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Background Amoebiasis caused by the protozoan species Entamoeba histolytica rarely develops into fulminant amoebic colitis (FAC), but when it does, it shows an aggressive clinical course including colonic perforation, necrotizing colitis, and high mortality. Surgical treatment for FAC patients should be carried out urgently. However, even after surgery, the mortality rate can be 40–50%. Although FAC is one of the most unfavorable surgical diseases with a poor prognosis, there are a few reports on the perioperative diagnosis and management of FAC based on autopsy findings. We herein report the surgical case of a 64-year-old man who developed multiple colon necrosis and perforation due to FAC. A detailed autopsy revealed FAC as the cause of death. Additionally, we reviewed the existing literature on FAC patients who underwent surgery and followed their perioperative diagnosis and management. Case presentation A 64-year-old man presented with anorexia, diarrhea, and altered consciousness on arrival to our hospital. Computed tomography revealed a large mass in the upper right lobe of his lung, and the patient was admitted for close investigation. Bloody diarrhea, lower abdominal pain, and hypotension were observed soon after admission. Urgent abdominal contrast-enhanced computed tomography scan revealed extensive intestinal ischemia, intestinal pneumatosis, and free intra-abdominal gas. The preoperative diagnosis was bowel necrosis and perforation with intussusception of the small intestinal tumor. Emergency subtotal colectomy and enterectomy were performed soon after the contrast-enhanced computed tomography. He was taken to an intensive care unit after surgery. However, he could not recover from sepsis and died with disseminated intravascular coagulation and multiple organ failure on the 10th-day post-surgery. A histopathological examination of the resected colon showed transmural necrosis and massive amoebae invasion. He was diagnosed with FAC. An autopsy revealed that he had developed pulmonary large cell carcinoma with small intestinal metastasis. The death was caused by intestinal ischemia, necrosis and the perforation of the residual bowel caused by amoebae invasion. Conclusions Since FAC is a lethal disease with a high mortality rate and antibiotic therapies except metronidazole are ineffective, preoperative serological testing and perioperative metronidazole therapy in FAC patients can dramatically improve their survival rates.

Background Systemic inflammation and immune response play crucial roles in tumor growth; neutrophil-to-lymphocyte ratio (NLR) is a known systemic inflammatory scoring system. Previous studies have reported that NLR is a prognostic biomarker in various human cancers. The aim of this study was to determine whether the NLR predicts tumor recurrence in patients with stage I-II rectal cancer after curative resection. Methods We retrospectively analyzed 130 consecutive patients with stage I-II rectal cancer who underwent curative resection between January 2006 and March 2015 at our institution without any preoperative treatment. We investigated whether clinicopathologic factors including NLR were associated with cancer recurrence after curative surgery. Results There were four cases (3.1%) of cancer-specific deaths and 16 cases (12.3%) of recurrence; the 5-year disease-free survival rate was 85.6%. NLR, pathologic T-category, and lymphatic invasion were significantly associated with disease-free survival. Multivariate analysis further showed that these three factors were independently associated with disease-free survival. Conclusions Preoperative NLR could predict tumor relapse in stage I-II rectal cancer and might be a useful biomarker for predicting recurrence in patients undergoing curative resection.

Background Intraductal papillary neoplasm of the bile duct (IPNB) is a subtype of biliary tumor. The 5-year survival rate of patients with IPNB who underwent curative resection is 81%. However, IPNB is known to often recur in other parts of the bile duct. Nevertheless, its mechanism remains poorly understood. Herein, we report the case of a patient with recurrent IPNB, which was considered to be attributed to intraductal dissemination in the common bile duct at 12 months after curative resection. We also made a review of the existing literature. Case presentation A 69-year-old man was referred to our hospital for the evaluation and dilation of an intrahepatic bile duct (IHBD) mass. Computed tomography (CT) findings confirmed a mass in the left hepatic duct. Left trisectionectomy, extrahepatic bile duct resection with biliary reconstruction, and regional lymph node dissection were performed. Intraoperative examination of the resection margin at the common bile duct and posterior segmental branch of the hepatic duct was negative for the presence of malignant cells. Histologically, the tumor showed intraductal papillary growth of the mucinous epithelium and was diagnosed as non-invasive IPNB. It had a papillary structure with atypical epithelial cells lined up along the neoplastic fibrovascular stalks. Immunohistochemically, this was as a gastric-type lesion. At 12 postoperative months, CT revealed a 1.5-cm mass in the lower remnant common bile duct. We performed subtotal stomach-preserving pancreaticoduodenectomy. The tumor exhibited papillary growth and was microscopically and immunohistochemically similar to the first tumor. At approximately 16 months after the patient’s second discharge, CT showed an abdominal mass at the superior mesenteric plexus, which was diagnosed as recurrent IPNB. Chemotherapy is ongoing, and the patient is still alive. In this case, as described in many previous reports, IPNB recurred below the primary lesion in the bile duct. Conclusion Based on our review of previous reports on IPNB recurrence, intraductal dissemination was considered one of the mechanisms underlying recurrence after multicentric development. Considering the high frequency and oncological conversion of recurrence in IPNB, regular follow-up examination is essential to achieve better prognosis in patients with recurrent IPNB.

