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After esophagectomy with reconstruction using a gastric conduit for esophageal cancer, anastomotic leak can cause serious complications and has a significant impact on the postoperative course. At our institution, gastric conduit reconstruction by hand-assisted laparoscopic surgery (HALS) is the first-line technique for reconstruction following esophagectomy due to its reliability and shortened operative time. In this study, we performed a retrospective review of the surgical outcomes. We reviewed characteristics and perioperative outcomes of 124 patients who underwent esophagectomy with gastric conduit reconstruction for esophageal cancer by HALS from February 2011 to December 2021. Surgical procedure: We created a gastric tube via the HALS incision. A 3-cm wide gastric tube was fashioned using the linear staplers. We mobilized and manually stretched the stomach to ensure the length of the gastric tube. Then the blood flow in the gastric tube was evaluated by ICG fluorescence method followed by esophagogastric anastomosis using a 25-mm circular stapler on the greater curvature side. Among the 124 patients, there were 99 males and 25 females with a median age of 70 years (range, 46 – 85 years). Neoadjuvant therapy was performed in 50 patients. The median operative time was 259 minutes (135-454 minutes). Complications related to the gastric conduit reconstruction included anastomotic leak in two patients (1.6%) and anastomotic stricture requiring dilatation in 39 patients (31.5%), of whom 15 (12.1%) underwent repeat dilatation. Gastric tube stenosis, gastric tube hemorrhage, and gastric tube-to-pulmonary fistula were also observed in one case each. In the present study, while the incidence of anastomotic leak was low (1.6%) in patients received HALS esophagectomy with gastric conduit reconstruction, almost one-third (31.5%) of the patients had anastomotic stricture and required dilatation.

Collison tumor of the stomach is rare, and its endoscopic and pathological features remain poorly described. A 70-year-old woman was referred to our hospital for examination and treatment of undifferentiated gastric cancer. Esophagogastroduodenoscopy revealed a whitish, superficial elevated lesion in contact with a reddish, superficial depressed lesion from the anterior wall of the gastric angle and antrum to the lesser curvature. Laparoscopic distal gastrectomy was performed for preoperative diagnosis of suspected early gastric cancer presenting as a differentiated and undifferentiated collision tumor, which led to the lesion being diagnosed as collision tumor, tub1-tub2+por1-sig, pT1a (M), ly0, v0, N0, stage IA. To our knowledge, this report represents a valuable addition to the collision tumor literature describing a rare case of preoperatively diagnosed collision tumor of the stomach.

Background Sarcoid-like reaction (SLR) is a histological pattern of granulomatous inflammation that is clinically differentiated from sarcoidosis. Since SLR is known to occur in several neoplasias and occasionally causes lymphadenopathy and mimics metastatic malignancy, it needs to be considered whether lymphadenopathy is due to metastasis or SLR for the choice of cancer treatment. Few cases of hepatocellular carcinoma (HCC) with SLR have been reported. Here, a case of HCC with lymphadenopathy diagnosed as SLR without metastasis is presented. Case presentation A 69-year-old woman was admitted to our hospital because of upper abdominal pain. She tested positive for hepatitis C virus ribonucleic acid. Imaging modalities showed an 81 × 65-mm-sized tumor with multiple nodules in segment 3 and a 17 × 12-mm-sized tumor in segment 5 with a common HCC enhancement pattern. In addition, a lymph node in the hepatoduodenal ligament was enlarged at 13 mm in size, suggesting the metastasis of HCC. Hepatectomy of the lateral segment and segment 5 and lymph node dissection in the hepatoduodenal ligament were performed. Both tumors in segments 3 and 5 were pathologically diagnosed as HCC without vessel invasion. The tumors contained necrotic cells and epithelioid cell granulomas with multinucleated giant cells, which is typically observed in sarcoidosis. The dissected lymph nodes also contained epithelioid cell granulomas, as well as giant cells with asteroid bodies. There was no malignancy in the lymph nodes. The pathological findings suggested the coexistence of malignancy and sarcoidosis. However, since the patient did not show any typical findings of pulmonary or cardiac sarcoidosis, the case was diagnosed as HCC with SLR in the primary lesion and regional lymph nodes. Conclusions SLR needs to be considered in the differential diagnosis when a cancer patient develops lymphadenopathy. However, lymphadenopathy due to SLR is indistinguishable from that due to metastasis even when using multiple imaging modalities. Pathological examinations may be helpful for the diagnosis.

