Background: We have attempted early resumption of oral feeding after colorectal cancer surgery by evaluating recovery from gastric ileus (GI) with the use of an opaque X-ray marker. Since this involves X-ray exposure for patients, we studied whether GI recovery could be evaluated ultrasonographically instead of by conventional radiography. Methods:(1) In 24 patients with colorectal cancer and 24 control patients, we measured the pyloric area (PA) during fasting, using ultrasonography.(2) In 6 healthy volunteers, we analyzed gastric emptying during fasting by chronologically measuring PA before and after ingestion of water and rice gruel.(3) In 24 patients with colorectal cancer, the marker (20) was orally administered at 08: 00 on the first postoperative day, followed 6 hours later by abdominal plain X-ray and PA measurement. On the second and subsequent postoperative days, two tests were conducted at 09: 00, and oral feeding was resumed when marker elimination exceeded 70%. Results:(1) PA during fasting did not differ significantly between colorectal cancer and control groups.(2) When PA was measured at multiple points after oral ingestion of water or rice gruel, PA returned to its preingestion level 30 minutes after ingestion of water and 240 minutes after ingestion of rice gruel.(3) The time required to resume oral ingestion after colorectal cancer surgery was 45 hours, shorter than the 48 hours required for the first gas elimination to occur postoperatively. In evaluation using the marker, 71% of all patients showed GI recovery on the second postoperative day. PA on the first postoperative day was higher than preoperatively, but returned to approximately the preoperative level on the second postoperative day, reflecting GI recovery. The time course of the marker thus appears to be identical that of PA. Conclusion: GI recovery is evaluated by ultrasonographically measuring PA.

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A 43-year-old man admitted for high fever, jaundice, dysphagia and elevated C-reactive protein was found in computed tomography (CT) to have diffuse wall thickening of the esophagus with intramural low density. En-doscopy showed the esophageal wall to be edematous and a blood culture indicated Klebsiella pneumoniae, yielding a diagnosis of acute phlegmonous esophagitis. After intravenous antibiotics, he improved but experi-enced dysphagia and odynophagia. Repeated chest CT and endoscopy following day 100 of hospitalization showed esophageal stenosis and extraluminal barium leakage. On day 126, we conducted right hemicolic inter-position for esophageal reconstruction. The postoperative course was uneventful and he was discharged on postoperative day 54.

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We report a rare case of corrosive esophageal stricture caused by drinking a large amount of Vodka. A 39-year-man admitted for heartburn and dysphagia in January 2004. He had attempted suicide by drinking a large amount of 94% “Vodka”. Esophagoscopy and esophagograhy showed ulcers and a wide-spread esopha-geal stricture. After being admitted to the psychiatric ward for mental treatment, he underwent jejunostomy in February 2004 due to severe esophageal stricture for enteral nutrition. In July 2004, he underwent transhia-tal esophagectomy followed by reconstruction using a gastric tube through a retrosternal route after his gen-eral and mental condition improved. The postoperative course was uneventful and he was discharged on post-operative day 32.

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We report a case of primary squamous cell carcinoma in a gastric remnant. A 70-year-old man undergoing surgery for early gastric cancer on December 2002 was found to have signet-ring cell carcinoma, m, n1. Endo-scopic examination, on January 2004 showed an elevated lesion-like SMT in the greater curvature of the gas-tric remnant, diagnosed as squamous cell carcinoma from a biopsied specimen. The patient had no other le-sions in the lung, head, neck, or esophagus. We conducted total gastrectomy with splenectomy. Histopathologi-cally, the tumor was diagnosed as moderately differentiated squamous cell carcinoma, mp, INFβ, ly0, v0, n0, without any adenocarcinoma component. No continuity was seen between the tumor and esophageal mucosa. From these findings, the tumor, yielding a definitive diagnosis of primary squamous cell carcinoma arising in the gastric remnant. The patient was discharged 21 days postoperatively and remains recurrence-free as of this writing. Primary squamous cell carcinoma of the stomach is rare and, including our case, 41 cases of pri-mary squamous cell carcinoma of the stomach have been reported in the Japanese literature. Our case is, to our knowledge, the first case reported arising from a gastric remnant.