Background Acute mediastinitis is a rare disease that rapidly progresses with a high mortality rate. Its most common cause is direct injury of the mediastinum, including iatrogenic causes such as cardiac surgery or upper endoscopy. Enzymatic mediastinitis is a rare complication of a pancreatic fistula caused by the inflammatory digestion of the parietal peritoneum spreading to the mediastinum. Here, we present two cases of enzymatic mediastinitis caused by total gastrectomy with splenectomy. One of them was successfully treated and cured after early diagnosis and transabdominal drainage. Case presentation Case 1 was that of a 60-year-old man (body mass index [BMI] 27) with a medical history of diabetes and hypertension who was diagnosed with advanced gastric cancer in the upper body of the stomach. A total gastrectomy with splenectomy was performed. The patient experienced acute respiratory failure 24 h after surgery. Pulmonary embolism was suspected, so a computed tomography (CT) scan was performed; however, no relevant causes were found. Although he was immediately intubated and treated with catecholamine, he died in the intensive care unit (ICU) 40 h after surgery. Post-mortem findings revealed retroperitonitis caused by a pancreatic fistula spreading towards the mediastinum, causing severe mediastinitis; a review of the CT scan revealed pneumomediastinum. We concluded that the cause of death was enzymatic mediastinitis due to post-gastrectomy pancreatic fistula. Case 2 involved a 61-year-old man (BMI 25) with a medical history of appendicitis who was diagnosed with advanced gastric cancer at the gastric angle between the lesser curvature and the pylorus, spreading to the upper body of the stomach. A total gastrectomy with splenectomy was also performed. The patient had a high fever 3 days after the surgery, and a CT scan revealed pneumomediastinum, indicating mediastinitis. As the inflammation was below the bronchial bifurcation, we chose a transabdominal approach for drainage. The patient was successfully treated and discharged. Conclusion Acute mediastinitis caused by gastrectomy is rare. The acknowledgment of abdominal surgery as a cause of mediastinitis is important. In treating mediastinitis caused by abdominal surgery, transabdominal drainage may be a minimally invasive yet effective method if the inflammation is mainly located below the bifurcation of the trachea.

We performed esophagojejunostomy after totally laparoscopic total gastrectomy (TLTG) using functional end-to-end anastomosis (FEEA) as the first choice and laparoscopic-assisted total gastrectomy (LATG) using a circular stapler with a transorally inserted anvil as the second choice.We examined 109 patients with gastric cancer who underwent TLTG and LATG. Among these, 100 patients underwent TLTG and the rest underwent LATG.The length of resected esophageal segment in LATG patients was significantly longer than that in TLTG patients (P0.001). The length of the resected esophagus segment was inversely correlated with body mass index in cases of esophagojejunostomy by FEEA (P0.05). Multivariate analysis revealed that T factor, N factor, and severe complications were the independent factors for survival.Esophagojejunostomy using FEEA or a circular stapler with a transorally inserted anvil should be selected according to the length of the resected esophageal segment and/or body mass index.

Key Clinical Message We encountered a patient with a large retroperitoneal solitary fibrous tumor, in whom we could preserve approximately 150 cm of the ileum even after pancreaticoduodenectomy combined with resection of the superior mesenteric artery, thus preventing short bowel syndrome.

Mesenteric phlebosclerosis is a recently discovered rare ischemic colon disease. The relationship between mesenteric phlebosclerosis and the use of herbal medicine containing gardenia fruit was recently reported. Although the relationship between colon cancer and mesenteric phlebosclerosis has not been described, some cases of colorectal cancer coincident with mesenteric phlebosclerosis have been reported. We treated a 63-year-old female who was diagnosed with ascending colon cancer coincident with mesenteric phlebosclerosis. She had been taking a Chinese herb containing gardenia fruit for over 18 years. The ascending colon cancer was clinically diagnosed as T2, N0, and M0 according to Japanese classification of colorectal carcinoma and the mesenteric phlebosclerosis had spread from the cecum to the descending colon. She underwent laparoscopic subtotal colectomy with en bloc removal of the regional lymph nodes, and both the ascending colon cancer and mesenteric phlebosclerosis were completely resected. The microscopic findings show that the tumor was well-differentiated tubular adenocarcinoma invading the muscular propria with no regional lymph node metastasis, and the mesenteric phlebosclerosis lesion was characterized by marked fibrous thickening of the venous walls with calcification, marked transmural fibrosis and deposition of the collagen in the mucosa, accompanied by macrophages within the vessel walls. In literature review, 10 cases with colorectal cancer coincident with mesenteric phlebosclerosis were reported. 9 of 10 cases (90%) had cancer in the right-side colon affected by mesenteric phlebosclerosis, and 5 of 10 cases (50%) were associated with the use of a Chinese herb containing gardenia fruit. It was recently demonstrated that genipin, which is a metabolite bio-transformed from gardenia fruit, possesses carcinogenesis. We speculate that genipin may be associated with not only the development of mesenteric phlebosclerosis but also carcinogenesis in the right-side colon. In conclusion, our findings suggest that the safety of gardenia fruit should be re-evaluated, and gastroenterologists should be aware that gardenia fruit may be risk factor for not only the development of mesenteric phlebosclerosis but also carcinogenesis in the proximal colon.

The impact of oral capecitabine as adjuvant chemotherapy for Japanese patients with resected colon cancer was unclear. We previously planned and conducted a prospective feasibility study (KSCC0803) and reported on the safety of oral capecitabine as adjuvant chemotherapy for Japanese patients with resected stage III colon cancer. The purpose of the current study was to assess the survival results from that study. The study subjects were Japanese patients with resected stage III colon cancer. The protocol adjuvant regimen consisted of oral capecitabine 1250 mg/m2 twice daily on days 1–14 of a 3-week cycle for a total of eight cycles. The 3- and 5-year disease free survival (DFS) rates and overall survival (OS) rates were analyzed in the eligible cohort. Ninety-seven patients were registered between September 2008 and August 2009 and treated with the protocol regimen. The median follow-up time was 60.7 months. The 3- and 5-year DFS rates were 71.2% [95% confidence interval (CI): 61.7–79.8%] and 69.7% (95% CI: 59.4–77.8%), respectively. The 3- and 5-year OS rates were 92.6% (95% CI: 85.2–96.4%) and 84.5% (95% CI: 75.1–90.5%), respectively. The survival results in this study are in line with those of previously reported, reliable, studies. The safety and tolerability of the protocol regimen have already been confirmed. Oral capecitabine is acceptable as adjuvant chemotherapy for Japanese patients with resected stage III colon cancer.

