Purpose:Since the reissuance of organ donation law, lung transplantation has been increased in number in Japan. The purpose of this study was to investigate the current status and future perspectives of lung transplantation in Japan.
Patients and Methods:Using the data on lung transplantation in Japan as well as in the world, current status of lung transplantation in Japan was evaluated and its future perspectives were also presumed.
Results:One hundred and eighty-seven lung transplantation (100 living-donor lobar lung transplantation and 87 cadaveric lung transplantation) were performed until at the end of 2010. In 2010, 25 cadaveric lung transplantation and 11 living-donor lobar lung transplantation were performed. Since the number of cadaveric lung transplantation has increased so rapidly, the sum of cadaveric lung transplantation just surpassed that of living-donor lobar lung transplantation in July, 2011. Of note is that living-donor lung transplantation, which has not been performed worldwide, is still being performed by approximately 10 cases annually in Japan. The outcome of lung transplantation in Japan is outstanding with more than 75% of 5-year overall survival rate. Furthermore, the utilization rate of cardaveric donors is also high in Japan owing to medical consulting system unique to Japan.
Conclusions:The number of lung transplantation has been increasing constantly with favorable outcomes.

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Since October 1997 as of May 2011, a total of 102 pancreas transplantations from brain-dead donors have been performed in Japan. Of those, forty pancreas transplantations were performed within 11 months after enaction of the Modified Organ Transplantation Law. But the large increase of pancreas transplantation in a short time produced several problems. The present unfair kidney sharing system between simultaneous pancreas and kidney transplantation (SPK) and kidney transplantation alone should be revised first. And the new pancreas sharing system is necessary to combine pancreas and islet transplantation. Moreover, the marginal donors must be treated carefully because the majority of brain-dead donors in Japan are marginal.　We investigated these problems based upon our experience and prospected the future of the pancreas transplantation in Japan.

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Indications for laparoscopic surgery are expected to increase in the gastroenterological surgery field in the future. Laparoscopic appendectomy is one of the basic techniques in the course of acquisition of laparoscopic surgeries, along with appendectomy by open abdominal surgery. It contains many basic procedures to be learned. Laparoscopic appendectomy standardizes procedures and also permits safe performance without impairing benefits for patients under appropriate instructions. This has been found to be a useful technique for improving the skills of gastroenterological surgeons inexperienced in surgical operations.

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Purpose: Recent clinical studies proved oral UFT/leucovorin (LV) regimen, in which the drugs are taken for 28 consecutive days every 35 days, equivalent to an infusional 5-fluorouracil/LV regimen for treatment of colorectal cancer (CRC). The 5-day-on/2-day-off schedule for UFT/LV, which is taken for 5 consecutive days followed by 2 days off, has been proposed, since the 5-day-on/2-day-off schedule for UFT has been reported to be safe and to have good compliance. However, feasibility of the regimen has scarcely been reported in long-term setting. Patients and Methods: We assessed the complicance of the regimen as adjuvant chemotherapy in 28 CRC patients. UFT (300 mg/m²/day)/LV (75 mg/body/day) is taken for 5 week days followed by 2 weekend days off. One course contained 5 weeks, and 15 courses (75 weeks) were given. Results: Eighty-six percent (24 of 28) received all scheduled doses of the regimen. The mean relative dose intensity was 0.92. Mean treatment courses given were 13.8. The toxicities were generally mild. No patients developed toxicity grade 3 or more. Adverse reactions in the 5-day-on/2-day-off schedule of UFT/LV were mild. Conclusion: These results indicated that the 5-day-on/2-day-off schedule of UFT/LV would be feasible in long-term adjuvant chemotherapy for CRC.

