The author, as the President of the Japanese Society of Gastroenterological Surgery, discusses the process of the foundation of our Society, the number of gastroenterological surgeons required in Japan, the license system for the specialist of gastroenterological surgery, the present status of teaching institutions for the specialist, and the problems and ideals of our Society, particularly in relation to social needs.
Finally, J. F. Kennedy's words remind him of the importance of bringing up “another self” and listening carefully to the internal voice of “another self”, who pursues what we should do at any time and in any situation.

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Objectives and Methods: The most frequent recurrence in patients with gastric cancer is peritoneal metastasis. Since July 1997, we studied CEA in peritoneal washing from 221 patients with primary gastric cancer, 105 stage Ia, 26 stage Ib, 37 stage II, 21 stage IIIa, 14 stage IIIb, and 18 stage IV, and in peritoneal effusion from 21 patients with peritoneal dissemination after gastrectomy for gastric cancer. Our objective was to evaluate the usefulness as a predictor in diagnosing latent peritoneal dissemination, and cytology was conducted on the same samples. Results: (1) In patients with peritoneal effusion (33 cases, 46 samples), the incidence of positive cytology from peritoneal effusion was 61.4% and the positive result for CEA (>100 ng/g protein) in these samples was 91.3% (p<0.001).(2) In 25 patients with peritoneal dissemination, but not ascites, the incidence of positive cytology from peritoneal washing was 35% and positive CEA 68% (p<0.05).(3) In 30 patients with H0 P0 and serosal invasion and lymph node metastasis, whose curability was A or B, the incidence of positive cytology from peritoneal washing was 25% and positive CEA 62% (p<0.01).(4) In 11 patients with H0 P0 se n0, no case had positive cytology and 1 case had positive CEA.(5) In 48 patients with H0 P0 m-ss and lymph node metastasis, the incidence of positive cytology was 2.8% (1) and positive CEA 18.8% (p<0.001).(6) In 125 patients with H0 P0 m-ss n0, the incidence of positive cytology from peritoneal washing was zero and positive CEA 1 (ss n0). In almost all cases, CEA could not be determined because it was lower than the detectable range.(7) No correlation was seen between CEA in peritoneal effusion or washing and in serum.(8) In 35 patients with stage II and 16 with stage IIIa (16 cases), for whom better prognosis, was expected, survival curves for those undergoing curative surgery showed no significant difference between patients with positive and negative CEA from peritoneal washing, but in the positive CEA group, all recurrent patient died for peritoneal dissemination. Conclusion: We found that CEA in peritoneal effusion and washing correlated strongly with peritoneal dissemination and may be useful as a predictor in diagnosing latent peritoneal dissemination.

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Although postpancreatectomic complications have decreased due to improved surgical technique and perioperative care, intraabdominal hemorrhage caused by anastomotic leakage or pancreatic fistula remains a potentially lethal complication. Several types of pancreatectomy have been done in benign pancreatic disease, but with the same complications. Patients and Methods: We analyzed hemorrhage characteristics and postpancreatectomy management. Between January 1996 and December 2000, of 90 patients undergoing pancreatectomy at our hospital, 6 (6.7%) suffered intraabdominal hemorrhages and 2 recurrent hemorrhage. Diseases involving hemorhage were 1 pancreatic cancer, 1 common bile duct cancer, 3 intraductal papillary mucinous tumors, and 1 of pancreatitis. Results: Hemorrhage was more frequent in benign disease than in malignancies, of though not statistically significant (p=0.0555). Surgery involved pancreatoduodenectomy in 2 cases, pylorus-preserving pancreatoduodenectomy in 1, and segmental resection (SR) in 3, so hemorrhage was significantly more frequent in SR than in any other operation (p=0.0367). No significant differences were seen in reconstruction or in anastomosis technique, or between cases with or without leakage among the 90 cases (p=0.0787). Delayed hemorrhage was significantly more frequent in anastomotic leakage (p=0.0462). Hemorrhage was managed by 6 laparotomies in 5 patients and transcatheter arterial embolization in 2 cases, all with favorable outcomes. Conclusion: Hemorrhage after pancreatectomy was significantly more frequent in segmental resection. Although the outocome after hemorrhage in laparotomy patients had not been good, a good outcome is now possible in hemorrhage after pancreatectomy whom hemostasis is induced immediately.

