Purpose: We clarified the prognostic factors of stage IV colorectal cancer. Materials and Methods: We analyzed 161cases of stage IV colorectal cancer clinicopathologically to determine prognostic factors. Results: We found 37cases (23.0%) with curability (cur) B, 110 (68.3%) with cur C, and 14 (8.7%) with curability unknown. For the number of non-curative factors, 111cases (68.9%) had a single factor and 50 (31.1%) multiple factors. The most frequent factor among single non-curative cases was liver metastasis (57.7%), followed by peritoneal metastasis (18.9%). Multivariate analysis indicated that curability, differentiation, tumor depth, the number of non-curative factors, and lymphatic invasion are independent prognostic factors. All those surviving over 5years had a single non-curative factor with well-to moderately-differentiated adenocarcinoma, and underwent cur Bresection. Conclusions: Extended resection for metastatic lesions may prolong survival in stage IV colorectal cancer when a) a single non-curative factor exists and b) adenocarcinoma is well-to moderately-differentiated.

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Purpose: The diagnosis of lymph-node-negative colorectal cancer should imply a good prognosis, but the outcome for TNM stage II patients remains spotty. We determined whether the number of lymph nodes found affects this prognosis. Materials and Methods: Data on TNM stage II or III patients who underwent surgery for colorectal cancer between 1981 and 2000 was taken from a database and surgery compared using Kaplan-Meier curves and the log-rank test. Multivariate analysis was conducted using a Cox regression model. Results: We analyzed 229 TNM stage II cases and, for comparison, 204 stage III cases. Lymph node retrieval in stage II cases was affected by patient age (P=0.0035), emergency operation (P=0.0010), and tumor site (P=0.0030). In stage III cases, lymph node retrieval was affected by gender (P=0.0108) and invasion depth (P=0.0085). Decreased lymph node detection was associated with an increased hazard ratio among 229 TNM stage II patients. Five-year survival for patients with stage III tumors with only 1-3 positive lymph nodes (61.6%) was similar to that of patients with stage II tumors who had 11 or fewer lymph nodes (68.5%). Conclusions: The prognosis of TNM stage II colorectal cancer depends on the number of lymph nodes found and, presumably those with stage II tumors and only a few nodes found routinely be provided postoperative chemotherapy.

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Small-cell neuroendocrine carcinomas are frequent in the bronchial tree but are very rare in the gastrointestinal tract. A 52-year-old man seen for dysphagia was found in endoscopic examination to have a polypoid lesion at the middle thoracic esophagus. Pathological examination of biopsy specimens showed neuroendocrine carcinoma. Since remote metastasis was not detected, we conducted esophagectomy through thoracolaparotomy. Histopathologically, the tumor was evaluated as pSMpN2IM0M0H0P0 Stage II based on Classification of Esophageal Carcinoma. Immunopathologically, positive staining was recognized for CD56, NSE, S-100 protein, chromograninA, and synaptophysin. Multiple liver metastasis and intraperitoneal lymph node recurrence were detected 1.5 months postoperatively and he died about 2 months thereafter. A detailed study of the tumor showed well-differentiated epithelium-like parts intermingled with poorly differentiated sarcoma-like parts. ATBF1 expression was found mainly in the nucleus of the epithelium-like parts and in the cytoplasm of the sarcoma-like parts, but was absent in the lymphatic spread.

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We experienced distal gastrectomy with D2 lymph node dissection and arterial reconstruction between the splenic artery and an in situ right gastroepiploic artery graft for a case of advanced cancer in the lower portion of the stomach after coronary bypass grafting using the right gasroepiploic artery (RGEA) as an in situ graft. A 73-year-old man, who had undergone triple coronary artery bypass grafting 7 years previously, presented with tarry stools and was diagnosed as having advanced cancer in the antrum. He underwent the above operation and the postoperative course has been uneventful. This procedure presents merits in coronary arterial revision only in the intraabdominal approach and a precise lymph node dissection, particularly in No.6, by ligation and division of the basis of RGEA. We consider this procedure one of the options for advanced gastric cancer after coronary bypass grafting using the RGEA. No other report like this was found in the literature, to the best of knowledge, and we report this case herein.