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Purpose:We reviewed the outcome of gastro-intestinal emergency operations performed for elderly patients to evaluate the associated problems and to develop optimal treatment strategies.Methods:The subjects in the current study included 38 patients over 80 years of age who underwent emergency gastro-intestinal surgical procedures over for the past 5 years. The patients were divided into two groups, those with and without post-operative complications (POC). Perioperative parameters, and E-PASS score as well as POSSUM score were compared.Results:Most POC were included infectious diseases. The patients with the diagnosis of gastrointestinal perforation or those who had undergone intestinal resection had significantly higher incidence of POC as compared to those without. As for the scoring systems, significant difference between the two groups was achieved only in the Portsmouth POSSUM score.Conclusions:Our data suggest that timely treatment of postoperative infection, especially pulmonary infection is important, and the Portsmouth-POSSUM score seems to be useful for estimating the outcome.

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Introduction:The letter of consent is legally a private document. The authenticity of which derives from the personal signature regardless of the presence or absence of seals.Methods:First, we asked medical staff and patients whether the document really requires a seal. Then, we explained that under Japanese civil law a seal is unnecessary if there is a signature. Finally, we asked them if they still felt a seal was necessary and recorded attitudinal changes.Results:Answers were received from 24 surgeons, 35 nurses, and 20 patients. Surgeons and nurses who had experienced being told that documents without seals were invalid consisted of 33% and 51%, respectively. Placing a thumbprint on the document is the most frequent processes of coping without a seal. After the legal explanation, more people thought that only the signature was necessary. More medical staff thought the mark indicating where the seal should be placed on the document has to be abolished. Most patients thought the seal could be eliminated, depending on the hospital.Conclusion:Seals are unnecessary legally, and can infringe on patient’s rights. Most of both medical staff and patients now think the use of a seal on letter of consent can be abrogated.

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Scirrhous gastric cancer often develops in lymph nodes and metastasizes to the peritoneum, thus resulting in poor prognosis. Even aggressive surgical procedures and adjuvant chemotherapies have done little to improve the survival rates in patients with scirrhous gastric cancer. Hence, the development of novel therapeutic strategies is urgently required for the treatment of patients with advanced scirrhous gastric cancer. ERas is a recently identified oncogene involved in the tumorgenic growth of embryonic stem (ES) cells. We examined the significance of ERas expression in scirrhous gastric carcinoma, and the possibility of ERas as a tumor-associated antigen of gastric cancer for developing a cancer vaccine. ERas expression was determined in scirrhous gastric carcinoma specimens by immunohistochemical staining. To assess the possibility of the ERas protein as an anti-cancer vaccine target, we examined whether ERas for HLA-A-restricted epitope peptides were capable of eliciting cytotoxic T lymphocyte (CTL) activity. We successfully established CTL clones stimulated by HLA-A*2402-restricted ERas peptides (FALDDPSSL). These peptides have specific cytotoxicity against cancer cells that endogenously express ERas. Our results suggest that ERas is a novel tumor-associated antigen with the potential application to be a vaccine against scirrhous gastric cancer.

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Colorectal cancer is a common disease which accounts for around half a million deaths yearly worldwide. Nakamura et al have performed genome-wide exploration by using cDNA microarray profiling, and successfully identified a new tumor-associated antigen (TAA) that can induce potent cytotoxic T lymphocytes specific to tumor cells, i.e., RNF43, KOC1, TOMM34, VEGFR1 and VEGFR2. We conducted a phase I dose escalation study and a Phase II study using these five tumor associated antigen epitope peptides for colorectal cancer patients. For the breakthrough of the tumor escape mechanisms, immuno-chemo-combined therapy has been conducted. Tumor cell killing by anticancer drugs may be supported by their immuno- and pharmacologic effects. Chemotherapy is in fact able to up regulate tumor-associated antigen expression, and down regulate tumor cell resistance to the death signals induced by tumor antigen-specific cytotoxic T lymphocytes. This provides the rationale for combining chemo- and immunotherapy. We conducted a phase II trials, administration of epitope peptides alongside chemotherapy (5-fluorouracil, folic acid and oxaliplatin; FOLFOX) to evaluate immunologic and clinical responses.

