We treated 6 patients with remnant stomach cancer after proximal gastrectomy from 1971 to 1997. Remnant stomach cancer after proximat gastrctomy was 5.0% in 120 patiets with proximal gastrectomy. 5 men and 1 woman aged 48 to 75 years old (averege: 65.2). The average term from proximal gastrectomy was 100.5 months (48 to 204), with all patients selecting esophagogastrostomy. Primary lesions involved early gastric cancer in 3 (m, n (-) 1;sm, n (-) 2), advanced gastric cancer in 2 (mp, n2 (+) 1;se, n1 (+) 1) and leiomyoma in 1. Remnant stomach cancer involved early in 4 (m, n (-) 2;sm, n (-) 2), advanced in 2 (se, n2 (+) 1;se, n4 (+) 1). Advanced cases resulted in death due to recurrence, while early cases survived (12 to 138 months). We also reviewed 26 cases of remnant stomach cancer after proximal gastrectomy in the Japanese literature. Primary lesions of early gastric cancer were more early remnant stomach cancer, primary lesions of benign lesion and advanced gastric cancer were more advanced remnant stomach cancer.

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Purpose:We clarified the clinicopathologic features and surgical strategies for early hepatocellular carcinoma (HCC), analyzing resected small HCCs. Methods: Of 82 patients with resected HCC less than 2 cm in diameter in the last 10 years, 20 were defined as early HCC, and the remaining 62 as non early HCC. We compared clinicopathologic features between groups. In early HCC, we also studied postoperative prognostic factors for tumor-free survival (TFS). Results:No significance was seen in preoperative liver functional tests and histological findings for the noncancerous hepatic parenchyma. Portal invasion and HBsAg were not detected in early HCC. The average of resected tumor diameter was 1.5 cm in early HCC and 1.7 cm in non early HCC (p<0.1). Multicentric occurrence numbered 5 (82%) in early HCC, and 6 (29%) in non early HCC (p<0.05). Postoperative TFS at 1 year in early HCC was 100% and 57% at 5 years, and 82% at 1 year in non early HCC and 22% at 5 year (p<0.05). NO significance was seen in survival after surgery between groups, and 67% of death was caused by cancer in both groups. In early HCC, 2 variables found to be independent postoperative prognostic factors were higher albuminemia and curative hepatic resection. Conclusions:Early HCC tumors were smaller and multicentric occurrence was more often seen. Portal invasion and HBsAg were not detected in early HCC. Postoperative TFS in early HCC was better, but the course after recurrence was same as in non early HCC. To ensure better survival in early HCC, we suggest curative resection for each nodular lesions.

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Background:The number of metastatic lymph nodes is considered an important prognostic factor in colorectal cancer in Europe and North America. Methods:We studied prognostic factors in 144 patients with Dukes C colon cancer undergoing curative surgery. Results:No significant differences was seen in survival due to the histological depth of tumor invasion and lymphatic or venous invasion. No significant differences was seen in 5-year survival between patients with n1 metastasis (n=94, 72.2%) and n2+n3 metastasis (n=45+5, 66.2%) based on the Japanese Classification of Colorectal Carcinoma (JCCC). Five-year survival in patients with 2 or fewer metastatic lymph nodes (n=86, 80.7%) was statistically higher than that in those with 3 or more metastatic lymph nodes (n=58, 52.8%) (p=0.011). Five-year survival in those with 3 or fewer metastatic nodes (n=104, 78.3%) was also statistically higher than that in those with 4 or more metastatic nodes (n=40, 46.7%) (p=0.022), as is the TNM Classification. Discussion:The number of metastatic lymph nodes, i.e., -2 vs 3-or-3 vs 4-, is a prognostic factor in patients with Dukes C colon cancer. The metastatic lymph node number is thus to be included in the JCCC.

