Purpose: To clarify their physical status, subjects undergoing gastroenterological cancer resection should be nutritionally screened. This requires a simple, useful index objectifying the relationship to complication incidence and postoperative hospitalization.
Subjects and methods: Subjects diagnosed with gastroenterological cancer numbered 368—70 esophageal, 107 gastric, 165 colon, and 26 pancreatic—undergoing resection from January 2005 to 2009. Nutritional screening evaluated age, serum albumin (Alb), body mass index (BMI), diabetes, percent vital capacity (%VC), and percent forced expiratory volume in one second (FEV 1.0%) versus complication incidence and postoperative hospitalization.
Results: A positive correlation was seen between these 6 parameters and the incidence of complications and postoperative hospitalization in subjects aged 70 years or older, Alb ≤ 3.6g/dl, and %VC ≤ 80%.
Conclusion: In subjects 70 years of age or older, Alb ≤ 3.6 g/dl and ≤ %VC 80% are useful nutritional screening indicators in those undergoing gastroenterological resection.

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Purpose:To investigate cases of recurrent inguinal hernia after mesh repair. Patients and methods:Of 68 recurrent hernia cases treated in our institution from January, 1999 to January, 2009, 22 hernias recurred after mesh repair. We analyzed the cases retrospectively. Results:Previous operations included mesh plug repair in 9 cases, inlay repair in 9 cases, PHS repair in 2 cases, inlay+plug in 1 case, and TEP in 1 case. Recurrent types were indirect in 6 cases, direct in 12 cases (10 cases were supravesicular), femoral in 3 cases, in and direct+femoral in 1 case. Seven cases in the group with mesh repair versus 4 cases in the group after conventional repair recurred within 3 months. Six cases in the group with mesh repair versus 5 cases in the group with conventional repair recurred after 3 to 12 months. Nine cases in the group with mesh repair versus 37 cases in the group with conventional repair recurred after 12 months. Of the 13 cases which recurred within 12 months, seven cases were the direct type. Conclusion:Recurrence after mesh repair characteristically occurred earlier than after conventional repair, and the direct type was an important factor associated with recurrence. The mesh should be fixed carefully, especially to the medial side.

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To minimize wound infection, accounting for 21.2% of the complications in our colorectal surgery, we revised wound closure. Briefly, we washed wounds with physiological saline through syringe pressure, introduced negative–pressure subcutaneous drainage and absorbable subcuticular sutures, and used absorbent see–through lattice foam film dressings. Infection incidence dropped significantly from 21.2% to 4.3%, demonstrating the revised wound closure′s effectiveness.

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We report a rare case of cervical epidural abscess due to postcholecystectomic catheter–related blood stream infection. A 66–year–old man diagnosed with acute cholecystitis and treated conservatively in total–nutrition therapy underwent cholecystectomy. Postoperatively, he experienced fever followed by sensory disturbance and right upper limb paresis with right cervical swelling and pain. Computed tomography (CT) and magnetic resonance imaging (MRI) indicated a cervical epidural abscess requiring debridement and drainage, after which symptoms disappeared.

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We report a rare case of giant malignant phyllodes tumor in a young woman.
A 20–year–old woman reporting a 6 cm left outer–quadrant breast lesion was diagnosed in core needle biopsy with a borderline phyllodes tumor. Contrast–enhanced computed tomography showed a diffuse pattern suggesting malignancy. Histological diagnosis of the resected specimen was a malignant phyllodes tumor. The general postoperative course was satisfactory.

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A 59–year–old woman found in chest examination to have an abnormal left lung shadow was confirmed in chest computed tomography (CT) to have a 4 cm tumor in the lingular left lung segment and right aortic arch. The lesion was diagnosed in brushing cytology as class V–adenocarcinoma. In surgery based on a diagnosis of left lung cancer, cT2N1M0, cStageIIB, thoracotomy showed advanced lung cancer with pleural dissemination. We conducted palliative upper left lobectomy, partial lower lobe resection and node sampling. No abnormalities appeared in pulmonary artery and vein branching or in bronchi. The tumor′s maximal diameter was 42 mm, and the pathological diagnosis was poorly differentiated adenocarcinoma, pT4N2M0, Stage IIIB. The postoperative course was uneventful and she was discharged on postoperative day (POD) 12, there after undergoing chemotherapy. The tumor showed no progression in the 5 months since surgery. In surgery for left lung cancer associated with the right aortic arch, conventional lobectomy is sufficient in the absence of pulmonary artery and vein and brouchial abnormalities. Attention is required in mediastinal node dissection, however, because subjects with right aortic arch often have the left recurrent laryngeal nerve sited in the arterial ligament.