Enterolithiasis associated with blind pouch syndrome secondary to functional end-to-end anastomosis is rare, and its endoscopic and radiological features remain poorly described. A 72-year-old woman was admitted to our hospital for abdominal pain and difficulty defecating. Colonoscopy (CS) with Gastrografin revealed a 10 × 8 cm calculus, an anastomotic ulcer, a blind pouch, and an end-to-end anastomosis in the transverse colon. The calculus was successfully crushed and removed with snares and alligator forceps through CS during the ensuing 4-day period. To our knowledge, this is the first report describing the endoscopic and radiological features of blind pouch syndrome-associated enterolithiasis successfully treated with CS.

Goblet cell carcinoid (GCC) of the perforated appendix is rare, and its pathological features and prognosis remain poorly described. A 71-year-old woman was admitted to our hospital for right lower abdominal pain, vomiting, and high-grade fever. She was diagnosed with acute appendicitis and underwent emergency laparoscopic appendectomy. Intraoperative examination revealed an enlarged and perforated appendix. Histopathological examination revealed GCC of the appendix with subserosal invasion. She underwent laparoscopic ileocecal resection with lymph node dissection (D3) following appendectomy. Histopathological findings showed no residual tumor or lymph node metastases. To the best of our knowledge, this report is a valuable addition to the GCC literature, describing a case of GCC of the appendix presenting as perforated appendix.

Introduction The effectiveness of several vaccines against coronavirus disease (COVID-19) has been reported in the real-world setting. However, it is still unknown how long antibodies persist following vaccination and whether or not the persistence of antibodies has a protective effect against COVID-19. Methods Healthcare workers who had received two doses of the BNT162b2 mRNA COVID-19 vaccine were enrolled, and a single-center study was conducted at the National Hospital Organization Hakodate National Hospital. Serum samples from all participants were collected 13–21 weeks (median: 20 weeks) after the second dose of vaccination. The antibody titers were measured using an electrochemiluminescence immunoassay (Elecsys® Anti-SARS-CoV-2 S). Data on characteristics of the participants were gathered from patient records and interview sheets. Results A total of 401 participants, among whom 70.1% were women and the median age was 42 years, were evaluated in this study. None of the participants had a definite COVID-19 history, and all participants who received complete vaccination showed positive antibody titers. The antibody titer was observed to be higher in participants with younger age (p

Rupture of pancreatic pseudocyst is one of the rare complications and usually results in high mortality. The present case was a rupture of pancreatic pseudocyst that could be treated by surgical intervention. A 74-year-old man developed abdominal pain, vomiting, and diarrhea, and he was diagnosed with cholecystitis and pneumonia. Three days later, acute pancreatitis occurred and computed tomography (CT) showed slight hemorrhage in the cyst of the pancreatic tail. After another 10 days, CT showed pancreatic cyst ruptured due to intracystic hemorrhage. Endoscopic retrograde cholangiopancreatography revealed leakage of contrast agent from pancreatic tail cyst to enclosed abdominal cavity. His left hypochondrial pain was increasing, and CT showed rupture of the cyst of the pancreatic tail into the peritoneal cavity was increased in 10 days. CT showed also two left renal tumors. Therefore we performed distal pancreatectomy with concomitant resection of transverse colon and left kidney. We histopathologically diagnosed pancreatic pseudocyst ruptured due to intracystic hemorrhage and renal cell carcinoma. Despite postoperative paralytic ileus and fluid collection at pancreatic stump, they improved by conservative management and he could be discharged on postoperative day 29. He has achieved relapse-free survival for 6 months postoperatively. The mortality of pancreatic pseudocyst rupture is very high if some effective medical interventions cannot be performed. It should be necessary to plan appropriate treatment strategy depending on each patient.

