Background: We evaluated the condition of postoperative gastroesophageal reflux disease (GERD) after distal gastrectomy. Subjects and Method: We investigated the questionnaires about reflux for 109patients who underwent distal gastrectomy for gastric cancer. On the basis this, we examined the pre-and postoperative His angle, the length of the residual stomach's lesser curvature, sex, lymphnodal dissection and connection with reflux symptoms. In 26cases, the severity of esophageal biliary reflux was determined with Bilitec2000 postoperatively. Based on these findings, the presence or absence of reflux esophagitis and above factors and severity of biliary reflux were examined. Results: A questionnaire showed reflux symptoms (reflux group) in 23 (21%). Among etiological factors positive for reflux, postoperative His angles were 92.6±32.2° in the reflux group and 74.7±26.5° in the non-reflux group. In the reflux group, the angle increased (p=0.007). We studied the length of the residual stomach's lesser curvature (N cm).Reflux was observed in 9 (41%) of 22 patients with an N of 5 or less, (p=0.026). The incidences of reflux in men was 15.5% and women 31.6%. We measured the frequency of bile regurgitation in 26 patients using a Bilitec 2000 (Synectics Medical AB, Stockholm, Sweden) device. In 20 patients in whom the frequency of bile regurgitation was 5% or more, the His angle was 90.6±21.5°. In 6 with regurgitation of less than 5%, the His angle was 74.5±14.2°. In the group with bile regurgitation, the His angle increased. Conculusions: Based on these results, we concluded that morphological changes in the cardia, demonstrated by enlargement of the His angle, residual stomach size, and gender are important in determining the onset of GERD after distal gastrectomy.

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A 56-year-old woman with dysphagia and chest pain was diagnosed in esophagography and manometry as having esophageal achalasia and was treated by pneumatic dilation. Because the first attempt was insufficient, another attempt was made 4 days later. Esophagography following dilation revealed leakage of the contrast medium from the left wall of the lower esophagus, necessitating esophageal perforation repair the next day. Perforation of esophageal wall was confirmed and sutured primarily because the esophageal wall and mediastinum were slightly polluted. The postoperative course was uneventful and the patient has remained well on a regular diet in the 4 years since surgery.

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A 54-year-old man suffering upper abdomen trauma after being hit by lumber was found after admission to evidence abdominal muscular defense and tenderness. Abdominal computed tomography showed fluid collection around the stomach and discontinuity of the antrum, indicating gastric rupture. Laparotomy showed that the stomach had been completely transected at the antrum. The duodenum was ruptured at the posterior wall of the descending portion. We conducted distal gastrectomy and reconstruction by the Billroth II procedure. The laceration of the duodenal wall was closed directly. We assume that shearing stress between the lumber and vertebra caused the complete transection of antrum.

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We diagnosed a patient who experienced lumbago after total gastrectomy for advanced gastric carcinoma as having bone metastasis of gastric carcinoma, but the diagnosis resulted in osteomalacia. Bone metastasis is diagnosed based on hot spots in bone scintigraphy, low intensity of T1-weighted images and high intensity of T2-weighted images on bone by MRI, the increase of serum alkaline phosphatase, etc. Osteomalacia is linked hot spots in the cost-chondral junction of bone scintigraphy and hypocalcemia. MRI cannot differentiate between bone metastasis and osteomalacia. Osteomalacia after gastrectomy is prevented by sun-bathing, exercise, consuming dairy products, and serum calcium monitoring. In hypocalcemia, it is necessary to take calcium and vitamin D. Because bone metastasis and osteomalacia cannot be differentiated, it is necessary to prevent and treat osteomalacia after gastrectomy.

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A 60-year-old man undergoing Nissen's fundoplication 3 years earlier and admitted for abdominal pain and fullness was found in radiography to have severe stomach distension. He reported severe abdominal pain just after the first examination. The second examination showed free air, leading to a diagnosis of stomach rupture. Laparotomy showed digested food and flammable gas in the peritoneal cavity and a 5-cm longitudinal tear at the lesser curvature of the stomach, necessitating peritoneal drainage and total gastrectomy. Histological examination showed neither peptic ulcer nor cancer. We surmised that stagnant digested food fermented and generated gas swelling the stomach. The antireflex mechanism of fundoplication prevented gas from escaping, however, inducing the rupture.

