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Purpose: This study aimed to evaluate the relationship between the body mass index (BMI) and the short-term outcomes of laparoscopic total gastrectomy (LTG). Subjects and Methods: Data of patients who underwent LTG for gastric cancer at six institutions between 2004 and 2018 were retrospectively collected. The patients were classified into three groups: low BMI (= 18.5 and = 25 kg/m2). In these patients, clinicopathological variables were analysed using propensity score matching for age, sex, the American Society of Anaesthesiologists physical state, clinical stage, surgical method, D2 lymph node dissection, combined resection of other organs, anastomosis method and jejunal pouch reconstruction. The surgical results and post-operative outcomes were compared among the three groups. Results: A total of 82 patients were matched in the analysis of the low BMI and normal BMI groups. There were no differences in operative time (P = 0.693), blood loss (P = 0.150), post-operative complication (P = 0.762) and post-operative hospital stay (P = 0.448). In the analysis of the normal BMI and high BMI groups, 208 patients were matched. There were also no differences in blood loss (P = 0.377), post-operative complication (P = 0.249) and post-operative hospital stay (P = 0.676). However, the operative time was significantly longer in the high BMI group (P = 0.023). Conclusions: Despite the association with a longer operative time in the high BMI group, BMI had no significant effect on the surgical outcomes of LTG. LTG could be performed safely regardless of BMI.

Background: This study aimed to compare the postoperative outcomes after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using the overlap method or the functional method in a multicenter retrospective study with propensity score matching. Methods: We retrospectively enrolled all patients who underwent curative LTG for gastric cancer at 6 institutions between January 2004 and December 2018. Patients were categorized into the overlap group (OG) or functional group (FG) based on the type of anastomosis used in EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. The surgical results and postoperative outcomes were compared. Results: We identified 69 propensity score-matched pairs among 440 patients who underwent LTG. There was no significant between-group difference in the median operative time, intraoperative blood, or number of lymph nodes resected. In terms of postoperative outcomes, the rates of all complications [Clavien-Dindo (CD) classification >= II; OG 13.0 vs. FG 24.6%, respectively; P=0.082], complications more severe than CD grade III (OG 8.7 vs. FG 18.8%, respectively; P=0.084), and the occurrence of EJS leakage and stenosis more severe than CD grade III (OG 7.3% vs. FG 2.9%, P=0.245; OG 1.5 vs. FG 8.7%, P=0.115, respectively) were comparable. The median follow-up period was 830 days (range, 18 to 3376 d), and there were no differences in overall survival between the 2 groups. Conclusions: There was no difference in surgical outcomes and overall survival based on the type of anastomosis used for EJS after LTG. Therefore, selection of anastomosis in EJS should be based on each surgeon's preference and experience.

A 67-year-old woman was presented with a mediastinal tumor extending from the left lobe of the thyroid and passing through the posterior trachea, causing displacement of the esophagus to the left side of the patient and then descending into the right side of the mediastinum to below the carina. Surgery was performed under two-lung ventilation with the patient in a prone position; general anesthesia was performed with a single-lumen tube combined with artificial pneumothorax. In thoracoscopic surgery, we were able to confirm and preserve anatomical structures. After detachment of the tumor at the level of the left and right subclavian arteries, the patient was placed supine, a cervical incision was added, and the tumor was extracted. The tumor was diagnosed as a nonmalignant mediastinal goiter (MG). No such surgical report was found in the literature, and one would be useful for this new approach to MG removal.

Purpose: We used propensity score matching to compare the complication rates after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using a circular or a linear stapler. Methods: We retrospectively enrolled all patients who underwent curative LTG between November 2004 and March 2016. Patients were categorized into the circular and linear groups according to the stapler type used for the subsequent EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Clinicopathological characteristics and surgical outcomes were compared. Results: We identified 66 propensity score-matched pairs among 379 patients who underwent LTG. There was no significant between-group difference in the median operative time, extent of lymph node dissection, number of lymph nodes resected, rate of conversion to open surgery, or number of surgeries performed by a surgeon certified by the Japanese Society of Endoscopic Surgery. In the circular and linear groups, the rate of all complications (Clavien-Dindo [CD] classification ≥ I; 21 vs. 26%, respectively; p = 0.538), complications more severe than CD grade III (14 vs. 14%, respectively; p = 1.000), and occurrence of EJS leakage and stenosis more severe than CD grade III (5 vs. 2%, p = 0.301; 9 vs. 8%, p = 0.753, respectively) were comparable. Conclusions: There is no difference in the postoperative complication rate related to the type of stapler used for EJS after LTG.

Despite its spread and advances, laparoscopic gastrectomy (LG) for advanced gastric cancer (AGC) remains controversial. The aim of this study was to evaluate the oncologic outcomes and to identify the potential risk factors for recurrence and survival after LG in AGC patients. The medical records of patients who underwent radical LG for histopathologically diagnosed stage IB or more advanced gastric cancer from 2004 to 2012 were collected. The clinicopathologic factors and outcomes were evaluated retrospectively. LG was performed for 300 patients, with a median operative time of 278 min and blood loss of 46 ml. Postoperative morbidity was defined as Clavien-Dindo grades III and IV and occurred in 13 patients (6.3%) in the laparoscopic distal gastrectomy group. The pathologic stage was IB in 109 patients (36.3%), IIA in 77 patients (25.7%), IIB in 48 patients (16.0%), IIIA in 31 patients (10.3%), IIIB in 19 patients (6.3%), and IIIC in 16 patients (5.3%). Median follow-up period was 55.2 months. The 3-year relapse-free survival (RFS) rate was 92.7% for stage IB, 87.0% for IIA, 68.8% for IIB, 64.5% for IIIA, 47.4% for IIIB, and 43.8% for IIIC. The 5-year actual overall survival rate was 91.1% for stage IB, 72.7% for II, and 62.5% for III. Multivariate analysis revealed postoperative complication as an independent risk factor for RFS. LG for AGC was feasible and provided comparable oncologic outcomes with those previously reported. Postoperative complications correlated with poor prognosis. Randomized control trials should be conducted to confirm these results of LG for AGC in the general population.