Castleman's disease (CD) is an uncommon benign lymphoproliferative disorder of unknown etiology. A rare case of cervical CD diagnosed at lymph node dissection for esophageal carcinoma is reported. An esophageal tumor was identified in a 67-year-old man during a follow-up examination after surgery for oral carcinoma. Esophagoscopy revealed a type 1 tumor in the cervical esophagus. Histology of esophagoscopic biopsies indicated squamous cell carcinoma. Contrast-enhanced computed tomography revealed swollen lymph nodes of the right cervical region. No distant metastasis was detected. Esophageal carcinoma, T2N2M0, Stage IIIA was diagnosed. Neoadjuvant chemotherapy was recommended, but the patient rejected the chemotherapy. The patient underwent laparoscopic-assisted transhiatal esophagectomy. The histopathological diagnosis was moderately differentiated squamous cell carcinoma with pT1bN0M0, Stage IA. On histology, the swollen lymph nodes of the right cervical region revealed CD. The patient's postoperative course was relatively good.

Duchenne muscle dystrophy (DMD), X-linked recessive genetic disorder, causes a variety of complications including scoliosis. We report a case of bronchial obstruction and hemorrhage caused by scoliosis with DMD. A man in his forties having been hospitalized due to DMD since the age of 6, produced bloody sputum. A chest X-ray showed atelectasis in his right lower lung. A computed tomography and bronchoscopy indicated that scoliosis and thoracic deformity due to muscle dystrophy caused compression of a right main bronchus by the vertebra, leading to bronchial obstruction and bleeding. We decided to follow closely without therapy because the bleeding had stopped as of the bronchoscopy. A high-risk surgery or bronchial stenting may be needed if he presents with severe bleeding or infection.

An unusual case of pancreatic arteriovenous malformation (P-AVM) combined with esophageal cancer is reported. A 59-year-old man was admitted with upper abdominal pain. Contrast-enhanced computed tomography showed numerous strongly enhanced abnormal vessels and a hypovascular lesion in the area of the pancreatic tail. Angiographic study of the celiac artery confirmed racemose vascular networks in the tail of the pancreas. Endoscopic retrograde pancreatography revealed narrowing and displacement of the main pancreatic duct in the tail of the pancreas. Screening esophagoscopy showed a 0-IIa+IIc type tumor in the lower thoracic esophagus. Histological examination of esophagoscopic biopsies showed squamous cell carcinoma. Based on these findings, P-AVM or pancreatic cancer and esophageal cancer were diagnosed. Video-assisted thoracoscopic esophagectomy and distal pancreatectomy were performed. Histological examination of the resected pancreas revealed abundant abnormal vessels with intravascular thrombi. In addition, rupture of a dilated pancreatic duct with pancreatic stones and both severe atrophy and fibrosis of the pancreatic parenchyma were observed. The final diagnoses were P-AVM consequent to severe chronic pancreatitis and esophageal carcinoma. The patient's postoperative course was relatively good.

Pancreaticoenterostomy remains one of the most stressful parts of pancreatoduodenectomy. We introduce herein a new convenient and secure invagination procedure for pancreaticojejunostomy. We performed our new procedure during pancreatoduodenectomy in 15 consecutive patients (7 men, 8 women). The features of the procedure are as follows. First, it is performed using only four sutures. Second, the pancreas stump is invaginated into the jejunum, mainly by two sutures that penetrate the parenchyma and are continuously purse-string sutured to the jejunum. Third, all needle holes on the surface of the pancreas are covered with the jejunal wall. Eight patients were classified as showing no pancreatic fistula, and seven displayed a grade A fistula, according to the International Study Group on Pancreatic Fistula criteria. The median operating time for these 15 patients using the present procedure was about 60 min shorter than that for the previous nine patients who underwent duct-to-mucosa pancreaticogastrostomy in our hospital. The present method allows pancreaticojejunostomy to be performed swiftly and conveniently.

