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Patient: Female, 85-year-old Final Diagnosis: Scirrhous gastric cancer • upside-down stomach Symptoms: Heartburn • loss of appetite • vomiting Medication: — Clinical Procedure: Surgery Specialty: Gastroenterology and Hepatology Objective: Mistake in diagnosis Background: The upper stomach can be involved in 1 type of esophageal hiatal hernia in which the degree of stomach insertion is considerable and accompanied by a twist in the shaft of the stomach. The diagnostic accuracy of upper endoscopy or barium meal examination decreases in patients with upside-down stomach, thus making diagnosis of stomach lesions very difficult. No previous reports have described scirrhous gastric cancer in a patient with upside-down stomach. Case Report: An 85-year-old woman presented with loss of appetite and vomiting after eating oxalic acid-containing food 2 months previously. Computed tomography revealed an upside-down stomach, and upper endoscopy revealed loss of distensibility and superficial gastritis of the entire stomach. Upside-down stomach was diagnosed; accordingly, laparoscopic hernia repair was planned. Laparoscopic exploration revealed retention of serous fluid (i.e., ascites) containing gastric carcinoma cells (pathologically identified intraoperatively) and induration of the entire stomach. After converting to laparotomy, induration of the stomach was confirmed, continuing to the adjacent 4 cm of the distal esophagus. The patient was diagnosed with scirrhous gastric cancer. Esophageal hiatus hernia repair was performed due to the patient’s age and the risks associated with esophagojejunostomy. Preoperative complaints of symptoms disappeared. The patient was transferred to the medical hospital on postoperative day 52 with no complications. Conclusions: Specific symptoms of gastric cancer can mimic those of esophageal hiatal hernia in patients with hernia. In cases of upside-down stomach with loss of distensibility and increased wall thickness, physicians should be aware of the possibility of scirrhous gastric cancer.

Patient: Male, 70-year-old Final Diagnosis: Intravascular lymphoma • superior mesenteric vein thrombosis Symptoms: Abdominal pain Medication:— Clinical Procedure: Small intestine resection Specialty: Gastroenterology and Hepatology Objective: Unusual setting of medical care Background: Superior mesenteric vein thrombosis (SMVT) is a relatively rare form of acute abdominal disease; less than 0.1% of laparotomy surgeries are performed for SMVT. In the presence of severe intestinal ischemia or necrosis caused by SMVT, immediate surgical intervention is required. Macroscopic diagnosis of intestinal viability is sometimes difficult; its over-resection may carry the risk of short bowel syndrome. A near-infrared fluorescence imaging system with indocyanine green (ICG) has recently been developed for intraoperative, real-time evaluation of intestinal perfusion. This is the first report on the use of ICG fluorescence imaging during surgery for intestinal ischemia caused by venous thrombosis. Case Report: A 70-year-old man presented with a general feeling of weariness. On examination, he was diagnosed with intravascular large B cell lymphoma. R-CHOP therapy was initiated. On day 3 of initial R-CHOP therapy, the patient experienced sudden severe abdominal pain while in the hospital. Contrast-enhanced computed tomography revealed SMVT and loss of contrast effect in the small intestine. We diagnosed small bowel necrosis caused by SMVT, and exploratory laparotomy was performed, which revealed a continuous ischemia of 150 cm. Intraoperative ICG fluorescence imaging was utilized, and the color boundary was consistent with the ischemic area detected by visualization. The necrotic small intestine was excised and anastomosed. The patient was transferred to the hematology department on postoperative day 10 with no severe complications such as anastomotic leakage or re-thrombosis, and re-embolization was not observed 6 months later. Conclusions: Venous thrombosis should be listed as a differential diagnosis when acute abdominal disease presents during chemotherapy for malignant lymphoma. ICG fluorescence imaging may be useful in the evaluation of intestinal blood flow for venous thrombosis.

Patient: Male, 76-year-old Final Diagnosis: Appendiceal-colonic fistula Symptoms: None Medication:— Clinical Procedure: Appendectomy • wedge-shaped resection of rectum Specialty: Gastroenterology and Hepatology Objective: Unusual setting of medical care Background: Treatment methods for appendiceal-colonic fistulas differ greatly depending on whether lesions are benign or malignant. If the tumor is malignant, appendectomy with lymph node resection (ileocecal resection or right hemicolectomy) should be performed. There is no consensus on the method of surgery for organs infiltrated by appendiceal cancer. Furthermore, there are no reported laparoscopic cases that could be prevented from over-surgery by laparoscopy examination or rapid intraoperative pathological examination. Case Report: A 76-year-old man presented with positive fecal occult blood. Lower endoscopy revealed a 10-mm tumor in the rectosigmoid colon accompanied by white moss. A biopsy showed inflammatory granulation and no malignancy. Fluorodeoxyglucose-positron emission tomography showed highly increased accumulation at the tip of the appendix, and the standardized uptake value max was 7.3. We suspected a benign lesion rather than appendiceal cancer with infiltration into the rectosigmoid colon; therefore, we performed laparoscopic appendectomy and wedge-shaped resection of the rectum of the sigmoid colon. An intraoperative rapid pathological examination showed no appearance of malignancy; therefore, additional resection was omitted, and an ileostomy was created in the right lower quadrant. A permanent pathological examination showed complicated appendicitis, with no appearance of malignancy. The ileostomy was closed on postoperative day 25, and the patient was discharged on postoperative day 32. Conclusions: In cases where there is difficulty in identifying whether the appendiceal-colonic fistula lesion is benign or malignant, laparoscopy and intraoperative rapid pathological examination may be useful in avoiding excessive treatment.

