Purpose: We analyzed the pertinence and consequences of simple neck dissection minimizing surgical invasion in esophageal cancer.
Subjects and Methods: Subjects numbered 425 men and women undergoing radical esophagectomy for thoracic esophageal cancer from 1997 to 2006. Supraclavicular lymph node #104 dissection was undertaken in those with middle thoracic (Mt) and lower thoracic (Lt) esophageal cancer lesions when node metastasis was suspected in radical diagnostics using, e. g., positron emission / computed tomography (PET–CT) and when intraoperative pathological examination indicated metastasis in pararecurrent nerve nodes #101 or #106.
Results:In 89 cases involving #104 node dissection, 39 (43.8%) indicated node metastasis. In 254 not undergoing #104 node dissection, 6 (1.8%) involved neck node metastasis, with 3 requiring additional dissection. No statistically significant prognostic difference was seen in conducting #104 dissection.
Conclusions: Combining radical diagnostics involving, e. g., PET–CT, and intraoperative pathological examination simplifies neck dissection in Mt and Lt esophageal cancer. Additional neck dissection is sufficient in treating neck node recurrence.

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To improve surgical treatment results, we reviewed 25 cases of advanced gallbladder cancer involving systematic optimal lymphadenectomy. Metastasis cases by lymph node group were as follows: pN1(+) : 10 (40%), pN2(+) : 9 (36%), pN3(+) : 5 (20%). Five–year survival was 73% for pN0, and 50% each for pN1 and pN2. One of 4 subject with pN3 lived over five years, but five–year survival was 25%. No recurrence survival was got from only 2 cases that added PD to a purpose of lymphadenectomy in pBinf(–) among pN2 or pN3 cases more than five years. Our results showed that lymphadenectomy in cases of pN2 lymph nodes appeared appropriate and effective in high–frequency metastasis. Results also suggest that pancreatoduodenectomy (PD) is appropriate in subjects with advanced pT2 or pT3 gallbladder cancer with lymph node metastasis. No metastasis to No.16 lymph node is observed; radical surgery is impossible without PD.

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Purpose:We evaluated the specific surgical organ index in nutritional screening for gastroenterological cancer resection.
Subjects and methods:Subjects numbered 70 with esophageal cancer, 107 with gastric cancer, 165 with colon cancer, and 26 with pancreatic cancer undergoing cancer resection from January 2005 to January 2009. The nutritional screening index was evaluated for age, serum albumin (Alb), body mass index (BMI), diabetes, % vital capacity (%VC), and % forced expiratory volume in one second (FEV1.0%), focusing on the relationship between these parameters, the incidence of complications, and postoperative hospitalization duration.
Results:The indices that related with complications and extended postoperative hospitalization were age ≥ 70, BMI ≤ 18.5, %VC ≤80%, and FEV1.0% ≤70% in esophageal cancer;age ≥ 70 and Alb ≤ 3.6 g/dl in gastric cancer;≥ 70, Alb ≤ 3.6 g/dl, DM (+), and %VC ≤80% in colon cancer;and alb ≤ 3.6 g/dl in pancreatic cancer.
Conclusion:Nutritional screening using the index specific to the surgical organ is vital in subjects indicated for gastroenterological cancer resection.

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Objectives:We retrospectively studied octreotide efficacy in treating the adverse side effects of malignant bowel obstruction (MBO) caused by cancerous peritonitis in those with advanced or recurrent cancer. Subjects and Methods:We examined octreotide dosage, efficacy, and adverse side effects in 7 subjects hospitalized within the last year. Vomiting was evaluated using the Japan Clinical Oncology Group (JCOG) toxicity scale, with octreotide judged effective if the toxicity score decreased. Results:Of the 3 men and 4 women, aged 38 to 81 years old (average:61.7 years) studied, 5 had gastric cancer, and 1 each had colon and pancreatic cancer. All were administered octreotide by continuous subcutaneous injection at 0.3 mg/day for an average of 19.1 days. Nausea and vomiting were ameliorated in 71.4%, usually within 3 days of octreotide administration from MBO onset in those showing improvement. One subject showed increased γ–GTP. Conclusion:It is thus important to administer octreotide early to ameliorate MBO symptoms in those with advanced or recurrent cancer.