Intraductal papillary neoplasms of the bile duct are generally thought to arise from neoplastic papillary proliferation of epithelial cells lining the bile duct. We herein report a case with findings that strongly suggested that the biliary cystic tumor might have derived from a peribiliary gland. A 69-year-old female was found to have a cystic lesion with intracystic protrusions at the anterior segment of the right hepatic lobe and underwent hepatic anterior segment resection. Fluoroscopy of the resected specimen injected with contrast medium into the cyst revealed a connection between the cystic lesion and the bile ducts. The cyst was multilocular in appearance. On microscopic examination, the cyst was located within the portal tract of the inferior branch of the anterior segment and connected with the inferior branch of the bile duct. The wall of the hepatic cyst lacked an ovarian-like stroma. The tumor was composed of papillary and glandular components, and the tumor cells were similar to gastric foveolar and pyloric gland epithelia and regarded as adenoma. These tumor cells were positive for MUC 5AC, MUC6, and HIK1083. The tumor was finally diagnosed as an intraductal papillary neoplasm of the bile duct (adenoma, gastric type) arising from a peribiliary gland.

A 90-year-old woman was admitted to the emergency department of our hospital with abdominal pain and a fever of up to 39°C. She had a history of hysterectomy about 30 years previously, and redness and swelling were seen at the abdominal median scar. Serum biochemistry showed minor elevation of C-reactive protein and creatine phosphokinase. Abdominal computed tomography (CT) showed an edematous intestinal tract image over the median abdominal wall. Incarcerated incisional hernia and intestinal necrosis were suspected. Therefore, emergency surgery was performed. On laparotomy, abundant purulent ascitic fluid was found. The small intestine was incarcerated about 100 cm orally from the terminal ileum, and a 2-mm perforation was present in the incarcerated small intestine. In addition, some white areas measuring 1 mm were found in the small intestinal wall. A press-through package (PTP) of a tablet was confirmed in the intestinal tract near the perforated area. We removed the PTP through the perforation and performed direct suture. Postoperatively, we retrospectively reviewed the CT image and found a high-density shadow which seemed to represent the PTP.

A 64-year-old man was transferred to our division with a suspicion of gastric cancer. Computed tomography showed widespread irregular thickening of the stomach walls close to the liver and pancreas. Gastrointestinal fiberscopy showed a type 5 tumor in the upper to lower stomach, histologically diagnosed as tubular adenocarcinoma. Gastric cancer with hepatic and pancreatic invasion was diagnosed. Distant metastasis was not proven and complete resection was planned. At laparotomy, the tumor showed general expanding growth and invasion through the lateral segment of the liver and pancreas. Total gastrectomy and combined resection of the distal pancreas, spleen and left segment of the liver were performed. Hepatic and pancreatic invasion and lymph node metastasis were microscopically proven. Pancreatic fistula occurred postoperatively. On postoperative days 40, he was discharged. He received two cycles of adjuvant tegafur/gimeracil/oteracil chemotherapy. He has had no sign of recurrence for 7 years and 8 months.

A 75-year-old asymptomatic woman was admitted to our hospital after an abnormal shadow was found on a chest roentgenogram. Chest computed tomography showed a round mass in the right lower lobe. Magnetic resonance imaging showed the mass with high signal intensity on T2-weighted images and intermediate signal intensity on T1-weighted images. Fluorine-18-fluorodeoxyglucose-positron emission tomography showed high fluorine-18-fluorodeoxyglucose accumulation in the mass. A lobectomy was performed thoracoscopically. The pathologic diagnosis was cellular schwannoma. Immunohistochemical staining demonstrated the presence of S-100 protein, and the Ki67 labeling index was 12%. We present this case of intrapulmonary cellular schwannoma, which is extremely rare.

