Purpose: Because severe acute pancreatitis (SAP) is increasing among elderly patients, we clarified SAP characteristics. Methods: We divided 137 patients with SAP into a high age group (32 patients 67 years old or older) and a low age group (105 patients 66 years old or younger) and compared the severity, blood parameters, special therapy, and treatment outcome between groups. We surveyed predictable clinical-course factors on admission in the high age group. Results : The percentage of women and gallstone-associated SAP and severity scores on admission (Ranson, APACHE II, and Japanese scores) were significantly higher in the high age group. For blood biochemical parameters on admission, BUN, creatinine, PaO₂, and CRP differed significantly between the high age group and low age group. Peripheral lymphocyte counts were significantly lower on days 7, 14, and 21 after admission in the high age group. Continuous hemodiafiltration was often required as special therapy in the high age group. The incidence of organ dysfunction and mortality significantly higher in the high age group, and predictable prognosis factors were blood sugar and Ca. Predictable factors of infection were LDH, CRP, and Ca. Predictable factors of organ dysfunction were Ca, white blood cell, IL-6, and base excess. In patients with serum Ca of less than 7.2mg/dl on admission among high age group, mortality and the incidence of organ dysfunction were significantly higher. Conclusions: These results suggest that organ dysfunction is closely related to mortality in elderly patients, and that serum Ca on admission is useful for predicting the clinical course.

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Background: Although surgical resection is the only therapeutic option for curing patients with local recurrence after rectal cancer surgery, the dismal prognosis often fails to justify the degree of adverse events associated with major surgery. To reassess the relevance of surgery, we analyzed the outcome of patients based on the site or extent of local recurrence classified based on preoperative imaging studies. Patients and Methods: Between 1981 and 2002, 84 patients with locally recurrent rectal cancer underwent curative surgery. They were classified into three groups based on the preoperative computed tomography or magnetic resonance imaging: recurrent tumors invading or touching the piriform muscles or internal obturator muscles, or touching the upper sacrum (S1, S2)(group A); recurrent tumors invading or touching the lower sacrum (S3, S4, S5) or the pelvic organs such as the prostate, the uterus, the seminal vesicles or the urinary bladder (group B); and recurrent tumors localized at the anastomosis site (group C). Prognostic data for 19 patients diagnosed during the same period who were found to have extensive tumoral invasion and were not indicated for surgery or failed to undergo resection were used for comparison (nonresection group). Results: Curative resection in all patients was 61.9%. That in group A was 31.8%, in group B 80.6%, and in group C 81.3%. Fiveyear survival following resection was 30.0% in all patients, 5.9% in group A, 32.7% in group B, and 67.0% in group C. The incidence of locoregional failure and distant metastasis following surgery for recurrent disease was significantly higher for Group A. The median interval between primary diagnosis of local recurrence and detection of distant metastasis was 8.4 months for group A and 18.0 months for the nonresection group, although no difference in overall survival was observed between the two groups. Conclusions: Patients in group A suffered from poor curative resection and early emergence of locoregional failure or distant metastasis, leading to a dismal prognosis. The indication for surgery, the optimal extent of surgical resection, and the application of adequate adjuvant therapies should therefore be seriously reconsidered for this subset of patients.

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We report a case in which the entire stomach prolapsed into a large esophageal hiatal hernia with mesenteroaxial gastric volvulus, resulting in acute congestive heart failure and cholecystitis with perforation. A 79-year-old woman admitted for epigastric and back pain and dyspnea was found in chest X-ray showed pulmonary congestion and an air bubble in the mediastinum. Ultrasonography and abdominal computed tomograms (CT) showed a swollen gallbladder with a thick wall. Under a diagnosis of esophageal hiatal hernia, acute cholecystitis, and acute congestive heart failure, we conducted conservative treatment. Heart failure improved after 3 and abdominal pain after 7 days. An upper gastrointestinal series showed that the entire stomach had migrated into the mediastinum with mesenteroaxial gastric volvulus. Abdominal CT showed a cystic lesion near the lateral lobe of the liver. Surgical treatment was selected under a diagnosis of esophageal hiatal hernia with volvulus and gallbladder perforation. The stomach prolapsed into the mediastinal hernial sac and the gallbladder was perforated with a “bile lake” near the lateral lobe of the liver, triangular ligament, and stomach. A cholecystectomy and Nissen fundoplication were done, and her postoperative course has been uneventful in the 3 years since surgery.

