Background: The function of the lower esophagus sphincter (LES) is closely related to the length of the esophagus exposed to the positive environmental pressure of the abdomen. Anti-reflux function is preserved postoperatively by maintaining the preoperative length of the intraabdominal esophageal segment. Subjects and Method: Proximal gastrectomy was indicated for early gastric cancer and MP caner with NO and gastrointestinal stromal tumor located in the upper third of the stomach. Subjects were 21 patients who had undergone proximal gastrectomy at least one year earlier. Reconstructive procedures were esophagogastrostomy (EG group, n=15) and jejunal pouch interposition in those patient whose remnant stomach was less thantwo-thirds (JPI group, n=6). The preoperative length of the intraabdominal esophageal segment was maintained postoperatively by anchoring the posterior wall of the anastomotic stoma to the median arcuate ligament (MAL) with 3 sutures following proximal gastrectomy. Patient QOL was evaluated by symptoms and changes in body weight. Results: Reflux symptoms were observed in 2 patients (13.3%) in the EG group, but none in the JPI group. In one of 2 patients who had reflux symptoms MAL fixing failed and in another one remnant stomach was less than two-thirds. The postoperative length of the intraabdominal esophageal segment in barium meal studies was from 1.0 to 3.0cm (2.0cm on the average) except for one patient who suffered reflux. Postoperative levels of the anastomotic stoma (circular staple) in contrast to vertebra showed almost no difference from preoperative levels of the esophagogastric junction except for the patient suffering reflux, presumably because MAL fixing failed. Endoscopy was done in 16 patients, who showed no evidence of esophagitis except for the one above exception. No significant difference was seen in pre-and postoperative intra luminal pressure of LES in 5 patients (P=0.4). The post-/preoperative ratio of body weight was 92.0±5% in the EG group and 84.3±7% in the JPI group. Conclusions: This easy, simple procedure preserves postoperative QOL well by preventing complications such as reflux esophagitis. Esophagogastrostomy is indicated for resection of less than one-third of the stomach.

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Purpose: We reviewed the effect of short-term neoadjuvant chemotherapy (s-NAC) in resected primary gastric lesions and metastatic lymph node postoperatively in patients with advanced gastric cancer. Materials and methods: We preoperatively classified 98 patients with advanced gastric cancer into 4 groups, i.e., 5-FU administration alone for 20 (group F), CDDP administration alone for 15 (group C), and both 5-FU and CDDP for 34 (group FC). Nothing was administered to 29 serving as the control group. s-NAC was conducted 3 days preoperatively. We studied apoptosis induction, cell growth in primary lesions and metastatic lymph nodes for each group, and expression of the apoptosis-associated gene on primary lesions. We also studied micrometastasis using an anticytokeratin antibody in lymph nodes. Results: Group FC showed apoptosis and restrained cell growth in primary gastric lesions and metastatic lymph nodes, with changes significantly higher than in other groups. p53 wild type, p21, and Bax expression were observed significantly highly positively in group FC. Significantly increased micrometastasis in lymph nodes was detected in group FC although fewer metastases were recognized in HE staining. Conclusions: s-NAC in advanced gastric cancer reduced lymph node metastasis recognized in HE staining to micrometastasis by extensively inducing apoptosis and depressing cell growth more in group FC than in groups F and C.