Background Respiratory failure is one of fatal postoperative complication after esophagectomy. The patient with COPD is tendency to contraindication of esophagectomy. Thoracoscopic esophagectomy preserve respiratory function comparing with open esophagectomy. We suppose to preserve more respiratory function with mediasinoscopic esophagectomy. Methods 77-year-old male. He had home oxygen therapy(HOT) by 1 liter oxygen per minute. Diagnosis was lower esophageal carcinoma with metastasis of upper mediastinum and cardiac lymphnode. We performed mediasinoscopic esophagectomy with lymphnode dissection. Results Pathological findings revealed adenocarcinoma with metastasis of cardiac and bilateral laringial nerve lymphnode. He recovered after one week mecanical ventilation. He discharged after rehabilitation. Conclusion The patient with COPD has high risk of esophagectomy. However, we suppose mediastinoscopic esophagectomy is one of the hopeful option incase of sufficient informed consent. Disclosure All authors have declared no conflicts of interest.

Background Recently, indocyanine green (ICG) fluorescent imaging has been applied as a real-time navigation tool in various surgical fields. We used ICG fluorescent imaging for gastric conduit reconstruction during esophagectomy. Methods A total of 92 consecutive patients with esophageal cancer who received gastric conduit reconstruction during esophagectomy from February 2011 to December 2017 were enrolled in the present study. We made gastric conduit with hand-assisted laparoscopic surgery (HALS) following esophagectomy. A gastric conduit with a width of 3cm was usually fashioned. After evaluation of the blood flow to the gastric conduit using ICG fluorescent imaging, anastomosis was done by circular stapler. Results The study group was comprised of 73 males and 19 females and the median age was 70 years (range 54–85 years). Nineteen patients received preoperative chemotherapy and eleven patients received preoperative chemo-radiotherapy. Forty-eight patients underwent thoracoscopic esophagectomy, nineteen patients underwent thoracotomy and twenty-five patients underwent laparoscope assisted transhiatal esophagectomy. In eighty-five patients, reconstruction was done via the posterior mediastinal route, while six patients ware treated by the retrosternal route, and the subcutaneous route was used in one patient. Cervical anastomosis was done in 84 patients and intrathoracic anastomosis was done in eight patients. The complications of the gastric conduit reconstruction were anastomotic leakage in one (1.1%) patient and stricture of the anastomosis site requiring esophageal dilatation in 26 (28.3%) patients. Periodic esophageal dilatation was done in 13 (14.1%) patients. There was one case of stricture of the gastric conduit, one case of bleeding of the gastric conduit and one case of fistula between the gastric conduit and the lung. Conclusion The gastric conduit reconstruction using ICG fluorescent imaging during esophagectomy may contribute to a reduction in the incidence of anastomotic leakage. However, further advancement of the relevant skills is required to improve the incidence of stricture of the anastomosis site. Disclosure All authors have declared no conflicts of interest.

症例は70歳,男性.多量の飲酒歴があり,慢性膵炎にてフォローをうけている.また胃潰瘍にて幽門側胃切除術(再建: Billroth II法)を施行されている.平成15年4月吐血のため当院入院,腹部CTで径6cm大の脾動脈瘤を認めたが内視鏡検査にて異常を認めなかった.十二指腸乳頭の観察は行えず,脾動脈瘤と消化管出血の関連が証明できなかったため経過観察となった.その後,吐下血のため10月に再入院,内視鏡検査では出血を確認できなかったが,下血が遷延するため最終的に脾動脈瘤が膵内に穿破したことによる消化管出血と判断し,膵体尾部脾切除を施行した.病理では,脾動脈は弾性繊維を欠如しており,膵仮性嚢胞内に穿破して仮性動脈瘤を形成し膵管内に出血を生じたものと推測された.慢性膵炎の経過中の消化管出血においては膵管を介する出血であるhemosuccus pancreaticusを念頭におく必要があると思われた.

症例は69歳,男性.平成7年1月に右肺癌のため右上葉切除術施行(pT4N0M0 stage III B),平成9年2月に右第1肋骨転移のため放射線照射60Gyを受けている.平成11年9月,腹部造影CT検査で肝後区域および右副腎に径4.5×5.0cm大の低吸収域を認め,右副腎転移,肝浸潤と考え右副腎切除・肝後区域部分切除術を施行した.平成13年6月の腹部造影CT検査では前回切除部と思われる肝後区域と右腎に低吸収域を認め,前回切除の断端再発と考え,肝右葉切除・右腎摘術を施行した.患者は初回副腎切除より6年経過した現在まで新たな病巣の出現なく,生存中である.