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A 75-year-old woman was found to have elevated serum CEA of 203ng/ml and elevated CA19-9 of 2, 090U/ml after mastectomy, but no reccurence of breast cancer. Gastroendoscopic examination showed a IIa+III lesion 6cm in diameter in the upper third of the posterior gastric wall. Biopsy and histopathological examination suggested poorly differentiated adenocarcinoma, necessitating total gastrectomy, splenectomy, and distal pancreatectomy in April 2001.The main tumor, which was white and fragile, was confined to the submucosal layer with no distant metastasis observed, but clinical stage IV, lymph node metastasis was seen along the proximal and distal splenic artery. In immunohistochemistry, tumor cells of both the tumor and metastatic lymph nodes stained strongly for CA19-9.Serum CA19-9 quickly normalized, and the woman remains alive 5 years after surgery.

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A 62-year-old man undergoing laparoscopic-assisted distal gastrectomy (LADG) for early gastric cancer and diagnosed with coexistent gastric tuberculosis postoperatively was admitted for appetite loss and tarry stool. Blood analysis showed marked anemia and gastrointestinal fiberscopy showed a giant gastric ulcer. Despite conservative therapy, the gastric ulcer was not cured. Gastrointestinal fiberscopy then showed early gastric cancer in addition to the gastric ulcer. After LADG, the man suffered persistent high fever. Histological examination showed gastric tuberculosis in the gastric ulcer. Despite administration of antituberculosis agents, his general condition worsened and he died. Coexistent gastric tuberculosis associated with gastric cancer is rare, but should be included in the differentiated diagnosis of tuberculosis.

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We report a case of primary follicular lymphoma of the duodenum with an unusual macroscopic lesion. A 62-year-old-woman admitted for epigastric pain had undergone direct hemostasis for a hemorrhagic duodenal ulcer 7 years earlier, and had been followed up regularly. Upper gastroendoscopic examination upon admission showed multiple elevated lesions covered with slightly whitish mucosa at the ampulla of Vater and, on the anal side, thickened folds with a waffle-like appearance. Biopsy indicated follicular lymphoma. Because no findings suggested other organ or mediastinum/celiac lymph node metastasis, we believed the duodenum to be the primary organ. After subtotal stomach-preserving pancreaticoduodenectomy, histopathological analysis showed lymph nodes 13 and 17 to be positive. The disease stage was II1E based on the Ann Arbor system and IIunder Naqvi classification. Because of curative resection and the early stage, she did not undergo chemotherapy or other postoperative treatment and after 7 months of follow-up shows no evidence of recurrence.

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A 80-year-old woman followed up for idiopathic abdominal pain, vomiting, and hepatic dysfunction that immediately improved in conservative therapy was admitted when she developed jaundice. Computed tomography showed an enlarged gallbladder and intrahepatic biliary dilation suggesting obstructive jaundice and a right Bochdalek hernia. Incarceration of the hernia was suspected when her symptoms worsened despite conservative treatment, necessitating emergency surgery. A portion from the gastric antrum to 2nd portion of the duodenum was incarcerated in the right Bochdalek foramen. We repaired the herniation and closed the right Bochdalek foramen. Her postoperative course was uneventful and without symptom recurrence.