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The case of a 55-year-old man with a primary squamous cell carcinoma (SCC) of the stomach that was cured surgically is reported. The clinicopathological features of 51 cases of primary SCC of the stomach reported in Japan were reviewed and compared with the data for the common type of gastric carcinoma. The male-tofemale ratio (3.3: 1) and patient age (64.5±12.6 yo) were higher than those of the common type of gastric carcinoma. In 51 cases, 24 cases (47%) showed that the lesion was located in the upper third of the stomach and only 2 cases (4%) were early carcinoma, both of which indicated that SCC of the stomach had characteristics distinct from those of the common type of gastric carcinoma. In 40 cases (78%) there was invasion beyond the subserosal layer, and in 35 cases (69%) there was local and/or distant metastasis. The majority of cases (70%) had already progressed to stage III-IV at the time of operation, which showed a very poor prognosis (5-year survival rate: 35.6%). The pathogenesis of this disease has been argued by many authors but remains obscure. Genetical studies will be necessary to clarify the pathogenesis of this rare tumor. Key words: gastric carcinoma, stomach, squamous cell carcinoma

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We report a case of hepatic abscess that developed secondary to penetration by a fish bone. A 53-year-old woman was admitted to our hospital complaining of right upper abdominal pain and fever and percutaneous abscess drainage was performed under ultrasonographic guidance. An abscess was diagnosed in liver segment 6. Abdominal ultrasonography and computed tomography revealed a hepatic abscess with a high echoic and a linear high density area, suggesting a foreign body. At laparotomy we diagnosed a hepatic abscess secondary to penetration through the duodenum by a fish bone. Although hepatic abscesses secondary to fish bone penetration are rare, it is important to find an area of linear calcification of a lesion by diagnostic imaging.

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We report a 53-year-old woman found in October 2001 to have occult blood. A tumor, 2cm in diameter, having a lower border 5cm from the anal verge was palpated in digital examination. Biopsy results indicated a carcinoid tumor. We conducted anterior resection with lateral node dissection and partial hepatectomy of a 5mm metastatic nodule in the S7 segment of the liver observed during surgery. Penetration of the rectal wall by the primary tumor was histopathologically classified as muscularis propria, and metastasis to the perirectal and left lateral lymph nodes was observed. After surgery, she was treated by adjuvant hepatic arterial infusion with 5-fluorouracil and mitomycin-C. Since metastasis to the S2 and S7 hepatic segments was observed 5 months later, the patient underwent percutaneous radiofrequency ablation (RFA). RFA was sequentially conducted on 20 metastatic foci through September 2005. As of 4 years since surgery, liver metastasis control is favorable, and no local recurrence or other distal metastasis has been observed. RFA is believed to be locally effective in multiple liver metastases in bilateral lobes of carcinoid tumors.

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We report a case of advanced gallbladder cancer derived from the Rokitansky-Aschoff sinus. A50-year-old man admitted for gallbladder wall thickening detected by ultrasonography had his condition confirmed in computed tomography, ERCP, MRCP, and EUS, No apparent gallbladder cancer was found. Under a diagnosis of adenomyomatosis with chronic cholecystitis, we conducted laparoscopic cholecystectomy. Macroscopic findings for the resected specimen showed wall thickening, but no malignant lesion in the mucosal layer. Histopathological examination of the resected specimen showed well-differentiated adenocarcinoma in the Rokitansky-Aschoff sinus accompanied by subserosal and perineural invasion. Histopathological examination of total segmentation of the resected specimen showed no malignant lesion in the mucosal layer of the gall-bladder. We conducted additional surgery, including partial hepatectomy, regional lymphadenectomy, and extra bile duct resection. We found no malignant lesion. Gallbladder cancer derived from the Rokitansky-Aschoff sinus is rare. In most reported cases, gallbladder cancer derived from the Rokitansky-Aschoff sinus is noninvasive carcinoma.

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A 59-year-old woman was admitted to our hospital because of suspicion of a tumor of the pancreatic body based on the abdominal ultrasound findings during a periodic medical checkup. Blood biochemical, tumor marker, and pancreatic endocrine hormone testing yielded no abnormal findings. The tumor was strongly enhanced by abdominal contrast-enhanced CT and angiography, and differentiated from a pancreatic nonfunctioning endocrine tumor. MRI showed that the tumor contained a large serous portion, and pancreatic serous cystadenoma was suspected. Distal pancreatectomy was performed. Sectioning of the tumor revealed a solid structure and no cysts. The histopathological diagnosis was serous cystadenoma. We report a case of pancreatic serous cystadenoma that appeared to be a solid tumor based on the diagnostic imaging and macroscopic findings.

