Purpose: To clarify the significance of pylorus in patients after vagal nerve preserving distal gastrec- tomy with jejunal J pouch interposition, we studied gastric emptying and postoperative quality of life in those with or without pylorus. Materials and methods: We studied emptying time of a semisolid diet (radioisotope method using ^99mTc-tin colloid-labeled rice gruel) and postoperative quality of life in 18 patients [group A: 12 men and 6 women 48-72 years old (average: 60.9 years)] who underwent both vagal nerve and pylorus pre- serving distal gastrectomy with jejunal J pouch interposition (D1+αlymphadenectomy, curability A) and in 18 patients [group B: 10 men and 8 women 34-70 years old (average: 63.1 years)] who underwent vagal nerve preserving distal gastrectomy with jejunal J pouch interposition (D1+αlymphadenectomy, curability A) for early gastric cancer. Controls were 18 vagal nerve and pylorus preserving distal gastrectom patients (D1+αlymphadenectomy, curability A)[group C; 12 men and 6 women 36-75 years old (average 56.7 years)] for early gastric cancer. Results: Early dumping syndrome and reflux esophagitis were less detected in groups A and C than group B. A feeling of gastric fullness after meals was more significant in group B than in groups A and C (p=0.0012, P=0.0007, respectively). Microgastria was significantly detected in group C than groups A and B (p<0.0001, p=0.0023, respectively). The time to 50% residual rate was 65.3±8.7 min- utes in group A, 80.5±16.2 minutes in group B, and 61.9±10.2 minutes in group C. Results showed more de- layed emptying time in group B than in groups A and C (p=0.0005, p<0.0001, respectively). Residual rate in the jejunal J pouch after 120 minutes was 30.1±6.8%in group A, 37.9±5.6%in group B, and 24.5±8.9% in group C. The residual rate after 120 minutes was significantly higher in group B than in groups A and C (p= 0.0020, p<0.0001, respectively). Conclusions: These results showed that pylorus preserving distal gastrec- tomy improved postoperative delayed emptying of a semisolid diet and prevented a feeling of gastric fullness after meals due to retention in the residual stomach.

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Objectives and Methods: Rapid blood flow changes occur in the liver following massive liver resection or in the grafted liver following liver transplantation, under which shear stress change induced by flow change may determine postoperative results. We observed changes in liver tissue structure and liver-specific function, and the extent of apoptosis progression in cultured rat liver tissue to which shear stress was applied, and consequently assessed shear stress effect on liver tissue. Results: Cultured liver tissue exposed to continuous application of moderate shear stress expressed and maintained long-term liver-specific function. Evidence also indicated that destruction of the liver structure was inhibited. Cultured liver tissue not exposed to shear stress or exposed to high shear stress was shown to lose liver-specific function soon after expression. The liver structure was destroyed in early incubation. Apoptosis progression in the cultured liver tissue exposed to continuous application of moderate shear stress was most inhibited compared to tissue not exposed to shear stress or exposed to high shear stress. Conclusion: These results suggested that continuous application of appropriate shear stress has advantages over other types of stress in protecting liver tissue.

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We report successful hemostasis with interventional radiology using an intraportalexpandable metallic stent (EMS) for esophageal variceal bleeding caused by portalvein invasion of a hilar cholangiocarcinoma. A 65-year-old man admitted for tarry stool and anemia had a history of biliary stent placement for unresectable hilar cholangiocarcinoma 1 year earlier. Close examination showed that hematemesis was dueto rupture of esophageal varices formed under portal hypertension caused by portalvein invasion of hilar cholangiocarcinoma. Despite endoscopic injection sclerotherapy, variceal bleeding was not controlled. An EMS was placed with interventionalradiology for hemostasis of the collateral flow. After stent placement, no esophageal varices and bleeding were confirmed but the hepatopetal portal flow in the EMSwas not sufficient. The patient recovered satisfactorily and was discharged. Intraportal EMS placement is considered nonaggessive and effective in treating gastrointestinal bleeding caused by malignant portal obstruction.

