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A 64-year-old woman was diagnosed with hereditary spherocytosis 30 years ago and underwent splenectomy. She presented to the hospital with lower abdominal pain and was diagnosed with sigmoid colon cancer(cT3N3M1[LYM], H1, Stage Ⅳ)for which sigmoidectomy was performed. On the 7th postoperative day, a fever of 40℃ and an inflammatory reaction were observed. She developed a consciousness disorder the next day, and her condition rapidly deteriorated along with the development of septic shock and disseminated intravascular coagulation(DIC). With the aid of a ventilator, immediate treatment for DIC was started, but reversion of septic shock and DIC was not possible, and the patient died of multiple organ dysfunction on the 17th postoperative day. Computed tomography and urinalysis performed during the course of treatment showed no infected lesion, but Citrobacter spp. was detected thrice in venous blood culture. Hence, the patient was diagnosed as a case of Citrobacter overwhelming post splenectomy infection(OPSI). To our knowledge, this is the first report of Citrobacter spp. infection following an abrupt course of OPSI.

We report the case of a 79-year-old woman with repeated abdominal wall recurrence of gallbladder cancer. The original diagnosis was gallbladder carcinoma. She underwent open liver bed dissection and lymph node dissection. Postoperative pathological examination indicated T2N1M0, Stage III disease. She received 6 courses of postoperative chemotherapy with gemcitabine. Two years and 2 months after the surgery, we detected a 13 mm mass under the abdominal wall scar on CT, and we resected this tumor. Pathological findings indicated adenocarcinoma, which was found to be metastasis of the gallbladder cancer. She was treated with S-1 for 8 courses postoperatively. However, 3 years 4 months after the first surgery, a tumor of 22mm was detected in the abdominal wall on the caudal side away from the previous tumor excision site. We resected the abdominal wall including the tumor. The pathological examination revealed adenocarcinoma, which was again metastasis from gallbladder cancer. The increase of CA19-9 was confirmed around 4 years and 7months after the first operation. An abdominal wall tumor of 45mm was detected in contact with the iliac bone near the last excision site and it proved to be a recurrence of gallbladder carcinoma. We performed abdominal wall tumor resection, again identifying adenocarcinoma, which was the third recurrence of gallbladder cancer. Despite continued abdominal wall recurrence, she is alive and well without metastasis for more than 5 years.

A patient was 60-year-old man. In March 2011, the small bowel tumor with perforation was found and the partial resection of small intestine was urgently performed. KIT of resected specimen was positive. Then, diagnosis as GIST was defined. Oral administration of imatinib was started, but it was finished in 5 months because of development of the systemic edema. In February 2013, the abdominal CT revealed a tumor of 20 cm in size in the pelvis. Upon laparotomy, we detected the GIST recurrence generated at the region of small intestine anastomosis where manipulated previously, then resected all of tumor and partially small intestine. Afterward, we diagnosed as a recurrence of GIST. In March 2014, the abdominal CT found 4 cm sized mesenteric tumor and 2 cm sized abdominal wall tumor. The laparotomy was performed and we found 5 disseminated nodules intraperitoneally. We confirmed that all of these disseminated nodules were successfully removed. We defined them as re-recurrence of GIST. Six years and 5 months have elapsed since the first operation was performed, but there is no sign of three times recurrence.

Previous studies from Western countries have shown similar survival outcomes after both open and laparoscopic resections. In Japan, radical D3 dissections performed by open resection have been routinely performed for ≥T2- or ≥N1-stage cancers, and relatively favorable survival outcomes were obtained. This study compared the survival in patients with Stage I/II colon and upper rectal cancers undergoing laparoscopic and open resection. A total of 145 patients were initially enrolled. Propensity score matching was applied to assemble a study cohort. D2 lymph node dissection for T1 cancer and D3 for ≥T2- and ≥N1-stage cancers were applied. The primary outcome measure was the disease-free survival; the cancer-specific and overall survival rates were secondary outcomes. A total of 64 patients were matched for the analysis. The length of hospitalization, postoperative complication rates, number of lymph nodes removed and surgical margins were similar between the groups. The disease-free survival following laparoscopic surgery was better than that following open surgery, but the difference was not statistically significant. Neither the cancer-specific nor overall survival rates following laparoscopic surgery were inferior to those associated with open surgery. The outcomes of the laparoscopic approach were comparable to those for open surgeries accompanied by radical lymph node dissection.