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Background: Diagnosis and treatment of acute mesenteric ischemia (AMI) is difficult and often delayed, re-sulting in irreversible bowel injury that easily develops into multiple organ failure involving high mortality. Materials and Methods: We clinically analyzed patients who underwent surgery for AMI. To determine prognostic factors in the disease, we compared clinical factors between a group of 20 survivors and a group of 29 nonsurvivors. Results: Postoperative survival was 41%. Mean age was 70.7 years (male: female: 33: 16). Associated cardiovascular disease was found in 94% of patients, 76% of whom had undergone cardiovascular surgery. Of the 27% were preoperatively diagnosed with AMI confirmed by and abdominal angiography. Where AMI occurred after ischemic heart disease or acute aortic dissection, mortality was higer. Differences were significant in perioperative serum LDH, GPT, Cre, and base excess levels between the groups. Higher mortality was observed among patients with bowel injury to both superior and inferior mesenteric arteries (2 branches) than among those with injury to 1 branch. Although the time from onset to surgery, surgical proce-dures and postoperative Ca-antagonist infusion did not affect prognosis, postoperative heparinization signifi-cantly improved it. Conclusions: In previous illness, liver and renal dysfunction, the extent of vascular disorder in bowel ischemia, and postoperative metabolic acidosis may be candidate predictors for AMI prognosis. Angiography may be useful in early diagnosis, and beginning treatment before the occurrence of multiple or-gan dysfunction is crucial. Complete resection of ischemic lesions and heparinization could prevent postopera-tive continuation and recurrence of mesenteric ischemia, improving AMI prognosis.

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A 55-year-old man admitted for hematemesis and dysphagia had severe anemia, Hb 3.9g/dl. Serum alphafetoprotein (AFP) was extremely high at 47, 800ng/ml. Gastrointestinal endoscopy showed an elevated lesion in the lower esophagus extending to the esophagogastric junction. Computed tomography showed multiple lung metastases. Emergency surgery for uncontrollable bleeding from the tumor in laparotomy and a transhiatus approach, involved distal esophagectomy and reconstruction using a subtotal gastric tube. In histological examination, the tumor was diagnosed as esophageal adenocarcinoma similar to hepatic cell carcinoma. Immunohistochemical study indicated positive AFP. The tumor was AFP-producing adenocarcinoma of the esophagus. After surgery, serum AFP decreased to 1, 900ng/ml. The patient was discharged on postoperative day 10. Despite adjunctive chemotherapy, he developed lung and bone metastases with increasing serum AFP, eventually dying 9 months after surgery. Only 6 such cases have been reported previously in Japan. In addition, we discussed problems on the classification of adeocarcinoma at the esophagogastiric junction.

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We report a rare case of gastric cancer metastatizing from ovarian cancer. A 46-year-old woman with advanced gastric cancer and epigastral discomfort and weight loss underwent subtotal gastrectomy, but a tumor appeared over the lower abdomen during adjuvant chemotherapy. A complete gynecological examination delivered a definitive diagnosis of ovarian cancer. She underwent total abdominal hysterectomy and bilateral salpingooophorectomy. The comparison of ovarian and stomach tissue in postoperative micropathological findings indicated a stomach lesion in submucosa and immunohistological findings for CA125 suggested gastric cancer metastatizing from ovarian cancer.

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An 87-year-old man admitted for lower extremity edema was found to have severe hypoproteinemia (serum total protein: 3.2g/dl, serum albumin: 1.7g/dl) and a giant elevated cauliflower lesion in the stomach. Gas-tric juice included very high protein (1, 180mg/dl), and a ^99mTc-HSA protein-losing test showed the leakage of HSA into the gastric lumen. The patient was diagnosed with protein-losing gastric cancer. Administration of albumin before surgery did not prevent hypoproteinemia. Partial resection reduced the edema and hypoproteinemia. The tumor was diagnosed as early gastric cancer (papillary adenocarcinoma, sm). Surgery resulted in curability B, and no recurrence was found during 11 months of postoperative follow-up. Protein-losing gastric cancer is relatively rare, and only about 40 cases have been reported in the Japanese literature, most of which were treated with distal gastrectomy or total gastrectomy. Our case is the first undergoing partial resection of the stomach. Because patients with this disease often suffer preoperative malnutrition and early stage despite its tumor size, surgery should be minimized.

