Purpose: The incidence of chemoradiation therapy (CRT) increased in order to improve the surgical resec- tabilty and clinical outcome. It is important to accurately assess the effect of CRT for selecting further treatment and predicting prognosis. We tried to make the new criteria for imaging diagnosis after we reevaluated the discrepancy between clinical and histological effect of CRT. Methods: Subjects were 36 patients with ad- vanced esophageal cancer who underwent esophagectomy with lymphadenectomy after CRT that consisted of 5-fluorouracil plus cisplatin and 40Gy of radiation. The clinical and histological response was firstly evalu- ated based on esophageal disease guidelines for clinical and pathologic studies on carcinoma of the esophagus by the Japanese Society of Clinical response in imaging was reassessed based on the histological response. Re- sults: The number of tumors judged as clinical CR/PR/NC was 0/26/10, and the histological grading 1/2/3 was 17/11/8, respectively. Imaging for Grade 1 tumors showed the existence of viable cancer cells in biopsy specimen. Of 16 patients with such finding, 14 (88%) were histologically judged as Grade 1. Imaging character- istics for grade 3 tumors was more than a 75% reduction in esophagography, and the existence of scar forma- tion by esophagoscopy. All five (100%) patients with these findings were histologically judged as Grade 3. The findings of grade 1 and 3 based on new criteria were independent predictive factors for CRT effect. Conclu- sions: According to new criteria, it was possible to predict the histological effect by the combination of esophagography and endoscopy in more than 80% of patients after CRT. Our new criteria may offer impor- tant information on the selection of further treatment or the prediction of prognosis after CRT in patients with esophageal cancer.

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Introduction: Esophageal cancer is frequently accompanied by other primary cancer, especially head and neck cancer (HNC). We endoscopically diagnosed and treated primary esophageal cancer associated with head and neck cancer. Materials and Methods: From 2000 to October, 2004, we conducted upper gastrointes- tinal (UGI) endoscopy with iodine staining in 150 patients with HNC. Results: Single unstained lesions were seen in 23 cases, including 5 cancers, multiple unstained lesions were seen in 38 cases, including 9 cancers. Of the 14 patients with multiple primary cancer of HNC and esophageal cancer, 13 with early esophageal cancer, 11 patients had stage IV HNC. The sake and Brinkman index in patients with multiple primary cancer did not have a difference in comparison with nonmultiple primary cancer patients significantly. Four with simultane- ous esophageal cancer and HNC were treated for both by chemoradiotherapy (CRT). Among 10 already un- dergoing CRT for HNC, 7 with controlled HNC had operation or endoscopic mucosal resection (EMR) based on treatment planned for esophageal cancer. Conclusions: It is important to diagnose esophageal cancer by UGI endoscopy as early as possible in patients with HNC. To treat esophageal cancer discovered in this screening, therapy depends on treatment timing and HNC progression.

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Aim: We clarified whether the maximal horizontal size of subserosal invasion influences prognosis. Materials and Methods: Of 69 patients with gallbladder cancer who underwent surgical resection between 1975 and 2002, 28 had T2 gallbladder cancer (depth of invasion ss, including hinfα and excluding positive binf). We stud- ied the relationship between pathological factors of resected specimens and prognosis. Results: Subjects were 28 patients- 6 men and 22 women aged 45 to 82 years (mean 67.6 years). Five-year postoperative sur- vival of the 28 was 48%. Presence of lymph node metastasis, positive em, and positive bm were significant fac- tors related to poor prognosis. Patients with INF α showed relatively good prognosis, as did those with subse- rosal invasion less than 10mm in maximal horizontal size, whose prognosis was significant good. Discussion: Results suggested that the factor showing good prognosis was a maximal horizontal size of less than 10mm in- vading the subserosal layer. Preoperative diagnosis of subserosal invasion is reported to be possible to some extent by EUS, so this factor will provide useful preoperative information.