The aim of this study is to evaluate complications of gastrectomy for gastric cancer in patients aged over 85 years.Thirteen patients received curative gastrectomy between April 2007 and March 2008. The surgical complications were evaluated using the Clavien-Dindo classification.There were 11 patients aged 85-89 years and 2 who were over 90 years old. The median body mass index was 18. Nine patients underwent distal gastrectomy and 4 underwent total gastrectomy. The median operation time was 142 minutes and the median blood loss was 148 mL. Complications greater than Grade 2 were observed in 5 patients(38.5%). All complications were Grade 2. No surgical mortality was observed.The morbidity rate in elderly patients over 85 years of age may be higher than in patients aged 75 and lower. Our results suggest that gastrectomy for patients aged over 85 years is acceptable.

The aim of this study was to evaluate the safety and feasibility of gastrectomy in elderly patients aged over 80 years.A total of 393 patients who underwent gastrectomy for gastric cancer were assigned to 2 groups: those aged over 80 years(n=48; elderly group)and those less than 80 years(n=345).Clinicopathological features, operative factors, post-operative complications(Clavien-Dindo Grade II or higher), and mortality were retrospectively analyzed.Rates of distal gastrectomy(73% vs 59%, p=0.043)and D1 or D1+dissection(73% vs 58%, p=0.046)were significantly higher in the elderly group.There were no significant differences in post-operative complication rates(23% vs 20.3%, p=0.255)or mortality rates(2.1% vs 0.6%).Our results indicate that gastrectomy in elderly patients aged over 80 years may be safe and feasible.

症例は61歳，女性．繰り返す嘔吐と腹部膨満を主訴に当院内科に精査目的にて入院．検索の結果上腸間膜動脈症候群と診断され，保存的治療にて様子をみていたが改善せず，手術目的にて外科紹介となった．手術は腹腔鏡下十二指腸・空腸吻合術施行．術後経過良好にて退院．術後１年２カ月経過するも再発はない．腹腔鏡下十二指腸・空腸吻合術は，低侵襲で本疾患には有用な方法と考えられた．

症例は61歳の男性で，腹部の違和感と下血を主訴に来院した．腹部超音波検査および腹部CTで上行結腸に腸重積に特徴的な所見を認めた．注腸X線検査，下部消化管内視鏡検査で盲腸に約3 cmの表面にびらんを伴う硬い隆起性病変を認めた．腹腔鏡下回盲部切除術を施行し，切除標本の病理組織，および免疫組織学的検索で盲腸のgastrointestinal stromal tumor（以下，GIST），uncommitted typeと診断した．本邦において，盲腸原発GISTの報告例は2例と極めてまれであるため報告する．

症例は63歳の男性で, 心窩部痛を主訴に来院した. 腹部は軽度膨満し腹部単純X線検査で小腸ガスの貯留と鏡面形成を認め, 腹部CTでは右上腹部にtarget signを呈する腫瘤像を認め, 回腸上行結腸型の腸重積症と診断した. また, 胃壁の肥厚を認めたため上部消化管内視鏡検査を施行, 粘膜不整像と巨大皺壁を認めた. 病理組織学的検査 (胃) で悪性リンパ腫が疑われたが, 確定診断は得られなかった. 組織型の診断確定と腸重積解除目的に開腹手術を行った. 開腹時腸重積は解除されていたが, Bauhin弁から10cm口側の回腸粘膜下にポリープ様腫瘤が多発しており, 粘膜下腫瘍を切除し, 病理組織学的検査でマントル細胞リンパ腫の診断であった.胃と回腸に多発病変を有し, 回腸末端のポリポーシスを先進部として回腸上行結腸型腸重積を来していた. マントル細胞リンパ腫による成人腸重積の報告は自験例を含めて国内, 国外合計7例のみと極めてまれであり, 文献的考察を加え報告する.

