We evaluated the postoperative function of vagus nerve preserving gastrectomy for early gastric cancer to relieve postoperative sequelae and improve quality of life (QOL) by mesans of questionnaires and glukagon test. Patients who underwent distal gastrectomy with D2 lymph node dissection were divided into 2 groups: vagus-preserved and vagus-sectioned. The difference in the concentration of c-peptide at 6 min after glukagon injection between preoperation and postoperation was significant in the vagus-sectioned group (2.87±0.39), compared to the vagus-preserved group (1.12±0.265). The occurrence of postoperative diarrhea was 4% in the vagus-preserved group and 16.3% in the vagus-sectioned group (P<0.03). We evaluated patient problems assigning a score. In the vagus-sectioned group, diarrhea was the most unpleasant symptom. We presumed that the rate of diarrhea was reduced by vagus-preserved. These results suggest that we must work to preserve the vagus nerve in surgery for early gastric cancer.

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Introduction: We studied the relationship between biliary carcinoembryonic antigen (CEA) and liver metastasis after pancreatic cancer resection.Methods: The biliary level of CEA was examined in 21 patients with pancreatic cancer who underwent radical surgery with curability A and B. Postoperatively, liver metastasis occurred in 13-early metastasis within 6 months of surgery in 6, and late metastasis in 7-and no liver metastasis in 8. Bile was collected through a percutaneous transhepatic biliary drainage (PTBD) tube preoperatively and a retrograde transhepatic biliary drainage (RTBD) tube postoperatively.Results: No significant differences were seen in clinicopathological factors between patients with and without liver metastasis. Preoperative biliary CEA was 41±89ng/ml in the liver metastasis group and 12±14 ng/ml in the no liver metastasis group. Postoperative biliary CEA in the liver metastasis group was 295±432 ng/ml and 67±62ng/ml in the nonmetastasis group. Postoperative biliary CEA in the early liver metastasis group (476±572 ng/ml) was significantly higher than in the non liver metastasis group (67±62 ng/ml). Biliary CEA increased markedly on day 28 compared to that on day 14 in the early liver metastasis group.Conclusions: Postoperative biliary CEA is useful in predicting early liver metastasis after radical surgery for pancreatic cancer.

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We report a case of intestinal malrotation following gastric cancer. A 73-year-old man with general fitigue was found in gastroscopy, upper gastrointestinal series, barium enema examination, and abdominal computed tomography to have intestinal malrotation seen for gastric cancer. At laparotomy, the small intestine was located on the right and the large intestine on the left, yielding a diagnosis of nonrotation. Distal gastrectomy with D2 dissection and Billroth I reconstruction were conducted without intestinal fixation for intestinal malrotation. Intestinal malrotation has been diagnosed in 72 children and adults in Japan between 1993 and 1999. In children, 13 of 14 cases (93%), were observed with abdominal symptoms due to embryonal anomalies including malrotation. In middle and old age, 24 of 40 cases (60%) were detected during investigation for intestinal tumors, appendicitis, and etc. Among 8 cases of intestinal malrotation with gastrectomy reported from 1983 to 2000, 2 cases of intestinal malrotation induced midgut volvulus postoperatively.

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We report a case of combined hepatocellular and cholangiocellular carcinoma with sarcomatous change that rapidly recurred in peritoneal dissemination after hepatectomy.
A 58-year-old man referred for a liver mass was found in dynamic computed tomography (CT) and abdominal angiography to have a tumor with a diameter of 3cm not similar to hepatocellular carcinoma. Needle biopsy yielded a diagnosis was moderately differentiated hepatocellular carcinoma necessitating right hepatectomy of the liver. The 4.0×3.3×3.2cm tumor was an elastic hard, clear nodule without a capsule. Histologicaly it was combined hepatocellular and cholangiocellular carcinoma. On postoperative day (POD) 60, he was readmitted for abdominal distension and appetite loss. Abdominal CT showed peritoneal dissemination and accumulated ascites, cytological class V. After admission, his condition worsened rapidly and he died on POD 77 of peritoneal dissemination and peritonitis carcinomatosa. Microscopic findings of peritoneal dissemination on autopsy showed spindle cells and strange proliferated cells with a sarcomatous pattern. We believe these sarcomatous changes caused the rapid clinical course.