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Although formation of a bezoar in the remnant stomach is not a rare complication after gastrectomy, we know of no report of a bezoar in a stomach tube after esophagectomy. Of our 2 cases, was complicated with a hemorrhagic gastric ulcer and the other with cancer of the stomach tube. A 55-year-old man who had undergone esophagectomy for esophageal cancer 6 years early reported epigastralgia and tarry stool in November 2000 and was hospitalized to treat digestive tract bleeding. A bezoar was found in his stomach tube with a gastric ulcer by gastrofiberscopy. The bezoar was removed by snare forceps. A 56-year-old man who had undergone esophagectomy for esophageal cancer 4 years earlier reported discomfort after a meal and a bezoar and stenotic pylorus were detected by barium esophagogastrography in September 1989. Further examination showed cancer of the stomach tube. He was diagnosed with peritonitis carcinomatosa at laparotomy. Bezoars of the stomach tube were accompained by a hemorrhagic gastric ulcer and cancer of the stomach tube in our patients, So it is important to take into consideration possible hidden conditions contributing to the formation of a bezoar in the stomach tube.

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We report a case of a 70-year-old woman with gastric cancer, presenting with extensive lymphangitis car- cinomatosa in the gastric wall, though primary lesion remained in the submucosal layer. A depressed lesion detected in the cardia was found by gastroendoscopy to extend to the lesser curvature of the middle stomach. A series of biopsies showed GroupV, so she was referred to our hospital for treatment. We diagnosed the le- sion as type IIc-early gastric cancer, conducting total gastrectomy. Pathological findings showed no direct in- vasion beyond the submucosal layer, but prominent lymphatic permeation further scattered deeply and ex- tensively into the subserosal layer indicated lymphangitis carcinomatosa. Retrospectively, mucosal folds pre- senting “twisting ” spreading beyond the primary depressed area may have resulted from edematous changes in the gastric wall. We hypothesize that lymphatic congestion due to tumor embolism in the lymph vessels resulted in edematous changes in the gastric wall, may be characteristic of lymphangitis carcinoma- tosa of the gastric wall.

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We report a case of primary leiomyosarcoma of the liver in a 76-year-old, woman. Ultrasonography showed hypoechoic tumor growth over time in hepatic segment VIII. Computed tomoraphy and angiography did not detect the tumor. We conducted percutaneous liver biopsy. In histological study, including immnohistological study, the lesion was found to be leiomyosarcoma. After embolization of the right hepatic artery and right portal vein, we conducted extended right hepatectomy. The tumor consisted of malignant spindle cells in necrotic tissue. Tumor cells were positive for vimentin and alpha-smooth muscle actin in immunohistochemical staining.

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A 78-year-old woman with anorexia was found in an abdominal ultrasonography to have a hypoechoic irregular mass with a right dilated intrahepatic duct in the right lobe. Abdominal CT showed a low-density mass in the right lobe. The peripheral intrahepatic duct of the mass and the right caudate branch were dilated. Another nodular mass attached to the right portal vein was located at low density on CT. Portography via the superior mesentric artery showed slight compression of the right portal vein and obstruction of the right anterior segmental vein. ERCP showed a filling defect suspected as an intraductal tumor thrombus at the hepatic hilus. Right extended hepatectomy and right caudate lobectomy combined with bile duct resection were done under a diagnosis of intrahepatic cholangiocarcinoma. Resected specimens showed a tumor thrombus from the right intrahepatic duct to the extrahepatic duct. Microscopic findings showed moderately differentiated intrahepatic cholangiocarcinoma. The gross appearance of the tumor was mass-forming and intraductalgrowth on macroscopic classification.

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Liver adenomatosis (LA) is a rare disease defined by the presence of multiple hepatic adenomas. Notable complications of LA requiring a surgical resection are intraperitoneal rupture and malignant transformation. However, among several reports of LA, few studies have summarized cases with LA complicated by intraperitoneal rupture. The present casereport showed a patient with LA who underwent an emergency hepatectomy due to spontaneous intraperitoneal rupture, and summarized reported cases of LA with intraperitoneal rupture. A 41-year-old French white female presented with a sudden onset of severe epigastralgia, unconsciousness, and hemodynamic shock. She had been taking an oral contraceptive for the last 5 years. Abdominal images showed intraperitoneal fluid collection, multiple bilobar hepatic nodules, and another ruptured hepatic tumor in the left lateral lobe. An emergency surgery was performed and the diagnosis of LA was proved. The ruptured tumor was resected by a left lateral segmentectomy with an intent of hemostasis, and the patient was cured. A pathological examination confirmed multiple adenomas of the liver. Ten LA cases with intraperitoneal rupture and hemoperitoneum have been reported including the present case. Characteristics of these patients were young generation, slight female preponderance, relation of oral contraceptive use, a risk of rupture in case of a more than 5 cm nodule of LA, and a risk of rupture of a left lobenodule.