症例は60歳，男性。2005年４月18日に盲腸癌の診断で腹腔鏡下回盲部切除術を行った。術中所見としては，病変は漿膜には露出していなかったが盲腸全体が後腹膜に強固に癒着していた。腹腔鏡下に回盲部切除を行い，腹腔鏡用linear stapler 100mmを使用し，機能的端々吻合で再建した。２型，55×50mm，mod，ss，ly1，v0，n1，stage IIIaであった。2005年10月21日腸閉塞にて入院。腹部超音波検査，腹部造影CT検査，腹部MRI検査にて，右臍横５mmポート留置部に一致した腹壁腫瘤および中等量の腹水を認めた。Port site recurrence，腹膜播種再発と診断し，2005年11月９日に腹壁腫瘤摘出術を施行した。術後FOLFOX4を９クール施行し，2007年５月現在，元気に外来通院中である。早期のport site recurrenceと広範な腹膜播種が，腹腔鏡下手術と関係があると考えられた。

症例は59歳,男性.回盲部を主病巣とする悪性リンパ腫(非ホジキンリンパ腫)に対して CHOP 療法を2クール施行した後,腸閉塞を発症した.手術適応と診断したものの,発症時,骨髄抑制(白血球数1,800/μl)を認めたため, G-CSFを投与.白血球数が3,000/μl以上に回復するのを待ち,腸閉塞発症約2ヵ月後に回盲部切除術を施行した.病理組織学的所見では,狭窄部に高度な線維化と慢性炎症細胞の浸潤を認めるとともに,一部では大型の異型リンパ球の集籏巣を認め, diffuse large B-cell lymphomaの診断であった.術後経過は良好で,経口摂取開始後,化学療法を再開した.化学療法の進歩の一方で,本症例の如く骨髄抑制を合併した手術適応症例については,待機手術が可能であるか,慎重な治療戦略を立てる必要がある.

We report a rare case of a solitary metachronous metastasis of renal clear cell carcinoma (RCC) presenting as a thyroid tumor 19 years after a nephrectomy. Our search of the English-language literature found only sporadic reports of late RCC metastases to the thyroid. Fine-needle aspiration biopsy of the thyroid tumor was not accompanied with thyroglobulin (Tg) staining, leading us to initially suspect a primary follicular thyroid carcinoma. The patient, a 77-year-old man, underwent a total thyroidectomy with modified neck dissection. Histological examination confirmed the tumor to be RCC metastasis, and immunohistochemical analysis revealed that both Tg and thyroid transcription factor-1 (TTF-1) were negative in the tumor cells. Thus, the possibility of late RCC metastasis to the thyroid should be considered, even in a patient with a remote history. Furthermore, TTF-1 is useful for identifying thyroid metastatic carcinomas.

INTRODUCTIONChylorrhea is a form of lymphorrhea involving digested lipid products absorbed in the small intestine. Here we report a rare case of chylorrhea after laparoscopy-assisted distal gastrectomy (LADG) with D1+ dissection that resolved following administration of a low-fat diet.PRESENTATION OF CASEA 35-year-old woman with early gastric cancer underwent LADG with D1+ dissection, and on postoperative day 4, the drain output increased and the fluid with a high triglyceride level (740mg/dL) changed from clear to milky. On postoperative day 6, oral intake of a low-fat diet was initiated after a 2-day fast, and the daily drain output decreased from postoperative day 9. The drain tube was withdrawn on postoperative day 15, and the patient was discharged on postoperative day 17.DISCUSSIOND1+ dissection does not typically cause injury to the lymphatic trunks, cisterna chyli, or thoracic duct. The maximum output of chylous ascites was minimal, and thus, we assumed that chylorrhea occurred from slightly injured lymphatics with anatomical variation.CONCLUSIONChylorrhea after LADG with D1+ dissection is very rare. The fasting of our case followed by a low-fat diet without TPN would be an effective therapy. As a result, our case recovered favorably without further therapy.

症例は68歳,男性. 1980年に直腸癌の診断で腹会陰式直腸切断術および人工肛門造設術施行下した. 2001年6月,人工肛門周囲皮膚の発赤を主訴に当科受診.抗生剤,抗炎症剤投与され帰宅.翌日早朝より発赤増悪,呼吸困難出現したため緊急入院となる.入院後腹壁全体暗赤色となり意識レベルが低下してきたため,気管内挿管し人工呼吸器管理とした.腹壁組織の塗沫染色より, A群溶連菌が検出され,劇症型A群溶連菌感染による壊死性筋膜炎と診断し緊急手術を施行した.手術は壊死領域の皮膚皮下脂肪織全層,筋膜全てを切除するsurgical debridementを施行した.数回の皮膚移植の後,術後126日目に軽快退院した.本疾患は発症後の経過が極めて急速で致命的となり易いため,早期診断早期外科的治療が必要であると考えられた.