Only a few studies have reported treatment options for stenosis after endoscopic submucosal dissection (ESD) for gastric neoplasms. This study aimed to identify the risk factors for and evaluate the management of stenosis after ESD for gastric epithelial neoplasms in the cardia and antrum. We retrospectively reviewed 1218 patients (1447 gastric epithelial neoplasms) who underwent ESD at Tonan Hospital from June 2004 to November 2015. Post-ESD stenosis was defined when a standard endoscope could not be passed through the site. Post-ESD stenosis occurred in 10 (21.3%) of the 47 cardia cases and 14 (3.2%) of the 432 antrum cases. A wide resection of more than three fourths of the circumferential extent was the sole significant risk factor related to post-ESD stenosis in both cardia and antrum. Prophylactic endoscopic balloon dilation (EBD) was performed in 3 of 10 patients with cardiac stenosis and 4 of 14 with antral stenosis. Post-EBD bleeding occurred in one cardia (10%) and one antrum (7.1%) case each and was endoscopically treated. Perforation during EBD occurred in two (14.3%) antrum cases, both of which required emergency open surgery. All complications were observed in patients with conventional EBD, and no complications were associated with prophylactic EBD. A wide resection of more than three fourths of the circumferential extent was the significant risk factor for post-ESD stenosis in both cardia and antrum, and prophylactic EBD could be a promising procedure for the management of post-ESD stenosis.

Only a few studies have reported long-term outcomes for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) in elderly patients. The aim of this study was to evaluate the efficacy of ESD for EGC in elderly patients ≥75 years with respect to both short- and long-term outcomes. We reviewed the clinical data of elderly patients ≥75 years who had undergone ESD for EGC at Tonan Hospital from January 2003 to May 2010. A total of 177 consecutive patients, including 145 with curative resection (CR) and 32 with noncurative resection (non-CR), were examined. Of the 32 patients with non-CR, 15 underwent additional surgery, and lymph node metastases were found in 3 patients. The remaining 17 patients were followed without additional surgery because of advanced age or poor general condition. Procedure-related complications, such as post-ESD bleeding, perforation and pneumonia, were within the acceptable range. The 5-year survival rates of patients with CR, those with additional surgery after non-CR, and those without additional surgery after non-CR were 84.6, 73.3, and 58.8 %, respectively. No deaths were attributable to the original gastric cancer; patients succumbed to other illnesses, including malignancy and respiratory disease. In elderly patients, ESD is an acceptable treatment for EGC in terms of both short- and long-term outcomes. Careful clinical assessment of elderly patients is necessary before ESD. After ESD, medical follow-up is important so that other malignancies and diseases that affect the elderly are not overlooked.

Chemoradiotherapy is the standard treatment for anal squamous cell carcinoma (SCC). Recently?it has been reported that a combination therapy of taxane, platinum and fluoride pyrimidine is useful for SCC. A 58-year-old woman was admitted to our hospital with anal pain and constipation. Computed tomography (CT) scan revealed a 9×6 cm tumor, stenosis in the anal region, and swollen pelvic and inguinal lymph nodes. She underwent laparoscopic ileal stomatoplasty and biopsy. A diagnosis of SCC of anal canal was confirmed by histopathological examination. She received a combination therapy with docetaxel, cisplatin and S-1 (DCS), followed by radiation therapy (RT). After her chemoradiotherapy, no abnormal accumulation was observed on a positron emission tomography-computed tomography (PET-CT) scan, and she was diagnosed with metabolic complete response (CR). The 3-drug combination therapy of taxane, platinum, fluoride pyrimidine followed by RT as primary treatment may be effective in the treatment of anal SCC.

Introduction Open thoracotomy laparotomy with extended dissection for esophageal cancer is associated with problems such as delayed postoperative recovery and decreased quality of life. In contrast, in minimally invasive surgery, these problems can be improved. In the present study, we investigated the feasibility of minimally invasive surgery in esophageal cancer. Methods In this retrospective study, we evaluated esophagectomy performed by the same surgeon in 98 patients with thoracic esophageal cancer. Open surgery was performed in 30 patients (open group), and minimally invasive surgery was performed in 68 patients (MIS group). We compared the invasiveness and radical cure of cancer by minimally invasive surgery with that of open surgery. Results Comparison between the open and MIS groups showed that intraoperative blood loss, intraoperative and postoperative transfused blood volume, and surgical site infection rates were significantly lower in the MIS group. The duration of postoperative endotracheal intubation and hospital stay were significantly shorter in the MIS group. The histopathologic type was squamous cell carcinoma in 93.3% in the open group and 92.6% in the MIS group. The respective 3-year survival rates were 36.7% and 71.5%, and the respective 5-year survival rates were 26.7% and 61.5%. Conclusion Based on a historical control study at a single institution, we are unable to conclude that minimally invasive surgery is superior to open surgery. However, our results indicate that minimally invasive surgery is feasible as a surgical procedure in esophageal cancer.

