The immunological state of sera derived from a total of 200 untreated gastric cancer patients was investigated using a T-cell growth suppression assay (TGSA). An interleukin-2 dependent CTLL-2 cell line was cultured with the sera, and its growth inhibitory effect was analysed. The results were then correlated with the clinicopathological features, immunological parameters, and the presence of tumor markaers in the serum. The prognosis of the patients were then analysed. The TGSA value of the gastric cancer patiens was significantly lower than that of patients with benign diseases, such as cholelithiasis and inguinal hernias. TGSA value decreased significantly in proportion to the grading of gastric cancer stages, the depth of tumor invasion, and the degree of macroscopic liver metastases. When the patients were divided into 2 groups (group 1: TGSA<67.0, group 2: TGSA≥67.0), the levels of IAP, CRP, CEA and the subset of neutrophils in the peripheral blood were significantly higher in group 1 than in group 2, whereas the subset of lymphocytes was significantly lower. The prognosis of the low TGSA group (group 1) was significantly poorer than that of the normal TGSA group (group 2). these findings indicate that TGSA values may reflect the grading of gastric cancers and could possibly be used as a parameter to estimate the humoral immune state of the tumor-bearing host.

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Introduction: We studied the critical evaluation of jejunal pouch interposition (JPI). Materials and Methods: Since 1996, we have used a procedure in which a 15 cm double jejunal pouch is interposed between the esophagus and remnant stomach after proximal gastrectomy, JPI for patients with early gastric cancer in the upper third of the stocach. The distal resection line was 10 cm from the pyloric ring in the lesser curvature and 12 cm away in the greater curvature. We conducted D2 excluding the lymph nodes along right gastroepiploic vessels (in part) and at the splenic hilum. We assessed the results of JPI in 49 patients, compared to 41 undergoing total gastrectomy with Roux en Y reconstruction (RY) during the same period. Results: Subjects were 34 men with a mean age of 61 years. Histopathological examination showed 18 with intramucosal, 21 with submucosal lesions, and 10 deeper than the proper muscular layer. No recurrent cases were observed and all patients continue to survive. Clinical variables including operation time, bleeding volume, and the postoperative hospitalization days, and postoperative complications including anastomotic leakage, stenosis, pancreatitis, hemorrhage, and intestinal obstruction. No significant differences were seen between groups. Postoperative endoscopic examination showed no significant defferences in stenosis and reflux esophagitis between groups. Reflux esophagitis followed by increased food residue and remnant gastritis was observed in JPI. Postoperative weight changes were lower in JPI than in RY at 6 months (p=0. 0132) and at 1 year (p=0.0462) after surgery. Vitamin B₁₂ in JPI tended to be high 2 years after surgery. Postoperative symptoms (questionnaire) showed appetite, nausea or vomiting, diarrhea, and early dumping syndrome to be significantly better (p=0.0132, 0.0014, <0.0001, 0.0051) and oral intake compared to that preoperatively was significantly higher in JPI 2 years after operation. However, heartburn in JPI was significantly higher (p=0. 0001). Conclusion: JPI involves low weight loss and good oral intake in the early phase after surgery. It is necessary to follow up long-term to evaluate heartburn and Vitamin B₁₂ and further improve postoperative quality of life.

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Accurate detection of peritoneal metastasis in colorectal cancer remains a diagnostic challenge. The accuracy of ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) in the diagnosis of peritoneal recurrence was evaluated, FDG-PET was conducted in 18 patients previously treated for colorectal cancer and suspected recurrence with clinical symptoms, computed tomography (CT), and tumor markers. Final diagnosis was obtained by histological evaluation (n=14) or clinical follow-up (n=4). FDG-PET sensitivity was 88%, and accuracy in detecting peritoneal recurrence was 78%. For CT scans, sensitivity was 38% and accuracy 44%. Six patients were suspected to have peritoneal recurrence based on FDG-PET and 5 were identified pathologically with peritoneal metastasis. Lesions smaller than 30 mm were not detected by CT. FDG-PET detected 15 mm lesions. In conclusion, FDG-PET is an accurate, noninvasive way to detect peritoneal recurrence in colorectal cancer and would play an important role in clinical management.