症例は69歳(第4癌手術時),男性. 1988年に胃癌にて幽門側胃切除, D2郭清術施行(f Type 0 IIc, T1 (SM), tub1, N0, P0, H0, stage IA,根治度A). 1994年にS状結腸癌にてS状結腸切除, D3郭清術施行(2型,高分化腺癌, sm, n1, H0, P0, M(-) stage IIIA,根治度A). 1998年に右肺扁平上皮癌にて右肺上葉切除,模状気管支形成, ND 2a郭清術を施行(中分化扁平上皮癌, p-T3 N1 M0 p0, pm0, ly0, v1, stage IIIA). 2001年に左肺腺癌にて左肺下葉S6区域切除, ND1郭清術を施行(高～中分化腺癌, p-T1 N0 M0 p0, pm0, ly1, v0 stage IA).第4癌術後1年5カ月経過した現在再発は認めていない. 14年間に多発肺癌を含む異時性4重癌に対して,それぞれ切除しえた稀な症例を経験したので報告した.

A rare case of osteoclast-like giant cell tumor of the pancreas is reported. A 45-year-old woman presented with upper abdominal pain and weight loss. Examination revealed a tumor in the tail of pancreas, and distal pancreatectomy with splenectomy was performed. Pathological findings showed the tumor was composed of two cell types: atypical mononuclear round cells and abundant osteoclast-like multinucleated giant cells with central nucleoli. Immunohistochemical study showed that the atypical cells were strongly reactive for vimentin and negative for CD68, while the giant cells were immunoreactive for CD68, but negative for vimentin. The tumor was diagnosed as osteoclast-like giant cell tumor of the pancreas. We report this case and review 31 cases previously described in the literature.

In this study, expressions of apoptosis related gene products, p53 protein and bcl-2 protein, and proliferating cell nuclear antigen (PCNA) in cancer tissues were explored by means of immunohistochemical staining, and their correlations with clinicopathological findings and prognosis were comparatively studied. The subjects were 50 patients operated on for colorectal cancer at the hospital. The positive rate to p53 protein was 60.0%, and had no significant correlations with clinicopathological factors. The positive rate to bcl-2 was 52.0%. The bcl-2 positive rates were significantly low in patients groups of depht of tumor invasion of si, ai, or more; venous invasion; lymph nodes metastasis; and hepatic metastasis (p

We have successfully resected metastatic lesions in the lung and pancrease 11 years after a radical operation for a renal cancer. A 64-year-old woman, who was underobservation after a left nephrectomy for renal cell carcinoma in 1984, was pointed out having a tumor shadow in the right lower lung field on a chest-ray film in November, 1995. Abdominal CT was conducted for the purpose of the general exploration, and a tumor about 35mm in the longer diameter which was internally heterogenous and ill-defined was detected in the pancreatic body. With a suspicion of pancreatic tumor and metastatic lung tumor, the patient was operated on. Histopathologically, the both lesions were darified to be metstases to the pancreas and lung from th 11-year previous renal cell carcinoma. There has been no sign of recurrence and the patient is doingwell, as of 10 months after operation. Renal cell carcinomas can cause delayed and distant metastasis after radical operation, and hense strict post operative obsevation of clinical course including the adjacent organ, the pancreas, is necessary. As to the metastatic foci of the pancreas, a better prognosis can be expected by surgical resection, but its precise inducation would demand further investigation.

A total of 32 patients, who had undergone surgical currative resection of colorectal cancer liver metastasis, were retrospectively analyzed. Recurrences were observed in 75% of the 32 patients. These recurrences were hepatic in 33.3% of patients with recurrence, intra-and extrahepatic in 37.5% and extrahepatic in 29.2%. The residual liver recurrence rate was significantly higher in H2H3 cases than in H1 cases. The five year survival rate of H1 cases was 50.0%, while none of the H2H3 patients survived more than three years. Advanced wall invasion in the primary tumor was unfavorable prognostic indicator in H1 cases, without statistical significance. The patients who underwent adjuvant intrahepatic arterial chemotherapy had a favorable residual liver recurrence rate and survival rate, but this did nor reach statistical significance. To prolong survival in patients with undetected extrahepatic residual disease at the time of hepatic resection, effective adjuvant therapy, combining hepatic arterial chemotherapy and systemic chemotherapy, is required.