Background Hepatoid carcinoma (HC) is an extra-hepatic neoplasm that shares the morphological and immunohistochemical features of hepatocellular carcinoma. Pancreatic HC exists as either pure or combined type. Pure pancreatic HC is extremely rare, with only a few cases reported in the literature to date. Because of the rarity of pure pancreatic HC, its clinical features including incidence, behavior, and prognosis remain unclear. We herein report the case of a 56-year-old man who developed pure pancreatic HC treated with surgical resection. We also include a review of the existing literature. Case presentation A 56-year-old male patient was admitted to our hospital after a pancreatic cyst was identified by abdominal ultrasonography on a comprehensive medical examination. Endoscopic ultrasound revealed a cystic mass measuring 13 mm in size in the pancreatic head and a low-density mass measuring 16 mm in size in the pancreatic tail, which was partially enhanced on contrast-enhanced ultrasound. Contrast-enhanced computed tomography (CT) revealed a branch duct type intraductal papillary mucinous neoplasm in the pancreatic head and an early enhanced nodule measuring approximately 10 mm in size in the pancreatic tail. Endoscopic ultrasound-guided fine-needle aspiration of the hypervascular tumor was performed. The hypervascular tumor was suspected to be a solid pseudopapillary neoplasm. Laparoscopic spleen-preserving distal pancreatectomy was performed. Histology was identical to hepatocellular carcinoma of the liver. Immunohistochemically, the tumor cells were positive for hepatocyte paraffin 1, and a canalicular pattern was confirmed on the polyclonal carcinoembryonic antigen staining. The patient was diagnosed with a moderately differentiated pancreatic HC. The patient was followed up without adjuvant chemotherapy, and there was no evidence of recurrence at 6 months post-operatively. Conclusions We present a case of moderately differentiated pure pancreatic HC. For the accurate preoperative diagnosis of pure pancreatic HC, biopsy is preferred to cytology or preoperative imaging studies such as CT. The prognosis of pure pancreatic HC depends on its differentiation.

Patients with advanced esophageal cancer frequently experience dysphagia and dyspnea, and relief of such symptoms is important. We wished to clarify the efficacy of endoscopic stent placement in patients with dysphagia or dyspnea caused by advanced esophageal cancer. A database of patients with esophageal cancer who underwent esophageal and airway stent insertion between 2005 and 2012 was analyzed retrospectively. Effects and complications of stent insertion, and survival after stent insertion, were investigated. Eighteen patients were treated by esophageal (n = 10) and/or airway (n = 9) stent placement. Marked improvements in food intake were recognized in eight patients after esophageal stenting. Marked improvements in breathing were observed in all patients after airway stenting. Dysphagia scores in the esophageal stent group as well as dyspnea grades in Common Terminology Criteria for Adverse Events v4.0 (CTCAE 4.0) in the airway stent group were significantly improved (p = 0.0078). In the esophageal stent group, major complications (CTCAE grade ≥3) occurred in seven of ten patients (70 %). In the airway stent group, major complications occurred in three of nine patients (33 %). Median survival of all 18 patients was 87.5 (range 13–1952) days after esophageal and/or airway stent placement. Stent placement is effective for the improvement of malignant dysphasia and dyspnea caused by advanced esophageal cancer.

This study is a case report on a 49-year-old woman who had a gastrectomy and lymphadenectomy for pStage IIIa gastric cancer. Shortly after a 12-month course of adjuvant chemotherapy, CT showed a nodule adjacent to the gallbladder. High (18) F-fluorodeoxyglucose accumulation was detected, with a standardized uptake value of 10. Therefore, laparoscopic excision was performed for diagnosis and treatment. The histopathological finding was suture granuloma. Suture granulomas with high standardized uptake values on PET scans are uncommon and often cause surgeons to provide an inaccurate diagnosis. Our study suggests that suture granuloma should be included in the differential diagnosis of a new or recurrent mass detected in patients with a history of prior surgery; however, surgeons must bear in mind that false-positive fluorodeoxyglucose-PET results can be observed in suture granuloma.

Despite the widespread use of proton beam therapy (PBT) as locoregional therapy, there is currently a lack of histological evidence about the therapeutic effect of PBT for hepatocellular carcinoma (HCC). We present a case of hepatectomy and histological examination of HCC initially treated by PBT. A 76-year-old man with chronic hepatitis C underwent routine ultrasound surveillance, which revealed a 22-mm HCC in segment 4 of the liver. His hepatic reserve was adequate for surgical resection of the tumor; however, he chose to undergo PBT because of his cardiac disease. The patient received 66 Gy in 10 fractions with no toxicity exceeding grade 1. Six months after completion of PBT, contrast computed tomography showed that the tumor had increased in size to 27 mm, and the marginal part of the tumor, but not the central region, was enhanced. Additionally, two new hypervascular nodules were present in segments 5 and 6. The patient underwent surgical treatment 7 months after PBT. The operation and postoperative clinical course were uneventful. Nine months later, however, computed tomography demonstrated new, small, enhanced nodules in the remnant liver (segments 3, 5 and 6) and sacrum. In conclusion, PBT is a valuable treatment for HCC; however, it is difficult to evaluate therapeutic effect of HCC during the early post-irradiation period and provide an alternative treatment if PBT is not effective, especially in HCC cases with good liver function.

Laparoscopic surgery is frequently performed, and laparoscopic gastrectomy (LG) is also widely performed for gastric cancer. Elderly population with gastric cancer has increased in East Asia, including in Japan. We examined 1131 patients with gastric cancer who underwent laparoscopic and open standard surgeries (OG). A total of 921 patients of age

T4 esophageal cancer (EC) that invades the trachea or bronchus often has poorer prognosis than other T4 ECs. We investigated the long-term results of definitive chemoradiotherapy (dCRT) or induction chemoradiotherapy followed by surgery (iCRT-S) in patients with T4 EC with tracheobronchial invasion (TBI). From 2003 to 2013, 71 patients with T4 EC with TBI were treated in our institution; 58 underwent dCRT, and 13 underwent iCRT-S. The long-term results associated with survival were retrospectively analyzed, and prognostic factors were examined by univariable and multivariable analysis. The 1-, 2-, and 5-year overall survival for all patients with T4 EC with TBI treated by dCRT or iCRT-S was 57, 29, and 19%, respectively. Multivariable analysis revealed that clinical lymph node (LN) metastasis and the treatment period were significant prognostic factors. Clinical LN positivity had significantly poorer prognosis than LN negativity. The treatment outcome in the later period was significantly better than that in the earlier period. In particular, the outcome after dCRT revealed significantly better prognosis in the later compared with the earlier period, whereas the outcome after iCRT-S did not show such a difference. With respect to treatment modality, no significant difference in survival was observed between dCRT and iCRT-S. Clinical LN negativity and later treatment period were significantly good prognostic factors for T4 EC with TBI. The recent improvements in dCRT outcomes may help to achieve survival comparable to that of iCRT-S.