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We report a rare case of coexisting hepatocellular carcinoma and aldosterone-producing adrenal gland adenoma. 64-year-old man admitted for acute myocardial infarction and angina pectoris was shown by laboratory data to have hypernatremia, hypokalemia, liver dysfunction, positive hepatitis C virus antibody and elevated PIVKA-II. Hormonal examination, standing shoulder and tolerance of angiotensin-converting enzyme inhibitor showed no responsive hyporeninemia or hyperaldosteronemia. Abdominal computed tomography showed an enhanced liver tumor in S8 and a left adrenal gland tumor. Abdominal angiography showed a tumor stain in S8 of the liver, and adrenal gland scintigraphy showed a hot tumor in the left adrenal gland. He was diagnosed with hepatocellular carcinoma with liver cirrhosis and aldosterone-producing adrenal gland adenoma. During medication for acute myocardial infarction and angina pectoris, we conducted transarterial embolization for hepatocellular carcinoma and drug control for Conn's syndrome. After heart function stabilized, he underwent hepatectomy of the anterior segment and left adrenalectomy. Resected specimens showed hepatocellular carcinoma and left adrenal gland adenoma. Liver cirrhosis was also recognized. It is important to think region of the adrenal gland caused by secondary aldosteronisms in hepatocellular carcinoma with liver cirrhosis.

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We report a case of hepatocellular carcinoma (HCC) with tumor emboli in the inferior vena cava (IVC). A 51-year-old man suffering from HCC due to HBV cirrhosis since 3 years previously and undergoing TAE and percutaneous ethanol injection (PEI) several times was referred to our hospital for surgery for recurrent HCC. Abdominal CT in July 2000 showed a 3 cm tumor in segment 7 that extended to the IVC through the middle right hepatic vein (MRHV). The tumor continuously formed 4.0 cm emboli in the IVC in August 2000. Right hepatic lobectomy and tumor emboli removal were conducted by total hepatic vasculr exclusion (THVE). His postoperative course was uneventful and he was discharged on postoperative day 24. THVE is useful in HCC embolectomy, which extended to the IVC, provides a survival benefit for patients. We recommend the operation for HCC with tumor emboli into the IVC because of the improved quality of life (QOL).

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Our long survival case is aggressive neoplasm, despite the histological diagnosis as carcinoid of the gallbladder. Case: A 61-year-old woman with right upper quadrant pain was found in ultrasonography (US) and computed tomography (CT) to have a tumor surrounding the gallbladder. Under a preoperative diagnosis of gallbladder adenocarcinoma, we conduced right liver lobectomy of the liver. Microscopically, the tumor showed a carcinoid tumor consisting of nests of small oval cells with round to oval nuclei. Tumor cells were positive for Grimelius'stain. Immunohistochemically, these cells were positive for chromoganinA. Although hepatic metastasis, right renal metastasis, abdominal paraaortic lymph node metastasis, and right adrenal metastasis were detected after the operation, aggressive therapy led to 81 months (6.5 years) of survival.

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Side-to-side anastomosis between the duodenum and bile duct conducted for choledocholithiasis may expose the biliary tract to reflux and stasis of duodenal contents including micro flora, food materials and activated pancreatic juice. Chronic mechanical and chemical irritation of the bile duct mucosa may thus result in inflammatory and/or dysplastic changes over a decade, which may be precursors of cancer. A 61-year-old man who had undergone choledochoduodenostomy 24 years earlier developed bile duct obstruction. We conducted extrahepatic bile duct resection and choledochojejunostomy to treat the biliary complication following side-to-side choledochoduodenostomy. The resected specimen showed hyperplastic and dysplastic changes in the biliary mucosa supporting the above view. Careful long-term follow-up is thus necessary in patients with side-to-side choledochoduodenostomy.

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A 74-year-old man with nausea and vomiting was found by gastric fiberscopy a pylorus-blocking gallstone. Abdominal computerized tomography (CT) and ultrasonography (US) showed gallstones in the gallbladder and that the border between the stomach and gallbladder was unclear. After making the diagnosis of cholecystogastric fistula, the patient underwent fistelectomy and cholecystectomy. Histopathologically, mucinous adenocarcinoma observed in the neck and body of the gallbladder, and invaded the subserosal layer. Cholecystogastric fistula has been reported to occur in 4% of all internal biliary fistulas, but only a few cases of cholecystogastric fistula with carcinoma in the gallbladder have been reported.