Spontaneous hemopneumothorax (SHP) is a rare clinical entity, and an emergent operation due to continuous bleeding or hypovolemic shock is at times necessary. Although allogeneic blood transfusions are urgently required for significant blood loss, autologous blood transfusions can also be considered in patients with SHP. We herein report two cases of successful autologous blood transfusions using blood in the pleural space, decreasing or obviating the need for allogeneic blood transfusion.

A 55-year-old man was seen at the hospital because of nausea and vomiting, and admitted for close examination. On admission Hb was 9.2g/dl, indicating slight anemia. Upper gastrointestinal series and barium enema revealed no abnormality. Intestinal fluoroscopy visualized a whole-circumference stenosis 15cm anal side from the Treitz ligament. Superior mesenteric arteriography showed a moderate degree of hypervascularization locating at the same area as the tumor existed, as well as vascular obstruction and extension. Endoscopy of the small intestine revealed an irregular whole-circumferential elevated lesion at the same site. Biopsy indicated a growth of atypical gland, moderate degree of atypical cell. From these findings a preoperative diagnosis of malignant tumor of the small intestine was made. Partial excision of the small intestine with lymph nodes dissection was carried out. Histopathologically it was well differentiated adenocarcinoma. This paper presents a case of malignant tumor of the small intestine which was able to be diagnosed preoperatively.

Twenty-two patients with postoperative acute cholecystitis seen in the department from 1980 to 1992 were divided into two groups by the severity of the condition, namely, mild and severe groups, and compared for the clinical features of the disease. Eleven patients had severe postoperative acute cholecystitis and some of them also had serious complications other than cholecystitis after surgery for the primary disease. This disease was common in the old. Severe cholecystitis was more frequently found in patients with cardiovascular disease as the primary disease than in patients with gastrointestinal carcinoma. Five of the eleven patients with severe cholecystitis died. The mortality was 50% in each patient group undergoing cholecystectomy, cholecystotomy or conservative treatment. Only one patient who underwent PTGBD had a healed lesion. Most patients with mild cholecystitis healed with conservative treatment. It is important to evaluate the severity early on and employ less invasive therapy including PTGBD, because severe postoperative acute cholecystitis often develops in patients with severe other complications after surgery for the primary disease or compromised hosts such as aged people.

The patient was a 31-year-old man. An abnormal shadow was detected on chest radiography during a medical check-up conducted at the work place, and the patient consulted our department. While the patient was waiting for surgery under the diagnosis of a mediastinal tumor, he experienced sudden chest pain and dyspnea, and was admitted on an emergency basis. Thorax computerized tomography (CT) and MRI revealed a mass with irregular inside and a capsule in the middle mediastinal right hilar region, as well as right pleural effusion. The operation was performed under a diagnosis of a mediastinal tumor and pleurisy. Pleural effusion was absent during the operation. Since the tumor adhered to the central side of the right superior lobe so intensely that it was difficult to detac, we resected the tumor together with the right superior lobe. A yellow-white pultaceous substance and pus were seen in the resected specimen, and a hair-like substance was noted in some areas. Cavity formation was observed at the site where the tumor invaded the lung, and the inside of the cavity was filled with pus. Mature teratoma, with abundant sebaceous and salivary glands, was diagnosed histopathologically. A mediastinal tumor invaded inside the lung in this surgical case.

To elucidate the cause of gallstone disease after heart valve replacement according to the types of gallstone, 140 patients with valvular heart disease undergoing valve replacement in the department from 1969 to 1990 were studied. Thirty-two of these patients, who had gallstones by abdominal echography, were evaluated for the nature, type and incidence of the calculi, as well as related biochemical findings including the liver function and occurrence of hemolysis, and relations to the presence or absence of hepatosplenomegaly. Pigment stones were echographically discovered in 19 of the 32 patients (59.4%) with gallstone disease after heart valve replacement, No relationship between the type of stone, position and type of valve replaced was observed. No association with gallstone disease and abnormal hemolysis or liver function was found. The high incidence of pigment gallstones complicated by hepatomegaly, however, suggests that gallstone disease after heart valve replacement may be caused by some liver disorders such as stasis of the liver.