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A 72-year-old woman seen for severe back pain and epigastralgia found in computed tomography (CT) to have a slight high-density area in the gallbladder (GB), suggesting GB hemorrhage. She was treated for essential thrombocythemia (ET) for 3 years at another hospital. Abdominal ultrasonography (US) and magnetic resonance imaging (MRI) showed hemobilia and GB wall irregular and thickening. Gastrointestinal fiberscopy showed fresh hemobilia from the papilla of Vater. Based on a preoperative diagnosis of GB hemorrhage and cholecystitis with bile duct occlusion, we conducted emergent surgery due to rapidly deteriorating. Cholecystectomy, microwave coagulation therapy (MCT) of the liver bed, D1 lymph node dissection, and bile duct irrigation were done to relieve hemorrhagic symptoms. Operative cholangiography showed the intrahepatic bile ducts and common bile duct clearly. Resected specimens showed a Borrman II tumor with a clot in the GB fundus. The patient's course remains uneventful after 5 months of follow-up.

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We treated an extremely rare case of gallbladder cancer with duplication choledochus and anomalous junction of the pancreaticobiliary duct. A 75-year-old woman was admitted to the Department of Surgery at Minoo City Hospital for evaluation of a gallbladder tumor and radical surgery of the biliary tract. Subsequent examination including abdominal computed tomography (CT) indicated the tumor may be cancerous, so we conducted extended cholecystectomy and lymphadenectomy of the hepatoduodenal ligament. Intraoperative cholangiography showed the patient had an inverted Y-shaped double choledochus and anomalous junction of the pancreaticobiliary duct. Intraoperative frozen section diagnosis suggested the cystic duct was involved adenocarcinoma.
Additional surgery to resect the choledochus and reconstruct the biliary tract were then done. Unfortunately the patient contracted severe postoperative colitis due to mechicillin-resistant staphylococcus aureus, which developed into acute renal failure and gastrointestinal hemorrhage, with the woman dying on 30 postoperative day due to multiple organ failure.
Permanent section histology of the cystic duct showed moderate mucosal atypia but no invasion or occurrence of adenocarcinoma. The gallbladder contained I polypoid and multiple adenocarcinoma foci induced by chronic chemical irritation of bile mixed with pancreatic juice. These anomalies appeared due to maldevelopment of the hepatic antrum in the hepatic diverticle and dorsal pancreas in the early fetal stage, but no embryological conclusion could be made about these anomalies.

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A 62-year-old woman referred with high fever and right hypochondriac pain in March 1995 was found in abdominal ultrasonography to have a large mass 10 cm in diameter occupying the body and the fundus of the gallbladder, suggesting gall bladder carcinoma, plus 3 stones 1 cm in diameter in the neck of the gallbladder. At surgery, the liver bed next to the gallbladder, 1 cm wide, was grayish white, suggesting hepatic invasion of gallbladder carcinoma. The gallbladder, segments 4a and 5 of the liver, and the common bile duct were resected. Histologically, the 65-mm-diameter tumor was papillary adenocarcinoma, which showed serosal and high-grade angiolymphatic invasion, with lymph node metastasis. The grayish-white liver bed showed highgrade inflammatory change with marked fibrosis but no cancer invasion. A solitary metastatic lesion 8 mm in diameter was detected in the resected liver. To prevent hepatic cancer recurrence, continuous infusion chemotherapy (5-FU) was con conducted postoperatively into the hepatic artery for 20 weeks and the portal vein for 4 weeks via catheters placed at operation. She remains alive without cancer recurrence in the over 7 years since surgery. Incidental resection of liver metastasis plus liver-perfusion chemotherapy seemed to have contributed to long-term survival, despite her high risk for hepatic cancer relapse.

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Pseudoaneurysm rupture is a majior complication in managing patients with pancreatic pseudocysts. We treated a ruptured splenic pseudoaneurysm associated with an alcoholic pseudocyst with transcatheter arterial embolization (TAE) followed by distal pancreatectomy. A 31-year-old man followed up for alcoholic pancrea titis and a subsequent pancreatic pseudocyst over 3 years was found in initial abdominal computed tomog raphy (CT) to have a cystic lesion 5 cm in diameter localized in the pancreatic tail. The CT study was made due to a history of recent abdominal pain. The enhanced tiny lesion was found near the splenic hilus in addition to the previously found pseudocyst, suggesting the development of splenic pseudoaneurysm. CT repeated 3 months later in follow-up showed the ruptured pseudoaneurysm to the pancreatic pseudocyst. TAE using a microcoil was used to avoid rupturing the enlarged pancreatic pseudocyst, a potentially fatal event for the patient. Elective distal pancreatectomy and splenectomy 2 weeks resulted in satisfactory recovery and freedom from disease more than 2 years after surgery.

