Introduction: Validity of thoracoscopic esophagectomy and lymph node dissection as a radical operation for thoracic esophageal cancer invading the adventitia was retrospectively evaluated by comparing the results with that after esophagectomy through conventional thoracotomy.Materials and Methods: Subjects were 28 esophageal cancer patients with nodal involvement who underwent video-assisted thoracoscopic esophagectomy and lymphadenectomy after meeting indications of no extensive pleural adhesion, no contiguous tumor spread, and pulmonary function capable of sustaining single lung ventilation (VATS group). Controls were 39 esophageal cancer patients who met the same indications and underwent through right thoracotomy before VATS (control group).Results: No difference was seen in the background, duration of thoracic procedure or blood loss between groups. The 5-year survival rate was 53.6% in the VATS and 45.1% and in the control group, not statistically significant. Survival did not differ in the presence of lymph node metastasis between groups.Conclusions: The same radicality as open surgery can be obtained by VATS for patients with thoracic esophageal cancer invading the adventitia.

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Objective: To investigate the indications for lymph node dissection in cases with submucosal invasive colorectal cancer, we examined the clinicopathological factors related to lymph nodemetastasis.Methods: We identified 113 cases of submucosal invasive colorectal cancer receiving D1 or greater extended lymph node dissection. Among these cases, 13 clinicopathological factors were examined in relation to lymph node metastasis.Results: Lymph node metastasis was observed in 14 cases (12.4%). A univariate analysis showed that the vertical depth of the submucosal invasion, the width of submucosal invasion, budding and lymph vessel invasion (ly) were significant associated with lymph node metastasis. A multivariate analysis showed that among these four factors, ly and budding related to lymph node metastasis. Budding and ly also showed a significant correlation.Conclusion: Neither ly nor budding was observed in cases where the tumor invasion was less than 1mm in depth and less than 3mm width. Therefore, these cases can probably be curatively treated by endoscopic resection alone. Furthermore budding appears to be an important predicting factor of ly and lymph node metastasis.

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Background: We assessed the feasibility of early feeding following the resolution of gastric ileus in patients having elective open colonic surgery.Methods: This was a randomized controlled trial of 26 patients who were assigned to 1 of the 2 groups: Group A: patients were not forced to be mobile and allowed a diet following flatus or defecation. Group B: patients encouraged to be mobile postoperatively. A radiopaque marker was given orally on the first postoperative morning and X-ray film was taken daily until more than 70% of markers exited the stomach. Then patients received a diet regardless of flatus or defecation.Results: No significant differences were noted in age, gender, or type of procedures in either group. No patient vomited postoperatively. No significant difference was seen in the incidence of complications. The time to first flatus in group B (median, 48 hours) was significantly shorter than that in group A (median, 67 hours)(p=0.03). No significant difference in nutritional parameters was found in either group. The length of hospitalization in group B (median, 7 days) was significantly shorter than that in group A (median, 10 days)(p=0.02). Conclusion: Early feeding following the resolution of gastric ileus is safe and feasible without vomiting in patients who have elective colonic surgery.

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Carcinoma of esophageal diverticular origin has rarely been reported. We report a case of esophageal carcinoma originating in the upper thoracic esophageal diverticulum, the 30^th such case reported in Japan. A 57-year-old man with appetite and weight loss was found in barium studies to have diverticulum of the upper thoracic esophagus. Endoscopy showed an elevated lesion in the esophageal diverticulum. A biopsy suggested well-differentiated squamous cell carcinoma that had invaded the muscle layer, necessitating total thoracic esophagectomy through a median sternotomy and median laparotomy. The resected specimen consisted of a round elevated 3cm lesion in the upper thoracic esophagus. The pathological diagnosis was well differentiated squamous cell carcinoma, pT3N0M0 stage II. The man was discharged on postoperative day 32. This is the second case, to our knowledge, of carcinoma arising in the upper thoracic esophageal diverticulum.

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This paper presents a case of an advanced gastrointestinal stromal tumor (GIST) that dramatically responded to IMATINIB MESYLATE. A 82-year-old man had general fatigue with severe anemia. Endoscopic findings showed an ulcer on a large submucosal tumor in the stomach. Abdominal CT scan showed a protruding lesion of approximately 9 cm at the lumen of the gastric body, giant metastatic liver tumors and multiple disseminated tumors in the abdominal cavity. Histological findings of the biopsied specimen showed spindle shaped cells in the submucosa. Immunohistologic staining revealed that the spindle cells were positive for c-kit. Treatment with 300-mg of IMATINIB MESYLATE was started on September 24, 2002. The main tumor and all disseminated tumors had all dramatically reduced after 4 weeks of treatment (reduction rate of 90%). Thus, we evaluated the response as PR. Interstitial pneumonia was observed, but it was immediately improved by steroid-pulse-therapy. As of February 2003, tumors at all sites have continued to respond positively to treatment and the patient remains clinically well.