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To decrease postoperative wound infection incidence, we modified wound closing in hepatobiliarypancreatic surgery as follows:saline wound syringe–pressure irrigation, closed–suction drainage of the subcutaneous space, subcuticular absorbable suture, and transparent film dressing with see–through absorbent pad. We then compared wound infection incidence in 31 subjects undergoing modified procedures to that in 34 undergoing conventional procedures, i.e., saline wound irrigation without pressure, no subcutaneous drainage, interrupted transdermal suture, and nontransparent dressing. Wound infection appeared reduced in the modified procedure group at 6.5 vs 20.6%. Among subjects with median incision, infection was significantly reduced in the modified procedure group at 0 vs 18.5%(P=.0189). These results indicate that our modified wound closing reduces wound infection incidence in hepatobiliarypancreatic surgery.

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A 68–year–old woman undergoing quadrantectomy with axillary lymph node dissection for right breast cancer in May 2007 was diagnosed pathologically with scirrhous carcinoma (p, nuclear grade 3, ly3, v3, n1 (1/12), ER (-), PgR (-), HER2 (3+)). Despite postoperative irradiation and oral 5–fluorouracil tegafur (UFT) administration, erythema, swelling, and whole right breast inflammation occurred from March 2008, followed by right arm and neck pain and edema. Despite trastuzumab/letrozole chemotherapy, skin lesions increased and were diagnosed as local inflammatory breast cancer recurrence based on skin biopsy. Second–line trastuzumab/docetaxel produced no skin lesion response, and easily bleeding ulcers formed. Third–line TS1/paclitaxel improved skin symptoms and skin grafting controlled ulcer bleeding. Right arm and neck pain and edema disappeared. Computed tomography (CT) showed improved marked right chest wall swelling and positron emission tomography (PET) CT showed markedly decreased fluorodeoxyglucose (FDG) accumulation.

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We report a rare case of spine metastasis 26 years after mastectomy. A 60–year–old woman who had undergone extended radical mastectomy for left breast cancer 26 years earlier reported lower back pain and was found in vertebral magnetic resonance imaging (MRI) to have rear spinal cord exclusion due to a metastatic spine tumor at Th12/L1. Computed tomography (CT) showed multiple lung metastasis, left pleural effusion and thicking, and a 3 cm tumor involving the sternum in the anterior thoracic wall. Histopathological findings showed atypical invasive proliferating small cells, immunohistochemical staining for ER and PgR was positive, the Hercep test score was 2+ with no FISH amplification, and CEA was elevated to 38.6 ng/ml and CA15–3 to 307 U/ml. The lower extremities became parlyed in palliative radiation therapy, so we conducted lumpectomy, posterior decompression, and stabilization. Postoperative quality of life (QOL) improved and she survived 18 months postoperatively. Prognosis in those with hormone–receptor–positive tumors is often favorable following late recurrence, and aggressive surgery should be considered in spine metastasis with neurologic manifestations.

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Malignant phyllodes tumor of the breast is relatively rare. We report the case of a huge malignant phyllodes tumor that had grown rapidly in a 53–year–old female patient. The patient had noted a mass in the right breast five months ago. She consulted our hospital complaining of rapidly glowing mass for these two months. At the initial consultation, a conspicuously large tumor measuring 18.0 × 13.5 cm with thinning and reddening of the skin was noted in the right breast. An ultrasonographic examination of the breast disclosed an extremely large hypoechoic mass composed of solid and liquid constituents, and a phyllodes tumor was suspected. Contrast–enhanced computed tomography and magnetic resonance imaging showed a solid constituents–containing intracystic tumor protruding into the lumen and enlargement of the right axillary lymph node. A core needle biopsy revealed only necrotic tissue leading to no definitive diagnosis. Based on the above findings, a malignant phyllodes tumor was strongly suspected, and right mastectomy and axillary lymph node sampling were performed. The pathological diagnosis was a malignant phyllodes tumor. The surgical margin was negative for malignancy, and there was no evidence of lymph node metastasis.