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A 56-year-old man who had undergone right pneumoresection for lung cancer and resection of metastasis to the brain was referred to us for further examination of a pancreas tail tumor. Follow-up CT showed a welldemarcated, growing tumor with a central low-attenuation area in the pancreas tail. ERP showed interrupted occlusion of the main pancreatic duct in the tail and EPR-guided biopsy was conducted from this lesion. Biopsied specimens suggested lung cancer metastasis in immunohistochemical staining, so we conducted distal pancreatectomy. Final histological findings were compatible with lung cancer metastasis. The man has remained well without evidence of recurrence in the 14 months since surgery. Surgical management may thus be an optimal option in treating metastatic pancreatic tumor when secondary tumors are limited to the pancreas with the controlled primary tumor.

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A 58-year-old female examined for liver disfunction was found on ultrasonography (US) and computed tomography (CT) to have a 5-6 cm long solid mass with a well-defined capsule in the body and tail of the pancreas. Magnetic resonance cholangiopancreatography (MRCP) showed no marked change in the main pancreatic duct. Angiography showed partial tumor vascularization with the splenic artery as the feeder. Collateral veins had formed due to oppressive obstruction of the splenic vein. We preoperatively diagnosed her condition as a neurogenic tumor from the retroperitonium or pancreas. During surgery we found a solid tumor with a well-defined capsule in the pancreas, removed by distal pancreatectomy with splenectomy. Microscopic examination showed a benign schwannoma with Antoni A-type cells. Nonepithelial tumors of the pancreas are very rare. Only 14 cases by pancreatic achwannoma including ours are reported previously in the Japanese literature.

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A 54-year-old man admitted for sudden severe left lower abdominal pain had a several-year history of gastric ulcer. We palpated a painful mass in the left lower quadrant of the abdomen. Abdominal ultrasonography (US) showed a low echogenic mass with high echogenic spots. Abdominal radiographic computed tomography (CT) showed a low fat density mass with concentric strands on the thickened anterior wall of the stomach angle. A small amount of ascites was also seen. We diagnosed the case as stomach ulcer perforation with abscess formation. At laparotomy, we found that the right free portion of the greater omentum was twisted and adheded to the stomach angle. We excised the necrotic omentum and the attached portion of the stomach. Pathology showed massive dilation of the vessels, hemorrhage, and infarction without thrombus. The postoperative course was uneventful. Primary torsion of the omentum is rare, but must be considered in differential diagnosis of acute abdomen. Abdominal radiographic CT is extremely useful in preoperative diagnosis.

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We report small intestinal Crohn's disease presenting with acute major rectal bleeding as the first symptom of the disease. A 16-year-old boy was admitted with a history of bloody stools followed by a syncopal episode. After admission, esophagogastroscopy and sigmoidoscopy were conducted with normal results. Superior mesenteric arteriogram revealed the extravasation of dye into the lumen of bowel from ileal branches. After 10 units of blood were transfused, he was taken to surgery on the fourth hospital day. Changes characteristic of Crohn's disease about 80 cm 40 cm proximal to the ileocecal valve were found and removel. Pathologic examination showed a 65-cm serial longitudinal ulceration and 2 small ulcers in the ileum. Microscopic sections showed transmural inflamation and multinucleated giant cells without central caseous necrosis. It is not generally appreciated that life-threatening hemorrhage may complicate Crohn's disease. The boy remained well for 6 years and 7 months without recurrent bleeding or other complications.

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A 51-year-old man admitted with abdominal pain was diagnosed with paralytic ileus and treated conservatively. When symptoms persisted, we conducted a laparotomy and found 40 cm of the anal side from Treitz's ligament of the jejunum irregularly mottled by necrosis and conducted partial jejunectomy. Postoperative angiography showed multiple aneurysms in superior and inferior mesenteric arteries. Screening for collagen disease was negative. Blood circulation was reconstructed 43 days after the first operation. Histological evaluation showed the media of resected aneurysmal wall to be segmentally absent, leading to a diagnosis of segmental arterial mediolysis. In aneurysms of abdominal splanchnic arteries, it is important to consider screening these arteries as broadly as possible due to possible segmental arterial mediolysis and the necessity of blood circulation reconstruction.

