Introduction: We evaluated serum vitamin A and E in patients undergoing gastrectomy for gastric cancer. Patients and Methods: Subjects were 55 patients-35 men and 20 women with a mean age of 66.7 yearswho had undergone gastrectomy for gastric cancer and had no evidence of recurrence. Surgery involved subtotal gastrectomy in 29 and total gastrectomy in 26. We measured postoperative white (WBC) and red blood cell counts, hemoglobin, hematocrit, platelets, and serum levels of vitamins E, vitamin B12, folic acid, total cholesterol, triglycerides, total protein, albumin, and body mass index. Results: Serum vitamin A levels decreased in 1 (1.8%) of the 55 and serum E levels in 12 (21.8%). Low vitamin E was associated significantly with low total cholesterol, low vitamin A, and high WBC count. Low vitamin E was significantly more frequent in the total gastrectomy group than in the subtotal gastrectomy group. In light of reconstruction procedures, the incidence of low vitamin E was significantly higher in patients without food passage through the duodenum. Discussion: While we assume that vitamin E deficiency is more common than thought, further assessment is needed to determine the relationship between gastrectomy for gastric cancer and vitamin A and E levels.

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A 59-year old man admitted for anorexia was found to have advanced poorly differentiated gastric adenocarcinomawith abdominal paraaortic lymph node metastasis, clinical stage IV (T4 (SI) N3H0P0M0). Since curative surgery was deemed not possible, we started chemotherapy using TS-1 (120mg/day) orally administered for three weeks and cisplatin (CDDP)(100mg/body) administered intravenously on day 8. After grade 3 pancytopeniadeveloped, we reduced TS-1 to 100mg/day and CDDP to 70mg/body. After two courses of chemotherapy, the primary lesion shrank and paraaortic lymph node metastases were no larger noted in abdominal computedtomography, achieving down-staging to clinical stage IIIA (T3 (SE) N1H0P0M0). After upper abdominalevisceration and dissection of a paraaortic lymph node (D3), cancer cells disappeared in both the main tumorand lymph nodes, and histological efficacy was evaluated as grade 3. He has had no recurrence as of 27 months postoperatively.

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A 58-year-old woman diagnosed with gastric carcinoma underwent total gastrectomy with D2 lymph node dissection in September 2005. The definitive diagnosis was f Stage IIIB gastric carcinoma (pT3, pN2, sH0, sP0, pCY0, cM0) and surgery had curability B based on the Japanese classification of gastric carcinoma, 13^th edition. Histological findings of resected specimens showed poorly differentiated non solid adenocarcinoma (por 2). She underwent adjuvant chemotherapy at 100mg/day of oral TS-1 from November 2005. She reported an abnormal throat sensation 3 days after beginning TS-1 treatment. Her left palatine tonsil had swollen to 30mm and biopsied samples showed group V (por2). The left tonsillar tumor was diagnosed as metastasis from gastric carcinoma, because the biopsied samples were similar pathologically to the resected gastric specimen. No other metastatic sites were seen in computed tomography. A complete response was acquired in the metastatic tonsillar tumor 14 days after TS-1 treatment and maintained for 8 months in June 2006. TS-1 treatment may thus contribute to good quality of life and improved poor prognosis.

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A 74-year-old woman, treated with ulsodeoxycholic acid for 10 based on a diagnosis of primary biliary cirrhosis (PBC) and referred for bloody stool was diagnosed as having a bleeding gastric ulcer and pyloric stenosis due to advanced gastric cancer, necessitating distal gastrectomy with D2 lymph node dissection and liver biopsy. Macroscopically, a type 1 tumor was located from the pyloric antrum to the duodenum, and was found histopathologically to be poorly differentiated adenocarcinoma invading to the muscular layer. The final stage of gastric cancer was IB. An Ul-II ulcer was also seen in the anterior wall of the gastric body, and Helicobacter pylori was detected from the background mucosa. Histologically, the liver biopsy indicated stage 3 based on Scheuer. s classification. The postoperative course was uneventful except for transient liver dysfunction. The patient was discharged on postoperative day (POD) 31. Patients with PBC sometimes have extrahepatic malignancies, and reports of gastric cancer coexisting with PBC are relatively rare. Gastric cancer occurring more than a decade after PBC diagnosis is very rare. Patients with PBC should thus be examined carefully for extrahepatic malignancies, including the gastrointestinal tract during follow-up.