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Introduction Subclavian vein cannulation is associated with a number of complications. Hemothorax occurs in approximately 2% of cases. Immediate surgical revision of the chest cavity is indicated in case of large blood loss or insufficient circulation. The management of hemorrhage in the pleural apex is extremely demanding due to its bad accessibility and conventional surgical procedures are often insufficient. In such situations the local application of topical hemostats can be used instead.
Case report The report presents a 36–year–old patient with a massive, left hemothorax developing after subclavian vein catheterization. Surgical review detected a source of bleeding in the superior thoracic aperture area that could not be stopped with conventional surgical procedures. As a result, TachoSil and Arista preparations were applied with good effects.

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Esophageal stents are often used in treating malignant esophageal stricture, but may occasion insertion difficulties. We report a case in which a new Niti–S™ esophageal stent model with improved maneuverability gave encouraging results.
An 80–year–old woman seen for dysphagia had esophageal stricture secondary to pulmonary carcinoma from the hilus pulmonis to the mediastinum. Esophageal intubation using a Niti–S™ stent enabled food ingestion and easy insertion and well maintained indwelling due to an external delivery diameter of 16.5 F (5.4 mm). Within 15 minutes of stent insertion, stricture symptoms were immediately relieved. The woman was thereafter able to ingest rice gruel until dying of the primary disease 2 months postoperatively.
These advantages of the new indwelling Niti–S™ stent solved marked stricture problems until then controlled only with difficulty using conventional devices, promising increased use of this device for esophageal intubation.

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In the case of a 76–year–old man followed up for esophagectomy in lower thoracic esophageal cancer and adjuvant chemotherapy, diffusion–weighted imaging (DWI) in magnetic resonance imaging (MRI) detected a 1.5 cm mass eight months postoperatively confirmed in CT and FDG–PET. Suspecting isolated esophageal cancer lymph node or pulmonary metastasis, we conducted mass reduction. The 2 cm elastic hard–surfaced, mass had invaded the pulmonary pleura and was histopathologically diagnosed as moderatelydifferentiated squamous cell carcinoma metastasising to the lung from esophageal cancer. We thus found DWI useful in diagnosing postoperative esophageal cancer metastasis to the lung, as may be further borne out as cases accumulate.

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A 57–year–old man referred for esophageal cancer was found in gastrointestinal endoscopy to have a type 2 lesion and a decolored iodine band, 36 to 38 cm, 25 cm from the upper incisors. Histologically, both lesions were moderately differentiated squamous cell carcinoma. Well–differentiated type 2 adenocarcinoma was found at the posterior wall of the middle gastric body. Following admission, pharyngofiberscopy showed a tumor in the right piriform recess, found histologically to be moderately to poorly differentiated squamous cell carcinoma. After two courses of neoadjuvant chemotherapy, the man underwent total esophagectomy and gastrectomy, hypopharyngolaryngectomy, and antesternal path right colonic reconstruction in a single operation. Postoperatively, he was discharged without complications. Histopathologically, the neoadjuvant chemotherapy effect on hypopharyngeal carcinoma was grade 3.

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The blood flow to the remnant stomach in distal gastrectomy with splenectomy in known to be important. A man in his 60s undergoing laparoscopic splenectomy for idiopathic thrombocytopenic purpura 10 years earlier, was diagnosed with early gastric antrum cancer. Preoperative splenic artery angiography showed posterior gastric and left gastroepiploic arteries, but no short gastric arteries. Conducting laparoscopy–assisted distal gastrectomy, we tied the left gastric artery at its trunk, preserving posterior gastric and left gastroepiploic vessel function. The postoperative course had no serious complications.

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A 70–year–old man underwent endoscopic submucosal dissection (ESD) elsewhere for multiple antrum–related gastric cancers. Pathologically, resected tumors were 0–IIc, tub1>tub2, 4 cm, sm, ly1, v1, LM (+), and VM (-). In observation two months after ESD, his CEA rose to 10.9 ng/ml and upper gastrointestinal endoscopy showed local recurrence and he was referred to us for gastrectomy. Postoperative pathology showed local gastric recurrence and subpyloric lymph node metastasis. Three months thereafter, his CEA rose to 61.2 ng/ml and CT showed multiple liver metastases. Endoscopic treatment in early gastric cancer has gone from endoscopic mucosal resection (EMR) to ESD and is increasingly applied clinically. Endoscopy is less invasive than open surgery, but requires considerable care in application.