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Recently, analyses of gene expression profiles of cancer and normal cells using cDNA microarray technologies have provided an effective approach for the identification of tumor-associated antigens. Two novel antigens, RNF43 and TOMM 34, were found to be up-regulated in more than 80％ of colorectal cancer tissues as compared to the corresponding noncancerous mucosa. We conducted a clinical trial of two novel peptide vaccine derived from RNF43 and TOMM34 in combination with UFT/LV for the treatment of recurrent colorectal cancer. Among 23 patients, 21 patients had completed the protocol. All patients were well tolerated with no severe toxicities. The median survival time was 24.4 months. Furthermore, we investigated the relationship between CTL response to both antigens and overall survival. The best long-term survival was observed in the group with CTL responses against both antigens, followed by the group showing CTL responses against only RNE43 or TOMM34. The patients with no response had the lowest survival. Further clinical trials are warranted.

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【Subject】To evaluate efficacy of dendritic cell (DC) based vaccine after curative operation for intrahepatic cholangiocellular carcinoma (ICC). 【Patients and Methods】 65 patients who underwent curative operation were chosen. To prevent relapse of tumor after curative operation for ICC, 26 patients out of 65 patients received DC based vaccine and 39 patients received chemotherapy. Then we examine disease free survival and overall survival. 【Results】Patients received DC based vaccine prolonged disease free survival and overall survival compare to the patients who received chemotherapy. Moreover 72% of patients revealed DTH response positive. In these patients, DC based vaccine prolonged DFS and OS compared DTH negative patients and patients received chemotherapy. 【Conclusion】DC based vaccine had potency of adjuvant therapy to prevent relapse of tumor after curative operation for ICC even with DTH response.

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We herein report 3 cases of advanced or recurrent gastrointestinal cancer who were treated with activated autologous lymphocytes. The case 1 was 44 year old female. She underwent total gastrectomy for advanced gastric cancer, pathologicaly CY1, Stage Ⅳ. But she couldn’t continue adjuvant chemotherapy for adverse events. Then she received a treatment with activated autologous lymphocytes. Four and a half years later, colonic stenosis due to peritoneal metastasis appeared, therefore we changed a treatment for combination therapy with the low-dose chemotherapy. After that, there was no change of colonic stenosis, but four years later, colonic stenosis got worse, so she underwent sigmoid colostomy. After that, the peritoneal dissemination is controlled by this combination therapy. The case 2 was 77 year old female. She underwent distal gastrectomy for advanced gastric cancer. A follow up CT revealed the metastasis to the para-aortic lymph nodes. Then she received a treatment for combination therapy with activated autologous lymphocytes and chemotherapy. The response of the treatment is CR. The case 3 was 63 year old female. She was diagnosed as multiple liver metastasis after radical resection for colon cancer. Then she received this combination therapy, the response is long-term CR for multiple liver metastasis.

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A 74-year-old woman, type 3 gastric cancer pointed out with upper gastrointestinal endoscopy for examination of anemia and was introduced our hospital. The left supraclavicular lymph node of the approximately 10mm size was seen at the first visit. Distal gastrectomy, D2 dissection, left supraclavicular lymph node biopsy were performed in July, 2003, and it was diagnosed Virchow’s metastasis of the gastric cancer. Chemotherapy by S-1 (80mg/body/day，day1-28, q6weeks) was started after surgery. The serum CEA level which showed high level before surgery was gradually normalized. It was able to maintain PR~SD including Virchow’s metastasis after surgery until five years, but presented with para-aortic lymph node metastases. Therefore it was switched to S-1+CDDP from April, 2010 and to S-1+DOC more from January, 2011, but it became PD, and perform S-1 alone therapy again now. Eight years passed after surgery, but are living. We report a very rare case of gastric cancer surviving long-term with Virchow’s metastasis.