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Introduction: The feasibility of hand-assisted laparoscopic splenectomy (HALS) for splenic tumors including benign or malignant neoplasms and the associated clinical outcome of the patients remain unclear. Method: A total of 10 patients with splenic tumors undergoing HALS were retrospectively analyzed in this study. The intraoperative course, postoperative course, and postoperative recovery were evaluated. Results: Ten pa- tients with splenic tumors consisted of 5 with benign tumors and 5 with malignant tumors. HALS was not con- verted to an open splenectomy in any of the patients. Mean operative time was 170 min (range 100-310 min). Mean estimated blood loss was 105g (range 10-900g). Mean splenic size and splenic weight was 13cm and 478g, respectively. Splenomegaly based on size or weight occurred in 50% of the patients. There were no in- tra-or postoperative complications. Postoperative chemotherapy was given to 4 patients with malignant tu- mors including metastatic carcinomas and malignant lymphomas. All the patients were alive at a mean follow- up of 26 months, ranging from 15 to 43 months after surgery. There was not port site recurrence after sur- gery in our study. Mean time to first flatus, mean time to first walking, mean time to resumption of oral intake, mean length of hospital stay, and mean duration of epidural analgesia were 1.8, 1, 1.5, 10.8 and 3.1 days, respec- tively. The results were equal in terms of intra- and postoperative course to those seen with a standard la- paroscopic splenectomy for 13 patients with idiopathic thrombocytopenic purpura. Conclusion: HALS may be a good indication for malignant tumors as well as benign tumors of the spleen.

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Aim: To clarify the significance of the roles of the pudendal motor and sensory nerves contribute to involun- tary defecation (soiling) in patients following low anterior resection (LAR) for rectal cancer, we studied the motor latency and sensory function of the pudendal nerves. Materials: Subjects were 28 patients 19 men and 9 women aged 47 to 77 years (mean: 65.4 years) divided into groups A [n=14; LAR with soiling] and B [n=15; LAR without soiling], compared to group C [n=29; control subjects, 19 men and 10 women aged 40 to 66 years (mean: age of 56.5 years)]. Methods: 1) Pudendal nerve motor latency was studied by stimu- lation of nerve roots S2-4 by magnetic stimulation (SMS) to determine the time interval between magnetic stimulation and the first muscle contraction of the external anal sphincter. The pudendal nerve terminal mo- tor latency of the right, left, and posterior side of the anal canal were determined. 2) Anal mucosal electric sen- sitivity was measured using an anal mucosal electric sensitivity test (AMES); The anal canal length was di- vided into 3 zones: lower [portion below 1cm from the dentate line (DL)], middle (DL), and upper zone of the anal canal (portion above 1cm from the DL). A small electric current from a constant current genera- tor was passed between the electrodes until the patient felt a sensation often described as tingling or pulsing. Results: 1) SMS: The conduction delay in group A was significantly longer than in groups B (p<0.01) and C (p<0.01). The conduction delay in group B was significantly longer than that in group C (p<0.01). The conduction delay of SMS in patients with soiling was the longest. 2) AMES: In group C, recording at the mid- dle zone showed the best results. Patients in group A showed the worst results in anal mucosal sensation. Sen- sation in group A was significantly duller than in group B at the upper (p<0.05) and middle (p<0.05) zones. Conclusion: These findings suggest that involuntary defecation (soiling) after LAR may be due to the dam- age to both the pudendal motor nerve and sensory nerve.

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Purpose: We studied the usefulness of tumor desmoplastic reaction (DR) as a predictor of lymph node metas-tasis in colorectal cancers with submucosal invasion. Methods: Subjects were 59 patients who underwentsurgical resection of colorectal cancer with submucosal invasion, 9 cases (15.3%) of whom were positive forlymph node metastasis (n). Clinicopathological factors and DR expression, especially DR expression on the tu-mor surface and DR expression in preoperative biopsy specimens were also studieded. DR was identified byimmunohistochemistry, and a result of α-SMA (+) and desmin (-) was defined as DR-positive. Results: DR expression was observed in 50 of 59 cases (84.7%) of colorectal cancers with submucosal invasion, while DR expression on the tumor surface was found in 24 cases (41.4%). In the depth of cancer invasion, DR ex-pression was observed in 8 of 14 (57.1%) sm1 cases compared to 42 of 43 (93.3%) sm2, 3 cases, with a signifi-cantly higher rate in sm2, 3 cases. DR expression on the tumor surface was seen in 16 of 50 (32%) n (-) casescompared to 8 of 9 (88.9%) n (+) cases, with a significantly higher rate in n (+) cases. Among 24 tumorsurface DR-positive cases, preoperative biopsies were conducted in 21, yielding 45 samples. Some 22 of the 45biopsy samples (48.8%) were also found to express DR. Among 9 n (+) cases, 7 underwent preoperative bi-opsies and 6 (85.71%) were DR-positive in biopsy samples. Conclusion: Our results indicated the usefulnessof tumor surface DR expression as a predictor of lymph node metastasis in colorectal cancers with submu-cosal invasion, and suggests the possibility of predicting lymph node metastasis from DR expression in preop-erative biopsy specimens.