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We report 2 cases of communicating accessory bile duct, Case 1: A52-year-old man diagnosed with intrahepatic and extrahepatic bile duct stones referred to our hospital was found in cholangiograrhy to have a ramification of the posterior inferior subsegmental branch (B6) from the common bile duct. B6 was connected to the anterior segmental branch upstream. The cystic duct was discovered close to the root of B6. A biopsy specimen from the lumen of the communication between B6 and the anterior segmental branch showed hyperplastic biliary mucosa with peribiliary glands. Case 2: A 72-year-old man diagnosed with gallbladder and common bile duct stones undergoing percutaneous transhepatic biliary drainage was found in cholangiography to have the accessory bile duct originating from the common bile duct, and the cystic duct deriving from the accessory bile duct. The accessory bile duct was connected to the right hepatic duct at the hilum of the liver. The communicating accessory bile duct may easily be confused with other anomalies of the biliary tree. We detail the classification of this congenital abnormality and its types.

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A 37-year-old woman kicked in the abdomen by her husband experienced epigastric and back pain 1 week later. She was hospitalized 2 weeks later due to remarked icterus. Abdominal computed tomography (CT) showed the head of the pancreas to be enlarged and biliary dilation. Endoscopic retrograde chorangiopancreatography (ERCP) showed stenosis of the lower part of the bile duct with no abnormality in the main pancreas duct. An upper gastrointestinal tract (UGI) series showed no duodenal abnormality. She underwent percutaneous trsanshepatic biliary drainage (PTBD), followed by cytologic examination of the bile after blushing of biliary stenosis. Because cytology was negative, we tentatively diagnosed traumatic biliary stricture. We failed to place an endoprosthetic device in the pronounced stenosis, so she was discharged with an external drainage catheter and followed up as an outpatient.
The endoprosthetic tube was removed 4 months due to spontaneous regression of biliary stenosis observed in follow-up cholangiography. Laboratory and CT examinations have shown normal results, with conservative therapy using the PTBD catheter yielding satisfactory results.
Traumatic biliary stricture is reversible because the pathological process is of a benign inflammatory nature. Conservative strategy is therefore a viable therapeutic options in treating traumatic biliary stricture.

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We report a case of ischemic biliary stricture following pancreaticoduodenectomy (PD). A 47-year-old man who had undergone PD for mucinous cystadenocarcinoma of the pancreas, during which the bile duct was transected at the level of the middle bile duct, presented with obstructive jaundice 7 months after the PD. Percutaneous transhepatic cholangioscopy showed both a pinhole stricture of the common hepatic duct just above the hepaticojejunostomy and intrahepatic gallstones. Histology of endoscopic biopsy specimens of the stricture showed no malignant tissue, leading to a diagnosis of benign biliary stricture with resultant hepatolithiasis. Although endoscopic gallstone retrieval was successful, endoscopic biliary dilation failed. At laparotomy, the common hepatic duct was densely fibrotic. We resected the fibrously thickened duct followed by bilioenteric anastomosis. The resected specimen showed histologically dense fibrous tissue with chronic inflammatory infiltrates, compatible with ischemic biliary stricture. This case and a review of the literature indicate that the bile duct was transected at the upper bile duct and back-bleeding from the transected ductal end, which ensures sufficient arterial blood supply, should be checked when in PD to prevent postoperative ischemic biliary stricture.

