Introduction: Recurrence after aggressive surgical resection for hepatic and pulmonary metastasis in colorectal cancer is a major clinical problem. We retrospectively studied on indications and operations for such repeated resection. Methods: We reviewed 36 cases of colorectal cancer involving hepatic and pulmonary metastasectomy at our hospital in the last 5 years: 16 involved hepatic metastasis alone, 5 pulmonary metastasis alone, and 15 combined hepatic and pulmonary metastases (six with synchronized resection). Results: The interval from resection of the primary lesion to hepatic metastasis was 2-35 months (mean: 8.5 months), and that to pulmonary metastasis 7-43 months (mean: 15.4 months). The stage of hepatic metastasis was H1 (n=27). H2 (n=4) and hepatic metastasectomy Hr0 (n=17). Hr1 (n=4). Hr2 (n=10). The stage of pulmonary metastasis was LM1 (n=12), LM2 (n=7) and pulmonary metastasectomy was wedge resection (n=16), lobectomy (n=3). The recurrence ratio after hepatic metastasectomy was 46.6%(14/30) and 9 of 14 cases underwent repeated resection. The recurrence ratio after pulmonary metastasectomy was 47.3%(9/19) and 6 of 9 cases underwent repeated resection. Cumulative survival 3 years after first hepatic and pulmonary metastasectomy was 69.7% and 44.6% at 5 years. No significant difference was seen between metastasis stage and operation type. Patients undergoing repeated resection for metastasis of the residual liver and lung showed the longest survival at 21-59 months. Conclusion: The recurrence ratio after hepatic and pulmonary metastasectomy of colorectal cancer was high at about 47%, that patients treated by aggressive resection showed a favorable prognosis of 69.3% survival at 3 years survivals, and 44.6% at 5 years. Repeated metastasectomy in metastasized colorectal cancer thus appears justifiable.

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Background: With the aging society accelerating in numbers, the frequency of surgery for elderly patients has increased. This study evaluated the efficacy and safety of emergency surgery for generalized peritonitis in the octogenarian. Subject: Between January 1993 and December 2004, 129 patients underwent emergency surgery for generalized peritonitis in our institution. Of those, 31 patients (24.0%) were octogenarians over 80 years old (Elderly group). We retrospectively compared this group with 25 patients in their 70's (Non-elderly (A) group) and 24 patients in their 60's (Non-elderly (B) group). Results: As for the site of perforation, theupper gastrointestinal tract was as high as 58.3% in the non-elderly (B) group, while in the non-elderly (A) and elderly groups, the appendix or colorectum comprised about 60%. The rates of preoperative morbidity in the elderly, non-aged (A), and non-aged (B) groups were 90.3%, 84.0%, and 75. 0%, respectively. The cardiac morbidityrate was significantly higher in patients over 70 years old than in patients in their 60's. There were no other significant differences in the preoperative course, preoperative blood test, surgical procedure, surgical duration or volume of blood loss. The incidence of patients requiring postoperative mechanical ventilation or administration of catecholamines was higher and the postoperative hospital stay tended to be longer for elderly patients. The rate of postoperative morbidity, especially major complications, was also higher for elderly patients. In each group, the overall survival-discharge rate was 70-80%, and there was no significant difference in surgical-death or postoperative hospital-death. However, in the elderly group only, we recognized a decline in ADL (activities of daily living) in 26.1% of the surviving patients at discharge. Conclusions: We concluded that emergency surgery for generalized peritonitis can be performed safely for octogenarians, resulting in a prognosis equal to that of non-elderly patients. We recognize patients over 70 years old as “the elderly” patients, and should perform strict perioperative management, especially the management of breathing and circulatory dynamics. For the octogenarian, prevention of postoperative ADL decline is an important problem that remains to be resolved.