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A 54-year-old man seen at another hospital for fecal occult blood was found by colonoscopy to have multiple colon polyps and a submucosal tumor 8 mm in diameter in the terminal ileum. A histological diagnosis of carcinoid was made from a biopsy specimen from the ileal lesion. After admission to our institution, we conducted ileocecal resection. Macroscopic findings for the resected specimen showed a submucosal tumor 8×7 mm in diameter in the terminal ileum. Histological findings showed the carcinoid tumor had deeply invaded the submucosal layer and resulted in a regional lymph node metastasis. Carcinoid tumors of the ileum are rare, with our case having the munimum diameter for lymph node metastasis in Japan. In the West, jejunoileal carcinoid tumors are common and about 20% less than 10mm in diameter involve regional lymph node metastasis. Patients with small ileal carcinoid tumors should thus be suitably treated to allow for the possibility of lymph node metastasis.

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A 19-year-old man with anal bleeding was diagnosed with ulcerative colitis in September 1999, and followed up and treated at another hospital. He was referred to us due to steroid resistance in March 2001. Thrombosis of the right iliac vein and lung was detected by abdominal computed tomography (CT) and lung scintigraphy. An inferior vena cava (IVC) filter was implanted and anticoagulant therapy started the day before surgery in prophylactic therapy for pulmonary thromboembolism. He underwent subtotal colectomy, ileostomy, and rectal mucous fistula. On postoperative day (POD) 8, thrombolytic therapy was restarted due to distal vein thrombus from the IVC. After removal of the IVC filter, warfarin was administered and his postoperative course was uneventful. It is thus important to consider venous thrombosis complications in surgical treatment of inflammatory bowel disease, which requires anticoagulant therapy and prophylactic management.

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Disseminated carcinomatosis of the bone marrow from colon cancer is extremely rare. We describe a case of ascending colon cancer with liver metastasis. A 57-year-old woman admitted for bowel obstruction with abdominal fullness for a month. We were diagnosed with ascending colon cancer with liver metastasis (H1), so we conducted right hemicolectomy to release obstruction. She reported lumbago and femoral pain a week postoperatively. Bone scintigraphy showed extensive accumulation in the spine, pelvis, and femur. Postoperative week 3s she experienced bleeding and increased myelocytes in the peripheral blood. We conducted spinal aspiration and bone marrow biopsy. A microscopic bone marrow section showed diffusely infiltrative metastatic carcinoma. The patient rapidly worsened due to DIC and died on postoperative 53 days due to intracerebral bleeding. Disseminated carcinomatosis of the bone marrow from well differentiated colon cancer is reported for the first time in the Japanese literature.

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A 53-year-old woman admitted with presacral tumor confused initially with ovarian cystoma was diagnosed with von Recklinghausen's disease based on physical findings, and an elastic hard mass was palpable on the posterior wall of the rectum. CT scan and MRI showed a solid cystic tumor 7 cm in diameter in the presacral space. Angiography showed a hypervascular mass fed by the middle and left lateral sacral arteries. We suspected the tumor was a malignant peripheral nerve sheath tumor, and extirpated it. The specimen was a 8×6×5 cm yellowish solid cystic tumor weighing 130g. The histopathological diagnosis was schwannoma. Presacral schwannoma in a patient with von Recklinghausen's disease is quite rare, and has not, to our knowledge, been reported in the literature except for 1 case.