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Background: We assessed the clinical and pathological features of patients with obstructive colorectal carcinoma by age group. Methods: We studied 550 patients with colorectal cancer undergoing colorectal surgery at our hospital, colonic obstruction were seen in 48 (obstructive group); 8 in aged 80 or over, 7 in their 70 s, 15 in their 60s, 18 in aged 40 to 59; 413 of the 550 patients without colonic obstruction (non obstructive group) had cancer that invaded through muscularis propria or further. Results: A significant differences between group were seen in the gender ratio of patients aged 80 or over and in serum CA19-9 in patients aged 40 to 59. In the obstructive group, the rate of emergency surgery, and the rate of curability C were higher than non-obstructive group. Overall survival for the obstructive group was lower with the difference especially great for patients aged 40 to 59. Patients undergoing curability A treatment showed no significant difference in survival from the other groups. Conclusions: Even in obstructive cases, curative cases showed similar survival to non-obstructive cases. It is noteworthy that pre-and/or post-operative multimodal therapy may lead to a better prognosis, especially among younger patients.

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Spontaneous esophageal rupture is rare in old age. We treated such a rupture successfully managed by suturing of the ruptured site and reinforcement by pedicled omental covering. A 75-year-old man seen by local physician reported vomiting, followed by chest pain, dyspnea, and abdominal pain after an episode of drinking. No signs of abnormality were seen in electrocardiography or echocardiography, so he was referred to our hospital with suspected acute abdomen. Upper gastrointestinal scopy showed rupture in the lower esophagus. Under a diagnosis of spontaneous esophageal rupture, we conducted emergency surgery 21 hours after symptom onset. After thoracotomy and laparotomy with an incision of the diaphragm, the esophageal rupture was sutured and the site reinforced with a pedicled omental covering to prevent suture failure. No suture failure or stenosis of the sutured site was seen postoperatively. The man was discharged 23 days after surgery. For spontaneous esophageal rupture, we found the pedicled omental covering procedure useful for reinforcing sutures.

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We report a case of early gastric cancer after pylorus-preserving pancreatoduodenectomy (PpPD). A 72-year-old man underwent UGI and gastrofiberscopy in follow-up after PpPD for pancreatic head cancer (mucinous cystadenocarcinoma) 4 years earlier. In gastrofiberscopy, IIa+IIc lesion was observed in the major curvature of the antrum, occupying 2 cm of the distal side apart from the pancreaticogastrostomy. A diagnosis of gastric cancer was made preoperatively, and distal gastrectomy conducted with B-II reconstruction for preserving the pancreaticogastrostomy. Microscopic examination showed moderately differentiated adenocarcinoma limited to the submucosal layer without lymphatic metastasis. Given increasing PpPD, the preserved stomach should be followed up carefully.

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Accurate preoperative imaging studies for a tumor location in the liver effect on the option in the treatment of hepatocellular carcinoma (HCC) with poor liver function. Two cases of extrahepatically growing HCC as an intrahepatically growing tumor on preoperative imagings are reported. One patient was a 77-year-old woman with a HCC in the segment 4-5 of the liver and laparotomic microwave coagulation therapy was contemplated owing to impaired hepatic function. The other was a 37-year-old man with a HCC in the segment 8. In both cases, preoperative CT scan and ultrasonography revealed intrahepatically growing tumors. On the contrary, operative findings disclosed the extrahepatically growing of the tumor and the tumor was resected safely in both cases. The evaluation of the protruding form of HCC in the preoperative imagings is important in the selection of treatment modalities in patient with impaired hepatic reserve.

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A 64-year-old man was admitted for epigastralgia and jaundice. Viral hepatitis markers were negative. He had previously undergone cholecystectomy for cholecystcholedocholithiasisis 1985. Tumor markers increased AFP of 43ng/ml, CA19-9 of 894U/ml, DUPAN-2 of 470U/ml and PIVKA-2 of 13.14AU/ml. Ultrasonography revealed intrahepatic bile duct dilatation and a high echoic mass at the porta hepatis. Percutaneous transhepatic cholangiography showed filling defects in the bilateral hepatic ducts, common hepatic duct and common bile duct. Computed Tomography (CT) scan showed a slightly enhanced mass at S-4 and a partially enhanced mass in the dilatated common bile duct, leading to a diagnosis of hilar cholangiocarcinoma. We conducted left hepatectomy, left caudate lobectomy, and hepaticojejunostomy. Postoperative pathological studies showed that hepatocellular carcinoma (HCC) at S-4 had infiltrated the bile duct. Resection in the case reports of icteric hepatoma are relative rare. It should be emphasized that positive radical resection may make it possible for the patients to obtain a better prognosis.