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A 58-year-old man hospitalized for upper abdominal pain, was referred to us due to a pancreatic tumorous lesion detected by abdominal ultrasonography (US) and computed tomography (CT). Although serum CEA and CA19-9 were within normal ranges, leucocytosis with eosinophilia was observed and CRP was elevated to 1. 9mg/dl. US showed an ill-defined hypoechoic mass in the pancreatic head and uncinate process, suggesting a hemorrhagic pseudocyst. Endoscopic ultrasonography (EUS) showed a heterogenous hypoechoic lesion with a cystic component. CT showed a low-density tumor with severe adhesion to the superior mesenteric vein (SMV). ERCP showed diffuse stenosis of the pancreatic duct in the pancreatic head, probably due to pancreatitis. Angiography showed slight tumor staining and stenosis of the SMV. Following pancreaticoduodenectomy, pathological examination showed the lesion to be invasive ductal giant cell carcinoma with severe infltration of neutrophils and eosinophils. Preoperative leucocytosis with eosinophilia improved just after surgery, and increase again at recurrence. The patient's postoperative course was uneventful, but the outcome was very poor.

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The arteriovenous malformation of the pancreas we report is very rare. A 53-year-old man with sudden severe hypochondralgia was found in enhanced computed tomography scan showed to have a high-density area in the tail of the pancreas. Magnetic resonance imaging T1 weighted imaging showd a signal-void sign at the same area. Four arteriovenous shunts were detected in the body and tail of the pancreas of SMA, IMA, splenic artery and left gastric artery by angiography. We diagnosed arteriovenous malformation of the pancreas, and conducted distal pancreatectomy. During surgery, we confirmed decreased portal blood pressure and portal blood O2 partial pressure before and after pancreatic resection. Surgical resection of the pancreas should be done to prevent portal hypertension by pancreatic AVM. Pancreatic resection has an extremely low recurrence of pancreatic AVM compared to transarterial embolization or surgical ligation of the feeding artery.

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Because of its'anatomical location and frequency, it is relatively difficult to determine a preoperative diagnosis of ileal leiomyosarcoma without abdominal symptoms, such as melena. A 53-year-old woman who had been treated for multiple liver abscesses in another hospital was referred to our hospital with a pelvic mass suggestive of gynecologic neoplasm. Pelvic MRI showed a 6×6cm irregular mass at the dorsal side of the bladder, and anterior to the uterus and rectum, Under a presumed diagnosis of solid ovarian tumor, a gynecologist performed a laparotomy. However, the tumor originated in the small intestine, and she was transferred to another surgeon. Partial ileal resection with tumor was carried out. The histological diagnosis was ileal leiomyosarcoma. since 1985 in Japan, 12 cases of small-bowel tumor presenting with liver abscess were reported. In our case, Streptococcus intermedius was found in the liver abscess. Physicians should consider small-bowel tumor, in-patients presenting with pelvic mass and liver abscess due to small intestinal bacteria.

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A 27-year-old man admitted for intestinal obstruction and abdominal pain was found in computed to mography (CT) to have a heterogenous tumor 10 cm in diameter tumor in the pelvis. Magnetic resonance imaging (MRI) showed compression of the urinary bladder and rectum by the tumor. A barium meal study of the small intestine revealed external compression of the ileum but no elevated lesion in the ileal lumen. Angi ography of the superior mesenteric artery showed compression of the ileal branch, but no pooling or tumor stain. The tumor was thought to be of the mesenteric organ of the ileum, so we resected the 12×10 cm tumor in the mesentery partially involving the ileum. The tumor, 180 cm proximal to the end of the ileum, was elasti cally soft with an iregular surface of cystic lesions filled with coagulated blood. The pathological diagnosis was cavernous hemangioma. To our knowledge, only 21 cases of mesenteric hemangioma have been reported in Japan, including our case. Mesenteric hemangioma is thought to be extremely rare.

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We report a case of heterotopic pancreas of the ileum causing intussusception. A 23-year-old woman admitted for 3 days of abdominal pain and vomiting but no remarkable personal or familial history was found, by palpation to have a mass about 5 cm in diameter with tenderness in the lower left abdomen. Ultrasonography (US) and computed tomography (CT) of the abdomen showed a Target sign and obstruction of the smallbowel. We conducted surginal exploration under a diagnosis of small intestinal intussusception, finding a polypoid mass 3 cm in diameter 90 cm orally from the terminal ileum. Histopathological examination showed heterotopic Heinrich type III pancreatic tissue. Heterotopic pancreas occurs near the pancreas in organs such asthe stomach, duodenum, and jejunum, but rarely arises in the ileum. Heterotopic pancreas of the ileum israrely found until it has caused intussusception. It then occurs most commonly in the lower ileum from theterminal ileum to 100cm.