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Mucinous cystadenoma of the gallbladder is rare. We report a case with segmental adenomyomatosis, and review two cases in the Japanese literature. A 85-year-old man with a history of cholelithiasis 12 years earlier was admitted for abdominal pain. On admission, he had no fever or jaundice, but had right subcostal tenderness. No mass was palpated. Laboratory data showed elevated billiary system enzyme. Abdominal ultrasonography, computed tomography, magnetic resonance cholangiography, pancreatography showed many stones and wall thickning of the body by a 17×20mm sized mass of multiple small cysts on the gallbladder. He was operated on for cholelithiasis, segmental adenomyomatosis, gallbladder tumor. The gallbladder showed a smooth serosal surface and no lymph node swelling intraoperatively, so we conducted laparoscopic cholecystectomy. The resected specimen was confirmed to be mucinous cystadenoma with adenomyomatosis in microscopically.

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The prognosis of advanced pancreatic cancer is dismal. It is difficult to resect advanced pancreatic cancer invading the superior mesenteric artery (SMA). We report a rare case with local healing of severe advanced pancreatic cancer invading the SMA. Pancreaticoduodenectomy with resection of the portal vein (PV) and SMA was conducted in a 59-year-old woman with jaundice. CEA was 155 ng/ml and CA19-9 13, 900U/ml. Abdominal Computed Tomography (CT) and ultrasonography showed a large mass 5 cm in diameter at the pancreatic head and body invading the PV and SMA. Four-cm PV and 3-cm SMA were resected, and each was reconstructed with an end-to-end anastomosis. Blood loss was 1, 785 ml. The postoperative course involved only slight diarrhea, and she was discharged 40 days after surgery. Both tumor markers decreased markedly postoperatively and she returned to regular activities 4 months postoperatively. She remained free of the disease 4 years, dying 5 years and 4 months postoperatively due to pulmonary and mediastinal metastasis of pancreatic cancer. Autopsy showed that the pancreas-intestine anastomosis, the preserved pancreas and the retroperitoneum surrounding the pancreas were intact with no cancerous lesions in the abdominal cavity.

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We report a case of recurrent acute pancreatitis caused by pedunculated tumor torsion at the duodenal papilla accompanied by abnormal pancreatic duct confluence. A 72 year-old man seeking emergency treatment for abdominal pain was diagnosed with acute pancreatitis. Upper gastrointestinal endoscopy showedpediculated tumor torsion at the duodenal papilla causing pancreatemphraxis and acute pancreatitis. Symptoms were relived when tumor torsion was released with forceps. Pancreatitis recurred due to same mechanism, however necessitating surgery. The duodenum was incised to extripate the tumor. The pathological tissue diagnosis was paraganglioma.

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We report 2 successive cases of mesenteric lymph node abscess formation following enterocolitis and mesenteric lymphadenitis of the ileocecal region which required surgical treatment. Case1 is a 70-year-old woman with chronic pancreatitis and diabetes mellitus who complained of a right lower quadrant pain and a fever. Case2 is a 73-year-old man with liver cirrhosis (HCV infection), diabetes mellitus, and hypertension who complained of a right lower quadrant pain. Both patients were elderly and with predisposing underlying disease. Yersinia enterocolitica (Y. ent) was isolated from pus in both cases. Y. ent occurs most commonly as selflimiting enterocolitis in young children, but may sometimes cause pseudoappendicular ileocecal enterocolitis and mesenteric lymphadenitis in adults. Mesenteric lymphadenitis in general rarely form abscesses. However, Y. ent may cause sepsis and extraintestinal abscesses on rare occasions depending on the virulence of the pathogen and the physical status of the host. Abscesses can form following mesenteric lymphadenitis, and may require surgical intervention. Potent antimicrobial therapy and close follow-up are mandatory.

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Perforations of Meckel's diverticulum commonly present as diffuse peritonitis. We report a patient with a penetration of Meckel's diverticulum who developed severe retroperitonitis. A 69-year-old man was referred to our clinic with a diagnosis of an acute abdomen. The patient had a history of hypertension and diabetes mellitus. On admission, the patient looked pale and unwell. His body temperature was 39.0°C, and his pulse rate was 108 bpm. His systolic arterial blood pressure was 74mmHg. A physical examination upon admission showed a diffuse tenderness throughtout the whole abdomen with rebound tenderness. An abdominal radiograph was normal and showed no free air. A computed tomographic scan of the abdomen, performed after the intravenous administration of a contrast material, showed emphysema in the mesenterium and retroperitoneum. Under a provisional diagnosis of diffuse peritonitis resulting from the perforation of a duodenal ulcer, an emergency operation was performed. A laparotomy revealed a penetration of Meckel's diverticulum to the mesenterium, with severe acute inflammation and retroperitonitis. As the penetration was covered by the mesoileum, the emphysema extended from the mesoileum to the mesocolon and retroperitoneum. Meckel's diverticulum was resected using a linear stapler and sufficient drainage was performed. The pathologic diagnosis of the resected specimen showed mucosal necrosis with severe inflammation around the penetration of Meckel's diverticulum. No aberration of the gastric mucosa or pancreatic mucosa was found. Although the postoperative recovery was complicated by septic shock, respiratory insufficiency, and a transient paralytic bowel obstruction, the patient gradually recovered and was discharged approximately 3 months after surgery. He has been well for 30 months after his discharge.