Here we report two cases of inverted hyperplastic polyps of the colon. The first patient showed three inverted hyperplastic polyps in the ascending colon, one of which was associated with adenoma. We immunostained this adenoma-associated polyp using anti-beta-catenin antibody and found accumulation of beta-catenin in the cytoplasm of the adenomatous lesion but not in the inverted hyperplastic polyp. This suggested an adenomatous polyposis coli (APC) mutation in the adenomatous region but not in the inverted hyperplastic polyp. The inverted hyperplastic polyp in the second patient was located at the caecum and was studied using magnifying colonoscopy. The polyp appeared to be flat and elevated with a depressed pit in the centre. After spraying with methylene blue dye, the pit pattern of the lesion was observed and small asteroid pits on the polyp were found, consistent with a hyperplastic gland pattern. From these results, we diagnosed inverted hyperplastic polyp of the colon by colonoscopy.

後腹膜腫瘍の3例を経験したので報告する.症例1は54歳男性,他疾患の手術中に後腹膜腫瘍(高分化型脂肪腫)を指摘,切除されたが半年後に再発し,当科受診. 2.3kgの再発腫瘍を切除した.症例2は77歳女性,心筋梗塞にて他科入院中に嚢胞形成性の後腹膜腫瘍を指摘され,腫瘍摘出術を施行. 1kgの神経鞘腫と診断された.症例3は71歳男性,左側腹部痛にて近医受診し,後腹膜腫瘍を指摘されたが放置. 17カ月後に再受診し腫瘍の増大を認めたため当院紹介され, 620gの後腹膜腫瘍(高分化型脂肪肉腫)を切除した.後腹膜腫瘍は症状に乏しいため巨大化し易く,また悪性腫瘍の場合再発の可能性が高いことから術中の慎重な診断と適切な術式選択が重要である.

症例は60歳, 男性.突然の呼吸困難感を主訴に近医を受診した.受診後に意識消失をきたし, 急性呼吸不全の診断で当院に搬送された.動脈血ガス分析はPo2 33.5torr, Pco2 34.6torrで, 直ちに気管内挿管, 人工呼吸器管理とした.胸部CTで後縦隔に腫瘍塊と, それによる左主気管支の圧迫狭窄を認めた.BFでは気管支粘膜に異常は認めなかった.動脈血ガスの改善が得られないため, 翌日左主気管支にDumonステントを挿入した.直後より意識は清明となり, 人工呼吸器を離脱した.画像所見から未分化癌を疑い, 縦隔腫瘍に放射線照射を開始した.理学所見で左頚部リンパ節の腫大を認めたため同部を生検, 病理組織検査にて多形性細胞と紡錘形細胞を認め, 免疫組織化学検査よりMFHの診断を得た.

症例は62歳, 男性.約1年前より慢性腎不全にて週3回の血液透析を施行されていた.定期の胸部単純X線で左肺上葉の無気肺を指摘され, 精査の結果, 左上葉入口部原発の扁平上皮癌で下葉支への浸潤が認められた.週3回の維持透析により患者の全身状態は良好にコントロールされており, 術前3日間連日透析施行後に, 左肺摘除術, 縦隔リンパ節郭清術を行った.術後は1日目より2日間透析を施行した後, 術前の透析スヶジュールに戻した.グルコース・インスリン療法を併用することにより術後の血清K値は良好に維持され, 術後18日目に退院した.