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We report a case of subdural hematoma due to dural gastric carcinoma metastasis following total gastrectomy. A 77–year–old woman seen elsewhere for vomiting and referred and hospitalized with a diagnosis of type 2 gastric cancer was found on admission to have a hemoglobin level of 4.2 g/dl, indicating anemia. Following total gastrecdtomy, splenectomy, and D2 dissection, the resected specimen showed advanced type 3 cancer, histopathologically classified as T2 (SS) N0 H0 P0 M1 (adrenal), stage IV. One day after surgery, she suddenly suffered left hemiplegia. Head computed tomography (CT) and magnetic resonance imaging (MRI) showed right parietal subdural hematoma. After two weeks, enhanced MRI showed abnormal dural enhancement, diagnosed as dural metastasis from gastric cancer. After radiation therapy on postoperative day 42, left hemiplegia improved. We thus found radiation therapy useful in dural metastasis from gastric carcinoma.

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Intussusception by an ileus tube is relatively uncommon in adults.
A man in his 70s previously undergoing inguinal hernia surgery 2 years earlier and admitted for ileus in September 2007 developed a sudden stomachache on day 7 after ileus tube insertion. Contrast–enhanced abdominal computed tomography (CT) showed mesenteric fat and the intestinal tract pushed into the small intestines with the ileus tube. A diagnosis of intussusception due to ileus tube misplacement necessitated emergency surgery. Invaginated intestinal tract circulation appeared disrupted. Intussusception was resolved by manual reduction. The band in the pelvis had caused an internal hernia probably causing ileus.

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Breast cancer metastasis to the small intestine is relatively rare. Herein, we report a case of breast cancer metastasis to the small intestine that was found by preoperative small–bowel endoscopy 19 years postoperatively. The patient was a 65–year old female who underwent radical mastectomy for Stage III A (T3a, N1a, M0, ER(+), PgR(–), HER2 (+1)) left breast cancer in 1990. She developed epigastric pain in January 2009, and visited a local physician. CT scan revealed the presence of an abnormal chest shadow and the serum CA 15–3 level was elevated to 124 U/ml, so the patient was referred to our hospital. A close examination at the outpatient department was initially scheduled, but she was hospitalized with the diagnosis of ileus in late March. Enteroscopy revealed circumferential stenosis of the jejunum, approximately 50 cm from the Treitz ligament, and a biopsy indicated metastatic adenocarcinoma (ER(+), PgR(–), HER2 (+1)). Laparoscopic–assisted partial small bowel resection was performed based on the diagnosis of breast cancer metastasis to the small intestine. Furthermore, disseminated disease, approximately 10 mm in length, in the greater omentum was also isolated. A histopathological examination revealed that it was infiltrating lobular carcinoma.

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A 53–year–old man admitted for lower right abdominal pain was found in abdominal computed tomography (CT) to have a fluid–filled mass 4 cm in diameter connected to the small intestine. In surgery for suspected abscessed Meckel′s diverticulitis, laparotomy showed the diverticulum to be 60 cm oral to the terminal ileum. We resected the diverticulum and part of the ileum using an endoscopic linear stapler. The resected specimen showed mucosal necrosis of the abscessed diverticulum. The postoperative course was uneventful and the man was discharged on postoperative day (POD) 7. We thus found laparoscopic surgery efficient in diagnosing and treating Meckel′s diverticulitis.

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Ischemic colitis following colon surgery is rare. We report a case of transient ischemic colitis one year after sigmoid colon cancer surgery. In September 2008, a man in his 60s had a sigmoid colon section resected due to colon cancer, pathologically by SS N0 M0 stageII. Adjuvant chemotherapy was not mandatory. In August 2009, the man reported diarrhea. Ischemic colitis was diagnosed anal to the sigmoid colon anastomosis based on colonoscopy and computed tomography. He recovered with conservative management.