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The prognosis of the patients with brain metastasis from gastric cancer is poor. The standardized treatment for metastatic brain tumor derived from gastric cancer has not been established. We report a case of long-surviving patient with metachronous brain metastasis from gastric cancer that underwent surgical operation and radiotherapy.　A 57-year-old man, who was diagnosed as having gastric cancer with invasion to the esophagus, underwent lower esophagus and total gastrectomy and splenectomy in left thoracotomy and laparotomy. Histological diagnosis was tub2+por1, pT3 (pSS), pN2, M0, pStage IIIA, so he received postoperative adjuvant chemotherapy with S-1 for one year. Seventeen months later, he complained of a headache and disorientation. A 2cm ring-like enhanced tumor was found in the right frontal lobe by brain computed tomography (CT) and was diagnosed as brain metastasis from gastric cancer. The opening-of-the-skull surgical resection of the tumor was performed, and additional radiation therapy of 40 Gy was enforced to the postoperative tumor floor. Five months after the resection of brain metastasis, he complained of disorientation again. Brain CT revealed the tumor with 1.5 cm size at the left parietal lobe. The recurrence of brain metastasis was found and treated with irradiation of 39 Gy. The tumor was disappeared and his condition has been improved. No recurrence has been observed in the 28 months since the first brain metastasis developed.

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A 70-year-old man was admitted to our hospital with a history of epigastric pain and vomiting. He had previously undergone distal gastrectomy with Billroth II reconstruction for the treatment of gastric ulcer. Based on the abdominal ultrasound and abdominal computed tomography findings, we diagnosed intestinal obstruction caused by intussusception. Intraoperatively, retrograde intussusception of the efferent jejunal loop into the anal side of the Braun anastomosis was found. The intussuscepted jejunum was resected, and it contained no tumor. The patient was discharged on the 18th postoperative day without complications. Until now, 2 years after the surgery, there has been no evidence of recurrence. There are few reports in the literature of recurrent intussusception. Intussusception after gastrectomy is rare, but should be considered in the differential diagnosis of ileus.　Because the postoperative course was relatively uneventful, the patient was discharged on the 18th hospital day. Until now, 2 years since the surgery, there has been no evidence of recurrence. Intussusception after gastrectomy, which is rare, also needs to be considered in patients presenting with intestinal obstruction.

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We report a rare case of intestinal obstruction caused by a Japanese persimmon seed. An 82-year-old woman was referred to our hospital because of abdominal pain and vomiting. She had received radiation therapy for uterine cancer, and she had worried about radiation enteritis for 43years. CT scan showed a stenosis of ileum. We diagnosed intestinal obstruction with radiation enteritis and started a conservative therapy after her admission. However, the obstruction did not become better, and an operation was performed. At laparotomy, we found a stenosis of ileum with radiation enteritis. We performed a partial resection of ileum and found a Japanese persimmon seed (2 cm ×１cm) in a resected intestine. Therefore, this foreign body probably caused the obstruction. At the 37th days after operation, she was discharged.

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A 57-year-old man who had lung cancer admitted to our hospital with chief complaints of abdominal fullness and vomiting. He was diagnosed as intestinal obstruction in the splenic flexure of colon. He underwent the operation of laparoscopic colostomy so that the dietary intake might become possible. On 4 days after the surgery, he suffered from peritonitis because of a perforated duodenal ulcer, and the second surgery, was undergone. In the surgery, partial colon containing the severe adhesion area to stomach and the obstructive area was also resected together with the perforated gastroduodenum. The intestinal obstruction was diagnosed as the peritoneal dissemination of lung cancer by surgical and histopathological findings. It went well the postoperative course, except for surgical site infection, and he was discharged on 22 days after the second surgery. There are no reports about the intestinal obstruction by the peritoneal dissemination of lung cancer in Japan. So, we describe this case and review the relevant literature.

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A 77-year-old woman was seen in our hospital because of positive fecal occult blood test. Colonoscopy showed a tumor 10 mm in diameter at the ostium appendicis vermiformis. Because the findings of intussusception were observed by follow-up colonoscopy, she was admitted to our hospital for surgery. Appendectomy was performed and a definitive diagnosis of mucinous cystadenoma of the appendix was made on the basis of the pathological findings. Postoperative course was uneventful, and she was discharged on postoperative day 18.