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Fifteen patients with uldcerative colitis after total colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis were neurophysiologically studied and compared with 16 healthy controls (A group;10 men and 6 women, aged 18-50 years with a mean age of 38.9 years). All of 15 patients (10 men and 5 women, aged 22-57 years with a mean age of 40.2 years) were divided into 3 groups (Group B;5 patients without soiling, Group C;5 patients with soiling at watery diarrhea, Group D;5 patients with soiling every day). The latency of response in the external anal sphincter muscle following digitally directed transrectal pudendal nerves (pudendal nerve terminal motor latency;PNTML) was measured. Following results were obtained. 1) The conduction delay of bilateral PNTML was signifivantly longer in group D than that in group A, B, and C (p<0.01, respectively). 2) The conduction delay of bilateral PNTML was significantly longer in group C than that in group A and B (p<0.05, respectively). 3) The conduction delay of bilateral PNTML in group B was longer than that in group A. But there was no significant difference between the group A and B. These findings support the hypothesis that the conduction delay of PNTML in the patients with UC may be caused by surgical demage to pudendal nerves. The degree of the conduction delay of bilateral PNTML correlated well with the symptom of soiling.

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We report an extremely rare case of metachronous spleen metastasis with esophageal cancer. A 77-yearold man was underwent a subtotal esophagectomy with regional lymph node dissection (D2);Lt, 1p1+IIb (55×47mm), moderately differentiated squamous cell carcinoma, 1y1, v1, ie (+), M0, pN1, pT3, pStage III. During the postoperative follow up, spleen metastasis was revealed using image diagnostic technique (US, CT and MRI). At 14 months after initial surgery, the splenectomy was performed. Subsequently, multiple skin metastasis appeared and he died at 5 months after splenectomy.

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We report a case of circular giant leiomyoma 13 cm in diameter in the esophagocardiac junction, and review the literature and 14 cases more than 8 cm in diameter in Japan, for which resection was indicated. A 45-year-old male US-resident pilot with hematemesis and melena was admitted to our department because upper GI series revealed a submucosal tumor in the lower esophagus. Endoscopy revealed a dumbbell-shaped elevated submucosal lesion from the lower esophagus to the cardiac region. On abdominal CT and MRI, the tumor showed a well-demarcated homogeneous pattern and no contrast effect. Under right thoracotomy and laparotomy, esophagocardiac resection was conducted with reconstraction by jejunal transfer. The tumor consisted of elastic, hard, and oval solid masses of all sizes, the largest measuring 13.0×8.0×5.0cm. A diagnosis of leiomyoma was made based on histopathological examination. He was discharged on postoperative day 15 and has gone back to work as a pilot.

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A 67-year-old man was admitted to our hospital due to right lower abdominal discomfort. Endoscopic examination revealed type 2 gastric cancer at the prepylorus. Although preoperative computed tomography (CT) and ultrasonography (US) did not detect liver metastasis, multiple small white nodules 2 to 3 mm in size were found over the whole liver, and diagnosed as liver metastasis of gasteic cancer by intraoperative histological examination of frozen tissue. Distal gastrectomy with regional lymph node dissection was done. A port for hepatic arterial infusion was also implanted. 5-FU, ADM, MMC, and Lentinan were administered via the hepatic artery every 2 weeks for 5 years. Liver metastasis was not detected with any image examination until the man's death. Lung metastasis appeared on chest radiograph as a solitary mass in the right lower lung 3 years after surgery. Palliative radiation therapy was done for hemoptysis. He received systemic chemotherapy with leucovorin and 5-FU thereafter. He eventually died of brain metastasis 7 years and 9 months aftrer gastrectomy. This case suggests that local and systemic chemotherapy is effective in some gastric cancer cases with liver metastasis.

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We report effective intraperitoneal and intraarterial combined chemotherapy for unresectable advanced Borrmann type IV gastric carcinoma. A 59-year-old man diagnosed with advanced stomach cancer in June 1999 was found at operation to have advanced gastric carcinoma T4 N3 P1 H0 M1 CY1. Three ports to both subphrenic pouches and Douglas'pouch were emplaced for intraperitoneal infusion chemotherapy with a modified low-dose CDDP and 5FU regimen. An artery port was also introduced into the aorta at Th9/10 for arterial infusion chemotherapy in September 1999. The patient was followed up as an outpatient and continued to undergo intraperitneal and intraarterial combined chemotherapy.

