Purpose: We studied the combined effects of carcinoembryonic antigen (CEA) release from cancer cell (PLC) using phosphatidylinositol phospholipase C (PIPLC) and ultrasound-induced cell lysis (US) in early peritoneal dissemination on diagnosis. Materials and Methods: Materials were 3 CEA-producing human gas-tric cancer cell lines-KATO-III, LoVo and MKN-45-and Subjects 46 gastric cancer patients undergoing gas-trectomy and peritoneal lavage cytology for 1 year 1998. Patients were divided into 4 groups-nontreatment, PLC (0.05U of PIPLC administered into sediment from peritoneal lavage fluid), US (ultrasound-induced cell ly-sis), and USP (combined PLC and US). The reaction was positive if supernatant CEA increased more than 10% compared to the nontreatment group. Results: CEA was higher in cytoplasmic KATO-III and MKN-45 than in apical LoVo. The effect of CEA release was more marked in the USP group versus cytoplasmic. Posi-tive CEA increased gradually by surgical stage grouping and the depth of tumor invasion-23.9% in nontreat-ment, 26.1% in PLC, 26.1% in US, and 28.3% in USP, with USP the most positive. The prognosis of positve groups in USP, PLC, and CY was significantly poorer than in negative groups. In cases showing T2 or T3 with negative peritoneal dissemination, no significant difference was seen in survival curves between positive and negative PLC, but the prognosis of USP (+) was significantly poorer than that of USP (-). Conclusions: The combination of PLC and US, i.e. USP, may be effective in early diagnosis of peritoneal dissemination in gastric cancer patients.

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Objectives: To exmine the preventive effects of Conventional 5-FU and sustained release type 5-FU ad-ministration on the hepatic dissemination of colorectal cancer cells during surgical maneuver in the animal model. Materials and methods: In this experiment, rabbits were used as an animal hepatic metastasis model utilizing the injection of VX2 carcinoma cells into the portal vein. Two forms of 5-FU, i.e. conventional 5-FU and sustained-release 5-FU, were orally administered with 3 different shedules. Three schedules of 5-FU oral administration were attempted as follows: 1) 10 mg/kg preoperative dosage only, 2) preoperative 10 mg/kg plus postoperative dosage at 6 mg/kg/day for 6 days, and 3) postoperative dosage at 6 mg/kg/day for 7 days. Te hepatic metastases were compared by volume among the 6 groups mentioned above and controls. Results and Conclusion: Statistical analysis revealed that preoperative administration of 5-FU significantly reduced the hepatic metastasis while postoperative administration of 5-FU did not influence the results. Compared to the efficacy of conventional 5-FU, sustained-release 5-FU tended to more effectively suppress hepatic metasta- ses.

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A 75-year-old man with dysphagia was found in an upper gastrointestinal series to have a tumor shadow at the fornix. A diverticulum was seen on the anterior subphrenic esophageal wall. An elevated lesion was seen from the lower proximal esophagus in endoscopy. The preoperative diagnosis was a gastric leiomyoma and subphrenic esophageal diverticulum. The diverticulum was seen on the proximal side of the tumor which located at the abdominal esophagus. The tumor was enucleated, the diverticulum was made contrary inside and the opened muscular layer was sutured. Histopathological diagnosis of the resected tumor was esopha-geal leiomyoma. In the many previous reports of our country, the origin of the esophageal diverticulum associ-ated with esophageal leiomyoma was traction. In our case, it is suggested that the diverticulum developed as a result of both traction and pulsion of the esophageal wall related to the growth of the tumor.

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Barrett's esophagus and subsequent adenocarcinoma have been increasingly encountered in the Japa-nese population due to dissemination of the Euroamerican lifestyle. We report a case of Barrett's adenocarci-noma in an extremely long Barrett's esophagus. A 45-year-old man followed up regularly for symptomatic gastroesophageal reflux diseases (GERD) was admitted for further examination of an abnorma shadow in the lower esophagus identified by an upper gastrointestinal series. Endoscopy showed a 3-cm type 2 tumor at the lower part of an extremely widespread Barrett's esophagus 15cm long. Tumor biopsy showed adenocarci-noma.The patient remains alive and recurrence-free 2 years and 9 months after radical thoracic esophagec-tomy with regional lymphadenectomy. Pathological diagnosis showed moderately differentiated adenocarci-noma invading the submucosal layer, but without lymphatic or vascular invasion. Immunohistochemical stain-ing showed that both the adenocarcinoma and adjacent noncancerous Barrett's epithelium in the posterior wall of the esophagus were positive for p53 mutation, suggesting its association with the development of Bar-rett's esophagus and subsequent adenocarcinoma. To our knowledge, our patient had the most widespread Barrett's esophagus in Japanese patients with complications of esophageal adenocarcinoma. Patients with early Barrett's adenocarcinoma are reported to enjoy an extremely favorable prognosis with proper surgical treatment. Endoscopic GERD follow-up may therefore play a crucial role in the early detection of Barrett's adenocarcinomas, leading to improved overall prognosis for patients developing this malignancy.