A considerable percentage of morbidity and mortality after esophagectomy for esophageal cancer is due to leakage of esophageal reconstruction, which is mainly caused by ischemia of reconstruction organ such as the stomach, free intestine, and pedunculated intestine. Therefore, we use a light-emitting diode (LED) excitation indocyanine green (ICG) fluorescence video navigation system to visually evaluate the reconstruction organ after esophagectomy, and we attempt anastomosis at a site that shows the best perfusion and for which the best possible elevation can be achieved.

患者は53歳の女性で，心窩部痛を主訴に近医受診し，CTにて十二指腸腫瘤を指摘され精査加療目的で当院紹介入院となった．精査にて十二指腸水平脚に大きさ約30 mm大の粘膜下腫瘍様の腫瘤が認められ，十二指腸gastrointestinal stromal tumor（以下，GISTと略記）と診断された．腫瘍の大きさより手術の相対的適応と判断され，腹腔鏡下腫瘍摘出術を施行した．トライツ靭帯近傍の空腸腸間膜に約40 mm大の腫瘍を認め，腸管切除を行わずに摘出術にて切除可能であった．免疫組織化学染色にて，S-100陽性，c-kit陰性，CD34陰性などの所見が得られ腸間膜神経鞘腫と最終診断した．術後経過良好にて，術後8日目に退院となった．術後12か月現在，再発を認めていない．腸間膜神経鞘腫はまれな疾患のため術前診断が困難で診断的治療としてのアプローチの選択に苦慮することが多いが，侵襲の少ない腹腔鏡下手術の良い適応と考えられた．

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, and of these, GISTs involving the rectum are uncommon. This report describes a case of effective neoadjuvant therapy for a rectal GIST expressing the c-kit gene, where a laparoscopic ultralow anterior resection was successfully performed, thus preserving the anus. A 57-year-old woman visited our hospital due to constipation and was found by a digital examination to have a soft mass on the right wall of the rectum. Computed tomography revealed an 8.0 x 5.0-cm mass with an unclear margin adjacent to the rectum. A biopsy specimen was positive for CD34 and the c-kit gene product, but it was not positive for smooth muscle actin or S-100 protein, and thus the tumor was diagnosed as GIST. An abdominoperineal resection is generally essential for large rectal GISTs; however, she refused this operation. Neoadjuvant treatment with Imatinib decreased the tumor size (4.0 x 3.5 cm) and the anus was preserved by a laparoscopic ultralow anterior resection with direct coloanal anastomosis. She had no evidence of disease for 24 months postoperatively. To preserve the anus, a rectal GIST expressing the c-kit gene is best treated with Imatinib as neoadjuvant therapy.

食道癌の化学放射線療法後のsalvage手術は侵襲が大きく, 手術関連死も含めて合併症が多いことが知られている. 治療の選択肢が多様化してきた現在, 侵襲の少ないsalvage手術術式の確立が必要と考える. 今回, 我々は中下部食道癌のsalvage手術として縦隔鏡下食道切除術を2例経験したので報告する. 症例1はstage IIの食道癌と診断され, 化学放射線療法を施行されたが, 非奏効と診断され当科紹介. 化学放射線療法後のhigh risk症例で病変が下部食道に限局していたため, 縦隔鏡下食道切除術を施行. 術後, 縫合不全を認めたものの保存的に軽快した.症例2はstage IIの食道癌と診断され, 化学放射線療法を施行. 途中, 食道穿孔と縦隔炎を発症したが保存的治療にて軽快. 食道狭窄症状が増悪したため当科紹介. 化学放射線療法後の食道穿孔を伴うhigh risk症例であり, 縦隔鏡下食道切除術を施行. 合併症なく経過し第15病日に退院した.

Purpose: A recently developed endoscopic mucosal resection (EMR) procedure, endoscopic submucosal dissection (ESD), makes en-bloc resection possible for mucosal cancer regardless of lesion size. ESD involves deeper and wider dissection of the gastric wall, and may therefore increase the difficulty of subsequent totally laparoscopic gastrectomy (TLG) and the risk of complications. However, the influence of ESD on subsequent TLG has yet to be demonstrated. The purpose of the present study was to clarify the influence of ESD on subsequent TLG. Methods: Between March 2006 and December 2013, we retrospectively collected data of 38 patients undergoing TLG with ESD (ESD Group) and propensity score matched 38 patients undergone TLG without ESD (non-ESD Group) for treatment of gastric cancer at Tonan Hospital and Hokkaido University Hospital. The covariates for propensity score matching were: age, sex, American Society of Anesthesiologists score, body mass index, and type of surgery. Clinicopathologic characteristics and surgical outcomes were compared between the two groups. Results: Operative times for TLG in ESD group and non-ESD group were 228.2 ± 53.9 and 228.1 ± 52.7 min (P=0.989), and blood loss was 45.7 ± 83.0, 71.3 ± 74.5 g, respectively (P=0.161). There were no significant differences between the groups of ESD and non-ESD in postoperative recovery and postoperative complications. In totally laparoscopic distal gastrectomy (TLDG), the patients with ESD-resected specimens of more than 50 mm in diameter had significantly longer operative times (P=0.009). Conclusions: In this study, TLG is feasible procedure treatment of gastric cancer regardless of ESD. However, TLDG is more difficult in cases where the ESD-resected specimen is more than 50 mm in diameter.