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We report a rare case of perforated cervical esophageal ulcer caused by an iron tablet. A 21-year-old woman took a ferrogradumet tablet prescribed for iron deficiency anemia, thereafter suffering neck pain necessitating a visit to the hospital emergency department. Esophagoscopy showed a red tablet adhering to the cervical esophagus too tightly to be removed. Since hypaque swallowing at another hospital showed contrast medium leakage and cervical emphysema, she was transferred to our hospital. Computed tomography showed emphysema in the neck, posterior mediastinum, and retroperitoneum. Under general anesthesia, she underwent upper mediastinal drainage and endoscopic removal of the tablet buried in the esophageal wall. She had sufferedfrom dysphagia and iron deficiency anemia for over 12 years. Histopathological examination showed epithelial injury with collagenous fiber resembling an esophageal web, indicating that an esophageal stricture from Plummer-Vinson syndrome may have caused the perforated esophageal ulcer. Careful attention should therefore be paid to a history of dysphagia, when iron tablets are prescribed for iron deficiency anemia.

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We report a rare case of intrathoracic hernia of jejunal pull-up through the retrosternal space after subtotal esophagectomy for esophageal cancer. A 62-year-old man with a history of distal gastrectomy (Billroth II) for duodenal ulcer perforation underwent subtotal esophagectomy for esophageal cancer after neoadjuvant chemoradiation therapy. Reconstruction was done with the jejunum through the retrosternal space under microsurgery. The postoperative course was uneventful, but he reported vomiting and dysphagia 2 months after surgery. Chest X-ray and computed tomography showed cystic dilation of the jejunum at the right side of the mediastinum. Gastrografin ingestion showed the jejunum to be stretched and twisted due to an intrathoracic hernia of the jejunal pull-up. We resected the jejunum under lower sternotomy and fixed the jejunum to the mediastinum to prevent recurrence of the hernia. The postoperative course was uneventful, but the man died of multiple organ failure after esophageal cancer metastasized 14 months after the first operation.

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Some 4-6% of esophageal cancer patients have liver cirrhosis, and the incidence of complication after esophageal cancer surgery in portal hypertension due to liver cirrhosis is high. One serious complication is anastomotic leakage due to congestion of venous flow in the early postoperative course. We conducted a venous shunt in addition to reconstruction of the esophagus after esophagectomy using the gastric tube in two cases of esophageal cancer with portal hypertension to avoid congestion in the gastric tube. In Case 1, a patient with portal hypertension due to liver cirrhosis had esophageal cancer type-III. After esophagectomy, we anastomosed the left gastric vein and the anterior jugular vein. In Case 2, a patient with portal hypertension due to chronic hepatitis had esophageal cancer type-II. After esophagectomy, we anastomosed the left gastric vein and the internal mammary vein. After anastomosis in both cases, we confirmed disappearance of congestion in the gastric tube. Short-term postoperative course are uneventful without serious complications such as anastomotic leakage.

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The patient was a 42-year-old male. After preoperative chemotherapy and radiation therapy for esophageal cancer in the mid-thoracic region, subtotal esophagectomy with three-field lymph node dissection was performed via a right thoracolaparotomy (the thoracic duct was preserved). Chest tube drainage increased suddenly on postoperative day 3.On the postoperative day 4, enteral nutrition was instituted, and the drainage fluid turned cloudy white. A diagnosis of chylothorax was made, and since the total volume of drainage fluid measured 1, 800ml and was affecting the patient's hemodynamics, surgery was performed. Ligation of the thoracic duct in the inferior mediastinum failed to stop the leakage from the superior mediastinum. The left superior mediastinum was therefore widened to localize the site of chyle leakage in the thoracic duct, and the duct was ligated distal to the site. The following day, however, a large volume of chyle again leaked from the drain, and intermittent subcutaneous ocreotide 50 μg ×3/day was instituted. On the second day of treatment, the drainage decreased markedly. Ocreotide was continued for a total of 8 days, gradually reducing the dose and then discontinued. It stopped the chyle leakage, and it became possible to discharge the patient. Chylothorax is a complication of esophagectomy that is difficult to manage. Intermittent subcutaneous ocreotide has no adverse effects and should be considered as a treatment option.