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The prognosis in liver metastasis from AFP-producing gastric carcinoma is generally considered dismal. We report a case of successful chemotherapy for liver metastasis from AFP-producing gastric carcinoma. A 71-year-old woman referred diagnosed with gastric cancer was found in a preoperative biochemical blood examination to have elevated AFP. Under a diagnosis of suspicious AFP-producing gastric carcinoma, distal gastrectomy was conducted on May 11, 1998. Elevated blood AFP decreased to the normal range postoperatively and AFP production in the tumor was confirmed histologically. Five months after surgery, liver metastasis with tumor thrombi in the main portal vein was detected via elevated AFP. Because of tumor thrombi in the main portal vein, neither major hepatic resection nor TAE was indicated. We therefore undertook hepatic arterial injection chemotherapy using FAM (5-FU, ADM, MMC) with additional oral use of UFT. Liver metastasis by 91% during the first 4 months and tumor thrombi in the portal vein had completely disappeared 28 months after the beginning of treatment. All chemotherapy was discontinued 4 years ago, and the woman remains well 6 years after surgery. Liver metastasis remains 1% of the original size, suggesting almost complete remission of AFP-producing cancer.

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A 67-year-old man presenting with erythroderma-associated hepatocellular carcinoma had previously developed pruritic erythrodermic lesions. Examinations showed hepatocellular carcinoma in segment 7, necessitating right hepatic lobectomy. After surgery, the man's erythroderma completely disappeared. In Japan, 63 cases of erythroderma-associated internal solid cancer have been reported. Ours is the second case of erythroderma-associated liver cancer. We discuss the relationship between erythroderma and solid cancer based on a review of the literature.

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A 66-year-old man admitted for nausea, appetite loss, and general fatigue was found in an upper gastrointestinal series to have obstruction of the fourth portion of the duodenum. Endoscopy could not reach the lesion. Abdominal computed tomography (CT) showed an enhanced mass 3.8cm in diameter in the fourth and third portions of the duodenum. Microscopic examination of the resected specimen showed type 3 cancer in the fourth and third portion of the duodenum 30mm from the anal side of the papilla of Vater. The tumor had penetrated the serous membrane and involved the lymph nodes around the head of the pancreas. In our opinion, pylorus-preserving pancreatoduodenectomy accompanied by lymph node dissection should be considered standard surgery for primary adenocarcinoma of the fourth portion of the duodenum.

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A 69-year-old man preoperatively diagnosed with non invasive intraductal papillary-mucious tumor of the pancreatic head had a common hepatic artery (CHA) and superior mesenteric artery stemming commonly, with hepatomesenteric hepatic arterial blood flow. We conducted pylorus-preserving pancreatoduodenectomy involving resecting of CHA. As the intraoperative total blood flow of the right and the left hepatic arteries measured over 100ml/min after resection of the proper hepatic artery, the blood flow was not reconstructed. No postoperative complications occurred. Pathological diagnosis was non invasive tumor with neither lymph node metastasis nor invasion of the vasculature. Special attention must be given in surgery on the pancreatic head in a patient with a variation of hepatic arterial blood flow. Particularly in a patient with a hepatomesenteric variation, the condition must be evaluated accurately.

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A 73-year-old man undergoing right hemicolectomy for carcinoma of the ascending colon in September 2000 and admitted for acute cholecystitis in October 2003 was found in CT to have a low-density pancreatic tumor 3.6cm in diameter. MRCP showed the main pancreatic duct and common bile duct to be obstructed. Angiography showed encasement and tumor staining of the inferior pancreaticoduodenal artery. A tumor in the pancreatic head show increased uptake of FDG leading to a diagnosis of a metastatic pancreatic tumor and pancreatoduodenectomy. The pathological diagnosis was moderately differentiated adenocarcinoma, compatible with colon cancer metastasis. The postoperative course was good and the patient was discharge 26 days after surgery. Only 12 cases of resection of pancreatic metastasis from colon cancer, including ours, have been reported in Japan. We present this case with a review of the literature.