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A 66–year–old woman admitted after two weeks of persistent right lumbago and fever was found in abdominal computed tomography (CT) to have a large retroperitoneal abscess. Percutaneous incisional abscess drainage was done. Two weeks later, CT showed abscess shrinkage and unswelling appendix in contact with residual one. Based on a diagnosis of retroperitoneal abscess due to appendicitis, we scheduled appendectomy two months later. With drainage discharge increasing and CT showing a huge mass in the retroperitoneal space, we conducted it two months after drainage. Excisional biopsy yielded a diagnosis of moderately differentiated adenocarcinoma. No primary lesion could be found except for the appendix, yielding a final diagnosis of retroperitoneal metastasis from primary appendiceal carcinoma. We treated it with chemotherapy. This case shows how difficult it is to precisely diagnose retroperitoneal abscess due to appendiceal carcinoma.

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We report a case of laparoscopically resected sigmoid colon cancer with horseshoe kidney. A 72–year–old woman referred for sigmoid colon cancer detected by colonoscopy was found in abdominal computed tomography (CT) to have a horseshoe kidney. 3D–CT showed aberrant renal arteries. Based on a tentative diagnosis of sigmoid colon cancer (cSS, cN1, cP0, cH0, cM0), we conducted laparoscopic sigmoidectomy. Ureter and aberrant renal artery locations must be evaluated preoperatively to avoid laparoscopic iatrogenic injury in those with horseshoe kidney.

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A 68–year–old man admitted for anemia and lower left abdominal pain without hereditary history or familial disease such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colorectal cancer (HNPCC) was found in barium enema and abdominal computed tomography (CT) to have a large circumferential tumor with luminal sigmoid colon stenosis. A temporary stoma was applied at the transverse colon to treat acute abdomen. Several additional lesions suspected of malignancy were too difficult for endoscopic mucosal resection (EMR), necessitating total coloproctectomy and ileal J–pouch anal canal anastomosis to limit high–risk metachronous carcinogenesis. The surgical specimen contained 10 adenomas and eight adenocarcinomas. p53 labeling score differed markedly between the left and right colon. Our case suggests that differing enteral environmental effects associated with tumor location influence the adenoma–carcinoma sequence in neoplastic transformation.

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A 73–year–old woman with rectal cancer undergoing low anterior rectal resection and temporary ileostomy under epidural anesthesia had a leak detected at the catheter insertion site on postoperative day (POD) 5, so we removed the catheter. That night, she exhibited fever, tremors, and abdominal pain, so we started intravenous antibiotics. The next day, she developed neck rigidity. Abdominal computed tomography (CT) showed a low–density pelvic area. Cerebrospinal fluid examination results were abnormal, diagnosed as minor anastomotic leakage and bacterial meningitis. Following antibiotic treatment, she recovered from the meningitis, assumed caused by the catheter infection and/or hematogenous infection from anastomotic leakage. Deep infection –meningitis or epidural abscess– may complicate continuous epidural block, necessitating early checkup and infection control for these subjects.

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A 75–year–old man diagnosed with sigmoid colon cancer and synchronous liver metastasis (S3). It showed no portal vein tumor thrombi in preoperative abdominal computed tomography (CT) but it was confirmed in intraoperative ultrasonography to have spread to the mein left branch of the portal vein. We conducted sigmoidectomy but not liver resection fearing portal vein tumor thrombi circulation by surgical procedure. The resected specimen showed tumor thrombi in the branch of the inferior mesenteric vein. Pathologically, the tumor had invaded the serosa with lymph node metastasis and venous and lymphatic duct involvement. He underwent l–leucovorin/5–fluorouracil therapy after initial surgery, but portal vein tumor thrombi and liver metastasis remained. Changing to FOLFOX4 for 6 courses markedly reduced portal vein tumor thrombi, enabling lateral segmentectomy. Histopathological response evaluation criteria of portal vein tumor thrombi were Grade 1b. He remains well and recurrence–free 2 years after the second surgery.

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An 85–year–old woman admitted for sudden epigastric pain had a nontender, hen's egg–sized mass palpated in the upper right abdominal quadrant. Abdominal computed tomography (CT) showed a swollen gall bladder with a deviated cystic duct. Magnetic resonance cholangiopancreotography (MRCP) showed extrahepatic bile ducts distorted to the right side and a tapering cystic duct interrupt. Laparoscopic cholecystectomy was conducted to correct gall bladder torsion. The gross type–II floating gall bladder was twisted countercrockwise 180 degrees along its longitudinal axis. The woman was discharged 3 days after surgery. It is important for elderly patient to diagnose quickly for aiming to reduce some complications.