食道癌患者のうち約4～6%に肝硬変の合併が認められるが, それらの患者における術後合併症の発生率は高く, 手術成績が不良であることが知られている. 今回, 我々は門脈圧亢進症合併食道癌症例に対し, 胃管のうっ血を改善するために微小血管吻合を付加し, 縫合不全なく, 経過良好であった症例を経験したので報告する. 症例1は肝硬変による門脈圧亢進症を合併した3型食道癌であり, 食道亜全摘後に左胃静脈と前頸静脈の吻合を付加した. 症例2は肝炎により門脈圧亢進症を合併した2型食道癌であり, 左胃静脈と内胸静脈の吻合を付加した. 両症例とも血管吻合後, 肉眼的に胃管のうっ血が解消され, 術後, 縫合不全, 出血などの合併症を認めなかった.

Some studies suggest that giving radiation therapy after surgery for hilar cholangiocarcinoma improves the survival rate; however, many of these studies did not specify numbers of subjects or provide an impartial analysis. Thus, we evaluated the effectiveness of radiation therapy as adjuvant treatment after surgery and attempted to establish appropriate adaptation standards. We reviewed the records of 69 patients who underwent surgery for hilar cholangiocarcinoma between June 1980 and April 1998. Thirty-nine patients were treated with surgery followed by radiation therapy and 30 were treated with surgery alone. The clinicopathologic features that might have influenced prognosis were similar in the patients who received radiation therapy and those who did not. Radiation as adjuvant therapy did not have a beneficial effect on overall survival (P = 0.554, log-rank test); however, it tended to improve survival in the group of patients who underwent curative resection for with p-stage III or IVa disease (P = 0.042, log-rank test). Radiation therapy after surgery did not show any clinical benefits for patients with hilar cholangiocarcinoma. However, it may be effective as adjuvant therapy after curative resection in a small subgroup of patients with p-stage III or IVa disease.

Almost all reported cases of intraductal papillary-mucinous tumors of the pancreas (IPMTs) originate from Wirsung's duct (WD), the main pancreatic duct, or their branches. IPMTs arising from Santorini's duct (SD) and its branches have rarely been reported. This article presents the clinicopathologic features of IPMTs originating in SD and its branches. Of 36 IPMTs resected in our institution, 5 originated in the region of SD: 3 in SD and 2 from its branches. Both SD and WD were dilated in all cases on radiographic and ultrasonographic studies. The maximum diameter of SD, determined by computed tomography or ultrasonography, was larger than that of WD in all cases. Seven reports of IPMT arising from SD have been published. Four lesions originated from SD and the others from its branches. Overall, 9 of 12 lesions (75%) were considered malignant. In conclusion, the coexistence of an IPMT and a dilated SD suggests an origin in the SD. These tumors have a high malignant potential and should be excised.

Background The human Mut-L-Homologon-1 (MLH1) and Mut-S-Homologon-2 (MSH2) are post replication mismatch repair (MMR) genes. Methods We examined the correlation of the clinical features of 122 patients with esophageal squamous cell carcinoma (ESCC) with the expression of MLH1 and MSH2 by immunohistochemical analysis. Results According to our criteria, 34 and 25 cases did not express MLH1 and MSH2, respectively. Expression of both the MLH1 and MSH2 gene products was observed in 73 (59.8%) cases; loss of MLH1 or MSH2 expression was detected in 35(28.7%) cases. Fourteen (11.5%) cases demonstrated loss of both MLH1 and MSH2 expression in ESCC. Loss of MLH1 and/or MSH2 gene expression significantly correlated with increases in malignancy, as evidenced by increases in the existence of metastatic lymph nodes (P = 0.0056), extensive invasion (P = 0.0007), and poor differentiation (P = 0.0992). The MLH1-negative patients had a significantly poorer prognosis than those in the MLH1-positive group (P = 0.0043). Similar results were observed for MSH2 expression (P = 0.0002). Patients both MLH1 and MSH2 negative exhibited the most poor clinical outcome than other patients (P

Figure 1-4 are missed., Purpose: Stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric arteries is a radical operation performed for locally advanced cancer of the pancreatic body. However, it is not known whether the collateral pathways that develop immediately from the superior mesenteric artery to the gastroduodenal and hepatic arteries provide sufficient blood flow to support the hepatobiliary system and the stomach. This article examines the ischemic gastropathy that can occur after this procedure and identifies the predisposing conditions. Methods: Between 1997 and 2001, nine patients underwent stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric arteries. Concomitant resection of the right gastric artery or gastroduodenal artery was performed due to cancer infiltration in three patients. Results: Irregular, shallow, and wide ulcerations thought to be ischemic in origin developed in these three patients, but all the ulcerations healed in 1–2 weeks with antiulcer medication. None of the other six patients had evidence of gastric ischemia. Conclusions Ischemic gastropathy is rare after distal pancreatectomy with celiac axis resection alone; however, division of additional arteries supplying the stomach may predispose to ischemic gastropathy.

Recent studies have demonstrated the importance of tumor immunity for a cancer patient's prognosis. In some types of cancer, it has been shown through immunohistochemical analysis that the existence of CD8+ tumor-infiltrating lymphocytes (TILs) is a crucial factor in determining prognosis. In an experimental model, CD4+ lymphocytes together with CD8+ lymphocytes contributed significantly to tumor immunity.Specimens were taken from 80 surgically resected pancreatic adenocarcinomas between 1992 and 1999. Immunohistochemical staining of CD4, CD8, and S100 protein was performed, and the levels of these proteins were determined by microscopic analysis. The percentages of patients in the CD4(+) and CD8(+) groups were 59% (47/80) and 25% (16/80), respectively. When separated into 4 groups, CD4/8(+/+), CD4/8(+/-), CD4/8(-/+) and CD4/8(-/-), the overall survival rate was significantly higher in CD4/8(+/+) patients (13 cases) compared with those in all other groups combined (67 cases; P = 0.0098). CD4/8(+/+) status was negatively correlated with tumor depth and TNM stage. Multivariate analyses showed that CD4/8(+/+) status was an independent favorable prognostic factor. The number of tumor-infiltrating S100 protein positive cells was also significantly higher in the CD4/8(+/+) group than in others (P = 0.0084).In pancreatic adenocarcinoma, the presence of CD4+ TILs together with CD8+ TILs serves as a good indicator of the patient's outcome after surgical treatment.