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We report a case of appendiceal endometriosis with intussusception resected by laparoendoscopic single-site (LESS) surgery. A 47-year-old woman was noted to have fecal occult blood in the previous hospital. Endoscopic examination and barium enema showed a submucosal tumor (SMT) at the bottom of the cecum. An abdominal computed tomography (CT) revealed a tumor of appendix vermiformis with intussusception. LESS surgery (ileocecal resection with lymph node dissection) was performed because of possibility of malignant tumor. Histopathological examination showed appendiceal endometriosis. Appendiceal endometriosis is a rare disease, and very few have been diagnosed preoperatively. LESS surgery is a less invasive operation and is regarded as the most useful way to obtain final diagnosis of appendiceal endometriosis.

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We describe herein a 29-year-old woman who experienced right lower quadrant abdominal pain and visited a local doctor in October 2010. At that time, appendicitis was diagnosed and she was referred to our hospital. On admission, an abdominal CT scan showed no swelling of the appendix but revealed enlargement of lymph nodes in the pericecal area. Based on these findings, malignancy was suspected. PET/CT scan showed abnormal accumulation of FDG in lymph nodes and the cecum. Colonoscopy was thus performed and revealed a type-3 mass 4 cm in diameter in the cecum. Biopsy revealed a moderately-differentiated adenocarcinoma. The patient was diagnosed as having advanced cecal carcinoma with lymph node metastasis. She underwent a right-sided laparoscopic colectomy with D3 dissection. Histopathological findings were tub2, pSS, pN1 (#201), H0, P0, M0, pStage IIIa and curability A (no residual tumors). A detailed family history revealed that this patient met Amsterdam criteria II for hereditary non-polyposis colorectal cancer (HNPCC). It is important for clinicians to remember that young patients with colorectal cancer may have a family history of HNPCC.

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A 61 year old female case of huge liposarcoma, occupying whole abdomen, originated from the sigmoid colon mesenterium with liver metastasis is reported. On computed tomography (CT), 35cm sized tumor in diameter showed enhanced irregular density with a smooth surface.　Radical surgical resection of the main liposarcoma with surrounding organs included sigmoidectomy, right hemihepatectomy with thrombectomy in portal vein, left and right salpingectomy and Left oophorectomy. The resected tumor was 5,760g in weight and 32×24×15cm in dimension. The pathological examination of the resected specimens yielded a rare case of dedifferenciated liposarcoma. After 13 months, the recurrence of tumor emboli in portal vein and lung metastasis were found and the thrombectomy was performed again.　Dedifferentiated liposarcoma has a poor prognosis compared to those other histologic types. The surgery is the first choice for the disease. No effective adjuvant therapies including chemotherapy and radiotherapy have been established as yet.　The patient was lost 2 years and 3 months since the first radical resection.

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A 34-year-old woman underwent on operation for procedure for prolapsed and hemorrhoids (PPH) in neighborhood surgery. On postoperative days 1^st, her temperature had gone up and she referred to our hospital. She was diagnosed as perirectal phlegmonous inflammation due to anastomotic leak after PPH and admitted to our hospital. Her inflammatory sign was improved by conservative therapy without re-operation and left the hospital two months later. PPH is widely prevalent for painless in Europe and the United States, however, sometimes develops critical complications. At that time, we have to make decision immediately and adequate treatment.

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Prognosis of biliary tract cancer has generally been poor, and effective chemotherapy has not yet been established. A 64 year-old woman was admitted to our hospital for indications of gallbladder wall thickness. The diagnosis on computed tomography and ultrasonography was gallbladder cancer with liver metastasis in the inferior anterior segment. A cholecystectomy with partial hepatectomy was performed, and lymph nodes associated with the hepatoduodenal ligament, periampullary lesion, and common hepatic artery were dissected.Chemotherapy with gemcitabine after resection biweekly was administered. After 4 months, liver metastases in the anterior segment was recognized. A right hepatic lobectomy was performed. After another 4 months, lymph node metastases of posterior lesions of the pancreas head, and caudate lobe metastasis were found. We initiated combination chemotherapy using gemcitabine plus tegafur・gimeracil・oteracil potassium (S-1). Complete response to chemotherapy was confirmed after 12 cycles. CA19-9 values reverted to normal levels. No major events of toxicity were seen. After 15 months, complete response had been maintained. Biweekly gemcitabine plus S-1 combination chemotherapy was effective and well tolerated.