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A patient with duodenal adenoma underwent papilla of Vater and duodenal mucosa resection. A 60-yearold woman was found by endoscopy to have an elevated lesion cerebrally situated from the oral side of the papilla of Vater to the transitional point to the third portion of the papilla about a quarter. The lesion surface was white, finely granular, and soft, but malignant findings were not seen. Biopsy showed adenoma with moderate dysplasia and surgery was conducted due to possible cancer complication. The tumor was found surgically to be limited to the mucosal layer and the margin was clear. The tumor was resected from the normal duodenal mucosa keeping a margin 5 to 10mm in diameter. After papillectomy with confirmation of the tumor extent, the bile duct and pancreatic duct were reconstructed. Pathologically, the tumor was tubulovillous adenoma with mild to moderate dysplasia limited to the mucosal layer without cancerous lesions. The patient has been followed up for 1.5 years without evidence of recurrence, cholangitis, or pancreatitis.

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We report a primary duodenal adenocarcinoma associated with von Recklinghausen's disease (VRD). A 64-year-old woman visiting our hospital due to appetite loss and epigastralgia in April 1999 was diagnosed with nonampullary primary duodenal cancer in radiological studies, upper gastrointestinal endoscopy and histological diagnosis. We conducted pancreatoduodenectomy. Histological examination showed moderately differentiated adenocarcinoma. Tumors of the neural crest origin are known to occur frequently in patients with VRD. The concurrence of intestinal cancer in this present case, however, is very rare in the Japanese literature.

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A 60-year-old man was admitted to our hospital with a diagnosis of duodenal tumor was found, on endoscopic examination to have an ulcer with surrounding elevation in the second portion of the duodenum. Biopsy indicated adenocarcinoma. Diagnosing duodenal cancer, we conducted a pancreatoduodenectomy with regional lymph node dissection. The resected specimen showed a submucosal tumor-like lesion in the second portion of the duodenum. Histopathological and immnohistochemical examination revealed endocrine carcinoma, which has a dismal prognosis due to rapid metastasis. Only 14 cases of endocrine carcinoma of the duodenum have been reported in the Japanese literature, so this case was very rare.

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A 46-year-old woman was hospitalized for an elastic hard and ill-defined tumor about 2 cm in diameter palpated in the C area of the left breast. The leukocyte count was normal, but there was a slight increase in eosinophils of 17% and liver dysfunction was recognized. Ultrasonography showed a 3. 5×2. 5cm low echo-genecitic tumor in the right liver lobe and plain computed tomography (CT) showed a low density area. Feridex magnetic resonance imaging (MRI) showed high signal intensity. Angiography revealed an unclear tumor stain, and CT during arterialportography (CTAP) showed portal blood flow to be decreased. Mastec-tomy and microwave coagulationtherapy (MCT) were conducted under a diagnosis of left breast cancer and metastatic liver cancer. Parasitic infection of the liver was suspected due to the invasion of advanced eosino-phils in the liver biopsy specimen and fascioliasis diagnosed from the serum immunological test. Fascioliasis is usually treated by administering Praziquantel. Postoperative normalized liver function and eosinophils and no recurrence in the 2 years indicated that cure was effected completely by MCT.

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A 47-year-old man who drank alcohol heavily and had a medical history of acute pancreatitis was admit-ted to our hospital due to upper left abdominal pain and hematemesis. Endoscopic examination showed active bleeding from a stomach ulcer at the middle-posterior-body, and hemoclipping was conducted. Abdominal computed tomography showed blood was retained in the stomach and a pancreatic pseudocyst. Splenic angi-ography showed active bleeding from the branch of the splenic artery into the pancreatic pseudocyst and subsequently to the major pancreatic duct and to the duodenum. The splenic artery was occluded with a bal-loon catheter. This man was eventually diagnosed with having hemorrhage of the pancreatic pseudocyst com-plicated by hemosuccus pancreaticus and fenestration into the stomach, and underwent distal pancreatec-tomy, splenectomy, and partial gastrectomy. Many cases of acute alcholic pancreatitis are followed by chronic pancreatitis, and morphologic abnormalities are often obserbed, and a pseudocyst of alcholic pancreatitis has high risk of bleeding. If it were fenestrated into neighboring internal organs, sometimes it caused gastrointes-tinal bleeding. The vascular occlusion is an useful therapy for hemorrhage of the pancreatic pseudocyst, but operation is needed often thereafter. Stomach ulcer complicated with chronic pancreatitis must be diagnosed from pancreatic pseudocyst fenestrated into the stomach.