A prospective randomized multi-center study was undertaken for 2 years and 3 months from November 1982, with the aim of examining the significance of using a combination of futraful (FT) and tamoxifen (TAM) for postoperative adjuvant therapy for stage II breast cancer after curative surgery.Patients were divided into two groups and received one of the following treatment protocols: treatment A, intravenous administration of doxorubicin (DOX) 20 mg/body on the day of surgery and 10 mg/body the next day, followed by oral FT 600 mg/day for 2 years from the 14th day after surgery; treatment B, the same pattern of DOX administration followed by combined therapy with FT and TAM 20 mg/day for 2 years. The number of patients was 428 (treatment A 210 and treatment B 218), of whom 418 (97.7%) were followed for 10 years for analysis.Significantly higher 5- and 10-year overall survival (OS) rates were observed with treatment B compared with treatment A (p=0.0101 and 0.0219). Node-positive patients appeared to derive more benefit from TAM than node-negative patients. The difference in 10-year OS between treatment A and treatment B was more evident than that of the 5-year OS in patients with more than 4 positive nodes (p=0.0313 vs. 0.0479). No increase in adverse reactions was seen as a result of combining TAM with FT.The study results demonstrate that for stage II breast cancer concomitant administration of FT and TAM is superior to FT alone for postoperative adjuvant therapy, and administration of TAM for 2 years may contribute not only to 5-year survival rates but also to 10-year survival rates of node-positive patients.

Radical esophagectomy is a highly invasive operation for esophageal cancer, and improved techniques are being sought to reduce the invasiveness of this procedure. We devised a method in which an assistant inserts their left hand into the thoracic cavity, and the operator inserts their left hand into the abdominal cavity through a small incision in the upper quadrant during an endoscopic procedure. Between 1996 and 1999, we performed endoscopic esophagectomy on 18 patients. The median number of mediastinal lymph nodes removed by thoracoscopic surgery was 20.1 +/- 9.4 and the median number of abdominal lymph nodes removed by laparoscopic surgery was 11.1 +/- 5.6. The number of nodes dissected by endoscopic surgery did not differ significantly from the number of nodes dissected by conventional thoracotomy with laparotomy. Our experience shows that endoscopic esophagectomy with reconstruction of the esophagus assisted by inserting the hand into the thoracic and abdominal cavity, for safety and certainty, is an effective technique that is much less invasive than radical esophagectomy performed by conventional thoracotomy with laparotomy.

Effective treatment has not yet been established for intestinal pseudo-obstruction, a rare complication of malignant pheochromocytoma. We report the case of a 41-year-old man who presented with malignant pheochromocytoma associated with pseudo-obstruction of the colon. His serum catecholamine level was markedly elevated, and his large intestine was distended with gas and lodged stool. Laxatives and enemas were not effective in relieving his symptoms. We subsequently performed an ileostomy, after which the patient had good bowel movement and was able to resume oral food intake.

A 65-yr-old man who underwent pancreaticoduodenectomy with portal vein resection for pancreatic cancer is alive 8 yr after surgery. Originally, computed tomography (CT) revealed an 8-cm tumor in the pancreatic head. The tumor had infiltrated the portal vein, but grew expansively, so there was neither biliary obstruction nor jaundice. Pancreaticoduodenectomy with resection of the portal vein was performed for pancreatic cancer. Many tumor-infiltrating lymphocytes were seen within cancer cell nests on routine histopathology. We performed immunostaining for CD8, and found that a large number of the lymphocytes were CD8+ T cells. The patient’s prognosis was considered poor because the tumor was large and had infiltrated the portal vein. We suspect that long-term survival may be related to the response of CD8+ T cells to the cancer.

大腸癌の同時性卵巣転移の2症例を報告した.症例1, 25歳,女性.下腹部腫瘤を主訴に当院産婦人科を受診し,左卵巣腫瘍の診断にて,開腹手術を受けた.開腹時,卵巣とは別個にS状結腸にも全周性腫瘍病変が認められたため,ハルトマン手術を併施した.病理検査の結果, S状結腸癌の左卵巣転移と診断された.症例2, 56歳,閉経女性.腹痛,嘔吐を主訴に当科を受診し,下行結腸腫瘍による腸閉塞の診断にて,緊急的に横行結腸に人工肛門を造設した.その後の精査により,右卵巣腫瘍も認められたため,結腸左半切除術,子宮全摘術,両側附属器切除術を施行した.病理検査の結果,下行結腸癌の右卵巣転移と診断された.本邦における転移性卵巣腫瘍の原発巣としては胃癌が最も多く,大腸癌は比較的稀である.今回,大腸癌同時性卵巣転移の2例を経験したので,若干の文献的考察を加え報告する.