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A 59-year-old man had been under treatment chronic hepatitis C and cirrhosis, and was later diagnosed as having hepatic tumors. Three hepatocarcinomas were identified, and minimal resection was performed. After the operation, the patient developed repeated episodes of intraperitoneal bleeding due to decreased coagulability of the blood and reduced platelet counts, which necessitated transfusion of fresh frozen plasma and platelets. While hemostasis was achieved shortly after each transfusion, the intraperitoneal bleeding recurred as the platelet count decreased over time. Partial splenic embolization (PSE) was performed, under the expectation that adequate hemostasis would be achieved as a result of improvement, following the procedure, of the thrombocytopenia associated with splenic hyperfunction. No recurrence of the intraperitoneal bleeding was noted thereafter. There are few reports of effective treatments against postoperative intraperitoneal bleeding caused by thrombocytopenia associated with splenic hyperfunction. We present a case of postoperative intraperitoneal bleeding which was successfully controlled by PSE.

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A 78-year-old woman was admitted to our hospital because of her right upper abdominal pain. During her hospitalization, the abdominal pain deteriorated and peritoneal signs were observed. Then we attempted the emergency operation under a diagnosis of acute generalized peritonitis. Because the inflammatory mass lesion with the necrosis in the great omentum was revealed at the operation, partial omentectomy and abdominal cavity drainage were performed. A definitive diagnosis of primary omental abscess was made on the basis of the surgical and pathological findings, although no identifiable etiology was found.

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Abridged version : An 84-year-old woman with suspected sigmoid colon volvulus was transferred by an ambulance from a nearby hospital to our hospital. A large intestine endoscope was used to release the torsion but because it did not work. Then the patient underwent an emergency operation. Surgical examination did not reveal volvulus of sigmoid colon. Greater omentum was found to adhere to transverse colon, while stenosis and perforation was observed. Her symptom was judged as colon stenosis and perforation caused by a malignant disease. Colectomy was performed and an artificial anus was created at appendix and descending colon. The result of immunostaining was as follows : Calretinin(+), HBME-1(+), EMA(+) and CEA(-), which diagnosed her with malignant mesothelioma. History taking revealed no exposure to asbestos. Obvious pleural thickening was not observed by chest CT scan. The onset frequency of malignant mesothelioma is about 0.2% of all malignant mesothelioma, out of which about 20% develop at peritoneum. It lacks in specific manifestations and causes ascites retention in many cases, but the proper diagnosis rate by cytologic diagnosis is low. Therefore, tissue biopsy is the last diagnostic method. Now we report a case of peritoneum malignant mesothelioma, with a few bibliographic considerations, which was detected in an emergency surgery for abdominal bloating and acute abdomen.

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We report two cases of open wound of pyomyositis successfully treated with combination of negative pressure wound therapy (NPWT) and local administration of basic fibroblast growth factor (bFGF). Patient 1 was a 73-year-old woman with pyomyositis of the chest wall. After debridement of the lesion, the wound was left open and irrigated daily with saline solution. Two weeks later, inflammatory symptoms disappeared. NPWT and local administration of bFGF was commenced. Granulation tissue was formed in the wound and the surface was gradually epithelized. The wound healed completely after two months. Patient 2 was a 54-year-old man with pyomyositis of the thigh. Debridement of the lesions was performed followed by the same procedure as that in Patient 1. The wounds healed completely after four months. Thus combination of NPWT and local administration of bFGF seems to be effective in open wounds of pyomyositis and to reduce healing periods as reported in chronic ulcers such as pressure ulcers and diabetic ulcers.

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