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We report two patients who underwent surgical treatment for corrosive stricture of both the hypopharynxand the esophagus. Case 1 was a 47-year-old man with schizophrenia who had drunk 10% KOH-a commonlyavailable cleaning agent. He underwent cervical and mediastininal drainage due to esophageal perforation. Onthe 209th day after swallowing the hydroxide, he underwent resection of the hypopharynx, larynx, and cervicalesophagus followed by an esophageal bypass using the colon. The postoperative course was uneventful. Hewas able to take solid food and was discharged on the 95^th day after the operation. Case 2 was a 58-year-oldwoman with depression who had attempted suicide with KOH and NaOH cleaning fluid. We performed anesophageal bypass using the colon without laryngectomy on the 323^rd day after swallowing the hydroxide.Postoperatively, she could not take food orally due to repeated aspiration. We therefore performed laryngealpull-up on the 181^st postoperative day. Aspiration was still not improved, so she underwent laryngectomy onthe 219^th day after the 1^st operation. Finally, she could take solid food, and was discharged. In choosing the operativeprocedure to treat corrosive stricture of the hypopharynx and the esophagus, especially whether ornot to preserve the larynx, required considerations include the extent of the hypopharyngeal injury, the willand consent of the patient and family, and the patient's background including who takes care of the patient, because such patients frequently have some mental illness.

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Esophageal perforation induced by fish bones is rare and no case of pseudoaneurysm caused by esophagealperforation has been reported to our knowledge. We report a case of delayed pseudoaneurysm of the aortadue to fish bone-induced esophageal perforation. A 71-year-old woman seen locally for a fever reported dyspneaand X-ray showed left pleural effusion after 2 days of follow-up. Despite combinations of broad-spectrumantibiotics and parenteral hyperalimentation, she grew worse. CT showed mediastinal emphysema and pleuraleffusion. Sepsis and empyema due to esophageal perforation necessitated emergency surgery. Removal ofthe fish bone and suction drainage of the thoracic cavity were done. Follow-up with CT on 4POD visualizedpseudoaneurysm of the aorta. Pseudoaneurysm was treated by stent, and the postoperative course was uneventful.She was discharged 60 days after surgery.

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A 66-year-old woman undergoing esophageal resection on September 16, 2003, was pathohistologically diagnosedwith esophageal carcinoma, moderately differentiated squamous cell carcinoma (SCC) pAd n2 M0 stageIII. From July 2004, she suffered nausea and vomiting and abdominal X-ray examination showed a dilatedsmall intestinal loop with air and fluid level (ileus), necessitating that she be admitted on August, 2004. Examinationincluding radiography of the small bowel and abdominal CT suggested stenosis of the ileum, so we conductedsurgery on September, 2004. The tumor-like lesion located on the 70-cm oral side from the ileum waspathohistologically diagnosed as metastasized esophageal carcinoma.

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We report a case of tracheoesophageal rupture following blunt trauma. A 56-year-old man falling directly onhis chest against a steel frame was conscious but his face, neck, and chest were swollen with palpable emphysema.He was immediately intubated nasally for dyspnea, and chest CT showed obvious tracheal rupture andpneumomediastium. Esophagoscopy showed esophageal rupture necessitating immediate surgery via a mediansternotomy. The trachea and esophagus were repaired. The pedicled greater omentum was interposedbetween the trachea and the esophagus to prevent the formation of a tracheoesophageal fistula, effectively ensuringrepair due to relatively low aggressive insult and good operative view.