Submerged aquatic vegetation (SAV) such as seagrass alters hydrodynamics as a drag force. Many studies have investigated the SAV drag force, but the time scales studied have been short (several days to a few weeks), ignoring seasonal variation, and the spatial scales have been small (several meters). Here, we performed field research and developed a new physical model incorporating seasonally varying SAV morphology (leaf length, leaf width, and shoot density) to investigate the effects of SAV drag force on the current field. We found that SAV attenuated the current velocity 50–70% during the 5-month computational period. Furthermore, the model showed a clear negative relationship between the leaf area index calculated from SAV morphology and current velocity. The physical model developed in this study can facilitate more accurate quantification of organic matter burial rates and the estimation of blue carbon sequestration by considering the SAV drag force.

症例は79歳，男性．平成19年2月上旬より発熱があり，その後悪寒戦慄，意識状態の低下があり近医を受診．CRPの上昇を認め，腹部CTにて肝左葉に低吸収域を認めたため肝膿瘍の診断に入院．入院後抗生剤投与と膿瘍ドレナージにて軽快．肝膿瘍の原因検索として胆道系に異常を認めず，大腸内視鏡でRsに全周性の2型病変を認め，生検にて高分化型腺癌であった．3月に当科入院．CTにて肝膿瘍は消失しており他に肝腫瘍の所見は認めず．直腸癌の診断にて高位前方切除を施行．病理所見は高分化型腺癌，ss，ly1，v0，n0，stageIIであった．術後経過は良好で術後17日目に退院．現在術後3年経過するが直腸癌，肝膿瘍の再燃は認めていない．本症例の様に胆道系異常の認めない原因不明の肝膿瘍では大腸癌合併などを想定した消化管精査が必要と思われた．

肝動注療法後のbiloma内にpseudoaneurysmが形成され原因不明の下血として発症した1例を経験した．症例は73歳，男性．上行結腸癌同時性多発肝転移にて回盲部切除術，胆嚢摘出術，肝動脈リザーバー留置術後に肝動注化学療法を施行した．5カ月後に肝内側区の梗塞と肝門部から肝S4にかけてのbilomaを認めた．CPT-11による全身化学療法に変更し約1年後に肝転移は消失したがbilomaに変化を認めなかった．その後下血をきたし入院した．入院から3度目のCTでbiloma内にpseudoaneurysmが認められ，MRIでbiloma内への出血と診断された．肝動脈塞栓術を施行し下血は軽快した．5カ月後，再度下血が出現．初回とは別の血管に形成されたpseudoaneurysmに塞栓術を施行した．出血源の確定にはCTを繰り返し撮影することが有用であり肝動注療法においてはbilomaの部位にpseudoaneurysmが繰り返し形成される可能性を念頭におくべきである．

膵管内乳頭粘液性腫瘍（IPMN）は粘液貯留による膵管拡張を特徴とする腫瘍で，過形成，腺腫の良性腫瘍から腺癌までを含む疾患群であり，通常型の膵癌と比べ予後が良好と言われているが，再発や多中心性発生の可能性がある．今回，われわれは膵管内乳頭粘液性腺癌（IPMC）にて膵体尾部切除後の残膵再発を切除し，さらに膵鉤部に発生した膵癌に対し残膵全摘術を施行した症例を経験した．症例は59歳男性で，1999年4月微小浸潤を伴うIPMCにて膵体尾部，脾切除術施行した．2002年11月に膵断端に嚢胞性腫瘍を認め，膵部分切除術施行した．組織所見はIPMC由来の浸潤癌と診断された．2004年7月膵鉤部に腫瘍を認め，残膵全摘術を施行した．組織所見は浸潤性低分化型腺癌であり，異時性膵癌合併が示唆された．IPMNは粘液の漏出による再発，多中心性発生，通常型膵癌の合併の可能性があり，慎重な経過観察が必要である．

To assess the possibility of using hepatocytes from ischemic liver, as a bioreactor of a hybrid artificial liver, we investigated the influence of warm ischemia on the isolation and culture of hepatocytes in rats. Warm ischemia was induced by clamping the liver hilus and the animals were divided into 3 groups according to the duration of ischemia: group A (no ischemia), group B (10 minutes) and group C (20 minutes). Hepatocytes were isolated by the collagenase perfusion method and cultured for 5 days. The yield and viability of the isolated hepatocytes were lower in group C. Rate of attachment was decreased as the duration of ischemia increased. There was no significant difference observed in functions in culture. Sufficient hepatocytes, as a bioreactor, can be isolated and cultured from warm ischemic liver within 10 minutes. Though the number of available hepatocytes were diminished, hepatocytes procured from longer warm ischemic liver could be utilized as a bioreactor.

A 3-year child presented with episodic lower abdominal pain; during the eighth attack, a mass was palpable in the left upper quadrant, and a barium enema revealed a stenotic area in the transverse colon. This was resected and an uneventful postoperative course followed. Subsequently, the child has remained symptom-free. instruments are no longer in use.