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A 53-year-old man admitted for abdominal pain had no history of surgery or injury. An abdominal X-ray film showed niveau. Symptoms were not eliminated by conservative therapy using an ileus tube under a diagnosis of intestinal obstruction. At 24 hours after symptom onset, he experienced abdominal rebound tenderness, and was found in abdominal computed tomography to have fluid in the abdominal cavity and a C-shaped fluid-filled small-bowel loop with a twisted mesentery necessitating emergency surgery under a diagnosis of panperitonitis. During surgery, we found incarceration of the small bowel (the small intestine pushed its way from the space between the stomach and pancreas in the omental bursa with the greater omentum into a lesser sac space) and the proximal small bowel was dilated. We reduced the incarcerated ileum manually, and closed the hernia orifice since no circulation obstacle of the affected ileum was seen. The postoperative course was uneventful and the patient was discharged on postoperative day 9. It was difficult to diagnose the cause of intestinal obstruction as due to a slit of gastropancreatic physiologic adhesion, and we emphasize the need for rapid surgical intervention if strangulation or circulatory disturbance of the small intestine is indicated. The occurrence of internal hernia is rare, and we know of no other such case in Japan. Bibliographical comments are presented.

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We report a case of sclerosing encapsulating peritonitis (SEP) improved by surgical treatment. A 55-yearold man had begun hemodialysis in 1996 for chronic renal failure. In March 1997, the therapy was changed to mai ntenance continuous ambulatory peritoneal dialysis due to insufficient blood access via the shunt. Thereafter, the man suffered 9 episodes of peritonitis and was diagnosed with sclerosing peritonitis in November 2001. In July 2002, he was referred to our hospital with ileus. He was diagnosed with SEP, and surgery was conducted in August 2002. Laparotomy showed abdominal organs to be covered with a white fibrous membrane, which was removed followed by total adhesiotomy of the small intestine, freeing it. The man enjoyed a good outcome. Although surgical treatment is considered highly risky and to yield poor results, we suggest that timely surgical treatment with careful management is useful in treating SEP.

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We reported a rare case involving portal and superior mesenteric venous gas. A 81-year-old man with peritonitis underwent emergency surgery for portal, superior mesenteric, and peripheral mesenteric venous gas detected by computed tomography and ultrasonography. Most of the jejunum and ileum and their mesen- teric portions showed postischemic change, and 10 cm of the involved ileum showed transmural necrosis without perforation. Only the transmurally necrotic part of the ileum was resected. Mucosa of the remnant small bowel was black but peristalsis, wall tension, and mesenteric pulsation of the remnant small bowel were maintained, indicating ischemic change was reversible and nonocclusive due to a transient decrease in systemic blood pressure. We surmised a chance existed for the remnant ischemic small bowel to recover by maintaining systemic circulation, and conducted intestinal anastomosis. Although the patient suffered from postoperative pneumonia, he was transferred to another hospital without progression of ischemic changes in the remnant small bowel.

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We report a case of adult Burkitt's lymphoma with ileocecal intussusception. A 67-year-o1d man admitted for multiple colon polyps. He had suffered from intermittent abdominal pain, nausea, vomiting, and anorexia for 1 month. Abdominal ultrasonography showed ileocecal intussusception. Preoperative colonoscopy and barium enema showed that a tumor of Bauhin's valve had caused intussusception. We conducted right hemicolectomy including the intussusception. Histologically, the resected tumor was diagnosed as Burkitt's lymphoma. Serum EBV-VCA IgG was 320 times that of normal. Eleven months after chemotherapy, no evidence exists of Burkitt's lymphoma recurrence. We review 5 Japanese reports of Burkitt's lymphoma associated with adult intussusception and their clinical features.