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We report a retroperitoneal malignant schwannoma resected with the right liver lobe and inferior vena cava in a patient with von Recklinghausen's disease. A 29-year-old woman was admitted with right abdominal tumor and pain. Abdominal computed tomography (CT) showed a mass about 25 cm in diameter in the retroperitoneal space that ventrally depressed the inferior vena cava. Venography showed a defect in the inferior vena cava from the third vertebra and presence of collateral circulation. Under a diagnosis of retroperitoneal malignant schwannoma, the tumor was extirpated. Specifically, the liver was split anteriorly and the tumor resected together with the right liver lobe and inferior vena cava. The inferior vena cava was not reconstructed due to stable blood circulation following resection. The woman was discharged on postoperative day (POD) 24 without complication. Retroperitoneal malignant schwannoma is rare without subjective symptoms and has a poor prognosis, partcularly in patients with von Recklinghausen's disease. Treatment requires complete surgical extirpation.

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A 55-year-old woman undergoing pancreaticoduodenectomy 12 years earlier was admitted with abdomi-nal pain and nausea in December 1999. Plain abdominal radiography showed multiple air-fluid levels. A sponge-like mass was noted by computed tomography (CT) in the small intestine. Ultrasound (US) of the mass showing an intraluminal echogenic mass with acoustic shadowing. Overconsumption of persimmons was confirmed in a detailed medical history intervuew. Surgery was conducted based on diagnosis of small bowel obstruction due to a diosphyrobezoar. A dark brown egg-sized mass of foreign matter removed from the impacted ileum contained over 98% tannic acid.

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A 57-year-old man hospitalized with lower abdominal pain was found to have panperitonitis diagnosed through tenderness, rebound tenderness, and muscular defense in the lower abdomen. Abdominal plain film showed a 3-cm linear shadow corresponding to the site of tenderness and abdominal computed tomography showed a 2-cm linear shadow in the intestine. We thus diagnosed an intestinal perforation due to a fishbone and undertook emergency surgery. Fish bone perforation of the ileum was diagnosed preoperatively. Were-view 271 cases of intestinal perforation by fish bones repirted in the Japanese literature since 1990. Many per-foration sites were observed, including the ileum, the transverse colon and the sigmoid colon with the mesen-terium and not fixed to the retroperitoneum. Surgery was performed in 229 cases, from which 51 cases were diagnosed preoperatively.

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Small intestinal AVMs with massive bleeding are relatively rare, and it is difficult to localize bleeding sites precisely by inspection and palpation during surgery, even by intraoperative mesenteric angiography. We report a 70-year-old woman with massive intestinal bleeding caused by an AVM in the jejunum. We in-serted and maintained a microcatheter adjacent to the bleeding site by selective mesenteric catheterization immediately before surgery. This enabled us to localize the lesion by catheter palpation during surgery, and to precisely confirm the 5×5mm AVM by transillumination holding the intestine up to the light. Angiography of the specimen showed abnormal capillary beds, a dilated feeding artery, and a large drainage vein that flowed back early. According to the Japanese literature, most AVMs are generally resected at an approxi-mate site by intraoperative angiography, and long intestines are resected unnecessarily. Some reports de-scribe inserting and maintaining a microcoil near the lesion by mesenteric angiography, but no sure method has yet been established to confirm the lesion during surgery as we were able to achieve in intraoperative precise localization.