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A 49-year-old, man diagnosed with hyperglycemia during a physical checkup in 1990 began losing weight in April 2000, dropping 5kg in 6 months. He was diagnosed elsewhere with a pancreatic tumor and was re-ferred to our department and admitted. On admission, we noted oxyhyperglycemia and hyperglucagonemia. Computed tomography (CT) showed multiple tumors in the pancreatic body and tail. Angiography showed hyperdense masses, suggesting tumors in the same lesion. Based on these findings, he was suspected of gluca-gonoma and underwent resection of the pancreatic body and tail. Three tumors detected in the pancreatic body and tail were removed tissue and vascular invasion was seen pathologically around the tumors, which were judged to be malignant. Tumor No.1 tested positive in immunostaining for both glucagon and pancre-atic polypeptide, Tumor No.2 weakly positive for glucagon, Tumor No.3 strongly positive for glucagon. All 3 tested negative for other pancreatic hormones. Although all were glucagon-producing, they differed in the production of other pancreatic hormones, and were thought as multicentric malignant glucagonoma. The postoperative course was uneventful, and blood glucagon normalized after surgery.

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A 51year-old woman a thyroid crisis was admitted and treated with antithyroid drugs, a βadrenergic blocker, and peripheral intravenous drip of an electrolyte infusion without vitamins. Vertigo with fixation nystagmus appeared on day 12 after admission. On day 33, magnetic resonance imaging (MRI) showed a high intensity lesion around the crebral aqueduct and laboratory data showed a low vitamin B1count, leading to a diagnosis of Wernicke's encephalopathy. Gastroscopy showed advanced gastric cancer with pyloric stenosis. Intravenous injection of vitamin B1 gradually improved vertigo, and was followed by distal gastrectomy. We inferred that the etiology of this encephalopathy was a high demand for vitamin B1by hypermetabolism due to a thyroid crisis and intravenous glucose injection, and poor supply of this vitamin due to pyloric stenosis from gastric cancer. We concluded that vertigo with nystagmus is an important incipient symptom of Wer-nicke's encephalopathy and if it appears in the patient with anorexia and/or hypermetabolism, requires swift, suitable treatment. Wernicke's encephalopathy due to pyloric stenosis and thyroid crisis is extremely rare and we found no case reports in the world wide literature.

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A 61-year-old woman was admitted with early carcinoma of the papilla of Vater 1year after recovering from acute pancreatitis treated conservatively. After acute pancreatitis stabilized, endoscopic findings of the papilla of Vater showed normal findings with a dilated main pancreatic duct revealed by magnetic resonance cholangiopancreatography (MRCP). Cytology of the pancteatic juice showed class II. After a 1-year follow-up, endoscopic retrograde cholangiopancreatography (ERCP) and abdominal computed tomography (CT) showed dilated main pancreatic duct without any findings of tumor in the pancteatic head. Histological biopsy of the papilla of Vater showed adenocarcinoma. Pylorus-preserving pancreaticoduodenectomy showed welldifferentiated adenocarcinoma limited to the mucosa of the duodenal papilla without vascular or pancreatic in-vasion or lymph node metastasis.

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A 78-year-old woman with abdominal pain admitted and diagnosed with cholangiocellular carcinoma underwent central bisegmentectomy of the liver and partial resection of the abdominal wall. The tumor was hard, yellowishwhite, and invaded the gallbladder. The histological diagnosis was adenosquamous carcinoma consisting of both adenocarcinoma and squamous cell carcinoma. The patient was readmitted with anal bleeding 11months after operation. We detected stenosis of the transverse colon and partially resected the colon for local recurrence of adenosquamous carcinoma. The patient died 16 months after the first operation. Primary adenosquamous carcinoma of the liver is rarely encountered, and we review cases reported in the literature.