Portal vein resection (PVR) has become more widely performed owing to improvements in the perioperative mortality rate. The present study was performed to determine whether portal vein infiltration is a contraindication against radical pancreatectomy for patients with pancreatic carcinoma. Between 1990 and 1997, a total of 66 patients with invasive ductal carcinoma of the pancreas underwent surgical resection at the Department of Surgery II, Hokkaido University Hospital. After the exclusion of those who underwent distal pancreatectomy, the remaining 43 patients were divided into a PVR(+) group (n= 28) and a PVR(−) group (n= 15). The clinicopathological characteristics, morbidity, and mortality were statistically compared between the two groups. The overall survival rate of the patients who required PVR was not significantly different from that of those who underwent pancreatic resection without PVR. These findings suggest that combined PVR should not be a contraindication to radical pancreatectomy for pancreatic carcinoma with positive vascular invasion.

BACKGROUND Caveolin-1 plays a regulatory role in several signaling pathways. Recently caveolin-1 was identified as a metastasis-related gene in prostate carcinoma. However, the clinical impact of caveolin-1 expression in esophageal carcinoma remains unknown. METHODS One hundred thirty surgical specimens of esophageal squamous cell carcinoma were immunohistochemically assessed for caveolin-1 expression by polyclonal antibody. Caveolin-1 immunoreactivity was correlated with patients' clinicopathologic parameters and outcome. RESULTS Positive caveolin-1 immunostaining was detected in 58 patients (44.6%). Positive caveolin-1 immunostaining correlated positively with pathologic stage (P = 0.029), pN (P = 0.023), and pM (P = 0.018). The overall survival rate was worse in patients with caveolin-1-positive tumors than in patients with caveolin-1-negative tumors (P = 0.0215). Univariate analyses identified caveolin-1 positivity (P = 0.0238), pT (P = 0.0002), pN (P < 0.0001), pM (P = 0.0002), lymphatic invasion (P = 0.0021), and positive surgical margin (P < 0.0001) as negative prognostic predictors. Multivariate analyses indicated that pT (P = 0.0296), pN (P = 0.0003), and a positive surgical margin (P = 0.0452) were independent prognostic factors. CONCLUSIONS Over-expression of caveolin-1 is associated with lymph node metastasis and a worse prognosis after surgery in esophageal squamous cell carcinoma. Cancer 2002;94:929–33. © 2002 American Cancer Society. DOI 10.1002/cncr.10329

A 28-year-old woman developed repeated neck swelling and remission over a 4-month period. Benign mediastinal teratomas also extended along her cervical region. It was not a teratoma which primarily developed in the neck. In this case, rich pancreatic tissue was histologically observed. The mechanism of the particular extension of the tumor considered to be: (1) an encasement by anatomical structures and the right-sided hard wall of the tumor, and (2) pancreatic tissue which developed cystic formation.

A 32-year-old man was admitted to our hospital complaining of abdominal pain in the left upper quadrant. A mass was palpable on the left side of the umbilicus. Laboratory data revealed anemia, elevated erythrocyte sedimentation rate, hypergammaglobulinemia, and prolonged prothrombin time. Computed tomography demonstrated a soft tissue mass in the mesentery of the jejunum, portal venous thrombosis, and cavernomatous transformation in the porta hepatis. The patient was eventually diagnosed by laparoscopic partial resection as having inflammatory pseudotumor of the mesentery. Four months later, all of his symptoms and abnormal laboratory findings completely disappeared without any therapy. Inflammatory pseudotumor should be kept in mind as a cause of portal venous thrombosis, and/or cavernomatous transformation although it is rare.

The practice of endoscopic surgery spread quickly around the world after an endoscopic cholecystectomy was performed in the late 1980s, and the number of organs to which endoscopic surgery is applied has increased steadily. Endoscopic treatment was actually introduced in the 1960s in the field of gynecology, and it was implemented in the form of single-port laparoscopic surgery (SPLS). The application of SPLS to many different organs is, however, something that began to emerge only a few years ago, and the recent rapid spread of SPLS is due largely to technological advances in endoscopic surgery over the past few years. The umbilical incision used in SPLS is subject to scar contraction; after surgery the scar shrinks so that it is almost unnoticeable. From a cosmetic perspective, the procedure offers greater advantage to patients than any other surgical method currently in general use. For surgeons, who are constantly required to reduce the cosmetic impact and implement minimally invasive approaches, SPLS is worthy of serious consideration. This chapter reviews the history of, and transitions in, SPLS, per the organ(s) to which it is applied.

Hepatectomy for liver metastases from colorectal cancer has recently received general acceptance as a safe, potentially curative treatment. Most patients, however, die of recurrent disease after hepatectomy. The predictive factors for recurrence after first resection of liver metastases have not yet been clarified. The authors aimed to determine the factors that can predict recurrence, especially hepatic-only recurrence after hepatectomy for colorectal liver metastases. Seventy-six patients who underwent liver resection of colorectal metastases were studied retrospectively. Forty-seven (61.8%) of the patients had a recurrence. The patients' disease-free survival after first hepatectomy and the second recurrence sites were univariately and multivariately analyzed using 16 clinicopathologic variables. Wall invasion, lymph node metastases, lymphatic invasion, venous invasion of the primary tumor, 24 months or longer disease-free interval after resection of the primary colorectal cancer, and bilateral liver metastases significantly influenced the disease-free survival (log-rank test: p0.05). The multivariate analysis revealed that venous invasion of the primary tumor and bilateral hepatic metastases were independent risk factors for recurrence after hepatectomy. The liver was the only site of second recurrence in 23 patients. Patients with lymph node metastases and venous invasion of the primary tumor had a significant difference between hepatic-only and extrahepatic recurrence after first hepatectomy (chi-square test or Fishers' exact test: p0.05). Recurrence after hepatectomy was influenced more by factors associated with the primary colorectal cancer than factors surrounding the first liver metastases. Venous invasion of the primary colorectal cancer was the most important predictable factor for hepatic-only second recurrence.