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We report a rare case of primary gastric lymphoma with spontaneous perforation. An 84-year-old woman admitted elsewhere for anorexia and diagnosed with gastric diffuse large B cell lymphoma suffered acute abdominal pain after a meal 1 day after admission to our hospital. Based on a diagnosis of a gastric perforation due to malignant lymphoma, we conducted emergency surgery, finding a 1cm perforation in the middle greater curvature of the stomach. Due to the woman's poor condition and an age, we temporarily closed the perforation with an omental patch and, 27 days later when her condition had improved, we conduced distal gastrectomy. Eight weeks and 2days after initial surgery, she was transferred to the internal medicine department. In so far as we know, only 24 spontaneous perforations in gastric malignant lymphoma, including our case, have been reported in the Japanese literature in the last 23 years.

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A 47-year-old man admitted in April 2006 for upper abdominal pain was found in laboratory data to have an elevated white blood cell count of 15, 200/mm³ and CRP of 22.63mg/dl. Abdominal computed tomography indicated a nonenhanced intraabdominal tumor connected to the stomach wall and ascites assumed to be blood. After inflammation decreased, we conducted distal gastrectomy for the tumor, which was located on the gastric wall and connected widely to the greater curvature of the antrum. Histopathologically, the tumor was hyperplasia of spindle cells with lymphocyte and plasma cell infiltration. Immunohistrogically, however, spindle cells were positive for vimentin, smooth muscle actin, and desmin indicating myofibroblasts. From these findings, we made a difinitive diagnosis of a rare omental inflammatory myofibroblastic tumor.

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A-73-year-old man infected with hepatitis type B virus and suffering upper right abdominal pain was hound in dynamic enhanced computed tomography (CT) to have 16×15×12cm hepatocellular carcinoma in the middle and right hepatic lobes, and invasion to V3 was suspected. Reconstructire 3-dimensional CT showed that the left hepatic vein diverged to confluence with V2 and V3 near the root, and V3 was compressed for 3cm by the A-73-year-old man infected with hepatitis type B virus and suffering upper right abdominal pain was hound in dynamic enhanced computed tomography (CT) to have 16×15×12cm hepatocellular carcinoma in the middle and right hepatic lobes, and invasion to V3 was suspected. Reconstructire 3-dimensional CT showed that the left hepatic vein diverged to confluence with V2 and V3 near the root, and V3 was compressed for 3cm by the tumor. We conducted right trisegmentectomy with vein reconstruction. The 1cm diameter Gore-Tex^®. expanded polytetrafluoroethylene graft was interposed between the segment 3 vein and inferior vena cava. Histpathological diagnosis was moderately differentiated hepatoceller carcinoma with capsule and septum. There was no vascular or biliary invasion. The surgical margin was free of invasion. The postoperative course was uneventful, and the man started to receive warfarin on postoperative day (POD) 6. He was discharged on POD 19. CT examination 6 months postoperatively showed graft patency. He remains alive with remnant liver recurrence and bone metastasis 1 year after operation.

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A 77-year-old man admitted for obstructive jaundice was found in endoscopic retrograde cholangiopancreatography to have stenosis of the inferior bile duct with an irregular wall. The presence of atypical cells in brushing cytology suggested adenocarcinoma. Following endoscopic biliary drainage, we conducted pyloruspreserving pancreaticoduodenectomy, finding a 2.3×1.5cm infiltrating nodular tumor considering histologically of adenocarcinoma on the mucosal side and fascicular atypical spindle cell proliferation (so-called spindle cell carcinoma) and angiosarcoma-like features on the invasive side of the bile duct. The definitive pathological diagnosis was inferior bile duct cancer with sarcomatous change. Despite chemotherapy treatment for multiple liver metastasis detected 6 months postoperatively, he died of the metastatic liver tumor 1.5 years thereafter. Only 15 cases of bile duct cancer with sarcomatous change or spindle cell carcinoma have, to our knowledge been reported in worldwide, and we report this case and review the literature.