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A 67-year-old woman admitted for sudden right hypochondrial pain, was found in ultrasonography to have gallbladder stones and diagnosed with a double gallbladder with cholelithiasis distal gallbladder by endoscopic retrograde cholangiopancreatography. It was classified as a Htype double gallbladder in the classification of Gross, necessitating laparoscopic cholecystectomy for the distal gallbladder with cholelithiasis. The postoperative course was uneventful and the patient was discharged on postoperative day 6. One year later, dripinfused cholangiography was conducted and 7 years later, magnetic resonance cholangiopancreatography was done to evaluate the residual gallbladder. Neither showed abnormal change. Double gallbladder is a rare anomaly with only 65 cases, including ours, reported in the Japanese literature. Both gallbladders often have cholelithiasis. The distal gallbladder alone was associated with gallstones in our case, so laparoscopic cholecystectomy was conducted on this alone, with the residual gallbladder followed up. Gallbladder carcinoma found 3 such cases indicate a need to strictly follow up the condition of the residual gallbladder.

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We experienced a rare synchronous double cancer: Cholangiocellular carcinoma with tumor thrombus in the teres hepatis and ureter carcinoma. A 71old man admitted for bloody urine was found in computed tomography to have a hypovascular tumor 5cm in diameter in segment 4 of the liver. Percutaneous trashepatic cholangiography showed tapered abrupt obstruction of the left hepatic duct. Portgraphy showed abrupt obstruction of the left portal vein. Ureterography showed a protruding tumor of the right ureter. We conducted extended left lobectomy with caudate lobectomy, combined resection of the portal vein, right nephrectomy and ureterectomy. Pathological study of the specimen showed moderately differentiated adenocarcinoma of the liver and transitional cell carcinoma of the ureter. Tumor thrombus of the portal vein extended to the teres hepatis. Postoperative course was uneventful, but the patient died of multiple liver metastasis 12 months after operation.

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We report 3 cases of intestinal Behcet's disease with perforation. All underwent emergency surgery with primary anastomosis, but perforation and anastomotic leakage occured postoperatively. To eliminate such leakage, we conducted ileostomy in 2 of the 3 cases. In Bercet's disease with perforation, steroid medication is required to amelirate disease symptoms. In the acute perioperative period, Behcet's disease frequently worsens and the incidence of postoperative complications is high. Coping with them requires the use of steroids to suppress disease activity. Double-barreled ileostomy may prove useful in avoiding primary anstomosis.

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We report a very rare case of capillary hemangioma of the small intestine. A 70-year-old woman admitted for severe anemia was found at intestinography to have bleeding through the ileus tube, even though no focal lesion was seen in examinations such as upper gastrointestinal endoscopy, barium enema, abdominal computed tomography, and ^99m Tc-RBC scintigraphy. Total colonoscopy showed a huge blood pool in the cecum through the terminal ileum, with bleeding arising from the small intestine. In intestinography through the ileus tube, we found a round shadow defect about 1.5cm in diameter in the middle of the small intestine. Since the lesion was considered the focus of bleeding, we conducted open laparotomy. A red soft mass was located in the serosa attached to the mesentery. We partially resected the small intestine, including the mass. The resected specimen showed an elastic soft 15×15×8mm tumor. Histological examination showed nonmalignant capillary hemangioma of the small intestine. The postoperative course was uneventful and the patient was discharged on postoperative day 21.

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A 62-year-old woman with diabetes mellitus referred for nausea and vomiting evidenced intestinal obstruction after admission. We palpated a moving mass from her abdominal wall, and ultrasonography revealed an intraluminal echogenic mass lesion with an intense acoustic shadow. A mottled gas pattern in this mass was seen in computed tomography. We preoperatively diagnosed small bowel obstruction due to bezoar. The bezoar was impacted at the jejunum 120cm from the Treitz ligament, and extracted by enterotomy. We diagnosed persimmon bezoar consisted of tannin, and speculated an influence of diabetes mellitus as its pathogenesis.

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A 67-year-old man with a history of diabetes mellitus, hypertension, and schizophrenia admitted for nausea and anorexia was found in physical examination to have severe abdominal distension without tenderness. Laboratory data was as follows: white blood cell count 8, 300/mm³, CRP(C reactive protein)12mg/dl, serous creatinin 2.4mg/dl, and serum blood sugar 324mg/dl. Abdominal radiography showed free air and dilated small intestinal gas, and abdominal computed tomography showed free air and emphysema in the wall of the dilated intestine and the mesenterium. In emergency laparotomy, diffuse emphysema was noted in the wall of the anal side of the small intestine and the mesenterium. We judged these emphysematous changes occured due to increased internal intestinal pressure. An ileus tube was emplaced after drainage of intestinal juice. The postoperative course was uneventful. Pneumatosis cystoides intestinalis is a rare disease forming multiple cystic emphysema in the wall of the intestine. Causes of this disease are considered to include increased internal intestinal pressure, intestinal ischemia, inflammation, rupture of emphysematous change of the lung in chronic pulmonary diseases, and some drugs. Conservative therapy usually is chosen, but in cases with severe inflammatory and/or ischemic findings, emergency surgery is indicated. In our case, we conducted emergency surgery due to the inflammatory reaction, increased creatinin, and caring underestimation of abdominal findings masked by schizophrenia and diabetes mellitus.