A 63-year-old woman was admitted to the hospital because of presenting with cough, feeling of heaviness in the chest, and dyspnea. She had a past history of undergoing a left pulmonary upper lobectomy for lung cancer 1 year and 2 months previously. Chest roentgenography showed left pleural effusion. Chest computed tomography (CT) showed the mediastinal shift to the right and the abnormal mass in left thorax. The old bloody pleural effusion was aspirated and its examination revealed that Hb was 4.0g/dl. The pleural effusion was aseptic and cytodiagnosis was class I. She underwent surgery by left thoracotomy and about 2, 000ml old blood was discharged. The bleeding point was not exactly revealed. Pathologically, the pleural biopsy showed that it had collagenous tissue with deposits of hemosiderin and many clusters of iron-laden macrophages. Eleven months after the operation, chest roentgenography and chest CT revealed no abnormal findings and dyspea was diminished. Expanding hematoma rarely occurs in patients with previous history of undergoing thoracotomy or artifitial pneumothorax. It is inferred that the disease often proceeded to chronic or organic pyothorax, if it is left in place for longtime. This case whitch was quickly treated resulting from manifestation of symptoms in a subacute phase of the disease is reported.

We inserted Dumon stent to 13 patients with tracheobronchial stenosis due to advanced or recurrent esophageal carcinoma. Severe dyspnea was improved in 11 patients except for 2 patients with bilateral recurrent nerve palsy. 3 cases who had radiation therapy or chemotherapy lived over 150 days. We inserted esophageal stent in 4 cases. 2 patients died due to hemoptysis after 156 days and 35 days. We conclude that Dumon stent is one of the useful treatments in order to improve quality of life and prognosis of advanced or recurrent esophageal carcinoma.

Background A study with chemotherapy and twice-a-day radiotherapy in patients with esophageal carcinoma was performed to evaluate toxicity and efficacy.

p16 (MTS-1, multiple tumor suppressor gene 1), a putative tumor suppressor gene, is one of the cyclin-dependent kinase inhibitors (CDI) and it regulates the G1/S transition of the cell cycle. To clarify the role of p16 in primary gastric cancer, we have investigated somatic mutations of this gene by using the polymerase chain reaction/single strand conformation polymorphism (PCR-SSCP) method. In 23 surgical specimens of primary gastric cancer, none were detected in exon1 and exon 2. Among the 6 human gastric cancer cell lines examined, PCR products were not found in 2, MKN28 and MKN45, suggesting the presence of homozygous deletions. No mutation was found in the other 4 cell lines. Furthermore, decreased expression levels were not observed in 13 gastric cancer tissues by reverse transcription PCR (RT-PCR). Considering the above results of PCR-SSCP and RT-PCR, genetic alterations of the p16 gene are rarely implicated in human gastric cancer tumorigenesis.

Background Recurrence patterns in patients who have undergone curative gastrectomy for advanced gastric carcinoma can be classified as peritoneal, hematogenous, or lymphatic. The aim of this study was to clarify differences in risk factors between these different types of recurrence pattern. Methods Postoperative courses, including sites of recurrence and periods between surgery and recurrence, of patients who had undergone curative gastrectomy for advanced gastric carcinoma (more than pT2 invasion) were surveyed in detail. Clinicopathological factors were examined as potential independent risk factors for each recurrence pattern, based on recurrence-free survival, using multivariate analysis. Results Multivariate analysis identified depth of tumor invasion (pT4 vs. pT2/3; hazard ratio (HR), 7.05; P < 0.001), number of lymph node metastases (pN2/3 vs. pN0/1; HR, 4.02; P = 0.001), and histological differentiation (G3/4 vs. G1/2; HR, 2.22; P = 0.041) as independent risk factors for peritoneal metastasis. The number of lymph node metastases (HR, 26.21; P < 0.001) and venous vessel invasion (HR, 5.09; P = 0.001) were identified as independent risk factors for hematogenous metastasis. The number of lymph node metastases (HR, 6.00; P = 0.007) and depth of tumor invasion (HR, 4.70; P = 0.023) were identified as independent risk factors for lymphatic metastasis. Conclusions This study clarified differences in risk factors between various patterns of recurrence. Careful examination of risk factors could help prevent oversight of recurrences and improve detection of recurrences during follow-up. The number of lymph node metastases represents an independent risk factor for all three patterns of recurrence; thus, patients with multiple lymph node metastases warrant particular attention.