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We experienced a case of signet ring cell carcinoma of the gallbladder which is rare as primary tumor of the gallbladder. The patient was a 70-year-old male. He had an operation of laparoscopic cholecystectomy with the diagnosis of cholecystolithiasis at the Hokkaido hno Hospital. A slightly elevated (IIa) whitish lesion (8×7mm) was detected on the mucosal surface of the abdominal side of the resected gallbladder body. Pathological diagnosis was signet ring cell carcinoma, slightly infiltrating into subserosa, and no other histological structure of malignant cells were detected. Lymphatic or venous infiltration was not detected. He was admitted to Surgical Oncology Hokkaido University for he treatment. CT denied residual cancer or lymphatic metastasis, but we decided to add operation. The operation method was cuneiform resection of the liver bed, and resection of the bile duct and D2 lymph node. He had no postoperative complication and the pathological examination indicated no residual malignant cell. He is alive without recurrence 34 months after the operation. Signet ring cells of the gallbladder tend to coexist with other histological forms of malignant cells, but in this case the signet the bile duct and D2 lymph node. He had no postoperative complication and the pathological examination indicated no residual malignant cell. He is alive without recurrence 34 months after the operation. Signet ring cells of the gallbladder tend to coexist with other histological forms of malignant cells, but in this case the signet well as in the stomach.

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Paraaortic lymph node metastasis has a dismal prognosis in patients with gallbladder carcinoma. We report a case of a gallbladder cancer patient with paraaortic nodal disease who survived over 5 years after resection. A 65-year-old man with locally advanced gallbladder cancer underwent radical resection involving cholecystectomy, wedge resection of the gallbladder bed, pancreaticoduodenectomy, and regional and paraaortic lymph node dissection. Histologic examination showed the primary tumor to be adenosquamous carcinoma with four positive lymph nodes, one of which was a dissected paraaortic node. The patient underwent repeat lymphadenectomy for paraaortic nodal recurrence detected by computed tomography 29 months after the initial resection. Some 36 months later, metastasis to soft tissue in the right knee was managed by amputating the right lower limb above the knee and that to the second lumbar vertebra by external-beam radiation. Left supraclavicular nodal disease found 60 months after the initial resection was resected. The man died of multiple pulmonary metastases 77 months after the initial resection. This case and a review of the literature suggest that paraaortic lymph node dissection may provide a survival benefit for selected patients with gallbladder carcinoma.

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We report a rare case of peritoneal metastasis of an intraductal papillary-mucinous neoplasm (IPMN) of the pancreas presenting pseudomyxoma peritonei. A 58-year-old man seen for a cystic tumor of the pancreatic head, was found in CT, MRCP and US to have multilocular cystic lesions in the pancreatic head and dilation of the entire main pancreatic duct. EUS showed thickening of the septum and mural nodule in the cystic tumor. We conducted pylorus-preserving pancreaticoduodenectomy in September 1995. The mucus-containing cystic tumor was 2cm in maximum diameter. The pathological diagnosis was noninvasive intraductal papillary carcinoma of the main pancreatic duct and branches. In January 2003, seven years and three months later after initial surgery, the 66-year-old patient was readmitted for hematochezia and abdominal distention. Serum CEA was 166.9ng/ml and CA19-9 was 10, 495U/ml. CT showed massive ascites and dilated intestines. Cytology of the ascites showed clustered epithelial cells and mucus. Pathological reexamination of the resected specimen showed cancer nests in mucus near the surgical margin. The patient deteriorated and died in February 2003 despite systemic chemotherapy with gemcitabine. An autopsy showed numerous gelatinous nodules of different sizes throughout the abdominal cavity. Histologically, cancer nests consisting of atypical mucinous cells with papillary growth floated in the mucinous material. Cancer was not found in the remnant pancreas. The definitive diagnosis was peritoneal dissemination from the original IPMN of the pancreas.