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We report a case of malignant hemangiopericytoma (MHP) in a 55-year-old man. Six years after the primary retroperitoneal tumor was excised, multiple metastases occurred in the liver, kidney, urinary bladder, lung, bone, left adrenal gland, cerebellum, and gluteus muscle. Initial liver metastases were limited to the right lobe 3 years after the excision of the primary retroperitoneal tumor, and were surgically resected. Two years later, multiple metastases occurred in both lobes of the liver. Since no indication for surgical resection was seen, we conducted TAE for metastatic tumors in consideration of the hypervascular tumor. Most tumors were almost completely necrotized by TAE. Radiofrequency ablation was used to treat incompletely necrosis. All treated tumors had disappeared on dynamic CT. No new liver metastasis has developed in the 1.8 years since treatment. We suggest here that TAE should be selected first in treating unresectable MHP liver metastasis and that radiofrequency ablation be used in cases where TAE is not sufficiently effective.

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A 76-year-old man admitted due to upper abdominal pain was found in abdominal ultrasonography to have wall thickness and multiple polypoid lesions of the gallbladder. Magnetic resonance cholangiopancreatography showed dilatation of the superior bile duct and multiple small defects of the gallbladder. Percutaneus transhepatic biliary drainage showed dilatation of the cystic duct and a long narrow segment of inferior bile duct. Total amylase concentration of gallbladder bile was 17, 097 IU/l. Anomalous arrangement of the pancreatobiliary duct was determined by endoscopic retrograde cholangiopancreatography. We conducted cholecystectomy and choledochectomy. The resected gallbladder had multiple polypoid lesions on the mucosal surface and histologically confirmed many foamy cells in the lamia propria, leading to a diagnosis of diffuse papillomatous cholesterosis with congenital dilatation of the bile duct associated with anomalous arrangement of the pancreatobiliary duct. This was the ninth case found in Japan of diffuse papillomatous cholesterosis and the third with congenital dilatation of the bile duct associated with anomalous arrangement of the pancreatobiliary duct. Diffuse papillomatous cholesterosis suggests a close relationship with anomalous arrangement of the pancreatobiliary duct and it is important to distinguish this from gallbladder carcinoma.

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We report the case of biloma due to cholecystitis showing unusual feature of imaging. The patient was a 64-year-old man. Two months ago he had right hypochondralgia and fever, and was diagnosed to have acalculous cholecystitis. Although the condition was improved by conservative treatment, the patient visited our hospital for the purpose of identification of the precise etiology. A cystic lesion of 4.5×2.0cm in size, which was adjacent to the neck of gallbladder and showed a clear border with the liver, was observed. Abdominal US revealed a structure of 1.4 cm in diameter with strong peripheral echo and no internal echo in the cystic lesion. Cholangiography showed compression of the cystic duct and a lightly contrasted area from the cystic duct to the cranial side of the neck of gallbladder. Double gallbladder or biloma due to cholecystitis was suspected, so conventional cholecystectomy was performed with excision of the cystic lesion. A cystic mass containing black-brown serous content was observed over the area from the cystic duct to the ventral side of the neck of gallbladder. The wall of the cyst did not have the mucosa and muscular layer of gallbladder and was composed of fibrous tissues. Coarse granular elevation consisting of necrotic tissues was observed inside. Thus, biloma was diagnosed.

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We report a case of tuberculosis of gallbladder associated with gallbladder carcinoma. A 73-year-old man admitted for upper abdominal pain was found on gallbladder ultrasonography to have wall thickening, debris, and a high echoic mass in the neck of the gallbladder. Endoscopic retrograde cholangiography failed to image the gallbladder due to neck occlusion, diagnosed as impacted cholecystolithiasis. We conducted cholecystectomy, and the resected specimen showed carcinoma in the gallbladder neck which confirmed by frozen pathological examination. We then combined extended cholocystectomy with 2-cm wedge resection of the gallbladder bed of the liver and regional lymphadenectomy. Microscopically, moderately differentiated tubular adenocarcinoma had invaded the subserosal layer of the gallbladder wall. We also found a thick fibrous wall surrounding a caseous center, in which acid fast bacilli were found by staining with Ziehl-Neelsen technique. A variable number of Langhans'giant cells and lymphocytes were also found compatible with tuberculosis of the gallbladder.