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We report a case of persistent sciatic artery which occluded spontaneously without lower limb ischemia. A 74–year–old woman presented with painless pulsation in her right buttock. She underwent computed tomographic angiography (CTA), which showed complete persistent sciatic artery. We decided on conservative management with 3–monthly CTA. After 12 months CTA showed that the persistent sciatic artery had developed spontaneous occlusion with thrombi. In conclusion, when there is little ischemia and risk of rupture, conservative treatment can be appropriate. CTA is a very useful imaging modality in the follow–up of persistent sciatic artery.

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We report a case of secondary reconstructive surgery using a thin tube in gastric obstruction due to delayed blood flow in the free jejunum graft after cervical esophageal cancer.
A 70–year–old woman undergoing chemoradiotherapy for cervical esophageal cancer in 2002 and bilateral cervical lymph node dissection in 2003 reporting hoarseness in April 2008 was found to have recurrent cervical esophageal cancer, necessitating total laryngectomy, cervical esophageal resection, and free jejunum graft interpositioning. Despite uneventful postoperative progress and mid–June discharge, skin over the right tracheal tunnel broke, resulting in pus discharge within a month and a gradually narrowed anastomosis. Based on a diagnosis of partial necrosis and free jejunum graft narrowing due to delayed blood flow disturbance, we resected the graft and conducted thoracic esophagectomy, hypopharynx anastomosis to the stomach via a posterior mediastinal approach, and enterostomy in late August. Postoperative progress was favorable, and the woman was discharged on postoperative day 30.

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We report a case of spontaneous esophageal rupture in an elderly woman saved by two–stage surgery over 72 hours after onset.
A 74–year–old woman seen as an emergency outpatient for persistent right chest pain and respiratory discomfort from the day before was diagnosed with aggravated chronic bronchitis and sent home. She went into shock the following day, however, requiring emergency hospitalization. The diagnosis of spontaneous intrathoracic esophageal rupture requiring surgery was based on imaging. Two–stage surgery was conducted when the primary suture could not close the rupture. The first surgery involved subtotal thoracic esophagectomy, external esophagostomy, enterostomy, and thoracic cavity and posterior mediastinum drainage. She developed intractable methicillin–resistant Staphylococcus aureus–induced pneumonia postoperatively but surrived. On hospital day (HOD) 122, the second surgery comprised antethoracic cervical esophagogastric anastomosis. Her postoperative course was satisfactory, and she was discharged improved on HOD 152. She remains well 12 months after surgery.

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We report a rare case of multiple esophageal cancers with coexisting small–cell and squamous cell carcinoma. A 63–year–old woman seen for epigastralgia and admitted was found in endoscopy to have esophageal cancer–Type 2 in the upper thoracic esophagus (Ut) and Type 1 in the lower thoracic esophagus (Lt). Preoperative biopsy showed both to be squamous cell carcinoma. Preoperative computed tomography (CT) showed neither definite lymph node nor distant metastasis, and both lesions were diagnosed as T2 N0 M0 cStage II, necessitating radical esophagectomy and three–field lymph node dissection. Histopathologically, the Lt tumor was squamous cell carcinoma and the Ut tumor small–cell carcinoma. Immunohistochemical staining showed small–cell carcinoma cells positive for NSE and CD56 (NCAM). Metastatic small–cell carcinoma cells were found in lymph node No.105. CT 10 months postoperatively showed mediastinal and hilar lymph node, multiple liver, and spleen metastases. The woman died of the primary disease 12 months after surgery, underscoring the dismal prognosis faced by those with small–cell esophageal carcinoma.