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We report a case of resected locally advanced pancreatic adenocarcinoma after chemoradiation therapy. A 54year-old man diagnosed elsewhere with locally advanced pancreas carcinoma was found in computed tompgraphy (CT) to have a pancreatic head lesion of 20mm invading the plexus of the supramesenteric artery and to the portal vein system. We found no hepatic or distant metastasis. Based on these findings, we conducted radiation therapy (50.4Gy/28 Fr) and chemotherapy (Gemcitabine at 200mg/week, full dose, 1, 000mg) as neoadjuvant therapy. Reevaluation CT after chemoradiation therapy showed no changes around the lesion (SD) and no distant metastasis. Based on these findings, we conducted pancreaticoduodenectomy with portal vein reconstruction two months after the chemoradiation therapy was completed. Pathological finding showed that a small amount of moderately differentiated adenocarcinoma cells were scattered in fibrous tissue. The pathological diagnosis was p Stage IVa with plexus invasion and without portal or artery invasion. No metastasis was observed in the lymph nodes. The postoperative course was uneventful, and the man remains well without recurrence in the 12 months since surgery. Preoperative chemoradiation therapy is thus a treatment alternative for locally advanced pancreatic carcinoma.

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Methotrexate-lymphoproliferative disorder in rheumatoid arthritis patients treated with Methotrexate. We reported a case of splenic T-cell malignant lymphoma in a patient with rheumatoid arthritis treated with Methotrexate. A 73-year-old woman treated with Methotrexate for 10 years showed high levels of CA125 334.8U/ml and IL-2 receptor antibody of 4, 390U/ml. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging showed mass lesions in the spleen. FDG-PET showed splenic FDG accumulation. Based on a diagnosis of malignant splenic lymphoma, we conducted manually assisted laparoscopic splenectomy.

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We present a rare case of advanced jejunal cancer with good response to TS-1 chemotherapy. A65-year-old woman admitted for appetite loss and vomiting, was found in enhanced abdominal CT to have thickening of jejunum wall and a large tumor mass on the right side of the ascending colon. Contrast examination of the small intestine showed local jejunum stenosis and dilation at its oral site. Chest CT showed two metastatic tumor nodules at right S8a 12mm in diameter and the left S1+2 5mm in diameter. Partial jejunectomy to reduce her ileus syndrome showed that the 5×3cm jejunal tumor measuring was mucinous adenocarcinoma with multiple disseminated nodules in the peritoneum. Postoperative chemotherapy with TS-1 for 24 months gradually reduced X-ray shadows of peritoneal and pulmonary metastases and she remains apparently healthy at present.

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We report a rare case of septic shock and acute respiratory distress syndrome (ARDS) associated with nonperforating appendicitis. A Japanese man in his 30s diagnosed with acute nonperforating appendicitis, treated conservatively with antibiotics upon admission, suffered severe septic shock the next day, necessitating emergency appendectomy. The appendix was gangrenous but not perforated macroscopically. After surgery, the patient suffered severe ARDS. He was treated with mechanical ventilation and endotoxin absorption therapy using polymyxin B-immobilized fiber direct hemoperfusion (PMX-DHP), enabling him to recover from sepsis and ARDS. Nonperforating appendicitis with severe sepsis are very rare, and only 7 cases, including our, have been reported in Japanese literature. It may thus be important to recognize the existence of nonperforating appendicitis with severe sepsis or ARDS.

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A 53-year-old man admitted for epigastralgia, anorexia, and high fever and undergoing right hemicolectomy based on a diagnosis of transverse colon cancer was found in histological examination to have poorly differentiated stageII colon adenocarcinoma. Fever appeared 2 months surgery and abdominal computed tomography (CT) showed a low-density mass 2.5cm in diameter in the posterior hepatic segment. Following treatment for a liver abscess, the mass grew after 1 month and was diagnosed by liver biopsy as liver metastasis from the colon cancer. After right hepatic lobectomy, fever reappeared 1.5 months later. Abdominal CT showed a lowdensity mass 2.5cm in diameter in the residual liver, suggesting recurrent liver metastasis. We started 3 courses of chemotherapy with l-LV/5-FU (RPMI regimen), after which abdominal CT showed a complete response. The patient remains recurrence-free at this writing 3 years and 4 months after chemotherapy ended.