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We report a case of a postoperative recurrence of a gastrointestinal stromal tumor (GIST) of the stomach that responded to the administration of imanitib mesylate. A 77-year-old woman who had been hospitalized because of epigastric discomfort was referred to us for the treatment of a submucosal tumor of the cardia that was detected during a gastroscopy examination. The patient underwent a total gastrectomy and splenectomy on June 11, 2001 after being diagnosed as having a gastrointestinal mesenchymal tumor of the stomach. Histo-pathologically, the tumor was composed of a fascicular proliferation of spindle-shaped cells with marked mito-sis. Immunohistochemically, the tumor cells were positive for c-kit and CD34 but negative for actin and s-100. The tumor was diagnosed as a malignant GIST. She was latter readmitted for nausea. A CT examination showed multiple liver metastasis and subphrenic tumors. Treatment with imanitib mesylate at a dose of 400mg/day for 16 days was initiated on June 25, 2002. This dosage was reduced to 200mg/day on July 12, 2002, be-cause of nausea. A CT scan showed rapid tumor shrinkage and cystic changes after 74 days of treatment, the response has continued to date. All toxicities were mild and tolerable. This case suggests that the administra-tion of imanitib mesylate may be an effective treatment for GIST recurrences.

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Diagnostic imaging techniques such as ultrasound, computed tomography (CT), and magnetic resonance imaging have rapidly progressed. Cone-beam CT provides excellent space by rotating a cone X-ray beam at 360°. We present three clinical cases of gastric lesions by 3 dimensional aerography using cone-beam CT. Pre-operative diagnosis of early gastric cancer (Case 1) was revealed. In advanced gastric cancer (Case 2), the le-sion was clearly observed from the intraperitoneal space. In gastric submucosal tumor (Case 3), tumor shape, size, surface, and site were clearly imaged, enabling a definitive diagnosis. Further study is needed, however, to improve diagnostic quality.

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Gastric cancer forming a tumor thrombus in the portal system is rare and the implications of surgical re-section are controversial. We report 2 such cases here. Case 1: A 58-year-old man suffering left flank pain was found in gastroscopy to have a “type 3” tumor in the lesser curvature from the middle to the lower gas-tric body. During surgery, we found a tumor thrombus from the left gastric vein to the portal vein, and con-ducted total gastrectomy with combined resection of the pancreas body, spleen and partial transverse colon, and removal of the tumor thrombus. He did not report any symptom during the 8 months following surgery, but died due to tumor thrombus recurrence in the portal vein 15 months after surgery. Case 2: A 74-year-old man suffering epigastralgia was found in endoscopic examination to have a “type 2” tumor in the middle gas-tric body. Preoperative ultrasonography, computed tomography, and angiography showed a tumor thrombus in the left portal vein, necessitating total gastrectomy with left hepatic lobectomy. Although the patient re-mained alive without any evidence of recurrence for 21 months, he died for metastasis to the liver 26 months after surgery.
In conclusion, we suggest that gastrectomy with removal of the portal tumor thrombus in gastric cancer is feasible in improving quality of life and prolonging survival.

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We reported a case of gastric adenocarcinoma with metastatic lymph nodes showing adenosquamous cell carcinoma. A 76-year-old woman with an abnormality in gastroscopy and admitted to our hospital was found to have a 0-IIc lesion on the posterior wall of the middle body and biopsy showed adenocarcinoma. We con-ducted total gastrectomy combined with distal pancreatectomy and splenectomy and Roux-en Y reconstruc-tion anastomosis. The pancreatic body was excised for lymph node invasion on the lesser curvature. Macro-scopic findings showed 0-IIc cancer measuring 4.0×2.5 cm on the posterior wall of the middle body and swol-len lymph nodes. Histologically, the lesion was diagnosed as poorly differentiated adenocarcinoma with signet ring cells and invasion limited to the submucosa. Microscopic findings of metastatic lymph nodes showed adenosquamous cell carcinoma-a very rare occurrence supporting the hypothesis that the majority of adenosquamous cell carcionoma probably arises from squamous metaplasia of adenocarcinoma.

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A 72-year-old woman was refered to our clinic for the treatment of a pancreas tumor. Examination of the lesion by angiography and abdominal computed tomography showed a tumor stain in the pancreas and gall-bladder. We diagnosed the lesion as an islet cell tumor of the pancreas head and a tumor of the gallbladder. The patient underwent a pyrolus-preserving pancreatoduodenectomy. The postoperative course was un-eventful. Histological examination of the resected specimens showed clear cell carcinoma, which was the same type as a renal cell carcinoma resected 17 years earlier. The patient has not shown any further signs of recur-rence for two years.

