Aim: The physical condition and quality of life of the patients who had distal subtotal gastrectomy were well studied, however the condition of psychological health of these patients is remained to be evaluated.Patients and methods: The General Health Questionnaire 28 (GHQ28) was used to interview 67 patients without signs of recurrence 12 months or more after distal subtotal gastrectomy and D2 lymph node dissection for gastric cancer. Higher GHQ scores mean poorer psychological health. Information about gastrointestinal symptoms was also obtained.Results: The GHQ score of the patients who underwent Billroth II reconstruction (n=21) was 7.2±5.0 and significantly higher than the scores of the patients who underwent Roux-Y (3.2±3.2, n=27, p<0.01) or Billroth I (3.8±4.6, n=19, p<0.05) reconstruction. At least one gastrointestinal symptom was present in 86% of the patients who underwent Billroth II reconstruction. The incidence of symptoms was significantly higher after Roux-Y (41%, p<0.01). The incidences of bitter reflux, nausea, and diarrhea were significantly higher in the Billroth II group than in the Roux-Y group.Conclusion: In preserving psychological health and reducing postoperative symptoms, Billroth II reconstruction should be avoided, when compared with Roux-Y or Billroth I reconstruction.

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Spontaneous esophagus rupture, a relatively rare disease usually due to vomiting in over drinking of alcohol, has a dismal prognosis if diagnosis and treatment are delayed. We report a case of spontaneous esophageal rupture suspected being caused by femoral hernia incarceration. An 86-year-old woman seen for emergency hematemesis had a slightly bulging abdomen, but no tenderness or peritonitis. Abdominal X-ray photography showed small amounts of intestinal gas, and abdominal computed tomography (CT) showed right femoral hernia incarceration and small intestinal ileus, with apparent free air seen around the esophagus. We conducted esophagoscopy to diagnose the free air or esophagus lumen after repairing the femoral hernia incarceration, conducting emergency surgery on a diagnosis of spontaneous esophageal rupture, followed by primary closer and fundic patch. The woman was discharged without complications.

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Granulocyte-colony stimulating factor (G-CSF)-producing gastric cancers are rare, and only 34 cases, including our own, have been reported in Japan. We report a case of gastric cancer in a patient with a high level of serum G-CSF preoperatively that was immunohistologically diagnosed as a G-CSF-producing gastric cancer. A 67-year-old man admitted to our hospital for epigastric pain was found to have type 1 gastric cancer in the upper gastric body by gastrointestinal endoscopy, and biopsy revealed poorly differentiated adenocarcinoma. The preoperative laboratory data revealed leukocytosis (19, 090/μl) and a high serum level G-CSF (91pg/ml). Total gastrectomy plus splenectomy was performed in June 2005. Postoperatively, leukyocytosis was improved, with the leukocyte count decreasing to a nadir 6, 760/μl, and the serum G-CSF level decreased to below 10pg/ml. The patient is alive 5 months postoperatively and recurrence-free. Immunohistochemical testing definite diagnosis of G-CSF producing gastric cancer was made.

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We report a case of hepatic resection for hepatic metastasis from colorectal cancer after radio frequency ablation (RFA). A 50-year-old man had multiple liver metastasis from colorectal cancer, and was admitted for complete liver tumor removal after partial RFA elsewhere. CT after RFA showed that each RFA lesion was hypovascular areas, which was larger than the size of the corresponding metastatic tumor, indicating that ablation made each tumor complete necrosis. However, after hepatic resection including RFA ablated lesions, postoperative histopathological findings showed viable tumor cells in ablated lesions in all resected specimens. Hepatic resection is widely accepted as the treatment of choice in colorectal hepatic metastasis, but the definite efficacy of RFA has yet to be established. Serious post-RFA complications such as local recurrence and tumor seeding have been reported, indicating that RFA should be carefully considered before being attempted in treating colorectal hepatic metastasis.

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We report a case of a 61-year-old woman with hilar carcinoma arising from the extramural peribiliary gland, a rare origin for biliary malignancy. Computed tomography (CT) showed a solid tumor 15mm in diameter closely localized to the hepatic hilus. A papillary-growing tumor at the confluence of the hepatic duct was showed by ERC and cholangioscopy. Based on a diagnosis of hepatic duct cancer that may invade the liverforming a solid tumor, we conducted left hepatectomy with extrahepatic bile duct resection. Papillary adenocarcinoma ormed a mass within the extramural peribiliary gland of the left hepatic duct and spread the hepatic ilus without obvious invasion into the surrounding parenchyma. It was not easy to identify the origin of the tumor or to discriminate it preoperatively from mass-forming intrahepatic cholangiocarcinoma. Wellcircumscribed nd spotty enhancement by CT may reflect the nature of papillary and expansive growth tumor.