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Intestinal perforation due to amyloidosis is rare and its prognosis is very poor. We report survival through emergently surgery for a small bowel perforation due to secondary amyloidosis. A 79-year-old woman with a history of chronic rheumatoid arthritis (RA) since age 40, underwent emergency surgery for panperitonitis due to intestinal preforation. Laparotomy showed a perforation 3 mm in diameter at the ileum 1 m from the ileocecal region. We resected about 80 cm segment of the ileum including the perforation, which was abnormally colored and thewall thickened. Mucosa of the resected ileum had multiple ulcers of different sizes. Histopathologicial examination showed amyloid deposits in the submucosal vascular wall. Immunohistochemical staining of amyloid showed amyloid A protein. Amyloidosis in this patient may have been secondary to RA. She left parenteral nutrition after 3 months and her recovery in the last year has been uneventful.

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A 60-year-old woman diagnosed in August 1998 with cancer of the ascending colon underwent right hemicolectomy. Histopathological findings showed well-differentiated adenocarcinoma, mp, ly₂, v₀, n₁, H₀, P₀, stage II. Twenty months postoperatively, metastases were discovered in liver segments S6 and S8, necessitating partial hepatectomy. During ultrasound (US) examination 18 months after the second operation, a 40-mm adrenal tumor found contacting the upper pole of the right kindney rapidly increased in size, was suspected of being metastasis to the right adrenal gland, and was excised. Histopathological examination showed highly differentiated adenocarcinoma similar to the primary focus, and since no other metastases or signs of recurrence were observed, we made a diagnosis of solitary adrenal metastasis. The postoperative course was favorable, and the patient was discharged on postoperative day 14. At present, 6 months postoperatively, the patient is being followed up as an outpatient clinic with no signs of recurrence. Only 19 cases of solitary adrenal gland metastasis colorectal cancer, including our case, have, to our knowledge, been reported in Japan. Since surgical invasion is minor and long-term survival is seen, surgery should be selected as an aggressive and positive treatment.

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A 61-year-old woman with progressive, persistent pain in the right lower abdomen was suspected of panperitonitis causing diverticulitis. Computed tomography (CT) showed oval fat density with a hyperattenuating ring adjacent to the ascending colon. Exploration showed a 6 cm×5 cm epiploic appendage on the ascending colon dark red with swelling because of torsion and adherence to the parietal peritoneum. The lesion was removed. Histopathological examination showed marked appendage congestion, hemorrhage, necrosis, and acute inflammation, leading to a diagnosis of epiploic appendagitis, a rare inflammatory disease. Clinical findigns are often similar to those of acute appendicitis or diverticulitis. CT findigns of oval fat density with a hyperattenuating ring adjacent to the colon are very useful for diagnosing epiploic appendagitis.

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A 60-year-old woman with 15-year sarcoidosis duration presenting with a tumor in the left supraclavicu lar fossa was found in aspiration biopsy to have moderately differenciated adenocaricinoma. Further investi gation showed advanced transverse colon cancer with paraaortic (No.216) and thoracic lymph node swelling. Under diagnosis of advanced transverse colon cancer with metastasis to the paraaortic and Virchow's lymph nodes and bilateral hilar lymphadenopathy (BHL) due to sarcoidosis, we conducted right hemicolectomy with D4 lymphadenectomy and left neck lymph node dissection. The resected lymph nodes at No.222, No.216_a2, and 216b₁showed mixed cancer metastasis and sarcoidosis. The patient remains alive and well without recur rence 3 years and 11 months after surgery with peroral chemotherapy of carmofur (300mg/day).
This good prognosis was due to both right hemicolectomy with D4 lymphadenectomy and left neck lymph node dissection and postoperative chemotherapy.