Background We aimed to clarify renal functional changes long term and serious urological complications in women with cervical cancer who undergo radical hysterectomy followed by pelvic radiotherapy and/or platinum-based chemotherapy to treat the initial disease. Methods Data on 380 women who underwent radical hysterectomy at the National Kyushu Cancer Center from January 1997 to December 2013 were reviewed. Main outcome measures were the estimated glomerular filtration rate (eGFR) and monitored abnormal urological findings. Results Postoperative eGFR was significantly lower than preoperative eGFR in 179 women with surgery alone and in 201 women with additional pelvic radiotherapy and/or chemotherapy (both P < 0.01). Two types of univariate analyses for eGFR reduction in women after treatment showed that older age, advanced stage, pelvic radiotherapy, and platinum-based chemotherapy were significant variables on both analyses. Two types of multivariate analyses showed that platinum-based chemotherapy or pelvic radiotherapy were associated with impaired renal function (odds ratio 1.96, 95% confidence interval 1.08-3.54 and odds ratio 2.85, 95% confidence interval 1.12-7.24, for the respective analyses). There was a higher rate of bladder wall thickening in women with pelvic radiotherapy had than those without it (17.4% vs. 2.7%, P < 0.01). One serious urological complication (intraperitoneal rupture of the bladder) occurred among women who underwent pelvic radiotherapy (0.6% vs. 0%). Conclusions Surgeons should be aware that eGFR is reduced after platinum-based chemotherapy and/or postoperative pelvic radiotherapy. Serious and life-threatening urological complications are rare, but surgeons should be aware of the possibility during the long follow-up.

A 55-year-old man had laparoscopic cholecystectomy for acute cholecystitis and unexpected gallbladder cancer, followed by a liver bed resection and lymph node dissection. Eleven years later, he had a port-site recurrence of gallbladder cancer requiring resection; at that time, no other site of recurrence was observed. The patient has survived for 20 months without another recurrence. Although a rare finding, clinicians should be alert to the possibility of such a recurrence even 11 years after complete cure of the primary tumor, particularly in patients who have undergone laparoscopic cholecystectomy for unexpected gallbladder cancer.

Background Neuroendocrine carcinoma (NEC) of the esophagus is a rare and highly aggressive disease but the biological features are poorly understood. The objective of this study was to analyze the clinicopathological and immunohistochemical features of NEC of the esophagus. Methods Fourteen patients diagnosed with NEC of the esophagus from 1998 to 2013 were included in this study. Clinicopathologic features, therapeutic outcomes and immunohistochemical results were analyzed. Results Eleven out of 14 cases showed protruding or localized type with or without ulceration. Only three patients were negative for both lymph node and organ metastasis and seven cases were positive for metastases to distant organs and/or distant lymph nodes. Of the six patients with limited disease (LD), three patients were treated by surgery. Three patients with LD and seven patients with extensive disease (ED) were initially treated with chemotherapy, except for one who underwent concurrent chemo-radiotherapy due to passage disturbance. The median survival of patients with LD was 8.5 months, whereas that of patients with LD was 17 months. Among the 14 cases, 12 cases (83.3%), 13 cases (91.7%) and 12 cases (83.3%) showed positive immunostaining for choromogranin A, synaptophysin and CD56, respectively. Nine of 14 cases (64.2%) presented positive staining for c-kit and most (8/9, 88%) simultaneously showed p53 protein abnormality. Two cases were negative for c-kit and p53, and positive for CK20. Conclusion Consistent with previous reports, the prognosis of NEC of esophagus is dismal. From the results of immunohistochemical study, NEC of esophagus might be divided into two categories due to the staining positivity of c-kit and p53. This study provides new insight into the biology of NEC of the esophagus.

We report an unusual case of gastric carcinosarcoma with rhabdomyosarcomatous and neudoendocrinal differentiation in a 71-year-old Japanese female. Gastric carcinosarcoma with rhabdomyosarcomatous and neuroendocrinal differentiation is a rare tumor. The tumor developed in the body of the stomach and was exophytic in appearance. By histochemical analysis, the tumor was shown a part of positive for desmin and myoglobin and a part of positive for synaphtophysin and vimentin. We conclude that, though rare, gastric carcinosarcoma with rhabdomyosarcomatous and neuroendocrinal differentiation thus is reviewed in the English literatures.

The treatment outcomes of patients with esophageal squamous cell carcinoma (ESCC) and head and neck squamous cell carcinoma (HNSCC) have been poorly documented. We investigated 50 patients with synchronous and metachronous ESCC and HNSCC. We focused on the treatment results of 20 patients with synchronous ESCC and HNSCC who received simultaneous chemoradiotherapy (CRT). There were 34 patients (68.0 %) with stage 0–I ESCC and 40 patients (80.0 %) with stage II–IV HNSCC. A total of 13 (26.0 %) patients underwent endoscopic mucosal resection and 28 (56.0 %) underwent CRT for ESCC, and 35 (70.0 %) of the patients with HNSCC were treated with CRT. The 5-year overall survival rates of the 50 patients with synchronous and metachronous ESCC and HNSCC was 57.8 %. For the 20 patients with synchronous ESCC and HNSCC who received simultaneous CRT, the CRT was completed in 19 (95.0 %) patients. Although grade 3–4 adverse events were observed in five (25.0 %) patients, there were no therapy-related deaths. Complete responses (CRs) of both ESCC and HNSCC were observed in ten (50.0 %) patients. The 5-year overall survival rate of the 20 patients was 60.0 %. CRs of both ESCC and HNSCC were obtained in seven (58.3 %) patients by using a cisplatin/5-FU regimen (n = 12), and in the other three (37.5 %) patients by a platinum-based monotherapy regimen (n = 8). The surveillance of double cancer and the use of radical treatment contributed to the favorable outcome of the patients with ESCC and HNSCC. The optimal chemotherapy regimen for simultaneous CRT remains to be determined.