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A 71-year-old man undergoing an overnight checkup for pollakiuria and gastromegaly was suspected from labo data to have hyperglycemia, ketonuria (DKA), and metabolic acidosis, and diagnosed with diabetic ketoacidosis. Despite conservative treatment, his gastromegaly gradually worsed, and abdominal CT suggested occlusion of the inferior mesenteric artery (IMA), poor blush of the intestinal wall within the limits of the IMA, and rectal stenosis. Colonoscopy suggested stenosis of the rectum and extensive necrosis at the oral site, yielding a diagnose of extensive colon necrosis caused by inferior mesenteric arterial occlusive disease, necessitating emergency surgery. A necrotic lesion extended from the descending colon to the rectum. We resected the necrotic colon and reconstructed it by end-to-end anastomosis, followed by ileostomy. The postoperative course was uneventful. The cause of disease in this case appeared to be severe hypovolema by DKA causing arterial occlusion.

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A 75-year-old woman was admitted for abdominal pain and vomiting was found in abdominal findings to have a tender 15×10cm mass. Abdominal computed tomography showed no aponeurosis at the lateral margin of the right rectus abdominis muscle and the omentum and intestinal tract projecting out of the abdominal cavity. X-ray examination of the small intestine showed no stenosis or dilation. Under a diagnosis of multiple Spigelian hernia, we resected the two hernia sacs and closed the orifice of the hernia with interrupted sutures. Spigelian hernia is uncommon in all abdominal wall hernia and multiple Spigelian hernia is even rarer.

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Case 1: A 67-year-old man admitted for lower abdominal pain and muscular rigidity with tenderness in the lower abdomen was found in abdominal computed tomography (CT) to have intraperitoneal free air, ascites, and wall thickening in the sigmoid colon. Preoperative electrocardiography showed findings within normal limits. Under a diagnosis of sigmoid colon perforation, we partially resected the sigmoid colon and constructed a terminal colostomy. The man suddenly developed ventricular tachycardia in electrocardiography just after surgery ended and before extubation. Coronary angiography for suspected coronary ischemia showed normal arteries, but left ventriculography showed apical akinesis and basal hyperkinesis. Left ventricular function normalized on postoperative day 18. The man was discharged from our hospital on postoperative day 78. Case 2: An 80-year-old man admitted for pyloric stenosis had preoperative electrocardiography and echocardiography findings within normal limits. Under a diagnosis of gastric cancer, we conducted a distal gastrectomy (D2). He suddenly developed cardiogenic shock and dyspnea five hours postoperatively. Mechanical ventilation support and infusion of dopamine and dobutamine was started, but his systolic BP was still around 60mmHg. Coronary angiography for suspected coronary ischemia showed normal arteries, but left ventriculography showed apical akinesis and basal hyperkinesis. Left ventricular function could not be normalized, and he died of cardiogenic shock two days postoperatively. The prognosis of takotsubo cardiomyopathy is generally thought to be good. We present a rare case of cardiogenic shock as a complication of takotsubo cardiomyopathy, with the patient dying two days after surgery. It is thus important for surgeons to recognize the possibility of critical complications of takotsubo cardiomyopathy occurring after gastrointestinal surgery.

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A 63-year-old woman diagnosed with sigmoid diverticulum perforation, underwent intraabdominal irrigation and sigmoid colostomy. Despite septic shock intraoperatively, no increase in intraabdominal pressure was apparent at closure of the abdominal wall. After large-volume fluid therapy and continuous hemodiafiltration, elevated peak airway pressure was recognized and intrabladder pressure measured at 30mmHg on postoperative day 5. Abdominal compartment syndrome was diagnosed, necessitating emergency surgery. Segmental necrosis was seen at flexures of the ileum, so the ileum was transected 150cm orally and the ascending colon was transected in half. Both stumps were used to form ileostomy and colostomy. The abdominal wall was opened and conventional vacuum packs applied. On POD 5 after reoperation, intestinal edema decreased together with intraabdominal pressure. Following resuturing of the abdominal wall, her general condition gradually improved and she was discharged 15 months later. Bowel necrosis following abdominal compartment syndrome is lethal, and elevated intraabdominal pressure must be detected as early as possible. We found monitoring of peak airway pressure under respirator control to be useful in detecting this condition early.

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