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A 67-year-old woman reporting abdominal fullness was found in abdominal ultrasonography (US) and computed tomography (CT) to have massive ascites. She was admitted for further examination. Ascites were serobloody and the result of cytology was class V (atypical adenocytes). Serum CA125 was elevated. Abnormal findings were not seen in the gastrointestinal tract, uterus, or ovaries. Surgery was done under a diagnosis of peritoneal carcinomatosis of ovarian cancer, or peritoneal serous papillary carcinoma. We found gross ascites, many disseminated nodules on the peritoneum and mesenterium, and a hard tumor on the omentum. Bilateral ovaries were normal in size and shape. We conducted omentectomy and bilateral salpingooophorectomy. Histological examination showed cancer cells extensively on the surface and inside the omentum, with findings resembling typical ovarian serous carcinoma, but the tumor invaded only the surface of the ovaries. The final diagnosis was peritoneal serous papillary carcinoma. After surgery, she underwent a combination chemotherapy of carboplatin and paclitaxel.

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Bleeding from varices outside the gastroesophageal region with portal hypertension is rare. We report a patient with bleeding from ruptured jejunal varices, confirmed by emergency laparotomy. A 59-year-old man treated for liver cirrhosis and hepatocellular carcinoma was brought in a hospital for shock, and emergency upper and lower gastrointestinal endoscopy showed no hemorrhagic point, so he was transferred to our hospital. Hemorrhagic scintigraphy was showed bleeding in the proximal small bowel, and emergency laparotomy showed jejunal varices near the ligament of Treitz. Endoscopy was done from the stomach and showed active bleeding from the jejunal varices. The jejunal varices were ligated within jejunal wall. The man has remained well in the 20 months since surgery.

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An 81 year-old woman suffering from anemia from May 2002 was diagnosed endoscopically with a huge polypoid cecal cancer tumor in August 2002. At surgery, the cecum was intact and the appendix had invaginated into the cecum. The tumor was preoperatively diagnosed as cecal cancer but proved to be invaginating appendical cancer, necessitating ileocecal resection with lymph node dissection. Histopathological examinations showed well differenciated adenocarcinoma with mucinous carcinoma of the vermiform appendix. We detail this rare case of primary carcinoma of the vermiform appendix invaginating into the cecum together with a discussion of the literature.

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We report a rare case of distal intramural metastasis by rectal cancer. A 63-year-old woman was admitted to a gynecological hospital for irregular genital bleeding. Ba-enema examination and colonoscopy disclosed cancer of the upper rectum. An elevated lesion (1.5cm) at the posterior wall of the fornix vaginae was detectede by vaginoscopy and this was preoperatively diagnosed as multiple rectal cancer. Abdominal computed tomography (CT) and angiography suggested a metastatic liver tumor of left lobe (H1). Posterior pelvic exenteration, left lobectomy of the liver, and cholecystectomy were done. Macroscopically type 2 rectal cancer was found and a polipoid lesion separated 7cm from the main tumor was located in the anus. Histopathologically, the main tumor in the upper rectum (circled) was a moderatelly differentiated adenocarcinoma and a1 n1, while the anal polipoid lesion was intramural metastasis of the rectal cancer. The presence of the tumoral embolism in lymphatic vessels, the growth pattern mostly at the submucosal and muscle layers, and the similarity of structural and cellular heterogenisity showed the polipoid lesion to be intramural metastasis invading the vagina. Furthermore in the DNA analysis, loss of heterozygosity of these tumors was consistent with the histopathological finding. Intramural metastasis (spread) in rectal cancer is rare. This is, to our knowledge, the first report to demonstrate that intramural metastastic tumor is located about 7cm from main tumor and it invades vagina. Rectal cancer with intramural metastasis has a poor prognosis. We should have meticulous care for follow up in this case.

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