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We report a rare case of undifferentiated small–cell carcinoma of the esophagus.
A 75–year–old man admitted for an incidentally detected lung tumor was shown in fluorodeoxyglucose positron emission tomography (FDG–PET) to have middle thoracic esophagus uptake. Upper endoscopy showed a tumor surrounded by a steep protrusion at the middle thoracic esophagus. Biopsy yielded a diagnosis of esophageal squamous cell carcinoma, necessitating subtotal esophagectomy with regional lymph node dissection. Postoperative pathology showed undifferentiated small–cell esophageal carcinoma. Multiple lung and liver metastases were noted 2 months postoperatively. The man died of multiple organ failure three months thereafter.

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We report a case of a man in his 60s with primary gastric cancer and total gastrectomy suffering sudden acute respiratory distress syndrome (ARDS) onset after extended–spectrum beta–lactamase (ESBL) producing Escherichea coli infection. Three days after total gastrectomy, he suddenly reported dyspnea and abdominal fullness from ileus, developing ARDS the next day. We suspected intestinal infection and started empirical meropenem. Three days after ARDS onset, we identified ESBL–producing Escherichea coli from small intestine juice, sputum, and pleural effusion cultures. ESBL occurrence is widespread, particularly in the hospital environment. Carbapenems are the therapeutic choice. We continued meropenem, ameliorating ARDS. The man was discharged on postoperative day 57 days.

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We report a case where laparoscopy proved useful in defecting small–intestine anisakiasis infection difficult to diagnose correctly otherwise.
A 57–year–old man seen the next day for abdominal pain starting the night of January 5, 2009, was found in abdominal computed tomography (CT) to have moderate ascites and small–intestine dilation and air–fluid levels. Emergency laparoscopy conducted when possible strangulation ileus could not be ruled out showed cloudy ascites and localized intestinal redness and edema but no ileus, terminating the operation. Three weeks after abdominal pain onset, positive antianisakiasis IgG+IgA antibodies yielded a final diagnosis of small–intestine anisakiasis infection.

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Laparoscopy–assisted surgery can be very useful in small–intestine surgery.
A 31–year–old man admitted for epigastralgia and intermittent abdominal pain was found in abdominal computed tomography (CT) to have ileal intussusception due to lipoma 2 cm in diameter. Intestinal obstruction symptoms appeared minor and were freated the next day using laparoscopy–assisted surgery. Intestinal intussusception at a slightly dilated, highly peristaltic area was pulled through a 3 cm laparotomy at the umbilical port for extracorporeal treatment. It was due to an inverted Meckel′s diverticulum with lipoma 2 cm in diameter, which was resected.

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Endotoxin appears to play a major role in the development of toxic symptoms in sepsis. The turbidimetric Limulus amoebocyte lysate (LAL) assay is usually used for the detection of endotoxin ; however, a novel rapid LAL assay for endotoxin has recently been developed that uses a laser light–scattering particle–counting method, called endotoxin scattering photometry (ESP). We report a case of sepsis in a patient with colorectal perforation, in which plasma endotoxin was detected by the ESP but not by turbidimetry. A 70–year–old woman with severe abdominal pain who received tocilizumab, an interleukin–6 receptor antagonist, was diagnosed with diffuse peritonitis caused by intestinal perforation. Emergency surgery revealed perforation of a rectosigmoid diverticulum, and the patient underwent Hartmann′s procedure. She presented with sepsis after surgery ; however, her overall condition rapidly improved. Decreased plasma endotoxin measured by EPS and reduction in plasma interleukin–6 appeared to accompany her improved septic condition. In conclusion, we experienced a successfully treated case of sepsis caused by colorectal perforation, despite tocilizumab administration. Moreover, ESP may more sensitively detect sepsis than the widely–used quantitative turbidimetric endotoxin assay.

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A 46–year–old man admitted for miction pain and pneumaturia was found in cystoscopy to have mucosal edema with left posterior bladder wall ulceration. Abdominal computed tomography (CT) showed multiple sigmoid diverticulosis with inflamed paracolic tissue, urinary bladder wall thickening, and air density 1.7 cm in diameter between the sigmoid colon and bladder. Based on a diagnosis of vesicosigmoidal fistula, he was treated conservatively, but relapsed and pneumaturia and enteruria occurred 4 months later. No complications or recurrence was seen following fistulectomy. Sigmoidectomy with cystectomy has been reported necessary for vesicosigmoidal fistula. Our subject was diagnosed with multiple sigmoid and descending colon diverticula. We considered sigmoid and descending colon resection for all diverticula to be high invasive and his prostatitis history indicated cystectomy reducing bladder volume could aggravate thamuria, so we conducted only fistulectomy.