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We recently encountered rare two cases of primary cystic duct carcinoma. Patient 1 was a 67-year-old man admitted for jaundice. Endoscopic nasal biliary drainage tube contrast enhancement shown a 15-mm filling defect at the junction of the common bile duct and cystic duct, leading to a preoperative diagnosis of cancer of the mid-portion of the bile duct. We conducted cholecystectomy and bile duct resection with 2-group lymphadenectomy and anastomosis of the common hepatic duct to the duodenum. A 1-cm nodular-invasivetype mass was found in the cystic duct, and mucin, part of which reached the common bile duct, was observed in the gallbladder. Histologically, the tumor was well-differentiated ductal adenocarcinoma, with no lymph node metastasis. Patient 2 was a 79-year-old man being followed up for diabetes mellitus and admitted when abdominal CT revealed dilation of the intrahepatic bile ducts, stones in the left and right hepatic ducts, and a mass in the cystic duct. Endoscopy showed a cauliflower-like enlargement of the papilla of Vater area, leading a preoperative diagnosis of a tumor of the papilla of Vater and cystic duct, and left and right intrahepatic ducts stones. We conducted pancreatoduodenectomy with 2-group lymphadenectomy. Stones were extracted from the cut end of the common hepatic duct and a pericutaneous transhepatic cholangio-scopy tube was inserted and externalized. A 3-cm exposed mass and a 2.5-cm papillary invasive mass were observed at the papilla of Vater area and from the cystic duct to part of the mid-portion of the bile duct. Histologically, both were well-differentiated ductal adenocarcinomas. Depth of invasion was ss and od, and cystic duct carcinoma metastasis was observed in group 1 lymph nodes.

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A 77-year-old man with acute onset of lower abdominal pain and generalized peritonitis showed numerous diverticula along the descending and sigmoid colon and ascites in abdominal computed tomography (CT). We diagnosed peritonitis secondary to perforation of the colonic diverticulum and conducted emergency laparotomy. The colon was intact but the small intestine had been perforated by a press-through-package (PTP) still containing a tablet. We removed the PTP and conducted wedge resection to close the perforation. Small intestinal perforation by a PTP is rarely diagnosed because most patients do not realize they have swallowed their medication with the packaging and have no specific complaints or radiologic signs. We conducted an experiment to determine the usefulness of abdominal CT in diagnosing PTP ingestion. We created a sausage-shaped cylinder as a phantom of the intestine, and was inserted an intact PTP, including a tablet in it. The phantom was immersed in a vinyl bag filled with water and CT was conducted. The PTP appeared as a triple-contrasted target lesion, consisting of high, low and slightly lower densities, corresponding to the tablet, air in the dome, and water around the PTP. This unusual sign in the intestine strongly suggests the presence of an ingested PTP and is an indication for surgery when peritonitis is present. Small intestinal perforation following PTP ingestion is relatively rare, and mostly due to carelessness. Improved design to avoid accidental ingestion, particularly in the elderly or impaired, and better training in PTP use should decrease the incidence of this problem.

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An 18-year-old woman was admitted to the hospital with a massive intestinal hemorrhage resulting in shock. The bleeding point was not detected by the fiberscopic examination of the stomach, duodenum and colon. Repeated abdominal angiography did not reveal the intestinal bleeding point, so an exploratory laparotomy was performed. A hard mass 1 cm in a diameter was found at 90cm on the anal side of the jejunum from the Treitz ligament. Partial resection of the jejunum including the hard mass was performed, and her postoperative course was uneventful. She was discharged two weeks after the operation. In the case of massive intestinal hemorrhage, emergent exploratory laparotomy is recommended when angiographic and scintigraphic examinations cannot visualize the bleeding point.