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A 42-year-old man admitted for right lateral abdominal pain was found in chest radiography and abdominal CT to have free air in the peritoneal cavity. Endoscopic examination suggested a perforated duodenal ulcer necessitating emergency laparoscopic surgery with lifting method. Two pieces of Kirschner wire were obliquely inserted and raised to obtain working space. Five trocars were then inserted into the peritoneal cavity; under umblication (5mm in diameter, scope port), below xyphoid (11mm), right upper and lower abdomen (5mm) and left upper abdomen (5mm), Laparoscopy showed a perforated ulcer in the anterior wall of the duodenum. Since the large omentum was too short due to inflamation, it was difficult to conduct a laparoscopic omental patch repair. We have done laparoscopic repair of perforated duodenal ulcer using the ligamentum teres hepatis. The operation took 120 minutes. The postoperative course was uneventful. Endoscopic examination on postoperative day 14 showed an H1-H2 stage ulcer. He underwent therapy to eradicate Helicobacter pylori. No further ulcers have recurred in the 6 weeks following. Laparoscopic repair using the ligamentum teres hepatis is thus useful in treating perforated duodenal ulcers.

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A 55-year-old man who had was undergone extended right lobectomy for a huge hepatocellular carcinoma (HCC) in February 1996 then underwent TAE to manage HCC recurrence twice and partial resection of the lung for metastasis twice in 3 years. A splenic tumor 2.5cm in diameter detected in computed tomography in November 2001 grew 5cm in diameter in 2 months. In laparotomy on January 31, 2002, under a diagnosis of splenic metastasis from HCC, we located the tumor in the upper pole of the spleen, firmly attached to the diaphragm and lateral lobe of the liver without peritoneal dissemination. We conducted splenectomy and partial resection of the diaphragm and liver. Pathologically, the tumor was identical to HCC histology and covered with a splenic capsule. Taken together, we diagnosed this case as splenic metastasis from HCC-a rare with a poor prognosis due to frequent metastasis to other organs. Treatment options are resection, chemotherapy, and TAE. In cases with no other lesion, such as in this case, surgical resection should yield a good prognosis.

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We report a case of primary hepatic neuroendocrine carcinoma. A 51 year-old man with liver dysfunction and a hepatic tumor of 10cm in the lateral lobe was found in plain computed tomography (CT) to have a lowdensity mass. Enhanced CT showed capsule-like structures surrounding low-density areas. A low-intensity mass observed in T1-weighted magnetic resonance imaging (MRI) became an heterogeneous high-intensity area in T2-weighted MRI. MRCP showed dilated peripheral bile ducts. We resected left hepatic lobe. Immunohistochemically, tumor cells were positive for CA19-9 and synaptophysin. The histopathlogical diagnosis was neuroendocrine carcinoma of the liver. Primary hepatic neuroendocrine carcinoma is extremely rare and prognosis is dismal. The patient has, however, been followed up for 13 months without evidence of recurrence.

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This paper presents a rare case of a communicating accessory bile duct associated with cancer of the papilla of Vater. A 72-year-old woman was admitted to our hospital because of obstructive jaundice. Percutaneous transhepatic biliary drainage was performed. Tube cholangiography revealed a low union of the hepatic ducts and an accessory bile duct connected the right and left hepatic ducts. The cystic duct inserted into the right hepatic duct. Pancreatoduodenectomy was performed. The right and left hepatic ducts were transected just under the cystic duct and anastomosed to the jejunum. We considered that this case had a communicating accessory bile duct as reported by Goor. In this case, the bile ducts formed a. circuit. at the hepatic hilum. Because each part of the circuit had almost the same diameter, it was difficult to determine which part was the communicating accessory bile duct. We review reported cases which had the same anomaly, and detail the classification of this type of anomaly.

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We report a case of clear-cell adenocarcinoma of the gallbladder. A 78-year-old woman admitted for evaluation of a gallbladder tumor about 5cm in diameter found in ultrasonography. Enhanced computed tomography (CT), and magnetic resornance imaging (MRI) showed a hypervascular gallbladder tumor. Cholecystectomy with liver resection of segments 4a and 5 was performed on suspicion of gallbladder carcinoma. Histologically, the neoplasm consisted mainly of a clear-cell component and the presence of dysplasia adjacent to carcinoma. The definitive diagnosis was clear-cell adenocarcinoma of the gallbladder, an exceedingly rare malignant neoplasm.

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A 75-year-old man was admitted to our hospital with melena. He was diagnosed as having an arterial hemorrhage of a submucosal tumor on the antimesenteric side of the second portion of the duodenum. Due to difficulties with endoscopic hemostasis and arterial embolization, we performed emergency partial resection of the duodenum. Examination of frozen sections confirmed that the tumor was a well differentiated adenocarcinoma arising from the heterotopic ductal structure. In addition, pancreaticoduodenectomy with preservation of the pylorus was performed. Immunohistochemical studies confirmed that the tumor was an adenocarcinoma arising from a heterotopic pancreas, which is extremely rare and makes an exact preoperative diagnosis difficult. We suggest that examination of frozen operative sections should be performed in confirming whether the heterotopic pancreas is benign or malignant and, in the case of a malignant lesion, extensive resection is required.