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A 73-year-old man admitted for sudden abdominal pain in August 2004 was found to have free air and ascites in abdominal computed tomography. Upper gastrointestinal endoscopic examination showed a large perforatedv gastric ulcer necessitating emergency surgery. At laparotomy, the anterior wall of the stomach was perforated by the ulcer, which extended to the lesser curvature and posterior wall, penetrating into the pancreatic body in the posterior gastric wall. Distal gastrectomy was conducted followed by Roux-en-Y reconstruction. Resected specimens of the stomach showed a perforated gastric ulcer 70×43mm from the anterior to posterior wall, centering on the lesser curvature. Pathologically, type III of early gastric cancer was detected in the distal edge of the perforated ulcer. Gastric carcinoma was histologically diagnosed as poorly differentiated adenocarcinoma limited in the mucosal layer. The final diagnosis was T1, N0, H0, P0, CY0, M0, stage IA. Helicobacter pylori was also detected. The postoperative course was uneventful and the man was discharged on postoperative day 53. Perforation of early gastric cancer is relatively rare, and the present case is rare from the point of extensive ulcer formation with perforation and penetration into the pancreas.

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We report three cases of gastrectomy for gastric cancer occurring after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). Patient 1 was a 75-year-old man who underwent CABG using the RGEA and found to have advanced type 3 cancer of the gastric antrum. Distal gastrectomy removing the D2 lymph node was done after percutaneous transluminal coronary angioplasty for the right coronary artery. Patient 2 was a 70-year-old man who underwent CABG using the RGEA. Endoscopy findings indicated a type IIc tumor in the angle of the stomach. Distal gastrectomy using the RGEA was conducted to remove the D2 lymph node completely after prior redoing CABG. Patient 3 was a 59-year-old man with a history of CABG using the RGEA. He had advanced gastric cancer of the antrum and underwent D2 distal gastrectomy. The RGEA was replaced with an other graft in redoing CABG before gasterectomy. We concluded that it is reliable to treat patient with coronary intervention before gastrectomy in gastric cancer after CABG using the RGEA.

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A 76-year-old man with a gastric abnormality detected in October 2001 had normal tumor markers in blood examination, but soluble IL-2 receptor of 926U/ml. UGI and endoscopy showed a type 2 tumor in the antrum. Malignant lymphoma was counterindicated by biopsy, so total gastrectomy and splenectomy were conducted in December 2001. We diagnosed small cell carcinoma of the stomach by immunopathological and histopathological examination. Postoperative chemotherapy was conducted by CPT-11. Abdominal CT in August 2003 showed a tumor measuring 22mm at S7 of the liver. No other recurrence was seen, so partial resection of S7S8 was conducted in November 2003. Histopathologicaly, we diagnosed metastatic small cell carcinoma from the stomach. Chemotherapy by VP-16 was done because of doubt of metastasis to the lung, and he is alive 3 years after gastrectomy and 1 year and 1 month after hepatectomy.

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A 66-year-old man who had lost about 10kg, and reported abdominal pain was found in CT of the abdomen to have much ascitic and paraaortic lymph node swelling. Digital examination showed a tumor at Douglas' pouch. Based on gastroscopy, the pathology was Group V and a diagnosis of type 5 advanced gastric cancer was given. He was diagnosed with peritonitis carcinomatosa. To control ascites, a reservoir was implanted in subcutaneous tissue. Following surgery, CDDP was administered at a dose of 100mg/week for 3 weeks. This was combined with oral administration of TS-1 (each course consisting of 120mg/day for 2 weeks, with one week of drug withdrawal). CEA was 3, 316ng/ml at peak, and decreased and ascites were vanished. Schnitzler's metastasis recognized by digital examination, and paraaortic lymph node metastasis disappeared. A gastroscopic examination indicated that the cancer had decreased. It was concluded that CR had been achieved and this condition was maintained for 22 months by ambulant chemotherapy without sacrificing high quality of life.

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Segmental resection of the duodenum has been reported in only several facilities in Japan. We report two cases of adenocarcinoma of the ampulla of vater, which were treated safely by segmental resection of the duodenum sparing the pancreas. In recent years there are four different procedures in the surgical management for ampullary tumors, Endscopic ampullectomy, transduodenal ampullectomy, segmental resection of the duodemum, and pancreaticoduodenectomy. We determined that segmental resection of the duodenum was an appropriate operation for focal cancer of ampulla, because the first two procedures result in high recurrence and complication rates, and pancreaticoduodenectomy is too invasive. Indications for the procedure have been reported as duodenal polyps, duodenal lyomyosarcoma, Crohn'disease, lypomas, gastrointestinal tumors, ampullary adenomas and adenocarcinomas invading only the mucosa. In both our cases, the adenomas were still in the early stage and the resection was considered to be complete microscopically, with no lymph nodes metastasis present around the pancreas head. No major complications were encountered except delayed gastric emptying for two weeks, and two months after the operation the patients'weight returned to the preoperative status.