The purpose of this study was to clarify the surgical indications for gastrectomy combined with distal or partial pancreatectomy (GP) in patients with gastric cancer.From January 1994 to December 2009, 29 patients with primary gastric cancer surgically invading the pancreas without distant organ metastasis underwent GP for R0 resection. The patients' characteristics, surgical data, and clinicopathological features were used for the analysis of survival and prognostic factors.The median disease-free survival and median survival time (MST) of all patients were 15 and 30 months, respectively. Only pN3 status (characterized by 7 or more pathologically metastatic lymph nodes) according to the Japanese Classification of Gastric Carcinoma, 14th edition, was shown to be a prognostic factor in a multivariate analysis. The MST of the patients with pN3 and the other patients were 12 and 51 months, respectively (p0.001).We suggest that pancreas invasion should not be considered a contraindication for gastrectomy and that patients with a small number of lymph node metastases (six or fewer) might be candidates for GP in the case of gastric cancer that requires pancreatectomy for R0 resection.

Purpose: Since a patient's obesity can affect the mortality and morbidity of the surgery, less drastic surgeries may have a major benefit for obese individuals. This study evaluated the feasibility of performing a totally laparoscopic distal gastrectomy, with intracorporeal anas- tomosis, in obese patients suffering from gastric cancer. Materials and Methods: This was a retrospective analysis of the 138 patients, who underwent a totally laparoscopic distal gastrectomy from April 2005 to March 2009, at the National Kyushu Cancer Center. The body mass index of 20 patients was ≥25, and in 118 pa- tients, it was

We encountered a case of esophageal mucocele with progressive respiratory symptoms which originated from an excluded thoracic esophagus that was closed at both the proximal and distal ends, and which occurred 24 years after esophageal bypass surgery for a spontaneous esophageal rupture. The patient was a 64-year-old male who was treated by a temporary external drainage for relief of his symptoms without subsequent complete resection of the mucocele via thoracotomy, because of the high surgical risks associated with such a procedure. Four-hundred and fifty milliliters of waste removed during the initial external drainage showed no signs of inflammation or malignancy, suggesting that the reason this excluded esophagus was a symptomatic mucocele was not the observed vigorous secretion, because of irritated esophageal mucosal cells or malignant cells, but instead was the result of gradual accumulation of secretions from the normal esophageal mucosa. This case suggests that an excluded esophagus without any inflammation or malignancy could form a large mucocele that can cause serious symptoms, for example respiratory difficulty, even after an extremely long interval. Although he has been both relapse-free and drainage-free for more than 5 years, further long-term follow-up in this case is mandatory.

Purpose It has not yet been elucidated whether there are specific complications associated with totally laparoscopic distal gastrectomy (TLDG). We evaluated the complications and the risk factors associated with TLDG. Methods A retrospective analysis was performed on 138 consecutive patients who underwent TLDG. The clinical and operative data, which included the body mass index, respiratory function, hematological data, pathological data, and the experience of surgeon, were analyzed. Results Intraoperative and postoperative complications developed in 10 and 28 patients, respectively. A univariate analysis determined that the patient age, concurrent respiratory disease, and operation time were important risk factors. A multivariate analysis found no significant risk factors in this set, although the operation time was the most promising risk factor. Conclusions The present data suggest that TLDG can be performed with acceptable perioperative complication rates, although a longer operation time may cause a higher frequency of postoperative complications.

Background: Delta-shaped (DS) anastomosis is a new reconstruction method for totally laparoscopic distal gastrectomy (TLDG) using a linear stapler. We evaluated the feasibility of using this method for TLDG. Methods: A retrospective analysis was performed in 114 patients who underwent TLDG with DS anastomosis. Twenty-four patients reconstructed with a Roux-en-Y (RY) anastomosis during the same period were analyzed as control subjects. Results: The patient characteristics of DS and RY anastomoses were slightly different in terms of tumor location and extent of lymph node dissection, since this was not a prospective comparative study. Blood loss, postoperative complication rate and postoperative hospital stay were not different between the two groups. There was only 1 case of anastomotic leakage, and no case of anastomotic stricture after DS anastomosis. The length of the operation using DS anastomosis was significantly shorter than for RY anastomosis. The rates of body weight loss were not significantly different at 1 year after the operation. Conclusions: Although this was a small retrospective analysis, DS anastomosis was feasible, required a shorter operation time, and had no associated complications. This method can therefore be recommended as a standard procedure for TLDG.

This paper documents the first case of gastric cancer associated with Recklinghausen's disease, which was successfully treated by a totally laparoscopic operation. A 67-year-old woman with Recklinghausen's disease was referred to this department to undergo surgical treatment for early gastric cancer. The physical examination showed multiple cutaneous neurofibromas throughout the body surface, which made an upper abdominal incision impossible. Laparoscopic surgery requiring only small incisions was well indicated, and a totally laparoscopic distal gastrectomy with lymph node dissection was performed. Billroth I reconstruction was done intra-abdominally using a delta-shaped anastomosis. The patient followed a satisfactory postoperative course with no complications. Since the totally laparoscopic gastrectomy has many advantages over open surgery, it should therefore be preferentially used as a less invasive treatment in the field of gastric cancer.

