内分泌細胞由来と考えられた．リンパ節郭清を伴う幽門輪温存膵頭十二指腸切除術を行った．病理組織検査結果は十二指腸乳頭部の神経内分泌腫瘍で，Ki-67/MIB1指数は低く，リンパ節転移を認めたため高分化型神経内分泌癌と診断された．患者は術後1年4カ月の現在，無再発健存中である．