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A 37-year-old man with upper abdominal pain and high fever originally diagnosed with inflammatory hepatic pseudotumor elsewhere was admitted when the tumor gradually grew during follow-up. Abdominal CT showed a slightly enhanced, heterogeneous mass occupying the left hepatic lobe, and an another tumor 2.5cm in diameter in liver segment VIII. Although accurate diagnosis was difficult, malignant disease was highly suspected both clinically and radiographically, necessitating hepatic lobectomy and partial liver resection. Histopathological findings showed diffuse large B cell non-Hodgkin lymphoma. Whole-body CT, Ga scintigraphy, and bone marrow biopsy did not demonstrate other lesions and the definitive diagnosis was primary hepatic malignant lymphoma. CHOP therapy postoperatively for 6 courses as adjuvant chemotherapy resulted in no recurrent lesions observed 18 months after surgery. It seems effective to perform surgical resection followed by adjuvant chemotherapy in the case of primary hepatic lymphoma without extrahepatic disease.

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A 72-year-old man with hepatocellular carcinoma (HCC) successfully treated with interferon (IFN) for hepatitis C virus (HCV)-related chronic hepatitis underwent right lobectomy of the liver for HCV-related HCC in June 1996. Pathological findings showed well-differentiated HCC. He underwent successful postoperative IFN therapy for chronic hepatitis C from September 1996. He showed retained loss of HCV RNA and normal aspartate and alanine aminotransferase (AST and ALT). HCC reccurred, however, in segment 4 of the liver, which was resected in January 2001. Pathological findings showed moderately differentiated HCC. Postoperatively, he showed retained loss of HCV RNA and normal AST and ALT. A new lesion was detected on ultrasonography screening in October 2003. Ultrasonography and CT showed a tumor 18 mm in diameter in segment 3 of the liver. Based on the diagnosis of recurrent HCC, he underwent partial resection of segment 3 in October 2003. This case underscores the importance of long-term observation in cases successfully treated with IFN for HCV-related hepatitis.

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Primary sclerosing cholangitis (PSC) is classified according to lesion site into a diffuse type and a localized type, and it is often difficult to accurately diagnose and appropriately treat either of them. We recently encountered and successfully operated two cases of localized-type PSC. Case 1 was in a 37-year-old man with localized-type PSC. During examinations for gallbladder polyps, diagnostic imaging revealed dilatation of the bile ducts in the left hepatic lobe. Since the possibility of malignancy could not be ruled out, the left hepatic lobe and the caudate lobe were resected. Histopathological examination of the resected specimen indicated PSC alone, with no evidence of malignancy. Case 2 was in a 63-year-old man with localized-type PSC. His chief complaints were weight loss and jaundice. Diagnostic imaging, including CT scanning, disclosed a tumor in the porta hepatis, and cytological examination of bile obtained during percutaneous transhepatic bile drainage (PTBD) revealed class V in cytology. Based on a preparative diagnosis of cholangiocellular carcinoma, we performed extended right hepatic lobectomy, and in both cases the postoperative course was favorable without any evidence of recurrence. We concluded that operative management should be actively considered for patients with localized-type PSC.

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A 64-year-old woman was admitted to our hospital for further examination, it was known that she had a gallbladder tumor before admission. Abdominal ultrasonography showed an iso-echoic mass lesion about 1 cm in diameter in the neck of the gallbladder. T1-weighted MRI showed an irregular iso-intense mass. Laparoscopic cholecystectomy and frozen section examination were performed. Gallbladder carcinoma was suspected based on the frozen-section findings, but invasion of the muscularis propria was unclear. Macroscopic examination of the resected specimen revealed a mulberry like mass measuring 12×8mm-size. Microscopic examination of the tumor revealed tumor cells in a trabecular pattern and containing round, hyperchromatic nuclei. The tumor cells were positive for Grimelius staining and immunohistologic chromogranin A staining. The patient is doing well, with no any signs of recurrence, 12 months after the operation.