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We report two resected cases of pancreatic metastasis from renal cell carcinoma. Case 1; A 59-years-old man who undergoing a left nephrectomy in May 1992 was diagnosed with left renal carcinoma. Ultrasonographic (US) follow up in 1999 showed several pancreatic tumors. Size and number had not changed in July 2000, he underwent a pylorus-preserving pancreaticoduodenectomy in August 2000. In July 2001, US and computed tomography (CT) showed tumors in the remnant pancreas, necessitating pancreatectomy and splenectomy in October 2002. The man remains without recurrence in December 2006. Case 2; A 65-years-old woman undergoing right nephrectomy in December 1995 and diagnosed with right renal carcinoma was admitted for back pain in June 2005. Based on pancreatic metastasis with multiple lesions from renal cell carcinoma, she underwent total pancreatectomy and splenectomy in August 2005. She remains alive without recurrence in December 2006. We found aggressive surgery to be effective in pancreatic metastasis from renal cell carcinoma.

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We report a rare case of splenic cyst with high serum CA19-9. A 49-year-old woman admitted for high serum CA19-9 of 149.5U/ml, was found in computed tomography to have a splenic cyst (10cm) with some calcification on the wall. Splenectomy was conducted, because of the a tumor. s size, and potential malignancy. The cyst was found histologically to be epidermoidal, and immunohistchemical staining was positive for CA19-9 at in cyst fluid, 12, 782.6U/ml. After surgery, serum CA19-9 returned to normal range.

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Adult mesenteric lymphangioma is relatively rare. A 20-year-old woman seen for lower abdominal pain 4 years ago and diagnosed a mesenteric cyst. But she suspended coming our hospital because of disappearance of pain. This time she was admitted for left flank pain. US, CT, and MRI showed a cystic lesion with septal structures. After a small bowel series and angiography, we diagnosed the condition as bleeding, infection, or torsion of a mesenteric cystic tumor. Laparotomy showed a soft white 9×9×6cm tumor in the mesentery of the jejunum with thickening of serosa from the tumor to the mesentery root. The tumor was excised with about 20cm of the jejunum. Histological findings showed a multiple cystic tumor with lymphatic dilation. The cyst was filled with chyle. Histological examination confirmed the diagnosis of lymphangioma. We review the case in the context of the Japanese literatures.

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We report a rare case of strangulated ileus caused by appendix epiploicas. A 61-year-old man admitted for sudden abdominal pain diagnosed as ileus had undergone cholecystectomy in 2001. Clinical findings and abdominal ultrasonography suggested strangulated ileus, necessitating emergency surgery. We found the small intestine to be strangulated about 80cm from the terminal ileum due to a band formed from appendix epiploicas of the sigmoid colon. The serosa of the sigmoid was torn. Strangulation was relieved, enabling us to avoid resecting the damaged small intestine.

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We report two cases in which diffusion-weighted imaging (DWI) played a major role in diagnosing primary small bowel carcinoma developing after colon cancer resection. Case 1: A 38-year-old woman undergoing transverse colectomy for transverse colon carcinoma 6 years earlier and seen for malaise and appetite loss was found in computed tomography (CT) to have circumferential thickening of the intestinal wall at the transverse colon anastomosis. The lesion presented as a high-signal area in both low and high b-value images in DWI and was thought to be a local recurrence. Upon further analysis of the same images, however, we concluded that the small bowel with a high signal area ran anteriorly to the transverse colon, yielding a diagnosis of malignant small bowel cancer. Case 2: A 71-year-old woman undergoing endoscopic mucosal resection due to ileocecal carcinoma (m) 9 years earlier and admitted for epigastric pain, appetite loss, and vomiting was found in CT to have superior mesenteric artery (SMA) syndrome for which conservative treatment was unsuccessful. DWI indicated malignant small bowel cancer extending horizontally between the duodenum and jejunum.

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A 78-year-old man, admitted for left upper quadrant abdominal pain and diarrhea was found to have a movable, tender hard mass in the left upper abdomen. We diagnosed intussusception based on gastrografin enema and computed tomography. Although gastrografin enema did not reduce the intussusception, it showed ileocolic intussusception and a completely inverted appendix on the cecum, necessitating emergency surgery. Intra-operative findings indicated that the right colon was not fixed to the retroperitoneum. The cecum was at the leading head, forming ileo-left transverse colonic intussusception, necessitating right hemicolectomy. No causative acting as the leading head was identified in the resected segment, except for the completely inverted appendix at the cecum. The post operative course was uneventful and the man was discharged on operative day 11. We speculated that both the unfixed right colon and appendix intussusception caused ileocolic intussusception.