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We report a rare case of gastrointestinal stromal tumor of the colon. A 35-year-old woman admitted with lower abdominal pain under a diagnosis of peritonitis underwent emergency. Laparotomy showed a large tumor of the sigmoid colon had ruptured, necessitating sigmoidectomy. Histopathological findings showed interlacing fascicles of spindle cells with high cellularity. Immunohistochemically, tumor cells were positive for ckit and CD34 and negative for alpha-smooth muscle actiin and S-100 protein. The pathological diagnosis was malignant gastrointestinal stromal tumor, uncommitted, of the sigmoid colon. The patient is free of tumor reccurence 18 months since surgery.

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We report 2 cases of intersigmoid hernia. Patient 1, a 71-year-old man, referred for abdominal pain, had undergone surgery 16 years earlier for gastric cancer. Eight hours after admission, abdominal distension and tenderness became worse. We diagnosed strangulated ileus and performed emergency surgery. Laparotomy showed an intersigmoid hernia. The strangulated ileum was reversed and the hernia orifice closed with sutures. Patient 2, a 78-year-old man, referred for abdominal pain, was found to have a slightly distended abdomen and mild lower abdominal tenderness. Plain radiography of the abdomen showed a small intestinal gas image and fluid. An ileus tube was inserted and annular stenosis found in the ileum. We diagnosed an ileum tumor or tuberculosis. An intersigmoid hernia was found by surgery. The incarcerated ileum was reversed and the hernia orifice closed.

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We report a case of liver metastasis of colon cancer, in which 3-dimensional images processed by multislice computed tomography (CT) were efficacious in determining suitable hepatectomy. A 63-year-old man referred for evaluation of a liver tumor appearing during follow-up of an initial operation elsewhere for descending colon cancer was found in axial CT images of the liver to have a tumor at the S3 segment of the liver developing to the S4 segment and requiring left lobectomy. Hepatic CT arteriography showed that the left hepatic artery branched from the left gastric artery, which seemed to feed the tumor. Portal CT venography showed that the P3 branch of the portal vein was intact. These results indicated S3 partial hepatectomy preserving the P3 main branch of the portal vein after dissection of the left hepatic artery. Multislice CT scanners are non-invasive and provide large amounts of information and have been introduced into clinical practice. Their usefulness in hepatic surgery is not well demonstrated, although in our case, multislice CT was efficacious in determining suitable hepatectomy for the liver tumor.

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We report a case of c-kit-positive gastrointestinal mesenchymal tumor (GIMT) of the rectum evaluated as a partial response (PR) and in which the quality of life (QOL) was improved by imatinib mesylate (Glivec).This drug is usually used to treat chronic myelocytic leukemia. The patient was a 64-year-old woman. Since the primary tumor was removed by rectal low anterior resection, 5 operations were needed to completely remove the tumors of intraperitoneal recurrence. She was again admitted on January 16 2002, for obstruction of the right urinary tract due to recurrent tumors in the pelvis. After we inserted a double-J catheter into the right urinary tract, imatinib mesylate (Glivec) at a dose of 400mg/day was administered orally for 2 months.The 2 lesions, estimable on computed tomography (CT), reduced to 62% and 70% in size, with no new lesion found. We evaluated it as a PR. Hypogastric pain and low back pain disappeared and both abdominal fullness and constipation improved symptomatically. Treatment by imatinib mesylate is thus useful in gastointestinal mesenchymal tumors in addition to strict GIST, if the c-kit expression is confirmed.

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We report a case of critical illness polyneuropathy (CIP) after surgery. A 49-year-old women diagnosed with diffuse peritonitis due to perforation of rectal cancer suffered from multiple organ failure (MOF) just after surgery, so we undertook hemoabsorption (PMX) and continuous hemodiafiltration (CHDF). Her consciousness improved on 50 postoperative day, and she recovered form MOF. She was weaned from the respirator but with severe flaccid tetraparesis. Neurological examination showed an absence of the deep tendon reflex. Computed tomogaraphy (CT) showed no organic change. Total proteiin of the cerebrospinal fluid was slighthy elevated. Serum Ig-G class antibodies to gangliosides were not detected. Sensory nerve action potential (SNAP) was severely decreased. Her limb strength improved (MMT3/5), but she was not able to swallow or speak 4 months after surgery. We diagnosed her condition as CIP complicated by severe sepsis. CIP is an acute axonal neuropathy that develops duriing treatment of patients with severe ill such as sepsis and SIRS. While there are many papers about CIP in Europe, only a few cases were reported in Japan.