Among 564 cases resected and reconstructed for an esophageal cancer at the department in a recent 12-year period, we experienced 4 cases (0.7%) of synchronous double cancer of esophageal and gastric early cancer. Of the 4 cases, 2 cases were referred to the hospital with the definite diagnosis which was made at elsewhere; one cases was detected having synchronous cancer at the outpatient clinic; and the remaining one cases was diagnosed by preoperative exploration for a rectal cancer. All 4 cases were diagnosed between 1991 and 1993 that might result from a remarkable improvement in endoscopic diagnostic technique. All 4 cases are alive and free from cancer. Operative procedure should be selected by the balance of surgical intervention and curability. The indication of more limited operation such as endoscopic mucosectomy or blunt dissection should be also considered for the esophageal cancer. The sufficient preoperative examination entertaining possible multiple gastric cancer, multiple esophageal cancer and synchronous triple cancer is important to gain a better prognosis.

症例は34歳,男性. 10年前にvon Willebrand病(以下vWD), type IIAの診断を受けていた.突然の下血と吐血を主訴に当院救急外来受診.上部消化管内視鏡検査にて,胃体上部より出血あり,止血を施行した. 3日後に胸部苦悶感が出現し,胸部X線写真にて,右胸水貯留を認め,胸腔ドレーンを挿入した.血性の排液を認めたが減少傾向なく,外科に依頼があり,緊急手術となった.肺尖部のブラおよび胸壁癒着部より出血がみられたため,肺尖部ブラ切除と胸壁の凝固止血を施行した. vWDは出血傾向を示す疾患として知られているが,様々な病型を含む疾患群であり,症状も治療法も病型によって異なる. vWDは主に一次止血の障害をもたらす遺伝性疾患であり,出血を契機に増悪することがあるため,出血が疑われた場合は一刻も早く止血する事が重要である.

Intraductal papillary neoplasms of the bile duct are generally thought to arise from neoplastic papillary proliferation of epithelial cells lining the bile duct. We herein report a case with findings that strongly suggested that the biliary cystic tumor might have derived from a peribiliary gland. A 69-year-old female was found to have a cystic lesion with intracystic protrusions at the anterior segment of the right hepatic lobe and underwent hepatic anterior segment resection. Fluoroscopy of the resected specimen injected with contrast medium into the cyst revealed a connection between the cystic lesion and the bile ducts. The cyst was multilocular in appearance. On microscopic examination, the cyst was located within the portal tract of the inferior branch of the anterior segment and connected with the inferior branch of the bile duct. The wall of the hepatic cyst lacked an ovarian-like stroma. The tumor was composed of papillary and glandular components, and the tumor cells were similar to gastric foveolar and pyloric gland epithelia and regarded as adenoma. These tumor cells were positive for MUC 5AC, MUC6, and HIK1083. The tumor was finally diagnosed as an intraductal papillary neoplasm of the bile duct (adenoma, gastric type) arising from a peribiliary gland.

Tumor budding is defined as an isolated single cancer cell or a cluster of cancer cells composed of fewer than five cells at the invasive front of a tumor. The aim of the present study was to identify correlations between tumor budding and clinicopathological factors and their impact on postoperative prognosis in invasive squamous cell carcinoma of the thoracic esophagus. The subjects were 82 patients who underwent curative resection. The number of tumors showing budding was counted immunohistochemically based on positivity for cytokeratin (AE1/AE3) to distinguish cancer cells from inflammatory cells, and the patients were divided into low-grade and high-grade budding groups. High-grade budding was defined as ≥5 budding foci per field under a 20× objective lens. One group of 36 patients (43.9%) and a second group of 46 patients (56.1%) were classified into the low-grade and high-grade budding groups, respectively. Patients in the high-grade budding group had significantly larger tumor size, deeper depth of invasion, more frequent lymphatic invasion and venous invasion, as well as more lymph node metastases, than those in the low-grade budding group. Disease-free and overall survivals were worse in the high-grade budding group than in the low-grade budding group (P