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We present a rare case of perforated jejunal malignant schwannoma associated with von Reckling-hausen's disease. A 39-year-old woman admitted with severe abdominal pain was found in chest radiography to have free air under the diaphragm, and abdominal computed tomography showed a tumor, 12cm in diame-ter, with internal necrosis and air, necessitating emergency surgery based on a diagnosis of panperitonitis caused by perforation tumor. The perforated tumor protruded from the jejunum, necessitating partial resec-tion of the jejunum together with the tumor. A small perforation was found between the resected jejunum and tumor. Histologically, the tumor consisted of spindle cells showing a nuclear palisading and abnormal mi-totic figures. The tumor was immunohistochemically positive for S-100 protein, but negative for actin. In Ja-pan, 12 cases of small intestinal malignant schwannoma associated with von Recklinghausen's disease were reported between 1955 and 2002. Only 2 cases, including ours, involved perforation of the schwannoma and a perforation between the jejunum and schwannoma. The remaining 10 cases did not involve any perforation and 1 case involved perforation of the jejunum. We suggest that perforation of the small intestinal malignant schwannoma was caused by perforation from the small intestine to malignant schwannoma.

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A 49-year-old man, who had previously undergone an appendectomy, was seen at our hospital because of a right lower abdominal pain. A diagnosis of ileus was made based on the results of an abdominal X-ray, and the patient underwent conservative therapy upon admission. A dull pain persisted in the right lower abdo-men, and the ileus symptoms showed repeated remission and relapse. Abdominal ultrasonography and com-puted tomography (CT) examinations revealed target signs in the ascending colon. A barium enema showed a multiple nodular-filling defect. A colonoscopy revealed ileocolic intussusception. A primary tumor was not seen, and the biopsy showed no signs of malignancy. Since the intussusception could not be reduced by colonoscopic restoration, a laparotomy was performed under a diagnosis of ileocolic intussusception. At the time of surgery, an intussusception was not seen but an ileocecal mass the size of a fist was found. A right hemicolectomy was performed. Histological findings of the specimen revealed multiple diverticulitis of the ter-minal ileum. Therefore, we believed that the mass was caused by chronic inflammation of the diverticula and surrounding fibrosis.

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A 22-year-old man was admitted to hospital with a diagnosis of intestinal obstruction. He had suffered a blow to the abdomen during a traffic accident about 3 weeks earlier but had not undergone abdominal sur-gery. Despite conservative treatment, peritoneal irritation developed and an emergency laparotomy was per-formed the following day, revealing purulent ascites. A defect with a diameter of 3 cm was found in the ileal mesentery about one meter from the end of the ileum. The distal ileum, which had not undergone ischemic damage, protruded through this defect, forming an intestinal obstruction. Necrosis and perforation, which had caused a localized abscess, had developed on the exterior surface of the same loop of the ileum as the mesen-teric defect. The affected portion of the ileum was resected, and an end-to-end anastomosis was performed. Mesenteric indurations were scattered elsewhere along the ileum, which was shortened by these lesions. Pa-thologically, fibrosis and inflammatory cell infiltration were found in the affected mesentery. These results in-dicated that posttraumatic ischemic damage to the mesentery, which had gradually progressed because of pressure produced by the expansion of the herniated ileum, had caused the necrosis and perforation. The pa-tient recovered fully and was discharged 18 days after the operation.

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secondary pouchitis that was successfully treated by salvage surgery. A 20-year-old woman with ulcerative colitis developed an acute, severe bloody diarrhea following a proctocolectomy, ileal pouch anal-canal anasto-mosis and diverting ileostomy. She was diagnosed as having secondary pouchitis arising from a peripouch ab-scess, apical bridge or blind loop formation. The remnant rectum and ileal pouch were excised, and a new ileal pouch-anal anastomosis and diverting ileostomy were made. The patient's postoperative course was unevent-ful, and she has shown no further signs of pouchitis. Salvage surgery may be a valuable treatment for treating secondary pouchitis when the pouchitis is caused by surgery-related complications.

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A 41-year-old woman complaining melena and constipation was seen at our hospital. She had been taking an LH-RH analog for the treatment of left ovarian endometriosis since 1996. She consulted a surgeon in April 1998 because of melena and constipation during menstruation. A final diagnosis of rectal endometriosis was made based on colonoscopic findings and biopsy results. An LH-RH analog was prescribed, and her symptoms improved. She experienced constipation once again in July 2002 and developed melena in August 2002. Stenosis of the rectum was confirmed by a complete examination, and surgical treatment was judged to be indicated in this case. We performed a low anterior resection combined with the removal of her uterus and both ovaries; the patient had a good postoperative recovery and was discharged on the 14^th postoperative day. The histological findings showed endometriosis with strong fibrosis in the submucosal layer from the serosa of the rectum. The present case shows the need for continued follow-up since the patient's condition progress and eventually required surgery even though the intestinal endometriosis improved with hormonal therapy. Appropriate treatments should be selected based on the stage of endometriosis progression and the patient's QOL.

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