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We report a case of intussusception induced by an indwelling ileus tube inserted to decrease pressure following ileus colon cancer surgery. A 52-year-old woman admitted for abdominal pain and vomiting had an ileus tube inserted due to suspected intestinal obstruction and leftcolectomy conducted for colon cancer. The tip of the ileus tube inserted in the end of the ileum with the balloon released, and the tube removed on postoperative day (POD) 4 after flatus was confirmed. That night, she experienced vomiting and distension and tenderness in the left abdomen. From enterography at tube reinsertion, we diagnosed postoperative intussusception of the jejunum. Operative findings showed 3-cylindrical antegrade intussusception, which we reduced manually, with no tumor, adhesion, twisting, or blood circulation disorder at the site. Since this case was antegrade and extension of the jejunum immediately before ileus tube removal was consistent with the intussusception site, we concluded that intussusception occurred during tube indwelling, base on operative findings and the position of the ileus tube, intussusception occurred when spasmodic constriction of the circular muscle due to peristalsis of the adoral jejunum impacted on the relaxed anal jejunum.

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We report a very rate case of endometrioid adenocarcinoma arising from endometriosis of the rectum. A 56-year-old woman referred for melena was found in colonoscopy and barium enema to have a submucosal tumor with central ulceration in the anterior wall of the middle third of the rectum. Pelvic CT and MRI indicated cystic lymph node metastases in the mesorectum. The tumor was located in the anterior wall of the rectum, fixed to the uterus and ileum. We conducted low anterior resection with additional resection of the uterus, bilateral adnexa and ileum. Histopathological study showed endometrial glands surrounded by stroma adjacent to adenocarcinoma that had metastasized to the lymph nodes, leading to a diagnosis of endometrioid adenocarcinoma arising from endometriosis of the rectum. Multiple cystic liver metastases were detected 5 months later and the patient died 10 months thereafter. Lymph node metastasis is thus a prognostic factor in intestinal endometrioid carcinoma.

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A 71-year-old woman admitted to evaluate a liver tumor was found by ultrasonography to have a homogeneously hyperechoic mass of 7×5 cm in diameter from anterior to median segments. Her history included rectal polyps treated by transanal resection 4 years earlier at an other hospital. The mass appeared as a lowdensity tumor with ring-like enhancement in the early dynamic computed tomography (CT) phase. Angiography showed a homogeneous tumor stain, leading to a diagnosis of liver cell adenoma that we treated with central bisegmentectomy. The histological diagnosis was carcinoid tumor, farther shown by histological findings of the rectal polyp, to be a rectal carcinoid 1.1 cm in diameter with submucosal (sm) invasion. The final diagnosis of this liver tumor was metastasis from a rectal carcinoid. Liver metastasis from a rectal carcinoid less than 2 cm in diameter and limited to the submucosal layer is rare, with only 12 cases, including ours, reported in the Japanese literature.

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A 56-year-old woman with an adrenal tumor reported diarrhea, body weight loss, and facial flush. She was found by abdominal computed tomographic study at a nearby clinic to have hypopotassemia and an adrenal mass near the pancreas tail and was referred to our hospital. On admission, WDHA syndrome was suspected because of watery diarrhea, hypopotassemia, facial flush, and glucose intolerance. Arteriography revealed a hypervascular tumor in the left upper abdomen and selective blood sampling of the left adrenal vein revealed a remarkably high level of catecholamines and vasoactive intestinal polypeptide (VIP), so we diagnosed a VIP-producing pheochromocytoma. The tumor, resected by left adrenalectomy, consisted of VIP-producing ganglioneuroma and pheochromocytoma by histological diagnosis. Symptoms improved dramatically after the surgery.

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We report a case of descending necrotizing mediastinitis treated by“anterior transmediastinal drainage”providing a good operative field view and excellrent drainage. A 56-year-man with a history of uncontrolled diabetes and chronic hepatitis transferred to our center had been diagnosed with phlegmon of the left anterior chest, neck and mediastinum. We conducted emergency cervical open drainage using a bilateral oblique incision to preserve the skin on the median side for tracheostomy and transcervical mediastinal drainage along the left vascular sheath. A tracheostomy tube was inserted obliquely from the right anterior, and anterior transmediastinal drainage conducted by partially resecting the third rib without thoracotomy directly reaching perivena caval space.

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