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A 30-year-old man admitted for epigastralgia was found in abdominal computed tomography (CT) to have a 42×39mm mass in the body of the pancreas. T1-weighted MRI showed a hypointensive tumor with a smoothmargin at the anticipated site. T2-weighted MRI showed a hyperintensive tumor compressing the splenic artery and vein. Endoscopic retrograde pancreatography and magnetic resonance cholangiopancreatographyshowed the main pancreatic duct to be obstructed. Angiography showed no tumor staining, but the splenic artery and vein were encased. Endoscopic ultrasonography-guided needle biopsy for a definitive diagnosis indicated an endocrine tumor of the pancreas. After pancreatosplenectomy, histological examination confirmedpoorly differentiated endocrine carcinoma. Immunochemical staining results were positive for CD56, synaptophysin, and Chromogranin-A. The pancreatic duct was infiltrated by tumor cells. The patient remains alivewithout recurrence 14 months after surgery.

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A 76-year-old man referred for jaundice and upper right quadrant pain was found in computed tomography (CT) and MRCP to have a 3cm multilocular cystic lesion in the pancreas head. The bile duct close to the pancreatic lesion was stenotic and the wall had thickened. Endoscopy showed an enlarged orifice of the papilla Vater with mucous secretion. The multilocular cystic lesion communicating with the main pancreatic duct (MPD) was observed in the pancreas head by ERCP and the MPD was dilated and filled with mucin. The pathological diagnosis of the biopsy specimen from the stenotic bile duct lesion was adenocarcinoma. EUS showed thickening of the septums, but no mural nodule. Pylorus-preserving pancreaticoduodenectomy with D2 lymph node dissection was conducted. The definitive pathological diagnosis was carcinoma of the bile duct invading to the subserosal layer and noninvasive intraductal papillary mucinous carcinoma of the pancreas. These were separately presented and diagnosed as synchronous double cancer. Clinical stage was IVa according to paraaortic lymph node metastasis (16b1). Since, to our knowledge, only 1 case of intraductal papillary mucinous carcinoma associated with bile duct carcinoma has been reported in the literature, we report our case in detail.

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A 66-year-old woman admitted for abdominal distension and left lower abdominal pain was found in abdominal CT and MRI to have massive acites and omental tumor mass with normal-sized ovaries. Serum CA-125 was 6, 125U/ml. Aspiration cytology showed adenocarcinoma cells but no primary tumor. Laparotomy conducted based on a diagnosis of peritoneal serous papillary carcinoma (PSPC) showed peritoneal implants throughoutthe peritoneal cavity, necessitating reduction surgery, including omentectomy. The definitive diagnosis was PSPC based on pathological findings and immunohistochemical results of Ber-EP4 (+) CEA (+) Calretini (-) CK5/6 (±). According to the literature the term “surface” in serous surface papillary carcinoma (SSPC) which is another name for PSPC originally meant surface epithelium of ovary, and didn't mean peritoneal surface. It is also confusing that PSPC is defined as being of peritoneal origin even though small lesions are found in the ovary. Although multicentric and synchronous origins of peritoneal implants of PSPC have recently been proposed in gynecological area, we found a patient in the urological literature who had ascites and omental tumors 5 years after orchiectomy for serous papillary adenocarcinoma of the tunica vaginalis testis, a vestige of the mullerian duct in a man, and we assumed that this case showed the possibility of metachronous and metastatic origin of peritoneal implants of PSPC.

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We reported two cases of Crohn.s disease associated with duodenal colonic fistulas treated surgical. Case 1; A 35-year-old man admitted for right-side hypochondralgia and anal pain was found in gastrointestinal endoscopy to have stenosis at the second portion of the duodenum. Upper gastrointestinal X-ray showed stenosis at the terminal ileum and a fistula between the caecum and terminal ileum. Fistulography confirmed a fistula between the duodenal bulb and terminal colon. Abdominal CT showed that an abscess had formed in the hepatic circumference. Case 2; A 23-year-old man seen for pyrexia and anal pain and having a 9-year history of Crohn's disease underwent colonic stenosis. Five years after the operation, colonoscopy and fistelography showed a fistula between the transverse colon and duodenum. Conservative preoperative treatment failed to close the fistulas necessitating transverse colon resection in case 2. Both men required fistulectomy, simple closure of the duodenal component of the fistulas and omental patching.