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We report 2 cases of primary volvulus of the small intestine in elderly patients. The first was a 85-year-old man admitted due to sudden severe abdominal pain. In emergency surgery under the diagnosis of acute abdomen, the ileum was twisted 360°rotated clockwise. We resected of the necrotic bowel and conducted an end-to-end anastomosis. The second patient was a 92-year-old woman with situs inversis totalis admitted because of hypertension and upper abdominal pain. The ileum was twisted 360°rotated clockwise. We resectioned the necrotic bowel and conducted an end-to-end anastomosis. Both patients enjoyed a smooth postoperative course. Reports of primary volvulus of the small intestine are rare in Japan, and care should be taken because this disease develops rapid necrosisi, resulting in high mortality, particularly in those of advanced age.

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A 56 year-old woman who had eaten raw sardines for dinner the previous evening reported epigastric pain and vomiting. She was treated for acute gastroenteritis, but diagnosed with intussusception of the small intestine when abdominal US and CT showed multiple concentric ring sign the next morning. In emergency surgery, we invaginated the jejunum from 25 cm at the portion about 10 cm distant from Treitz's ligament. After reducing the intussusception manually, we resected about 30 cm of the jejunum due to severe edema. Macroscopically, the resected mucosa was reddish and edematous, but histopathological findings showed the body of Anisakis in the submucosal layer to have eosinophilic leukocyte infiltration. Intussusception is relatively rare in adults, so it is important to note that Anisakidosis may potentially to intussusception of the small intestine.

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We report a rare case of appendicitis forming an abdominal wall abscess. A 32-year-old man referred for high fever and a reddish induration in the right lower abdominal wall was found on physical examination to have a fist-sized induration with slight tenderness at the medial right iliac crest, but showed no finding in other parts of the abdomen. Laboratory studies showed inflammation. Ultrasonography and computed tomography showed a spindle-shaped abscess in subcutaneous tissue and an intraabdominal inflammatory tumor. A barium enema did not show vermiform appendix, so we surmised that the abscess had formed due to a perforated appendicitis. On entering the peritoneal cavity, we found the tip of the vermiform appendix surrounded by the omentum was buried in the anterior abdominal wall. We conducted an appendectomy and opened the abscess after closing the abdominal wound. We completely drained the abscess and cleaned it, leaving it open because anaerobic bacterium infection was suspected. Pus cultures were positive for Bacteroides fragilis. The postoperative course was uneventful.

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A 68-year-old man reporting diarrhea and dyspnea on exertion was found barium enema and colonofiberscopy result to have a type 2 carcinoma of the sigmoid colon and fistula formation in the small intestine, necessitating resection of the sigmoid colon and the jejunum including the fistula. A tumor about 6.5 cm in diameter was found in the sigmoid colon and directly involved the jejunum 75 cm distal from Treitz' ligament. No liver metastasis or peritoneal dissemination was seen. The tumor was diagnosed as well-differentiated adenocarcinoma and the pathological staging as IIIa (si). Surgery resulted in curability A, and no recurrence was found during follow-up 18 months postoperatively.
Malignant jejunocolic fistulas due to colon cancer are rare, and only 18, including ours, have been reported in Japan. Our case is also the first of sigmoid colon cancer with jejunocolic fistula. Despite its invasiveness, invasiveness, this disease often involves low malignancy, as indicated by treatment in the 18 reported cases. Once radical surgery for colon cancer involving partial resection of the jejunum and fistula is successful, prognosis improves.

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Since the first report of pelvic exenteration by Brunschwig, the procedure has been accepted as a treatment modality for advanced gynecological malignancies and advanced colorectal malignancies, decreasing postoperative morality according to accumulated experience. Postoperative morbidity appears higher and postoperative hospitalization longer, however, than in other surgery for colorectal malignancies. One reason for this may be persistent perineal sinus due to fragile perineal wound repair and infection of the dead space left by multiorgan resection. We used a gracilis muscle flap to repair the perineal wound in total pelvic exenteration and studied whether the procedure decreased the length of hospitalization. Since March 1994, we conducted 9 pelvic exenterations for advanced or recurrent colorectal cancer. In 5 cases, the perineal wound was closed with a gracilis muscle flap. All 5 such cases were discharged within 30 days postoperatively. The mean postoperative hospital stay of these patients was shorter than that of the other patients whose perineal wound was simply closed with a remnant levator muscle and subcutaneous tissue. Perineal wound closure with a pedicle gracilis muscle flap after pelvic exenteration for advanced or recurrent colorectal cancer might promote earlier hospital discharge.

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