We report a case of immunoglobulin G4 (IgG4)-related lung disease presenting as a solitary pulmonary nodule with an irregular margin on computed tomography. The nodule showed a high standardized uptake value on positron emission tomography. A malignant pulmonary tumour could not be excluded. Middle lobectomy was performed. Histological analysis revealed marked lymphoplasmacytic infiltration and storiform fibrosis. Immunostaining indicated the presence of IgG4-positive plasma cells. A definitive diagnosis of IgG4-related disease was confirmed.

症例は95歳の女性. 開腹手術の既往なし. 主訴は腹痛, 嘔吐でイレウスと診断され外科転科となった. 小腸造影で小腸に滑らかな狭窄を認めた. その後, その肛門側に両端が狭窄した絞扼小腸ループ像が造影され2つの狭窄部は同位置で重なり合い, それより肛門側は造影されなかった. CT検査では腹水, 絞扼小腸像, 腸間膜の収束像を認めたが, 腫瘍など明らかなイレウスの原因を認めなかった. 以上より腸間膜や大網の裂孔による内ヘルニアと診断し, 開腹手術を施行した. Treitz靭帯より約130cmの部位から約80cmの空腸が直径約4cmの大網裂孔に嵌頓しておりこれを整復した. 術後経過は良好であった. 本症例では術前診断に小腸造影とCT検査が有用であった. 開腹歴のないイレウスの原因として内ヘルニアを念頭に置く必要があり早期診断が重要であると考えられた. なお, 本症例は本邦におけるこれまでの大網裂孔ヘルニア手術報告例の中で最高齢であった.

中下部胆管と肝内胆管に発生した異時性重複癌の1例を経験したので報告する. 症例は49歳の女性で1994年6月, 中下部胆管癌の診断で膵頭十二指腸切除術(Whipple再建)を施行, 絶対的治癒切除であった. 4年後, 下痢を主訴に再入院し, 腹部CTと胆道造影で中下部胆管癌のPTBD肝内瘻孔癌再発を疑い, 拡大肝左葉切除・尾状葉切除, 肝門部胆管空腸吻合部切除, 右肝内胆管空腸Roux-en-Y吻合を施行した. しかし病理組織学的所見から原発性胆管細胞癌と診断され, 異時性の重複癌と判明した.

症例は79歳の男性で発熱, 嘔吐, 上腹部痛を主訴に当院入院となった. 臍右側に腫瘤を触知した.腹部単純X線検査, 腹部超音波検査, 腹部CT検査, 大腸内視鏡検査, 注腸造影検査にて上行結腸横行結腸型腸重積に加えて盲腸癌が嵌頓して発症したイレウスと診断され, 緊急手術を施行した. 開腹すると上行結腸が先進部となり横行結腸右側まで入り込んだ結腸結腸型の腸重積に加えて盲腸癌を先進部として回盲部, 腸間膜がさらに嵌頓した盲腸結腸型の腸重積が確認された. なお移動盲腸も認めた. 重積状態のまま結腸右半切除術, D2リンパ節郭清術を施行したが盲腸癌は5.5×5.0cmの2型で, 組織学的には高分化腺癌, stage IIであった. 上行結腸には先進部の原因となるような器質的病変は認められず, この部位の重積の発症原因は特発性と考えられた. 自験例を含む最近10年間の盲腸癌による成人腸重積症の本邦報告例27例を集計し文献的考察を加えた.

We report a case of nonfunctioning endocrine tumor of the pancreas with extrapancreatic growth and cyst formation. A 48-year-old woman was admitted to our hospital with an upper abdominal mass, which was detected during a routine medical checkup. The preoperative diagnosis was a solid cystic tumor of the pancreas. The tumor, which measured about 7 cm in diameter, arose from the head of the pancreas and had a thin stalk, measuring about 1 cm in diameter. The histopathological diagnosis was a malignant nonfunctioning endocrine tumor of the pancreas. Cyst formation occurred in 67% of the reported cases with extrapancreatic growth in Japan. It is speculated that the cyst formation in this disease is related to the large size of the tumor and to the extrapancreatic growth.

Background: We have performed total pharyngolaryngoesophagectomy in case of double cancer, head–neck and thoracic esophageal cancer, or cervical esophageal cancer that extended down to the level of aortic arch. The procedure is very challenging. Methods: From April 1984 to May 1998, 14 patients underwent the procedures for double cancer of head–neck and thoracic esophagus (n=10), hypopharyngeal or cervical esophageal cancer (n=3), and synchronous esophageal cancer (n=1). The grafts used were whole stomach (n=6), elongated stomach roll (n=5), and stomach roll with free jejunum (n=3). The routes of reconstruction were posterior mediastinum (n=10), antesternal (n=3), and retrosternal (n=1). Results: Elongated stomach roll with microvascular anastomoses was long enough for reconstruction and the blood supply of the graft was sufficient. There was no fatal complication in this procedure. Oral feeding was achieved in 13 (93%) patients. Conclusions: The elongated stomach roll with microvascular anastomosis is efficient and the placement of the conduit in the posterior mediastinum is recommended to allow a better alimentary comfort in total pharyngolaryngoesophagectomy.