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A 62-year-old man with abdominal fullness and epigastralgia was diagnosed with intussusception caused by a submucosal tumor of the ascending colon based on colonoscopy, barium enema and abdominal CT-scan. Laparotomy confirmed ileocolic intussusception of the transverse colon. Intraoperative reduction was not successful, necessitating right hemicolectomy. Histological diagnosis of the tumor showed it to be benign schwannoma. Almost all adult intussusception results from organic disease such as a tumor. Gastrointestinal schwannoma of the cecum is especially rare.

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A 45-year-old man who had undergone a renal transplantation from a living donor 12 years earlier was admitted for abdominal pain. Because leukocytosis was elevated, we coducted abdominal CT, which showed massive pneumoretroperitoneum and free air in the abdominal cavity, necessitating emergency surgery. The mid sigmoid colon had been perforated, so, we conducted Hartmann. s operation, resecting the perforated region, making a stoma of the oral colon, and closing the anal rectum. Postoperative pathological examination did not evidence cytomegalovirus infection or a neoplastic region, but the diverticulum was suspicious. Immunosuppression therapy using cyclosporine, mizoribine, and methyl prednisolone was continued postoperatively but reduced to cyclosporine and methyl prednisolone. No major complications occurred and the transplanted kidney still functioned. Generally, in posttransplantations, abnormal conditions occur due to immunosuppressive agents used to suppress rejection reaction, corticosteroid hormones that induce tissue fragility, and deteriorated tissue curability due to low renal function. In the 12 cases of colon perforation after renal transplantation reported in Japan, the trend involves male cadaver transplantation and sigmoid colon perforation. Nine of these patients have survived, 1 has lost transplanted renal function, and 2 have died.

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We report an unusual case of recurrent colon cancer. A 62-year-old man who underwent right hemicolectomy for cecum cancer in 2000 had had a 7cm tumor resected and found histologically to be well-differentiated adenocarcinoma with lymph node metastasis along the middle colic artery. Seventeen months after initial surgery, a metastatic lesion was found in the rectovesical pouch. No other recurrent lesions were found, so we conducted total pelvic exenteration. In a resected specimen, a tumor was found in extraperitoneal connective tissue. Parietal peritoneum, mucosa of the rectum and bladder were free from cancer-cell invasion. Intraabdominal operative cytology findings were also negative. The definitive diagnosis was a solitary metastatic tumor in extraperitoneal connective tissue arising from cecum cancer. This recurrence is extremely rare, and more case reports are needed to determine the mechanism behind these metastases.

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Postoperative chylous ascites is believed to be a rare complication that may result in serious nutritional and immunological complications due to loss of proteins and lymphocytes. From April 2001 to March 2004, we analyzed cases of chylous ascites following hepato-pancreatic surgery. The complication rate in chylous ascites was 3.4%(7 of 204 cases), then it was not thought to be a rare complication. Regression analysis showd a significant association between the number of days in the presence of chylous ascites and serum albumin, suggesting that chylous ascites must be reduced to improve nutritional condition. Octreotide was effective in the treatment of chylous ascites and a positive outcome was observed within 3 days in all 6 cases of octreotide therapy. For improvement of nutritional condition, early aggressive octreotide use is vital to positive prognosis.

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We report 6 cases of extensive cytoreductive surgery conducted from January 1999 to September 2004 on 2 men and 4 women aged 45 to 71 years suffering from pseudomyxoma peritonei. Two were initial operations and four reoperative. Complete cytoreduction was possible in 4 of the 6. Based on the Sugarbaker procedure, we conducted colectomy, omentectomy, splenectomy, left and right subphrenic peritonectomy, cholecystectomy, bursectomy, gastrectomy, low anterior resection, hysterectomy, and pelvic peritonectomy as needed. Intraperitoneal chemotherapy was added in 3 cases. Anastomotic failure was encountered in 1.Histology involved mucinous cystoadenoma or adenocarcinoma with low-grade malignancy. No recurrence has been seen in 4 cases of complete cytoreduction, although follow-up is yet short. In 2 cases of incomplete cytoreduction, the patient' quality of life (QOL) was markedly improved. Our results suggest that 1) extensive cytoreduction for pseudomyxoma peritonei is safe, 2) complete cytoreduction provides the possibility of a cure, and 3) even incomplete cytoreduction effectively improves the QOL.

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