No standardized methods exist for the follow-up and treatment of recurrence after a curative esophagectomy for patients with thoracic esophageal cancers. One hundred seventy-five patients with thoracic esophageal cancer underwent a curative resection and were followed up during a median period of 3.0 years (3 months-18 years). The time to recurrence, the first indicators (FIs) to suspect recurrence, and the factors predictive of prognosis after recurrence were investigated. Recurrence occurred in 72 (41.1%) of 175 patients. Forty (55.6%) and 22 (30.6%) of 72 cases presented with recurrences in the first and second year after the initial operation, respectively. Clinical visit (anamnesis and physical examination), tumor markers, and imaging were FIs in 39 (54.2%), 33 (45.8%), and 49 (68.1%) of 72 patients with recurrence, respectively. Imaging was the exclusive FI in 19 (26.4%) cases. A multivariate analysis showed the favorable prognostic factors after recurrence to be recurrence later than 1 year after the initial operation and a case in which the FI was only imaging. Intensive follow-up is required in the first 2 years after surgery, and early detection of recurrence is important. The accumulation of clinical data based on a fixed schedule with consensus is necessary to obtain more definite evidence for the diagnosis and treatment of recurrent esophageal cancer.

症例は72歳，男性．検診で胸部異常陰影を指摘され近医を受診，肺小細胞癌の診断にて治療目的に当センター紹介となった．PETにて左肺門部から縦隔リンパ節の他に，虫垂部にもFDGの高集積を認めた．腹部CTにて虫垂は壁肥厚を認め，その先端は嚢胞状に拡張しており，内腔の閉塞が疑われた．肺小細胞癌虫垂転移，原発性虫垂癌を鑑別診断として，穿孔の危険性を考慮し化学療法に先行して腹腔鏡下虫垂切除術を施行した．術後病理検査にて肺小細胞癌虫垂転移と診断された．術後経過は良好に経過し，現在化学療法継続中である．肺小細胞癌虫垂転移は稀だが，本症例では術前に診断し無症状のうちに切除することが可能であったので文献的考察を加え報告する．

Background No standard procedure exists in respiratory management, including mechanical ventilation, which is commonly administered, after thoracic esophagectomy for esophageal cancer.

目的:大腸癌に対する腹腔鏡補助下リンパ節郭清の安全性・根治性に関し，利点・欠点をもたらす因子を明瞭にすることを目的とした．方法:広島県内26施設の外科医に，大腸癌リンパ節郭清において開腹手術に対する腹腔鏡補助下手術の利点・欠点をアンケート調査した．手術経験総数に応じて経験豊富な施設，中等度の施設，寡少な施設に分類し，分析した．結果:経験豊富な施設，中等度の施設，寡少な施設は，それぞれ8，7，11施設認めた．この手術の利点は，経験数の多寡に係わらず，拡大視および開腹では得られない視野であった．その欠点は，経験豊富でない施設で見られ，術者の技術不足，助手の視野展開の悪さ，およびスコーピストの技術不足により良視野が獲得されないというものであった．結論:腹腔鏡補助下での大腸癌リンパ節郭清の安全性・根治性の獲得には，術者・助手・スコーピストの協調作業による良視野確保が重要であり，手術チームで解決すべき問題である．

胃癌に対する腹腔鏡下手術は有望な低侵襲手術として増加の一途をたどっているが，腹腔鏡下リンパ節郭清は，経験が少ない施設においては安全性・根治性に問題がある可能性がある．この解決には腹腔鏡下手術の利点・欠点を明確にすることが重要である．腹腔鏡下手術を施行している施設を対象とし，腹腔鏡下リンパ節郭清の利点・欠点をアンケート調査した．返答のあった28施設のうち20施設で腹腔鏡下胃悪性腫瘍手術が施行されていた．この手術経験総数が豊富な施設と少ない施設は，それぞれ10施設ずつ認めた．経験数の多寡に関わらず，鏡視下の利点は拡大視および開腹では得られない視野であった．経験の少ない施設では，術者の技術不足，助手の視野展開の悪さ，スコーピストの技術不足によって良好な視野が得られず，視野範囲制限が出現するという欠点が認められた．この欠点克服には，個人の技術向上以上にチームとしての技術向上が重要であると考えられる．

術前multi-detector computed tomography (MDCT) のみにて胆嚢十二指腸瘻および胆石イレウスが診断しえた1例を経験した. 症例は86歳, 女性, 認知症を合併. 右下腹痛を主訴として当科受診. 受診時MDCTにて25mm径の胆嚢結石を認めたが, 主訴の原因となる病変は指摘できなかった. 入院後, 症状は軽快していたが4日目に再度臍部痛および嘔吐が出現した. 緊急MDCTを施行したところ, 胆嚢十二指腸瘻および小腸へ落下した胆嚢結石がイレウスを引き起こしている像が得られた. 超高齢で認知症を合併していたためイレウス解除術のみ施行した. MDCTを用いた“胆石イレウス+内胆汁瘻”の診断は, 低侵襲で, 簡単・迅速に施行でき, 胆石イレウスのような急性腹症例を全身状態が良好なうちに一期的根治術 (イレウス解除術+胆嚢摘出術+瘻孔閉鎖術) に導ける可能性があると思われる.

症例は58歳の女性, 2005年9月, 胃癌の診断にて胃全摘術およびD2郭清を施行した. 進行度はpT3, pN2, sH0, sP0, pCY0, cM0; fStage IIIBであり, 総合的根治度Bが得られた. 組織型は非充実型低分化腺癌 (por2) であった. 2005年11月より術後補助化学療法としてTS-1100mg/dayを開始した. この治療開始3日目に, 患者は咽頭違和感を自覚した. 患者の口腔内を観察し, 左口蓋扁桃が30mm径に腫大しているのを確認した. 生検にてgroup V (por2) の診断を得, 原発巣の組織型と類似していることより胃癌の左口蓋扁桃転移と診断した. この時点で, CT にて全身検索を施行したが, 他臓器に転移・再発を示唆する所見は認めなかった. TS-1投与開始14日目に完全奏効 (以下, CR) の腫瘍縮小効果が得られ, 2006年6月まで総合効果CRが維持された. 胃癌の口蓋扁桃転移は, 極めて予後が悪く, 患者のquality of life (以下, QOL) 低下が著しい, と報告されている. TS-1投与による胃癌口蓋扁桃転移巣の縮小効果が, 患者に予後の改善および良好なQOLをもたらすことが期待される.