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We report a rare case of a lymphoepithelial cyst (LEC) of the pancreas associated with pancreatic carcinoma. A 58-year-old man reporting abdominal pain and found to have a cystic mass in the pancreatic tail, and high serum CA19-9 was found in computer tomography and angiography to have a possible cystic neoplasm of the pancreas, possibly a cystoadenocarcinoma. Subsequent distal pancreatectomy diagnosed the mass as LEC. One year later, his serum CA19-9 again was elevated, and a solid cystic lesion was found in the residual pan-creas. Endoscopic fine-needle aspiration biopsy showed cancer in the residual pancreas, necessitating total pancreatectomy. LEC is a rare benign cyst of the pancreas lined by squamous epithelium and uncertain of pathogenesis. To our knowledge, this is the first report of LEC of the pancreas associated with pancreatic can-cer.

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A 60-year-old woman referred for examination of a retroperitoneal tumor was found in contrast-enhanced CT to have an enhanced, relatively demarcated mass with a small cyst in the retroperitoneal space. F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed high accumulation in the tumor. Neuronspecific enolase was 36.0ng/ml, the normal range being less than 10.0ng/ml, necessitating surgery for suspected retroperitoneal malignancy. The resected 77×24mm tumor proved histopathologically to be hyalinevascular Castleman's disease. The postoperative course was uneventful and she has shown no signs of recurrence. Castleman's disease is a relatively rare disorder characterized by the benign proliferation of lymphoid tissue. It is difficult to differentiate malignant retroperitoneal tumor and Castleman's disease because both are positive in FDG-PET.

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Recent advanced diagnostic imaging has increasingly detected portal venous gas in clinical practice, and the number of reports on this subject has increased. Portal venous gas has been considered to be indicative of poor prognosis and to have a mortality of 75%, although many case studies have reported successful treatment and survival. In addition, some reports have warned against immediate abdominal surgery without initial consideration of the reasons for portal venous gas. Here, we report a patient with portal venous gas whom we were able to treat conservatively. Three years after treatment, the patient was diagnosed with Behcet's disease, which was potentially related to the portal venous gas event.

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We report a case of ulcerative colitis with massive bleeding from the residual rectum after subtotal colectomy. A 51-year-old woman diagnosed with ulcerative colitis 4 years ago but well controlled since was seen for recurrence accompanied by rectal bleeding, diarrhea, abdominal pain, and tenesmus. When treatment with 30 mg of predonisolone per day was not effective, she was admitted and was placed on an intensive intravenous regimen of predonisolone at a dosage of 50mg per day. Gastrographine enema showed deep ulcers in the sigmoid colon and rectum. Ten days following therapy, her symptoms did not disappear, necessitating subtotal colectomy with ileostomy and suprapubic mucous fistula. On postoperative day 6, she bled massively from the residual rectum and suffered hypovolemic shock, necessitating emergency proctocolectomy with ileal pouch anal canal anastomosis and covering ileostomy was performed. The stetted rectum showed deep ulcers with much coagulation. Total proctocolectomy with ileal pouch anal canal anastomosis and ileostomy may thus be recommended in patients with continuous bleeding from deep rectal ulcers.

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We report a rare case of panperitonitis due to pyometral perforation due to rectal cancer invading the uterus. An 88-year-old woman with a high fever and appetite loss was diagnosed with panperitonitis due to appendix perforation, demonstrated by palpation, which showed diffuse muscle guarding, and abdominal computed to-mography (CT), which showed an abscess around the appendix. Emergency surgery showed perforation of the uterine fundus, which had been invaded by rectal cancer involving the left ovary, necessitating resection of the rectum, uterus, and left ovary. Pathologically, rectal cancer had metastasized to the uterus, where contamination uterine cavity contributed to pyometral perforation when progressing rectal cancer obstructed the uterus. The possibility of pyometral perforation should thus be considered in elderly women diagnosed with generalized peritonitis. The peritoneal cavity must also be thoroughly examined to rule out the rare inva-sion of malignant cancer.

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