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A 64-year-old man found in gastroscopy to have a submucosal gastric lesion 2cm in diameter was found in en-hanced computed tomography (CT) to have a cystic tumor in the gastric wall. We conducted tumor resection under laparotomy. Histological findings showed gastric mucosa in the internal mucosa of the cyst, and 2 mu-cosal layers were divided from each other by 2 muscularis mucosa layers. In one part of the internal mucosal layer, adenocarcinoma had arisen, but had not invaded the outer layer, so we diagnosed the man as having early gastric cancer arising in the gastric duplication cyst. Such malignant changes thus should be considered in the diagnosis of cystic gastric lesions.

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We report a case of human chorionic gonadotropin (HCG) producing gastric cancer with metastases to Virchow's lymph node and a paraaortic lymph node. A 65-year-old woman with cervical tumors was found in an excisional biopsy to have cancer metastasis confirmed based on a histological examination of the specimen. Immunological staining showed that the part with the cancer had cells positive for HCG. Gastrointestinal en-doscopy (GIE) and computed tomographic (CT) showed advanced HCG-producing gastric cancer with me-tastases to Virchow's lymph node and a paraaortic lymph node. Under a diagnosis of advanced HCG-producing gastric cancer with the above metastases, we administered TS-1 as neoadjuvant chemotherapy orally for 2 course. Since down staging was observed after the second course, total gastrectomy, splenectomy, and D2 lymphadenectomy were done. Histological findings confirmed the proposed diagnosis. Virchow' s lymph node swelling was observed on postoperative day (POD) 19 and thereafter. Despite repeated chemo-therapy with TS-1, the metastatic lesion in the lymph node enlarged rapidly and she died on POD 102.

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A 53-year-old woman with an unremarkable physical history and reporting sudden abdominal pain was diagnosed with panperitonitis due to a perforated duodenal ulcer. She underwent emergency laparotomy involving closure of the perforated duodenal ulcer with an omental patch, peritoneal lavage, and drainage. Before and during surgery, hypertension and tachycardia continued and diffuse swelling of the thyroid gland was pointed out on postoperative palpation of the neck. Symptoms and signs suggested thyroid crisis, so immediate treatment was started by intravenous injection of thiamazole 90mg/day and iopamidol 1ml/day, and continuous intravenous injection of diltiazem hydorochloride even before being shown blood levels of thyroid hormones. Later, a diagnosis of hyperthyroidism was established by laboratory data. The patient progressed favorably without signs of heart failure or delirium. The antithyroid drug was changed to injection for an internal medicine and a diet started. After blood thyroid hormones normalized, she was discharged on postoperative day 15. Thyroid crisis, which is life-threatening, is induced by surgery so a point that all surgeons should be aware of.

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A 38-year-old man seen for abdominal distension, abdominal pain, and vomiting was found in abdominal US and CT to have a pool of marked ascites and the whole bowel lumped together. These findings suggested strangulation or volvulus of the small intestine. A large amount of serous ascites was seen in the abdominal cavity. The peritoneum was covered by a thick white membrane and the bowel could not be distinguished. Bowel mobility was not visible during surgery. A hard white membrane covered the surface of the entire peritoneum including the cirrhotic liver. The operation finished with abdominal lavage with saline. Operative findings suggested diagnosis of sclerosing encapsulating peritonitis (SEP). Steroid pulse therapy enabled the man to eat on discharge, but he returned that day due to abdominal pain, diagnosed as perforation of the duo-denal bulb. Although we closed the perforated site, we recognized anastomotic failure. He died of sepsis and hepatic failure. SEP is a rare disease characterized macroscopically by a “cocoon-like appearance”, but sometimes reported as a complication of CAPD. To our knowledge, this is scarce report of SEP complicated by liver cirrhosis, which we thought was spontaneous bacterial peritonitis (SBP) complicated by liver cirrhosis. Repeated intra peritoneal chronic infection appeared related to SEP.