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We report a rare case of cancer of the bile duct with hemobilia. The patient was a 70-year-old male who had been followed up for upper abdominal pain, abnormal biliary enzyme laboratory data, and bile duct dilatations since October 2003. ERCP on September 2004 for closer examination of a bile duct tumor detected by US revealed hemobilia. In January 2005 we performed extrahepatic bile duct resection of fCurA for a preoperative diagnosis of bile duct tumor. Histopathological examination revealed stage II poorly differentiated adenocarcinoma in the middle portion of the bile duct.

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A 27-year-old man admitted for hematemesis with anemia was found in CT to have a 5-cm cystic mass in the pancreatic head and scattered calcification from pancreatic body to tail. Gastrointestinal fiberscopy showed a submucosal tumor in the second portion of the duodenum and active bleeding from the tumor center. Based on a diagnosis of pancreatic pseudocyst fenestration into the duodenum, we conducted emergency pancreaticoduodenectomy. Histopathologically, the tumor was diagnosed as a pancreatic pseudocyst fenestrating into the duodenum and connected to the main pancreatic duct. The postoperative course was uneventful and the man was discharged on postoperative day 18. Pancreatic pseudocysts fenestrating into the gastrointestinal organs is rare, especially into the duodenum.

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Skeletal muscle metastasis of pancreatic cancer is very rare and only 3 cases have been reported in Japanese literature. We reported a case of metastasis to the quadriceps femoris muscle after resection for pancreatic cancer 8 years earlier. A 66-year-old man underwent pancreaticoduodenectomy with portal vein excision in December 1993 due to pancreatic head cancer. In May 2002 he noticed a painful, 3×2cm tumor in the right femoral region. Based on a diagnosis of recurrent pancreatic cancer in the skeletal muscle because tumor markers such as CA19-9 and SPan1 had increased, we excised the tumor under local anesthesia. The tumor was well-differentiated tubular adenocarcinoma in the collagenous tissue. The man suffered lung metastasis 6 months later and died in February 2004, 11 years and 2 months after primary pancreatic tumor excision. Metastatic tumor must thus be considered when a skeletal muscle tumor is seen in a patient with a history with pancreatic carcinoma.

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A 72-year-old man with abdominal pain and vomiting admitted in an emergency was found in abdominal computed tomography to have gas in the left hepatic portal vein and a thickened small intestinal wall. In immediate surgery under a diagnosis of hepatic portal venous gas due to necrotic bowel, we resected the necrotic ileum 15cm to 75cm from the Bauhin valve and conducted end-to end anastomosis. The resected necrotic intestine showed the presence of many bubbles of submucosal gas. Microscopic findings showed mucosal necrosis and Clostridium perfringens infection in the mucosal layer. Hyperbaric oxygenation therapy for two days after surgery resulted in an uneventful postoperative course, with the man discharged on postoperative day 17.

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Leiomyoma of the small intestinal mesentery is very rare, and we report only the 15th case, to our knowledge, in the Japanese literature. A 66-year-old man with a full sensation of the abdomen and constipation was hospitalizedfor an intraabdominal mass. Physical examination showed a 14×11×14cm elastic, hard, movable smooth tumor generating pain upon pressure palpable in the left lower abdomen. Ehography, CT, and MRI showed a well-defined, lobular tumor with a heterogeneous internal structure. A small-intestine series showed only pressure to the small intestine due to the tumor. Angiography showed a dilated, crooked ileocolic artery. Upon laparotomy, the tumor was present in the small intestinal mesentery and had no invasive lesion. Partial intestinal excision revealed a 14×11×14cm lobular, elastic, hard tumor. Histopathological and immunohistologicalstudies showed c-kit (-), CD34 (-), S100 (-), and desmin (+). Leiomyoma arising in the small in-testinalmesentery was the definitive diagnosis. The postoperative course was uneventful and he has been free from recurrence, but 10%level in MIB 1 level index requires careful follw-up.