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We report two cases of anastomotic recurrence after functional end-to-end anastomosis (FEEA) for colon cancer, which, most likely due to implantation of exfoliated cancer cells. Case 1: A 68-year-old man undergoing right hemicolectomy with FEEA for advanced cancer of the ascending colon 3 years and 4 months earlier was found in colonoscopy to have an ulcerated tumor at the anastomosis line. Biopsy specimens showed adenocarcinoma, necessitating partial resection of the bowel including the anastomotic recurrence. Case 2: A 70-yearold man undergoing right hemicolectomy with FEEA for advanced cancer of the transverse colon 2 years earlier was found in colonoscopy to have an ulcerated tumor at the anastomosis line, necessitating partial resection of the bowel including the anastomotic recurrence. In so far as we know, 14 cases of anastomotic recurrence after FEEA for colon cancer have been reported in the Japanese literature. Intraoperative rectal irrigation before stapled anastomosis is the established standard for low anterior resection of rectal cancer to minimize implantation metastasis at the anastomosis site. Our experience together with that reported in the literature underscores the need for intraluminal irrigation or bowel cleansing before FEEA. Simple, effective means for intraoperative bowel irrigation or cleansing and anastomosis procedures for FEEA must thus be developed to prevent anastomotic recurrence.

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We report a case of endometrioid adenocarcinoma arising from rectal endometriosis. A 70-year-old woman with constipation and lower abdominal pain was diagnosed with a submucosal rectal tumor based on colonoscopy, pelvic computed tomography and magnetic resonance imaging. Following low anterior resection, the tumor measured 5.3×3.4×3.5cm. Sectioning showed brown fluid and a white, partially solid mass within the tumor. Well-differentiated adenocarcinoma contiguous with endometriosis extended from the adventitia into the rectal submucosa, CD10 and cytokeratin (CK) immunostaining was done. Spindle cells surrounding the endometrial glands showed reactivity for CD10, which was the marker for endometrial stromal cells. Tumor cells were positive for CK7 but negative for CK20, making the definitive diagnosis endometrioid adenocarcinoma arising from rectal endometriosis. Malignant metastasis from endometoriosis is extremely rare, and immunohistochemical staining in addition to usual histopathology is critical in confirming the diagnosis of this endometoriosis-associated intestinal tumor.

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In the present study, 15 patients with pseudomyxoma peritonei (PMP) were treated and correlation between Peritoneal Carcinomatosis Index (PCI) and degree of malignancy were studied for the introduction of PCI as a tool to select the treatments for PMP. PCI is the indicator of distribution and amount of peritoneal dissemination. In 15 patients, male: female ratio is 2:1, the mean age is 57. To make pathological diagnosis, HE stain, mucin stain and immunohistochemical stain were done. For all patients, results of mucicarmin stain, MUC2 stain and MUC5AC stain were positive. So diagnosis was confirmed as PMP. In these 15 patients, one and 12 cases originated from ovary and appendix respectively. According to the Ronnet. s histological classification, 8, 6 and 1 were diagnosed as peritoneal mucinous carcinomatosis (PMCA), PMCA intermediate malignancy, and disseminating peritoneal adenomucinosis respectively. Complete cytoreduction was done in 2 patients and PCIs of those were 9 and 10. On the other hand, PCIs of 13 patients who had received incomplete cytoreduction ranged from 22 to 35 (mean 29.5). Two patients who had received complete cytoreduction are still alive without recurrence. PCI is a useful indicator of malignancy for PMP. It is very important to calculate PCI before attempt the surgical therapy in PMP.

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