A 59-year-old man visited our hospital. After examination he was diagnosed with advanced gastric cancer with multiple liver metastases. At first, chemotherapy of S-1/CDDP was administered. After two weeks, he had severe diarrhea and anorexia, so the therapy was discontinued. Weekly paclitaxel was selected as the next therapy. Depending on the leukocytopenia, doses and intervals were controlled. After 4 courses, CT and MRI revealed that the liver metastases had disappeared, while the primary lesion remained. Seven months after beginning treatment, distal gastrectomy was performed. After the operation, 6 courses of paclitaxel therapy were given at the same doses and the same intervals as before the operation. Two years have passed since the operation, and no recurrence was seen on CT and MRI. Because of the relatively low frequency of adverse events in the digestive system, continued treatment with paclitaxel is possible. These findings show that paclitaxel is an effective drug for advanced gastric cancer with liver metastasis.

Cetuximab, a monoclonal antibody used to target the epidermal growth factor receptor(EGFR), was approved for refractory and metastatic colon cancer expressing EGFR, and the EGFR expression must be confirmed. But the EGFR expression may become false negative by immunohistochemistry. When we used a past operation specimen for a search in particular, a correct evaluation may be difficult for prolonged formalin fixation. We report a case successfully treated by cetuximab, who was diagnosed as EGFR-negative by the past operation specimen, but as EGFR-positive by the liver biopsy specimen. A 51- year old woman with multiple organ metastases, who had experienced failure with prior oxaliplatin, irinotecan(CPT-11), 5- FU and bevacizumab regimens, was administered cetuximab plus CPT-11 because it was EGFR-positive by liver biopsy, and the tumor was obviously reduced. It is useful to obtain another specimen such as by liver biopsy, when the EGFR expression is negative by a past operation specimen.

Pseudomembranous colitis, an antibiotic-associated diarrhea, needs early diagnosis and treatment for the high fatality rate in severe cases. We report a case of pseudomembranous colitis following the use of antibiotics in febrile neutropenia (FN). A 74-year-old man with non-curative resected sigmoid colon cancer was treated with cefepime in FN induced by chemotherapy. Complications of diarrhea were seen on day 2. Paralytic ileus and disseminated intravascular coagulation were also complications. He was diagnosed as pseudomembranous colitis for Clostridium difficile toxin-positive. Vancomycin enemas were administered because oral administrations were impossible, and the effect was provided. Vancomycin enemas are an effective therapy for patients with severe pseudomembranous colitis unable to tolerate oral medications because of ileus.

幽門輪と胃癌の進行度・予後との関係を調べる目的で, 下部胃癌症例162例を対象にし, 幽門輪に接した, または幽門輪を越えて十二指腸へ進展した胃癌 (幽門輪群) と, 幽門輪から離れた胃癌 (非幽門輪群) との間で臨床病理学的成績を比較・検討した.その結果, 幽門輪群は非幽門輪群に比べて進行癌の頻度が有意に高かった.リンパ節転移率も幽門輪群で有意に高率であった.しかし予後的漿膜面因子PS (+) 例のみの比較では両群間に差がなかった.組織学的分化度では両群間に有意な差を認めなかったが, 十二指腸進展例では, 組織型が分化型のものは限局性に, 未分化型は浸潤性に進展する傾向が認められた.治療成績では治癒切除例の5年生存率は幽門輪群40.7%, 非幽門輪群69.3%で, 幽門輪群で不良であった.しかしps (+) 症例のみに限定すると生存率による差はなかった.

We investigated whether sentinel lymph node biopsy using dye technique alone is useful or not in decision-making for less invasive surgery in patients with gastric cancer.The subjects were 43 patients who had undergone laparotomy for gastric cancer and consented to undergo sentinel lymph node biopsy using patent blue dye. The patients enrolled were 26 males and 17 females, with a mean age of 62.5 years. The tumor sites were upper third of the stomach in 14, middle third in 16, and lower third in 13 patients. The depth of invasion was mucosa in eight, submucosa in 19, muscularis propria in five, subserosa in five, and serosa in six patients. Total gastrectomy was performed in 12, subtotal gastrectomy in 28, and proximal gastrectomy in three patients.The mean number of sentinel lymph node biopsies per surgery was 3.5 +/- 4.1. We were able to perform blue node biopsy in 40 out of 43 patients, but could not find any blue nodes in three patients. Among the 40 patients in whom blue nodes were identified, 29 patients with no metastasis in blue nodes had no evidence of lymph node metastasis (NO). The depth of invasion was not deeper than subserosa in all these patients. Metastasis was observed in one out of the three patients in whom no blue nodes were found.When the depth of invasion was not deeper than the subserosa and blue nodes were identified, no metastases in either non-blue nodes or blue nodes could be found in the absence of metastatic blue nodes. Therefore, if the depth of invasion is not deeper than the subserosa in gastric cancer, metastatic search in blue nodes seems sufficient and less invasive surgery can be performed safely. Even when the invasion depth is not deeper than the submucosa, the tumor could be metastatic to Group 2 lymph nodes in patients in whom blue node biopsy revealed metastases. When metastasis is found in lymph nodes by intraoperative frozen section diagnosis, less invasive surgery for gastric cancer is not indicated.