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Lymphagioma originating from the greater omentum is rare in adults and its preoperative diagnosis is rare. We report a case of lymphangioma diagnosed preoperatively by computed tomography (CT), ultrasonography (US), and magnetic resonance imaging (MRI). A 55-year-old man reporting abdominal pain and enlarged abdomen was found in CT to have a solid tumor extending from the area adjacent to the greater curvature of the stomach to the pelvis. US showed the tumor to be multilocular and in MRI to have a cystic lymphangioma pattern. Based on these findings and other test, We diagnosed the tumor as lymphangioma originating from the greater omentum. When the abdomen was incised, we found a thin-membrane-covered tumor occupying the anterior abdominal cavity. After releasing the omental bursa then moving the greater omentum toward the head, the pancreas and gastrocolic ligament were noted and the tumor was confirmed to originate from the greater omentum. The tumor contained transparent, slightly viscous fluid. Pathological examination showed lymph vessel hyperplasia extending to a cyst in the greater omentum without atypical endothelial cells. The diagnosis of lymphangioma was thus comfirmed.

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A 70-year-old woman with appetite loss and vomiting was found in ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) to have a unilocular cystic tumor surrounded by the left liver lobe, stomach, and pancreas. Under a diagnosis of cyst of the lesser omentum or mesenterium, we conducted a laparotomy. The cystic tumor was located in the lesser omentum alone and not connected to other organs. Histopathological diagnosis showed lymphangioma. A lesser omental cyst is relatively rare, and even rarer in the aged.

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A 74-year-old woman with history of abdominal distension and pain was found in abdominal CT to have a slight fluid collection. Laboratory studies showed only high serum CA 15-3 and CA125. Laparotomy showed widespread metastasis to the parietal peritoneum and the greater omentum, but other abdominal organs were normal. Intraoperative pathological findigns diagnosed as a cancer something like ovarian cancer. We conducted omentectomy and CDDP administered intraperitoneally at surgery. Histology of resected tissues showed extra-ovarian peritoneal serous papillary carcinoma.
She underwent adjuvant chemotherapy with intravenous CDDP, with no sign of a peritoneal tumor found at the second-look operation after 8 months, although a few cancer cells were still found histologically in the resected residual omentum. She underwent additional chemotherapy and has shown no recurrence after 24 months of follow-up. It is important to think EPSPC as a differential diagnosis of peritonitis carcinomatosa with indistinct primary tumor.

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We treated a case of Morgagni's hernia symptomatic after laparotmy. A 69-year-old woman with dyspnea and vomitting about a week after gynecologic laparotomy diagnosed with Morgagni's hernia underwent abdominal surgery. The hernia contained the transverse colon and greater omentum. After reducing these organs, its sac was resected and the orifice was closed by direct sutures of the diaphragm. There is no sign of recurrence 7 months after surgery.

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We report a case of laparoscopic ileus surgery approached via a ritht inguinal hernia sac. A 68-years old man reporting nausea and diarrhea was given medication, that did not cured his symptom. He was admtted 2 days later. Abdominal plain film showed air fluid level. We diagnosed ileus, and a prolapsed fat component in the right inguinal hernia sac. The patient was treated conservatory and the air fluid level was improved, but was not completely cured. Surgery was conducted with a diagnosis of right inguinal hernia and small intestine ileus. We cut the right inguinal lesion, and prepared the hernia sac, inserting 12mm and 5mm trocars into the intraperitoneal space via the rithg inguinal hernia sac.
The abdomen was sufflated using carbon dioxide. Laparoscopic findings showed a cord-like omphalomesenteric band between the omentum and abdominal wall. We cut and coagulated the band by electoric monopolar scissors. This laparoscopic ileus operation approached via a right inguinal hernia sac is useful for a patients suffered from inguinal hernia and ileus because it avoids abdominal puncture or incision

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