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We report a case of gastrointestinal stromal tumor (GIST) of the ileum in which complete remission (CR) on computed tomography (CT) scan was achieved by imatinib mesylate treatment. In October 2000, a 70-year-old man visited our hospital, complaining of lower abdominal pain. A contrast abdominal CT showed a 15-cm tumor with solid and cystic components and a clear margin. A communication between a tumor and intestinal lumen was found in intestinal series and a CT with gastrografin contrast. The tumor was resected along with adjacent intestine. Immunohistochemistry showed positive staining for c-kit and CD34, and the diagnosis of GIST was confirmed. Peritoneal recurrence was observed 3 times in the next 3 years and the recurrent tumors were surgically removed. At the 3rd recurrence, multiple hepatic metastases were found. Because genetic analysis revealed the sequence variation in exon11 of the c-kit, the main tumors were surgically removed and imatinib mesylate treatment was selected for residual tumors in September 2003. After a 1-month of imatinib 300mg per day, reduction of tumors was confirmed. Imatinib mesylate was increased to 400mg per day. After a 10-month treatment, CR of the recurrent tumors and hepatic metastases was confirmed on CT. Imatinib mesylate treatment was continued. No side effects have been observed up to April 2005.

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A 65-year-old woman admitted for mucous diarrhea and melena was found in colonoscopy to have an encircling flat protruding tumor with a villous structure 1cm above the dentate line and extending upward for 13 cm. We diagnosed her as having rectal villous adenoma with well-differentiated adenocarcinoma based on a pathological examination of the biopsy specimen. She had dehydration, hypokalemia (2.1mEq/l), hyponatremia (117mEq/l), and hypochloremia (60mEq/l) at admission, leading to a diagnosis of electrolyte depletion syndrome (EDS), necessitating rehydration with saline containing potassium chloride. We performed abdomino-perineal resection and resection of a right ovarian cyst. The resected specimen was 15×12cm villous adenoma with well-differentiated adenocarcinoma. The postoperative course was uneventful and EDS has been ameliorated. To our knowledge, 55 case reports have been made of villous adenoma with EDS in Japan.

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Poorly differentiated adenocarcinoma of the large bowel is rare, and many of its clinical characteristics remain unknown. We report a case of poorly differentiated adenocarcinoma of the ascending colon with rapid clinical deterioration after resection of the primary tumor resulting in death. The patient's was strongly suggested disseminated carcinomatosis of the bone marrow, clinical course. The 48-year-old man presented with right abdominal pain and was diagnosed as having ascending colon cancer and was hospitalized. Since preoperative investigations showed signet ring cell carcinoma of the ascending colon, the right half of the colon was resected. The tumor was macroscopically classified as type IV and cytology of ascites showed Class V. Metastasis to Group 4 lymph nodes was observed. Pathologically, the tumor was diagnosed as poorly differentiated adenocarcinoma of the ascending colon. Back pain present preoperatively increased with thrombocytopenia from postoperative day 8. Bone scintigraphy revealed abnormal accumulation of 99mTc in the entire skeleton. He rapidly developed disseminated intravascular coagulation syndrome, and died about 2 months postoperatively. From his clinical course, he was considered to have disseminated carcinomatosis of the bone marrow from large bowel cancer. We report the present case in detail and discusses findings from the literature.

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A case is presented of a 75-year-old woman who underwent sigmoidectomy for sigmoid colon cancer in January, 1997 (well, se, ly1, v0, and n0; Stage II). Postoperative adjuvant chemotherapy was not carried out. From November, 2002, the patient.s serum CEA level increased and a 4×2cm-sized low density area was detected in the spleen with a CT scan study in March, 2003. FDG-PET revealed strong uptake at the tumor and no other lesion was discovered. Metachronous solitary splenic metastasis was suspected, a splenectomy was performed in May, 2003, and the postoperative histological findings confirmed splenic metastasis from sigmoid colon cancer. Adjuvant chemotherapy was not used but the patient is alive without any recurrences for 19 months after the splenectomy. Since a solitary splenic metastasis from a colon cancer is rare, this case is presented with a review of the literature.

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