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Multiple–cancer reports are increasing while combined carcinoid and colorectal carcinoma remain rare.
A 79–year–old man undergoing colonoscopy elsewhere for fecal occult blood was found in September 2007 to have sigmoid colon cancer and a rectal polyp, which was resected. Pathological examination indicated a carcinoid with free margin. The man′s history included severe hypertension, asthoma, paroxysmal atrial fibrillation, and diabetes. He was admitted in February 2008 for swollen lymph nodes detected near the sigmoid colon tumor. Enhanced computed tomography (CT) showed no lung or liver metastases. He underwent sigmoidectomy with D2 lymph node dissection, pathologically shown to be S, tub2, type 2, se, n1. The postoperative course was fair, without complications, and he remains alive with no recurrence 25 months after surgery.

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Transanal rectal foreign body insertion devolves mainly on sexual preference. We report five such cases—all men—treated from 2006 to 2007, two involving the same person. Subjects ranged from 30 to 67 years old (average:56.2 years). All reported the difficuity of extraction. Insertion motives involved autoeroticism in three cases, sadomasochism in one, and was unclear in one. Objects involved plastic bottles and caps, an automatic toothbrush, a spoon, and an ear of corn. All were diagnosed from abdominal X–ray film. Extraction involved one transanal extraction without anesthesia in one case, three with lumbar anesthesia, one with laparotomy under general anesthesia, and transanal extraction assisted by abdominal cavity manipulation. No postoperative complications occurred and hospitalization was 3 to 10 days, averaging 5.4 days.

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Foreign rectal body and injury in masturbation are comparatively rare. We report two such cases associated with human immunodeficiency virus (HIV) infection.
Case 1: A 54–year–old man admitted for rectally inserting a foreign body underwent emergency surgery under spinal anesthesia when the foreign body, a spray can, could not be removed at the outpatient clinic. Case 2: A 49–year–old man admitted for abdominal pain after inserting his arm into his anus showed guarding and rebound tenderness. Abdominal X–ray showed free air. We conducted emergency surgery under general anesthesia for diffuse peritonitis due to digestive–tract perforation. Perforation due to anterior rectal aspect ulceration necessitated Hartmann′s colostomy. Both men were discharged without complication.

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We present a case of hepatocellular carcinoma (HCC) rupture involving transhepatic arterial embolization (TAE) containing extrahepatic collaterals followed by elective surgery. A 62–year–old man admitted for right hypochondralgia. Computed tomography (CT) showed an 8 cm tumor at the right hepatic lobe with a huge subcapsular hemorrhage. Angiography showed the tumor to be hypervascular and by the right hepatic artery (RHA) and extrahepatic collaterals. Under a diagnosis of ruptured HCC, TAE was done through the RHA, collaterals;omental artery, and right intercostal arteries. His vital signs became stable. He underwent second–stage right hepatectomy 31 days after TAE and was discharged on postoperative day 80. He remains well without evidence of recurrence in the over 18 months since elective surgery.

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An 83–year–old woman with hypertension and dyslipidemia seen for epigastralgia, nausea, and anorexia and who only rarely drank alcohol had mild anemia. Computed tomography (CT) indicated hepatic left–lobe tumor rupture and hemorrhage. Prior to transcatheter arterial embolization (TAE), laboratory data showed mild liver dysfunction but was negative for HBsAg and anti–HCV, antinuclear antibody. AFP tumor markers were abnormally elevated at 44,000. Following left lobectomy, the tumor was diagnosed histologically as well–differentiated hepatocellular carcinoma (HCC). Liver background showed steatosis, hepatocytic ballooning, and inflammatory–cell infiltration without advanced fibrosis, yielding a final diagnosis of HCC arising in noncirrhotic, nonalcoholic steatohepatitis (NASH). Few case reports of HCC in noncirrhotic NASH are known, but subjects with NASH, especially with complications, such as diabetes, hypertension, and dyslipidemia, should be carefully monitored.