We report herein a rare case of an adenomyoepithelioma of the breast. A 21-year-old woman was admitted to our hospital for a painless lump in the upper outer area of the right breast. Ultrasonography of the breast demonstrated a 5-cm hypoechoic mass with a clear border and posterolateral shadow. The ratio of breadth to length of the tumor was 0.31. Ultrasound-guided fine-needle aspiration cytology showed class II. Wide excision of the tumor was performed. Histologically, the tumor was composed of proliferation of both epithelial and myoepithelial cell components. The mitotic index of the clear myoepithelial cells was low. Follow-up for fifty-six months has revealed no evidence of local recurrence or metastatic spread of the tumor. To our knowledge, this patient is the youngest one with this disease reported in the literature.

症例は23歳の女性. 右下腹部痛, 発熱を主訴に当科受診. 典型的な急性虫垂炎の所見を呈していたため, 腹腔鏡下に虫垂切除術を施行した. 虫垂の病理診断はAcute on chronic appendicitisと報告された. しかし, 術後も微熱, 右下腹部痛, CRP高値の持続がみられ諸検査にてCrohn病と診断された.その後, 上行, 横行結腸の狭窄が高度となりイレウス症状も出現したため結腸右半切除を施行し, その切除標本において病理学的にCrohn病が確認された. 虫垂の病理所見を再検討したところ虫垂根部に裂溝に伴う限局性急性炎症像がみられ, その深層に巨細胞を伴う非乾酪性肉芽腫を認めたことから, Crohn病による急性化膿性炎症と最終診断された. 本症例のように急性虫垂炎の原因としてCrohn病によるものがありえるため, 鑑別診断の1つとして本症を念頭に置くべきであり, また虫垂切除後の発熱, 腹痛, 炎症反応の持続がみられた場合は早期に本症を疑った精査が重要である.

Background: Distal splenorenal shunt (DSRS) with splenopancreatic disconnection (SPD) is an ideal operation for permanent control of variceal bleeding. However, it is a very complicated procedure, and DSRS without SPD has a functional disadvantage: It gradually loses its selectivity and portal blood flow. To overcome these conditions, we designed a new technique — modified DSRS, which is easy to perform and maintains long-term selectivity of the shunt. Methods: Modified DSRS was performed by using an external iliac vein graft without treating small pancreatic tributaries of the splenic vein. It was applied in 4 cases, and shunt patency and selectivity were examined by angiography during follow-up periods (6-76 months). Results: Modified DSRS was technically more feasible and less complicated than DSRS with SPD. Every attempt was successful. There was no operative mortality, and all the patients were discharged from the hospital in good condition. The shunts were patent in all of them, and the selectivity of the shunt was maintained better in comparison to standard DSRS. Conclusions: Modified DSRS is a much easier and safer technique than standard DSRS. We consider this procedure to be the best method for surgical management of portal hypertension causing esophageal and gastric varices. (Surgery 1999:126:577-80.)

We evaluated postoperative results in 49 patients (39 men, 10 women) who underwent pharyngoesophageal reconstruction with free-jejunal autograft following total pharyngolaryngoesophagectomy in the Department of Otolaryngology, Hokkaido University School of Medicine from 1989 to 1997. Evaluation was performed regarding the following points: 1) postoperative complications, 2) factors that determine the functional results of swallowing, 3) relation between forms of jejunal anastomosis and swallowing. The primary malignancy site was hypopharynx (39), cervical esophagus (4), larynx (3), thyroid (2) and trachea (1), Reconstructions were made with free jejunal autograft alone in 45 cases and with free jejunum in combination with gastric pull-up in 4. In patients who underwent reconstruction with jejunum alone, the anastomosis of the jejunum to the pharynx was performed in side-to-end fashion in 22, end-to-end in 18 and rho-shaped in 4. In the 1 remaining case, we used jejunal-patch graft. Postoperative complications including minor or nongraft related, occurred in 24 of 49 (49.0%) patients. Among these, graft-related complications were graft failure in 1 (2.0%), fistula formation in 3 (6.1%) and graft stricture in 2 (4.0%). Re-operations were required in one case of graft failure and 2 of fistula formation. Consequently, the overall graft-survival rate was 98.0% (48/49). Therefore, we considered the method of reconstruction to be a reliable procedure with a high-success rate. The swallowing function after reconstructive surgery was studied in 35 patients who underwent side-to-end (18) and end-to-end (17) anastomosis of the jejunum to the pharynx. We indicated that appropriate tension in the jejunum was the most important factor for adequate swallowing function. The end-to-end group had a higher rate of taking normal diet compared with the side-to-end group. The rate of swallowing dysfunction was only 5.9% (1/17) in the end-to-end group. On the other hand, 4 of 18 (22.2%) cases in the side-to-end group were regarded as having poor swallowing function. As a result we considered the end-to-end proximal jejunal anastomosis to be the more desirable form.

過去10年間の教室入院例を対象として, 長期生存率と術後のQOLから, 膵癌に対する門脈, 動脈合併切除再建の適応について検討した. 対象例の切除率は54%で, そのうち門脈単独の合併切除再建は36.8%に, 動・門脈合併切除再建は8.8%に施行した. 門脈単独切除例では血行再建を行わなかった切除例と比べ, 術後の合併症, 直接死亡率, 生存率に差を認めなかった. 動・門脈合併切除例では術後の合併症, 直接死亡は高率で, 生存率は血行再建を行わなかった切除例に比べて悪く, 平均生存はわずか7か月であった. これは非切除例とも差はなかった. さらに, 動・門脈合併切除例では非切除例と比べて在宅生存日数も改善をみなかった. 以上から進行膵癌に対する門脈合併切除は門脈浸潤例の予後を非浸潤例と同等にまで改善しうるが, 動脈浸潤例に対する動・門脈合併切除再建はその適応がないと考えられた.