In this study, we performed 13C-urea breath test in patients who had undergone total gastrectomy and investigated the content of (13)CO2 in the CO2 gas expired after direct influx of 13C-urea into the small intestine.13C-Urea breath test was performed in 31 patients who had undergone total gastrectomy at this department for the treatment of stomach cancer and consented to participate in this study. The test was performed in two ways, i.e. with and without mouth washing (gargling) on taking 13C-urea.Among 41 measurements, the delta13C was less than 2.5% per hundred in 9 measurements (22.2%) and less than 2.0% per hundred in 6 measurements (14.6%). The delta13C exceeded 50% per hundred, in 4 subjects (9.8%). There were no differences between the methods with and without gargling.The results of this study suggested the possibility that 13C-urea is decomposed even in the jejunum or the lower part of intestine resulting in absorption of H(13)CO3 and another possibility that 13C-urea is directly absorbed from the intestine and decomposed in the blood.

Although hemorrhage from the gallbladder (hemorrhagic cholecystitis) is not a common event, 1 , 2 urgent treatment is required to avoid critical complications, including gallbladder perforation. For earlier detection of this condition, an accurate and noninvasive imaging modality would be of great value in clinical practice. A case is described herein in which contrast-enhanced sonography provided illustrative features that contributed to a definitive diagnosis of this entity.

We report the successful management of multiple small-bowel perforations caused by cytomegalovirus (CMV) infection in a 60-year-old man, 1 day after CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) therapy induction for malignant lymphoma. Emergency laparotomy was performed for perforative peritonitis, but we did not resect the lesions at this time. Instead, we exteriorized the small bowel and then irrigated the peritoneal cavity and intestinal tract. His white blood cell count was low, at 200 cells/microl, so this therapy was continued until it recovered. The intestine was highly edematous, but it improved after irrigation with peritoneal dialysis solution. In the second-stage procedure, we resected the small bowel with the perforations, and constructed a jejunostomy and colostomy, then closed the abdominal cavity. Although the patient needed central venous hyperalimentation, he had a favorable postoperative course and started treatment again for the malignant lymphoma.

We previously investigated the effects of amoxicillin/omeprazole combined therapy on patients who were Helicobacter pylori (H. pylori) positive after gastrectomy for the treatment of gastric cancer, and we determined the difference in amoxicillin dosage between the therapeutic successes and failures. In the present study, assuming that amoxicillin dosage should be determined on the basis of body weight of each patient, we examined whether the eradication of H. pylori would be improved by using this novel dose-selection method.We have previously reported about eradication of H. pylori of remnant stomach as follows. Patients who underwent gastrectomy for the treatment of gastric cancer were enrolled if H. pylori was detected in their remnant stomach after the operation. Of these patients, 22 were treated with amoxicillin at 750 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks. For the evaluation of H. pylori eradication, endoscopic examination and 13C-urea breath test were performed 12 weeks after the initiation of the treatment. The amoxicillin dosage in the therapeutic successes was compared with that in the therapeutic failures, and we found that the dosage was 14.1 +/- 1.5 and 12.5 +/- 1.5 mg/kg/day in the successes and the failures, respectively. Following these results, another 10 H. pylori-positive patients were treated with amoxicillin greater than 16 mg/kg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks, and H. pylori eradication was evaluated as mentioned above. The efficacy of the drug therapy on H. pylori infection was compared between the two groups that one group (Group A) is treated with amoxicillin 750 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks and the other group (Group B) is treated with 1250 mg/day for 2 weeks and omeprazole at 20 mg/day for 8 weeks.The eradication rate of H. pylori in Group B (84.6%) was higher than that in Group A (42.1%). There was significant difference between the two groups (p = 0.028).We assumed that the optimal dosage of amoxicillin was over 15.6 mg/kg/day for omeprazole-amoxicillin combined therapy for gastrectomized patients who were H. pylori positive, and the favorable therapeutic effects could be obtained by applying this amoxicillin dosage to the eradication of H. pylori.