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We conducted laparoscopic partial excision of the cecum to treat mucinous cystadenoma of the appendix in a 67-years old woman admitted to our hospital due to submucosal tumor in the cecum on colonoscopy. Barium enema and abdominal computed tomography (CT) showed mucocele in the appendix and laparoscopic partial excision was conducted. Ileocecal stenosis occurred temporarily postoperatively, but no serious sequel was observed. Postoperative pathologic examination showed that the mucocele was benign mucinous cystadenoma. Even though the mucocele did not appear malignant histologically, it could induce pseudomyxoma peritonei, so surgery is often chosen with appendectomy, ileocecal resection, or right hemicolectomy done after abdominal section. Although laparoscopy has recently been applied to mucocele treatment, little attempt has been made to apply laparoscopic partial excision of cecum according to our search of a computer-assisted database. As indicated here, laparoscopic partial excision of cecum for a mucocele is beneficial in diagnosis and is safe and less invasive than conventional operation.

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Villous tumor of the appendix is uncommon. A 68-year-old woman was admitted because of abdominal pain localized at McBurney's point. Blood tests showed a white blood cell count of 15, 000/μl and C-reactive protein of 0.6mg/dl consistent with a diagnosis of acute appendicitis. Ultrasonography of the cecum and appendix showed irregular wall thickening with a hypoechoic pattern. We suspected a cecal tumor associated with acute appendicitis. Barium enema and colonoscopy disclosed a villous tumor of the orifice of the appendix, and biopsy specimens of the tumor showed tubulovillous adenoma. Laparoscopic partial cecoctomy was conducted, considering the possibility of early-stage cancer. The villous tumor was located from the distal end of the appendix to the cecum. Histologically, it was negative for malignancy. Ultrasonography was useful in preoperative diagnosis.

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We report a case of primary low-grade mucosa-associated lymphoid tissue (MALT) lymphoma of the ascending colon. An 82-year-old woman with transient ischemic was found to have a tumor with tenderness in the right lower quadrant of the abdomen. Barium enema showed a huge tumor about 5cm in diameter in the ascending colon. Colonoscopy revealed a nonepithelial, submucosal tumor, and biopsy specimens showed normal colonic musosa. Malignant lymphoma arising from the ascending colon was strongly suspected. Right hemicolectomy was conducted for diagnostic and therapeutic purposes due to the possibility of intestinal obstruction. Final diagnosis was low-grade MALT lymphoma of the ascending colon. Tumor invasion was limited to the serosa without nodal involvement. Adjuvant chemotherapy was not done. In the 4.5 years since surgery, the woman remains alive without recurrence. Low-grade MALT lymphoma rarely occurs in the large bowel, especially in the ascending colon. No standard surgery or therapeutic regimen has been established for this condition. MALT lymphoma has been reported to have a relatively good prognosis. Related surgery, however, should include lymph node dissection the same as for colon cancer due to the risk of nodal involvement.

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We report a case of recurrent ascending colon cancer in the pancreatic head 16 months after right hemicolectomy treated by pancreaticoduodenectomy. Case report: Barium contrast radiography of the upper gastrointestinal tract showed an obstruction in the duodenum of a 45-year-old woman. Computed tomography showed a lesion with central necrosis extending from the pancreatic head to the third portion of the duodenum. Portograpy showed that the mass lesion compressed the superior mesenteric vein. The patient underwent radical surgery to resect the ileum and transverse colon, plus pancreaticoduodenectomy and partial resection of the superior mesenteric vein and of liver. Pathological examination showed a metastatic tumor in the pancreatic head. Central necrosis was noted 3 cm in diameter. Fistula formation was observed between the duodenum and transverse colon through the necrotic cavity. Although the patient was discharged on postoperative day 36, she died of liver metastasis 192 days after surgery. Although prognosis is generally poor, pancreaticoduodenectomy is indicated in resectable cases of metastatic pancreatic disease from colon cancer.