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Fibrolamellar hepatocellular carcinoma (FLC) is a specific type hepatocellular carcinoma characterized by specific pathological findings, and is extremely rare in Japan. We report a case of a 23-year-old male Japanese patient with a huge FLC with lymphnode metastasis who remains alive without cancer recurrence in the over 14 years since surgery. During ultrasonography a tumor was seen in the liver of the patient, who was nega-tive for the hepatitis virus (HBV and HCV). Computed tomography (CT) of the abdomen showed a 16cm in diameter tumor in the right lobe of the liver. Dynamic CT and celiac angiography revealed a hypervascular tumor which had a non-enhancing lesion at the center. These findings suggested a central scar. Tc-99m phy-tate scintigraphy showed a large defect in the tumor. Under the preoperative diagnosis of an FLC, a right lobectomy of the liver, hepatic hilar lymphadenectomy, and hepatic arterial cannulation were perfomed. Histo-logical examination demonstrated polygonal eosinophilic cells separated by lamellar collagen.

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A 62-year-old man attended another hospital for abdominal pain, where dilatation of the intrahepatic bile duct in the left hepatic lobe was discovered, in which a tumor was detected. He came to our hospital for further ex-amination in July 2003. Abdominal CT and cholangiography revealed an intrahepatic bile duct tumor of the left lobe, which extended to the confluence of the right and left hepatic ducts. We diagnosed it as an intrahe-patic cholangiocarcinoma of the intraductal growth type, and left lobectomy of the liver was deemed neces-sary for curative resection. Despite the poor indocyanine green clearance test (R₁₅ 37%, K 0.089), the curative resection seemed to be possible because the estimated volume of the future resected liver was small as as-sessed by CT volumetry. We performed left hepatic lobectomy, caudate lobectomy and extrahepatic bile duct resection in August 2003. The patient was discharged on the 23rd postoperative day without any complica-tion. The intrahepatic cholangiocarcinoma in chronic viral liver disease has gained more attention recently, but many of which are of the mass-forming type. There has been no reported case of intrahepatic cholangio-carcinoma of the intraductal growth type in a patient with liver cirrhosis type C.

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A 54-year-old woman admitted for back pain was found in abdominal CT to have a 5cm low-density area at S1 and S7 of the liver. Abdominal MRI showed the tumor to be located mainly in the diaphragm, although part extended into the liver, necessitating right hepatic lobectomy and partial diaphragm resection. Pathologically, the tumor was poorly differentiated adenocarcinoma. Although we considered the tumor to be metastatic, we could not find the primary lesion, resulting in a diagnosis of cholangiocellular carcinoma with extrahepatic growth-a condition very rare in Japan.

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We report a case of a pericecal abscess that was treated endoscopically, followed by surgical resection. A 52-year-old man was admitted to our hospital with complaints of right lower abdominal pain and fever which was lasted for two weeks. Abdominal computed tomography (CT) revealed the presence of an ileocecal mass le-sion, 4cm in diameter, and diverticulosis. The lesion was diagnosed as a pericecal abscess secondary to diver-ticulitis. Although the symptoms improved with the conservative therapy, the ileocecal mass was still present on CT and Barium enema imaging. Colonoscopy showed a tumor-like protrusion with redness at the cecum, and a biopsy was performed resulting in the discharge of whitish pus. After the biopsy, the tumorous mass was reduced, and the lesion appeared to be cured. However, recurrence of inflammation was observed seven months later, and conservative therapy had no effect, so ileocecal resection was undertaken. The resected specimen showed a pericecal abscess due to the diverticulitis. Among eleven cases of pericecal abscess re-ported so far, in which pus discharge was observed endoscopically, there was no case that showed recurrence of inflammation after the endoscopic treatment. This case suggests that careful follow-up is still required tak-ing into consideration the recurrence of inflammation after the therapeutic endoscopic discharge of the absess component.

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We report a case of intestinal malrotation concomitant with intestinal obstruction due to an internal hernia. A 65-year-old woman admitted for right lateroabdominal pain and vomiting and diagnosed with intestinal ob-struction was found in upper GI contrast imaging and abdominal computed tomography to have intestinal malrotation concomitant with idiopathic internal hernia. Laparoscopy showed the hernia orifice to be located in an abnormal intramembranous adhesion between the inferior hepatic border and the peritoneum on the back wall. Incarcerated small intestinal loops were easily repositioned and the orifice was sufficiently ex-panded. The small intestine located on the right side and the large intestine on the left yielded a diagnosis of nonrotation. Laparoscopy proved very useful both in diagnosis and radical cure.