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The patient was a 67-year-old woman who underwent subtotal stomach-preserving pancreatoduodenectomy (pancreatogastrostomy) in April 2005 for cancer of the head of the pancreas, and the pancreatic duct tube was removed on postoperative day 27. Melena was first noted on the same day, and bleeding from the site where the pancreatic duct tube had been removed was suspected based on the upper gastorointestinal endoscopy findings. Abdominal CT was performed because the melena persisted, and portal vein stenosis was noted. Its relation to the melena was unknown, but a stent was placed in the portal vein to prevent liver failure and gastrointestinal bleeding as a result of the formation of varices. Abdominal CT 4 months after stenting showed no evidence of thrombosis or restenosis, and Doppler ultrasound of the abdomen at 6 months showed good blood flow in the portal vein. It has been 8 months since stenting, and there have been no signs of hepatic failure or portal hypertension.

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We report a perforation of the ileum caused by cytomegalovirus enterocolitis accompanied with immunodeficiency after Thymectomy. A 72-year-old man was admitted to our hospital complaining of abdominal pain. An abdominal CT scan showed intraabdominal free gases. We diagnosed the patient as having peritonitis and operated. We found a perforation of the ileum and resected four centimeters of ileum, including the perforated lesion. Histological findings showed that the perforation of the ileum had been caused by a cytomegalovirus infection. This patient had been immunodeficiency after a thymectomy. We consider this case to be a rare and valuable case history.

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A 76-year-old man admitted for sudden onset of epigastralgia, nausea, and vomiting was found in abdominal plain CT to have portal venous gas in the liver but no apparent findings of bowel necrosis. Although portal venous gas disappeared the next day, melena, wall thickness of the ileum, and ascites appeared. Based on these findings, we conducted emergency laparoscopy based on suspected mesenteric ischemia. Operative findings showed bloody ascites and an ischemic, edemoatous jejunum about 40cm long. We resected the lesion and conducted anastomosis. Mesenteric artery pulsation of the lesion was preserved. Histological findings of the resected specimen showed hemorrhagic necrosis of the jejunum without thrombosis or angitis in the mesenteric vessels. Based on these findings, the definitive diagnosis was nonocclusive mesenteric ischemia. Several cases of portal venous gas treated conservatively have been reported recently, but we should regard portal venous gas as a severe condition with poor prognosis, and bowel necrosis should be kept in mind. If we suspect bowel necrosis, laparoscopy, which is less invasive, is useful both for diagnosis and treatment.

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A 84-year-old woman admitted for sudden of abdominal pain onset found in plain abdominal radiography to have dilated loops of the small intestine. Abdominal computed tomography (CT) showed hepatic portal and superior mesenteric venous gas. Physical and laboratory examinations indicated that the pain could be treated conservatively. Fifteen days later, CT showed that hepatic portal venous gas had disappeared, but abdominal pain recurred repeatedly when she began oral intake. X-ray examination of the small intestine using an ileus tube showed segmental stenosis of the ileum. She underwent partial resection of the small intestine due to stenosis 45cm forward the oral side from the ileum end. The definitive was ischemic enteritis. Ischemic enteritis is uncommon in the small intestine and enteritis causing intestinal stenosis with HPVG is even rare.

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A 54-year-old woman was admitted to our hospital complaining of right lower quadrant abdominal pain. Based on abdominal CT findings showing a swollen appendix and right fallopian tube, the patient was diagnosed with acute appendicitis and received an appendectomy and a right tubectomy. A postoperative histopathological examination revealed the presence of a poorly differentiated adenocarcinoma with proliferation in a scirrhous fashion from the mucosa through the muscularis, as well as part of a serous membrane. One month following the initial operation, a right colectomy was performed in order to conduct D3 lymph node dissection. Tumor marker elevation and ascites retention were observed 2 years and 4 months after the radical operation. We diagnosed with recurrence of the appendiceal cancer, and treated the patient with chemotherapy, but a complete response was not attained. The patient died 2 years and 10 months after the initial diagnoses. Colonic carcinoma is rarely seen among appendiceal cancer and is very difficult to diagnose preoperatively. Therefore, many cases are initially diagnosed as appendicitis, and only later recognized as cancer based on intraopera tivefindings or a postoperative histological examination. Therefore, it is necessary for positive histopathological examinations after appendectomy. Furthermore, based on the depth of cancer invasion, appropriate additional operations must be considered.

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A 48-year-old man was admitted to our hospital for melena. He had a history of familial adenomatous polyposis and had undergone total colectomy with ileorectal anastomosis (IRA) for ascending colon cancer (mucinous adenocarcinoma, stage IIIb) 17 years previously. A few polyps in the residual rectum had been removed at that time, and the patient had been followed up for 1 year, but failed to return for further examination. After admission to our hospital abdominoperineal resection was performed to treat the numerous polyps in the residual rectum. Two advanced cancers were found in the resected specimen, and histologic examination revealed lymph node metastasis in the ρ-shaped ileal mesentery. It is important to be aware of the possibility of lymph node metastasis in the ileal mesentery of patients with carcinoma in the residual rectum after total colectomy with IRA.

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