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Treating type IIIb pancreatic injury requires different techniques, the appropriate one being selected based on the subjects general condition. We report a case of type IIIb pancreatic injury requiring emergency Letton–Wilson surgery.
A 19–year–old man brought by ambulance and seen for upper abdominal pain from an abdominal blow during a fight was found in abdominal computed tomography (CT) upon arrival to have type II (superficial) pancreatic and hepatic injury. Eight hours after injury and follow–up admission, CT showed ascites retention in Douglas′ pouch, fluid collection around the duodenum, and irritative peritoneal signs. Emergency surgery based on a diagnosis of injury–related hepatic/pancreatic peritonitis, showed complete pancreatic rupture (type IIIb pancreatic injury) necessitating surgery using the Letton–Wilson technique. A postoperative intraperitoneal abscess was relieved by puncture drainage alone and the man was discharged.

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We report a case of nonocclusive mesenteric ischemia (NOMI), whose etiology appeared related to dried persimmon ingestion. A 76–year–old man admitted in an emergency for severe lower abdominal rebound tenderness showed signs of shock upon admission. Abdominal computed tomography (CT) showed small–intestine wall thickening and oral–side small–intestine dilation. In emergency laparotomy based on a diagnosis of gut necrosis due to ischemic enteritis, we resected a discolored 100–cm small–intestine segment and conducted primary anastomosis. The resected specimen contained undigested dried persimmons, yielding a diagnosis of NOMI due to the absence of uniform necrosis along the intestine and the presence of histopathological intestinal necrosis and intramural hemorrhage. The unfortunate postoperative course ended with the man′s death from circulatory failure despite aggressive life support.

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We report a case of non occlusive mesenteric ischemia (NOMI) in chronic renal failure requiring hemodialysis. A 73–year–old man admitted for abdominal pain and high fever was found in abdominal computed tomography (CT) to have free air under the diaphragm and intramural right–colon gas. Suspected right–colon perforation necessitated emergency surgery. Intraoperative findings showed perforation due to right–colon and segmental ileal necrosis without impaired superior mesenteric arterial blood flow, yielding a diagnosis of non occlusive mesenteric right–colon and ileal ischemia necessitating right hemicolectomy and partial ileal resection. The possibility of NOMI should thus be considered in those undergoing hemodialysis.

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A 68–year–old woman seen for an abdominal mass was found to have a huge, 8×6 cm elastic hard lobular mass palpable in the left abdomen. Abdominal ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) confirmed a retroperitoneal mass adhering to the left kidney, causing hydronephrosis. The resected tumor was elastic, hard, and yellowish–white. Pathologically, it consisted of well–differentiated liposarcoma with lipoblasts and a lipoma–like pattern and malignant fibrous histiocytoma (MFH) with atypical spindle cell hyperplasia without lipogenesis. The histological diagnosis was dedifferentiated liposarcoma.

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A 54–year–old woman seen elsewhere for lower left leg numbness persisting 2 years was found in magnetic resonance imaging (MRI) to have a tumor near the left ovary. She was referred to obstetrics and gynecology. Based on a diagnosis of mucinous left ovary tumor, she underwent laparoscopic surgery. Intraoperative findings showed no uterine or adnexal abnormalities bilaterally but a left pelvic retroperitoneal tumor was seen. Changing to laparotomy, we found a tumor attached to the ileum and sacrum and tightly fixed within the pelvis. Preoperative nervous symptoms suggested that it had developed from the obturator nerve. Pathological tissue findings showed mixed Antoni A and B and immunostaining was positive for s–100 protein, yielding a diagnosis of neurilemmoma. Although lower left leg numbness remained, the postoperative course was favorable and no recurrence observed in the 8 months postoperatively.

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Five days after undergoing laparoscopic–assisted distal gastrectomy tightly closing 12 mm port site fascia, a 74–year–old man showed symptoms of ileus. Abdominal computed tomography (CT) showed bowel obstruction due to small–intestine incarceration. Finding in emergency laparoscopy that the small intestine was incarcerated, we pushed it back into the abdominal cavity, rendering intestinal resection unnecessary. We concluded that suturing of all abdominal wall layers—peritoneum, muscle, and fascia—is essential in laparoscopy.

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