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A 76-year-old man developing solitary splenic metastasis in ascending colon cancer underwent right hemicolectomy in April 1993. In October 2003, serum carcinoembryonic antigen was extremely high and ultrasonography showed a 10cm tumor in the spleen. Abdominal CT showed a low-density mass invading the left kidney and diaphragm, accompanied by lymph node swelling at the posterior left renal vein, necessitating splenectomy with extraction of the left kidney, left adrenal gland, and part of the diaphragm in January 2004. Macroscopically, the tumor was partly grayish white with massive necrosis and had invaded the left kidney, diaphragm, and left adrenal gland. Microscopically, the splenic tumor was diagnosed to be well-to moderatelydifferentiated adenocarcinoma consistent with the primary colonic tumor resected elsewhere 10 years previously. We diagnosed it as solitary splenic metastasis of ascending colon cancer with invasion to adjacent organs. Based upon the present case, a splenic mass detected by ultrasonography and/or CT in a patient with high serum CEA should be considered for metastasis during follow-up after curative resection in primary colorectal cancer.

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A 75-year-old man admitted for sudden abdominal pain following constipation for a week was found to have localized peritonitis in the left lower abdomen. Abdominal computed tomography (CT) showed impressive dilation of the sigmoid colon and the rectum containing massive amounts of stool, but no signs of perforation, suggesting conservative therapy. The next day, massive elevation of inflammatory markers and extrarectal escape of stool were seen on CT. Generalized peritonitis due to colorectal perforation was diagnosed and emergency surgery was conducted, revealing an oval 4.0 centimeter perforation in the right wall of the rectum and intramesenteric stool escape. We conducted Hartmann's operation. Although the patient suffered from multiple organ failure and postoperative wound and intraabdominal infection, he recovered, but prolonged neurological and mental symptoms led to a diagnosis of Binswanger's disease based on clinical findings and brain CT. He was transferred elsewhere on postoperative day 80 because neurological and mental symptoms were fixed. In sudden abdominal pain following persistent constipation in elderly patients with dementia, colorectal stercoral perforation must be considered and, if present, diagnosed early and treated promptly.

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Of 15 patients with residual gastric cancer after gastrectomy due to gastric cancer at The Japanese Red Cross Medical Center, 4 underwent proximal gastrectomy in initial operation. We studied the clinicopathology of residual gastric cancer after proximal gastrectomy of the 4 cases. Results showed that patients with residual cancer after proximal gastrectomy had a 2.8% frequency of occurrence and a 2.9 years mean time between initial operation and residual gastrectomy (11 to 50 months). All cases had a location in a non anastomotic area. All cases were early cancer and 3 were undifferentiated cancer invading the submucosal layer. Only one case showed lymph node metastasis, and all 4 patients survived and showed no sign of recurrence (4 to 125 months). Initial reconstruction was esophagogastrostomy in all cases, so it was easy to observe residual stomach with gastroscope. We also reviewed 24 cases of residual gastric cancer after proximal gastrectomy in the Japanese literature. The average of time between initial operation and residual gastrectomy was 7 years. Patients had a high frequency rate of well differentiated adenocarcinoma and advanced cancer. It is important to detect residual gastric cancer immediately noting the features mentioned above.

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An 81-year-old woman admitted for epigastralgia, and the angiography revealed occulusion of the superior mesenteric artery by thrombus. The operative findings showed massive bowel necrosis. Extensive bowel resection and jejuno-colic anastomosis was performed. The remaining length of the jejunum was 50cm. Postoperatively a major leakage of the anastomosis occurred, so an end-jejunostomy was performed. Patients with a jejunostomy have major problems with undernutrition, dehydration, and sodium depletion due to the large volume of stomal output. During the replacement of the total parenteral nutrition with enteral nutrition, the reduction of the parenteral saline supply or the increase of the enteral nutrition caused hyponatremia and hypochloremia. Using saline for the solution of the elemental diet, we could replace the parenteral nutrition with the enteral nutrition and peroral nutrition without electrolyte depletion. The elemental diet probably promotes dehydration, however, because of its hyperosmolality. Patients such as ours thus still need a parenteral saline supply

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