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Necrotic ischemic colitis spreading to the total colon is a rare, severe condition that can cause peritonitis via large intestinal perforation. A previously healthy 51-year-old woman admitted for epigastralgia. It was found in abdominal computed tomography (CT) to have a loss of haustration in the transverse colon. Bowel sounds were detected. She was initially diagnosed with enterocolitis. A few hours later, her abdominal pain worsened and the abdomen exhibited muscular defense. Five hours after admission, CT showed ascites and paralytic ileus. At laparotomy, massive bloody ascites was observed and the large intestine from cecum to splenic flexure was necrotic. Neither anatomical abnormalities in the mesentery vascular course nor blocked arteries were seen.
The gangrenous area of the colon migrated from the descending colon to the sigmoid colon during surgery.We conducted a subtotal colectomy and an ileostomy. Biological testing showed no infectious organism in ascites or feces. Histology showed a full thickness necrosis in the colon and massive congestion in the submucosal layer. This is lethal and the severest type of ischemic colitis, which may progress to the whole colon. Only immediate surgery can halt this.

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A 59-year-old man admitted with gastrointestinal stromal tumor (GIST) repeatedly developed recurrent tumors at different abdominal sites with liver metastasis after initial surgery in March 1996. We conducted 9 incisions to excise these tumors. In June 2001, several new intraabdominal tumors and liver metastases progressed in size and number, as documented by computed tomography (CT). Tumor cells stained positive for c-kit CD117. STI571 (imatinib mesylate) is a competitive inhibitor of tyrosine kinases, including BCR-ABL, KIT, and PDGF-R, that is currently used to treat chronic myelogenous leukemia. We started STI571 treatment for metastatic and unresectable GIST. After 9 months of treatment, CT showed that tumors had decreased to less than 10%in size and the metastatic liver tumor had disappeared. No new lesions appeared. As of May 2002, tumors at all sites continued to respond positively to treatment and the patient remains clinically well.

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A 86-year-old woman had fever and urinary occult blood with a hard mass palpable in the lower right abdomen. Abdominal computed tomography and magnetic resonance imaging detected a tumor 13 cm in diameter extending from the ileocecum to the inside of the pelvis, excluding the bladder. Colonofiberscopy showed an elevated tumor in the cecum. Biopsy from the tumor showed well differentiated adenocarcinoma. The tumor had deeply invaded the bladder, necessitating right hemicolectomy with partial resection of the bladder. The 12.0×11.5 cm tumor was type 2 and developed in the cecum, forming a fistula from the cecal ulcer floor into the bladder. Histopathologically, the lesion was identified as mucinous carcinoma, infiltrating into the muscular tunic of the bladder, while the fistula wall was found to be composed of inflammatory granulation tissue without tumor cell infiltration. Colon cancers with fistulization into the bladder are commonly either sigmoid colon cancer or rectal cancer, with rare cases of cecal cancer as identified in the present diagnosis. In our case, the expanding mucinous mass of the tumor oppressively excluded the bladder wall to necrosis, eventually forming the colovesical fistula.

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We report a rare case of an epitheloid hemangioendothelioma of the greater omentum. A 58-year-old woman admitted with periumbilical discomfort was found to have an elastic palpable soft mass of about 5cm close to the abdominal wall in the periumbilical region. Abdominal ultrasonography (US) showed a heterogenous hypoechoic tumor with cyst-like components mobile horizontally with respiration. Contrast-enhanced computed tomography (CT) showed a well-circumscribed tumor about 4 cm in diameter with low focal attenuation areas near the stomach and transverse colon. Endoscopy and barium enema detected no lesions in the gastrointestinal tract. These findings suggested a primary peritoneal tumor. As it showed displacement with respiration, we considered that it may have arisen from the greater omentum. The patient underwent sugery on November 22, 1999. The tumor presented in the greater omentum in firm contact with the gastric wall, necessitating total extirpation of the tumor combined with partial resection of the involved gastric wall. Microscopically, the tumor had features consistent with epitheloid hemangioendothelioma, and had infiltrated the gastric muscular layer. Immunohistochemically, endothelial markers CD34 and Factor VIII were partially expressed in tumor cells. The final pathological diagnosis was epitheloid hemangioendothelioma originating from the greater omentum. The patient's postoperative course was uneventful, with no evidence of recurrence after 30 months. Epitheloid hemangioendothelioma of the greater omentum is extremely rare. A search of the English literature on the Internet showed only 1 previous report, making the presentation of this case significant and necessary.

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