This observational study was conducted to compare the rate of symptomatic anastomotic leakage (AL), as defined by precise criteria, between laparoscopic and open surgery in patients with mid-to-low rectal cancer using a relatively novel statistical technique.A total of 1014 consecutive low anterior resection (LAR) patients were registered, of whom 936 were included in this prospective, multicenter, and cohort study (UMIN-CTR, Number 000004017). Patients with rectal cancer within 10 cm from the anal verge underwent either open or laparoscopic LAR at one of the 40 institutions in Japan from June 2010 to February 2013. The primary endpoint of this study was to compare the rate of symptomatic AL between the two groups before and after propensity score matching (PSM). The secondary endpoint was to analyze the risk factors for symptomatic AL in open and laparoscopic surgery.After PSM, the incidence of symptomatic AL in open and laparoscopic surgery was 12.4 and 15.3 %, respectively (p = 0.48). AL requiring relaparotomy occurred after 3.8 % of open surgeries and 6.2 % of laparoscopic surgeries (p = 0.37). Multivariate analysis identified male gender as an independent risk factor for symptomatic AL following laparoscopic surgery (p = 0.001; odds ratio 5.2; 95 % CI 2.0-13.8), and male gender (p = 0.004; odds ratio 2.6; 95 % CI 1.3-5.6), tumor size (p = 0.002; odds ratio 1.2; 95 % CI 0.7-0.9), and number of stapler firing (p = 0.04; odds ratio 4.1; 95 % CI 1.0-15.0) following open surgery.The rate of symptomatic AL was comparable following laparoscopic and open LAR in this large, multicenter, cohort study after PSM. Male gender was associated with an increased risk of symptomatic AL after laparoscopic LAR.

症例は27歳の男性で, 突然の吐血でショック状態となり搬送された. 初診時Hgb3.8g/dlと高度の貧血を認めた. 腹部CTでは膵頭部に約5cmの嚢胞性病変を認め, また膵体部から尾部にかけ石灰化が存在し, 慢性膵炎の像であった. 入院中突然の下血を認め, 緊急上部消化管内視鏡検査を施行した. 十二指腸下行脚は壁外性の圧排を受け, その中心部は壊死に陥り, 同部位より持続性の出血を認めた. 出血のコントロールは困難であり, 緊急で開腹手術を施行した. 術中所見では膵頭部に嚢胞性腫瘤を認め, 周囲は浮腫状であった. 膵仮性嚢胞の十二指腸穿破による出血と診断し, 膵頭十二指腸切除術を施行した. 病理組織学的検査では膵仮性嚢胞であり主膵管との交通も認めた. 術後経過は良好で, 第18病日に退院した. 膵仮性嚢胞の消化管への穿破はまれであり, 特に十二指腸への穿破の報告は少ないが, 嚢胞が原因となる出血により急激な経過をたどることもあり, 注意が必要と思われた.

S-1 adjuvant chemotherapy is commonly administered postoperatively for stage II and III advanced gastric cancer.This study included 113 patients treated with S-1 adjuvant chemotherapy after surgery for stage II and III advanced gastric cancer. These patients were divided into 4 groups: group A (n = 63), who had a longer duration (≥6 months) and earlier S-1 administration (≤6 weeks) after surgery; group B (n = 16), who had a longer and later S-1 administration (6 weeks) after surgery; group C (n = 27), who had a shorter duration (6 months) and earlier S-1 administration after surgery; and group D (n = 7), who had a shorter and later S-1 administration after surgery.The recurrence rates in groups A, B, C, and D were 15.7, 43.8, 44.4, and 57.1 %, respectively (A vs. B, p0.05, A vs. C and D, p0.01). The survival time of group A was significantly longer than that of other groups (p0.005). In addition, the survival time of patients with severe complications was significantly shorter than that of patients with non-severe complications (p0.05). An earlier S-1 administration after surgery was the only independent prognostic factor in the multivariate analysis.The prognosis of advanced gastric cancer was significantly related to the start of S-1 adjuvant treatment within 6 weeks after surgery.

The possible use of percutaneous low output microwave tissue coagulation therapy (PLMCT) using ultra-sonography under local anesthesia for small solitary liver cancer was studied.The subjects were 19 patients having primary or metastatic liver cancer with solitary liver tumor less than 4 cm in diameter. Consisting of 5 primary, 7 reccurent hepatocellular carcinoma and 7 metastatic liver cancers. PLMCT was performed continuously 3 times at the output of 30 watts for 30 seconds at a time. Tumors less than 3 cm in diameter were completely coagulated by irradiation from 2 to 6 times judged by enhanced CT.No tumor recurrence was recognized in the coagulation area. Thus, the results suggest that PLMCT is a useful therapy for small solitary liver cancer especially, recurrence of hepatocellular carcinoma as a minimal invasive surgery.

The purpose of percutaneous transhepatic low output microwave tissue coagulation therapy (PLMCT) is to locally treat using ultra-sonography under local anesthesia for small liver cancer. Usefulness of PLMCT has been described. This paper introduces special techniques which are useful to make the best use of PLMCT for liver cancer. Precautions necessary in procedure for PLMCT are as follows : 1) First of all, 16G needle aspiration biopsy of the liver tumor must be percutaneously performed under ultrasonographic guidance, and then 18G needle electrode is inserted into the 16G needle as a introducer. When this procedure is carried out, the needle electrode must not be pushed over the end of the introducer, for 18G needle electrode is weak. 2) While coagulating the tumor, the introducer had better be spun. 3) If the needle electrode is hot, cold alcohol had better be sprinkled on the needle electrode. We conclude that PLMCT is less invasive practical procedure for small liver cancer as a local control.