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We report a case of resected metachronous metastatic lung, thyroid, and aderenal cancer from sigmoid colon cancer. 47-year-old woman underwent sigmoidectomy due to adenocarcinoma of the sigmoid colon in February 7, 1994. Histological findings showed moderately differentiated adenocarcinoma-ss, ly1, v0, n0, stage II in the Japanese colorectal cancer classification. About 3 years later, she reported cough and fever, and a chest X-ray revealed a solitary nodule in the right upper lobe, and right upper lobectomy was conducted on September 10, 1997. One month later, she was found to have a solitary mass in the left thyroid lobe, necessitating left thyroid lobectomy. One year later, her serum carcinoembryonic antigen levels rose to 43.2ng/ml. Computed tomography showed a right adrenal mass, right adrenalectomy on July 8, 1998. All specimens showed adenocarcinoma the same as for sigmoid colon cancer. She has led a normal life since the last operation.

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Hirschsprung's disease is characteristically presents in infancy or childhood, with symptoms of severe constipation and abdominal distension. Surgical treatment is almost always completed in childhood. We report 2 cases of Hirschsprug's disease in adults. Case 1: A 23-year-old man was referred to our hospital with wors-ened constipation and abdominal distension and abdominal pain. Case 2: A 47-year-old woman consulted us about pyrexia, diarrhea, appetite loss, and weight loss of 9kg in 2 months. Secondary colitis mimicking inflamm- atory bowel disease such as Crohn's disease or ulcerative colitis was obvious in case 2, associated with longterm massive feces retention. In both cases, severe constipation had been presented since childhood, but con- trollable with laxatives and enemas. Barium-enema showed caliber change in the lower rectum, and the rec- toanal reflex was absent in the manometric study. The Duhamel-Ikeda procedure was conducted and the postoperative course was uneventful. Quality of life improved markedly in both cases. Pediatric surgery was recently instituted and Hirschsprug's disease rarely remains undiagnosed until adulthood. It should, how- ever, be considered in all adult patients who have had severe constipation since childhood involving the mega-colon.

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A 55-year old woman was referred to our hospital because of a positive fecal occult blood test during a mass screening examination. She had undergone a polypectomy of the rectum 4 years and 2 months previ- ously. The polypectomy specimen was a well-differentiated adenocarcinoma. No other surgical resections were performed, and a follow-up examination performed one year and four months after polypectomy pro- duced no abnormal findings. After her referral to our hospital, a colonoscopy showed a submucosal tumor-like lesion in the rectum. A chest X-ray roentogenogram showed multiple coin lesions. We diagnosed a local recur- rence and multiple lung metastases. An operation was therefore performed. The local recurrence occurred at the same site as the previous, polypectomized region. After a review of the previous polypectomized speci- men, vessel invasion was identified. The patient was diagnosed as having a recurrence of sm1 rectal cancer. The recurence of sm1 colorectal cancer is very rare.

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A 62-year-old man was admitted to our hospital due to a buttock tumor. After imaging examinations, the tumor was resected based on a diagnosis of myoma or sarcoma. At resection, the specimen was histologically diagnosed as gastrointestinal stromal tumor (GIST), malignant. A Miles operation was conducted following diagnosis. Histological examination of the resected specimen showed the tumor consisted of spindle-shaped cells. Immunohistochemical testing was negative for S-100, and positive for smooth-muscle actin, CD34, and c- kit, making this tumor a malignant smooth muscle GIST. Thereafter, 11 rectal GIST cases were reported in Japan. We reviewed the total of 12.

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Since 1995, a 69-year-old man had noted pus discharge and bleeding from the perianal region, where a soybeen sized tumor appeared in May 1999. He was admitted to our hospital in May 2000 because the perianal tumor enlarged gradually and bleeding and pus discharge from the tumor became frequent. Biopsy of the ul- cerated 38×27mm tumor showed moderately differentiated adenocarcinoma. Colonoscopy revealed an ulcer-ated tumor 20cm from the anus. Biopsy showed moderately differentiated adenocarcinoma. Because the his- tologic features of the perianal tumor closely resembled those of the sigmoid colon tumor, we considered exfo- liate cells from the sigmoid colon carcinoma had implanted and made the metastatic tumor in an anal fistula. The patient underwent abdominosacral excision of the sigmoid colon and rectum with an uneventful postop-erative course. Anal fistula is common, but our case emphasizes that the whole colon should be examined if carcinoma is found in an anal fistula. Anal fistula in a patient who has been operated on for colon cancer should be closely checked at follow-up.

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