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A 58-year-old woman reporting an abdominal mass was found to have a mass 4 cm in diameter in the middle of the abdomen. We diagnosed the tumor as originating in the mesentery. Laparotomy revealed an ovoid tumor 4.5×4.5×4.5cm solid in the cut surfece in the mesentery of the jejunum. Histologically, it was diagnosed as mesenteric fibromatosis. The woman is alive without recurrence 13 months after resection. Mesenteric fibromatosis is very rare in patients without familial polyposis of the colon (FPC) or those not undergoing previous abdominal surgery. To our knowledge, only 25 cases, including ours, have been reported in the Japanese literature. We discuss isolated mesenteric fibromatosis originating in the mesentery of the jejunum and review the literature.

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We report a case of mesenteric vein thrombosis. A 44-year-old man referred to our hospital for abdominal pain, melena, and fever after deep vein thrombosis was found to have a palpable dilated intestine with localized peritonitis. Colonospopy showed congestive necrosis of the sigmoid colon, necessitating emergency laparotomy. Operative findings showed inferior mesenteric vein thrombosis with congestion from the descending colon to rectosigmoid and congestive necrosis of the sigmoid colon. Resection from the transverse colon to rectosigmoid with colostomy was done. Although the patient was treated with heparin, superior mesenteric vein thrombosis occurred on postoperative day 46. Interventional radiology using urokinase and heparin prevented necrosis of the small intestine but the ischemic jejunal stricture had to be resected. Laboratory examination showed coagulation disorder of the lower level of protein S. This mesenteric vein thrombosis is thought to be based on protein S deficiency.

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A 48-year-old woman reported right lower abdominal pain involving mild tenderness in the right lower quadrant but no rebound tenderness and muscle guarding. Her white blood cell count was within normal limit. Barium enema showed a vermiform appendix partially drawn and wall irregularity in the cecum. Colonofiberscopy showed a reddened protrusion at the ostium of the vermiform appendix. A biopsy specimen from the protrusion showed marked infiltration of inflammatory cells and the presence of a multinucleated giant cell. Surgery was conducted under a diagnosis of granulomatous inflammation of the appendix or appendiceal tumor. Ileocolectomy was done to remove a finger-tip-sized tumor in the radix of the appendix. The resected specimen showed 2 protrusions at the ostium of the vermiform appendix involving a longitudinal 12 mm ulcer. Histologic examination showed transmural inflammation, a fissuring ulcer, and noncaseating epithelioid granuloma, indicating as a rare case of Crohn's desease confined to the appenix. This case could be suspected of appendiceal Crohn's disease by preoperarive examination of the biopsy specimen.

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A 24-year-old woman diagnosed with systemic lupus erythematosis (SLE) 7 years earlier was admitted due to lupus peritonitis associating SLE in August 1999. Despite intensive steroid pulse therapy, her abdominal pain intensified and radiological examination suggested intestinal perforation. An emergency laparotomy showed perforation of the transverse colon, which was partially resected followed by a colostomy was perfomed. Despite intensive treatment, she died of Disseminated intravascular coagulopathy (DIC) on postoperative day 35. Intestinal perforation associating SLE is rare but fatal, requiring strict follow-up and adequate therapy.

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An 81-year-old man reported abdominal pain and fever. Abdominal computed tomography (CT) revealed free air, numerous smoothly rounded gas cysts, and a tumor 5.5cm in diameter containing gas. We diagnosed Intestinal obstruction with imminent ascending colon rupture and conducted emergency laparotomy that revealed extensive cysts in the ileum, left colon, and rectum. We conducted right hemicolectomy. Histological examination of the ascending lesion levealed a mucinous stage II carcinoma (se, ly3, v0, n0, ow (-), aw (-), ew (-), ). Few cases of pneumatosis cystoides intestinalis (PCI) coinciding with colonic cancer have been reported. In our case, PCI was considered to due to intestinal obstruction by colon carcinoma.

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A 69-year-old woman admitted with left upper abdominal pain was found by preoperative abdominal computed tomography to have an 8cm retroperitoneal tumor. Left renal angiography showed that the tumor obstracted the left renal vein and the left kidney was drained by collateral vessels into the hemiazygos vein. We completely resected the tumor and the left renal vein, preserving collateral flow into the hemiazygos vein. Microscopically, spindle-shaped tumor cells were tightly arranged. Immunohistochemistry showed the tumor to be positive for smooth muscle actin and desmin, and negative for S-100 and c-kit. The final pathological diagnosis was retroperitoneal leiomyosarcoma. The patient had no postoperative renal dysfunction, and no evidence of recurrence or metastasis has been seen in the 18 months after surgery.

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