The possible use of percutaneous transhepatic microwave tissue coagulation therapy (PMCT) using ultrasonography under local anesthesia for small solitary hepatocellular carcinoma was studied.The subjects were 7 patients having primary or reccurent hepatocellular carcinoma with solitary liver tumor less than 3 cm in size, consisting of 4 primary and 3 reccurent hepatocellular carcinoma, PMCT was performed continuously 3 times at the out put of 30 watts for 30 seconds at time. Tumor was completely coagulated by irradiation from 2 to 6 times judged by enhanced CT.No reccurence of tumor was recognized in the coagulation area. Thus, the results suggest that PMCT is a useful therapy for small hepatocellular carcinoma as a local control.

Seventy-eight patients who were operated on for colorectal cancer from November 1994 to December 1995 were divided into two groups with random sampling; 33 patients were orally administered antibiotics (kanamycin+clindamycin) for chemical cleaning (Chemical Cleaning Group) and 45 patients were not administered antibiotics (No Chemical Cleaning Group) preoperatively. The frequency of leakage and wound infection were compared between the Chemical Cleaning Group and No Chemical Cleaning Group. There was no significant difference in the frequency of leakage and wound infection between two groups. Furthermore, these patients were divided into another two groups by the presence of stenosis (more than one third of the intestinal lumen was stenosed) based on barium enema study, and a similar study was conducted in the stenotic and non-stenotic groups. Entirly no significant difference in the frequency of leakage and wound infection was noted in non-stenotic cases (x2=0.000, p=1.000). It was thought that non-stenotic cases demanded no chemical cleaning. But, there was a tendency in stenotic cases that the leakage and wound infection were found more frequently in the No Chemical Cleaning Group than in the Chemical Cleaning Group. More studies in stenotic cases are needed. This study suggested that the chemical cleaning would not be necessary for patients with colorectal cancer who had no stenosis.

The efficacy and the indications of resection of synchronous or metachronous hepatic and pulmonary metastases from colorectal cancer (CRC) are controversial. This study retrospectively reviewed the cases of CRC patients who underwent both liver and lung resection to define the appropriate indications for surgical resection in patients with hepatic and pulmonary metastases. A total of 39 patients with both hepatic and pulmonary metastases from CRC underwent both liver and lung resection from January 1987 to December 2009. The relapse-free survival (RFS) and overall survival (OS) from the resection for the first metastasis were evaluated by a Kaplan–Meyer analysis. Prognostic factors were analyzed using the log-rank test and a Cox proportional hazards model. The median RFS and the 5-year RFS rate of all patients were 12 months and 2.6 %, respectively. The median survival time (MST) and 5-year OS rate of all patients were 66 months and 48.3 %, respectively. The MST of the patients with a long (>1 year) disease-free interval (DFI) could not be calculated, but their 5-year OS rate was 73.7 %. In contrast, the MST and 5-year OS rate of the patients with a short (

Laparoscopic gastrectomy is commonly performed for gastrointestinal stromal tumors (GISTs). Partial gastrectomy is usually achieved with a wedge resection to preserve gastric function; however, performing a wedge resection to excise a large tumor located close to the esophagogastric junction (EGJ) can result in deformation of the stomach and/or the stenosis of the EGJ if the gastric wall resection is excessive. We describe our procedure, in which the whole layer of the gastric wall was cut, maintaining a sufficient margin and confirming the distance between the tumor and the EGJ, by endoscopy and laparoscopy. The defect in the gastric wall was closed using linear staplers by hanging up the stay sutures. Five patients with GIST close to EGJ underwent this procedure, followed by a good postoperative course. Thus, we consider our procedure to be safe and effective for gastric GISTs close to the EGJ.

With the broadening indications for hepatectomy to treat colorectal liver metastases (CRLM), early recurrence is a major problem. The aim of this study is to identify risk factors of early recurrence, defined as recurrence within 1 year after surgery.A retrospective analysis was performed on 121 consecutive patients who underwent hepatectomy for CRLM.Among 121 patients, 52 (43.0%) developed early recurrence. The independent risk factor for early recurrence was "number of liver metastases ≥ 3" (odds ratio 2.65). There were significantly more patients with liver recurrence (51.9%) and recurrence beyond curative surgical resection (63.5%) in those with early recurrence. In addition, patients with three or more liver metastases had significantly more liver recurrence (66.7%; P = 0.02) and recurrence beyond curative surgical resection (70.8%; P = 0.04). The overall survival rates of both patients with early recurrence (5-year survival rate 20%) and those with three or more liver metastases (5-year survival rate 24%) were significantly worse.The independent risk factor for early recurrence is the "number of liver metastases ≥ 3." Patients with three or more liver metastases have a significantly higher risk of liver recurrence and a higher rate of recurrence beyond curative surgical resection, and these are correlated with a poor prognosis.

To evaluate the safety and feasibility of the triangulating stapling technique (TST) for cervical esophagogastric anastomosis after esophagectomy (CEGA).The subjects were 123 patients who underwent transthoracic esophagectomy with three-field lymph node dissection and reconstruction with a 3.5-cm wide gastric tube, for thoracic esophageal cancer. We performed the TST for CEGA in 33 patients operated on after December, 2006 (TST group) and hand-sewn anastomosis in 90 patients operated on between 2002 and 2006 (HSA group).In the TST group, CEGA was performed in an end-to-end fashion using three linear staplers. The first anastomosis was applied to the posterior walls of the remnant esophagus and gastric tube in an inverted fashion. The second and the third anastomoses were done in an everted fashion to make the anterior wall. The end-to-end HSA was performed with interrupted sutures using 4-0 absorbable material. Anastomotic leakage occurred in only 1 (3.0%) of the 33 TST patients, but in 13 (14.4%) of the 90 HSA patients (P = 0.07). The frequency of anastomotic stenosis was 9.1% and 25.6% in the TST and HSA groups, respectively (P0.05).Cervical esophagogastric anastomosis using TST may reduce the frequency of anastomotic leakage and stenosis. This technique is a safe and reliable alternative for CEGA after esophagectomy.