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A 76–year–old man with a history of left renal cell carcinoma, bladder cancer, and prostate cancer was found in plain computed tomography (CT) conducted as December 2007 postoperative follow–up to have a semicircular cystic pancreatic tail mass 28 mm in diameter. The lesion had grown to 40 mm in contrast–enhanced CT in March 2008. The partially filled cyst showed enhanced contrast comparable to that in the pancreatic parenchyma. Positron emission tomography (PET) showed FDG accumulation. Examinations for neuroendocrine tumor, renal cell carcinoma metastasis, retroperitoneal tumor, and pancreatic duct carcinoma showed no typical signs of these diseases. In April 2008 pancreatic tail resection, tissue examined histopathologically showed tumor cells with eosinophilic bodies and diastase–resistant PAS–positive small granules, yielding a diagnosis of pancreatic acinar cell carcinoma, a rare disease accounting for only 1–2% of pancreatic tumors. This cancer accompanied by a cyst as in our case, is highly atypical.

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A 57–year–old man admitted for abdominal pain, nausea, and vomiting after drinking and examined in detail was found in laboratory examinations to have elevated DUPAN–2 tumor marker. Abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed a pancreatic mass 40 mm in diameter in the pancreatic body with invasion to the celiac artery and surrounding tissue. Endoscopic retrograde cholangiopancreatography (ERCP) showed main pancreatic duct obstruction in the pancreatic body. Positron emission computed tomography (PET–CT) showed fluorodeoxyglucose (FDG) uptake in the mass and surrounding tissue, yielding a diagnosis of advanced unresectable pancreatic cancer. After chemoradiotherapy (CRT) combined with pancreatic radiotherapy (GEM) of 55 Gy+GEM, the man′s tumor shrank, tumor markers decreased, and PET–CT confirmed good local control. In the 4 years and 5 months since initial chemoradiotherapy, he remains disease–free with no evident local recurrence, demonstrating the potential efficacy of our treatment for locally advanced pancreatic cancer.

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Primary greater omental torsion is a rare cause of acute abdomen extremely difficult to identify preoperatively. We report three cases of primary omental torsion diagnosed preoperatively, discussing diagnostic and therapeutic aspects. Case 1: A 57–year–old man was admitted with upper right abdominal pain. Case 2: A 52–year–old man reported lower right abdominal pain. Case 3: A 39–year–old man reported epigastralgia. Abdominal computed tomography (CT) in all cases showed a preoperative whirl pattern of fatty streaks and vessels within the greater omentum secondary to torsion —the whirl sign and concentric linear strands. All cases were treated laparoscopically. Operative findings showed a necrotic omental mass closed where the entire greater omentum had undergone torsion. All recovered uneventfully, confirming laparoscopic surgery safety and effectiveness in promptly diagnosing and treating those with acute abdominal symptoms.

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A 45–year–old man under going surgery elsewhere in October 2006 for a right Spigelian hernia found the area to be swollen, in early November 2009, which we diagnosed as a recurrent Spigelian hernia. Surgery found a hernia sac under an external oblique muscular aponeurosis projecting from the operative abdominal mesh. Using an ULTRAPRO HERNIA SYSTEM (UHS), we repaired the Spigelian and inguinal hernias. The man's postoperative course was uneventful and he was discharged on hospital day 7.

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A 60–year–old man admitted for a presacral tumor was found in computed tomography. (CT) to have a low–density cystic mass. Magnetic resonance imaging (MRI) confirmed low intensity in T1 and high intensity in T2 weighted images. Surgery was transsacral. The tumor was completely removed without opening the abdomenleaked but tumor wall damage leaked fluid interoperatively. The wall consisted of flat stratified epithelium without skin appendages. We diagnosed it as a presacral epidermoid cyst. Adult presacral epidermoid cysts are rare and we report this case with a review of the literature.

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