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A 53-year-old man was admitted for right hypochondralgia, and CT and MRI revealed a mass 3cm in diameter in the head of the pancreas and enlarged lymph nodes around the celiac trunk. Magnetic resonance cholangiopancreatography (MRCP) showed common bile duct stenosis in the head of the pancreas. Tumor marker levels were within normal limits (CEA, CA19-9). We performed pylorus-preserving pancreatoduodenectomy with regional lymph node dissection, because of strong suspicion of pancreatic cancer. Microscopic examination of the resected specimen showed a granuloma with eosinophlic infiltration, which was highly suspicious of infiltration by parasites, but we were unable to identify any cancer cells or worms in the mass. A serodiagnostic assay by microenzyme-linked immunosorbent assay using monoclonal antibodies specific for Anisakis antigens led to a diagnosis of pancreatic anisakiasis. The postoperative course was favorable, and the patient was discharged 38 days after surgery. Only four cases of pancreatic anisakiasis, including our own, have ever been reported.

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A 54-year-old man suffering abdominal injuries in a traffic accident underwent emergency laparotomy due to shock following massive intraperitoneal hemorrhage. During surgery, we discovered damage at the head of the pancreas, but due to the potential hazard of pancreatic resection, we only controlled bleeding and drained pancreatic fluid. After the operation, his general condition was improved, but pancreatic fluid continued leaking.We diagnosed this as main pancreatic duct injury using endoscopic retrograde pancreatography (ERP). We percutaneously filled the fistula with fibrin glue to stop leakage because secondary surgery (pancreatoduodenectomy) was considered difficult. The fistula was closed without pancreatitis appearing, and he left hospital afterwards. He was hospitalized two months later for pancreatitis with a pancreatic pseudocyst 4cm in diameter. After percutaneous drainage, we attempted endoscopic transpapillary stenting. ERP showed that the proximal main pancreatic duct was connected by a pancreatic pseudocyst, so we inserted a stent from the main pancreatic duct to the pseudocyst. Pancreatic fluid leakage gradually decreased thereafter, although the stent came off naturally one week later. Six months later, pancreatic fluid leakage ceased completely, so the percutaneous drainage tube was removed. The patient remains in good condition without evidence of pancreatitis or pancreatic pseudocyst.

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A 26-year-old woman admitted with epigastralgia and duodenal bleeding was found in enhanced computed tomography (CT) to have a 50mm low-density mass in the pancreatic head invading the duodenum, and involving the hepatic artery and portal vein. She underwent hepatic arterial resection combined with pancreaticoduodenectomy (PD) and her postoperative course was uneventful. Pathological examination showed that the tumor consisted of moderately differentiated tubular adenocarcinoma, a common type of pancreatic ductal carcinoma. Adjuvant chemotherapy using Gemcitabine was performed at the outpatient clinic, but local recurrence developed 8 months after surgery. A total radiation dosage of 50.4Gy was used with the administration of 5-FU. Gemcitabine has been used until now and she is doing well without evidence of disease 18 months after chemoradiotherapy. Surgical resection has been considered contraindicated in patients with pancreatic cancer involving a major artery because of extremely poor survival. Our case suggests, however, that arterial resection combined with PD may be safe and effective in highly selected patients.

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We report a case of superior mesenteric vein thrombosis (SMVT) caused by protein C deficiency. A 63-yearold man with nausea and epigastralgia treated for acute enteritis had had a quite normal stomach appearance in his gastrointestinal endoscopy examination, but his symptoms did not improve so he went to the hospital again. During this visit, doctors decided via computed tomography and multiplanar reformation that he may have SMVT. We conducted emergency laparotomy, finding hemorrhagic ascites and congestive necrosis of the small intestine. We removed the thrombus in the superior mesenteric vein, resected the necrotic segment of the small intestine (90cm, including a seemingly normal section), and conducted end-to-end anastmosis. We observed patency of the superior mesenteric artery and occlusion of the superior mesenteric vein with the thrombus. A preoperative coagulation study showed low levels of and as lowered activity of the protein C antigen. We have reviewed the two cases reported in the Japanese literature of SMVT caused by a protein C deficiency, and we make this report to broaden knowledge available on this topic.

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We report a case of multiple gastrointestinal stromal tumors (GISTs) of the jejunum associated with von Recklinghausen's disease (R.s disease). A 54-year-old man with R.s disease had multiple neurofibromas and pigmented macules over the entire skin surface and was admitted to our hospital for anemia. Gastrointestinal fiberscopy revealed a hemorrhagic submucosal tumor on the third portion of the duodenum. At laparotomy a submucosal tumor was observed distal to the ligament of Treitz. and multiple submucosal tumors were found in the small intestine. We performed local resection and enucleations of the jejunum. These tumors were immunohistochemically positive for KIT and CD34, and negative for desmin and S100. However, genomic analysis of c-kit did not show any mutations. In sporadic GIST, 90% of the cases have been found to be caused by a gene mutation of c-kit and 5% by a gene mutation of PDGFR α. Recent studies have demonstrated the absence of the c-kit gene or a PDGFR α mutation in GISTs from NF1 patients. R.s disease is caused by a mutation of the NF1 gene on chromosome 17q11.2 that encodes the tumor suppressor gene neurofibromin. Disorders of neurofibromin due to mutations of NF1 cause tumorigenesis. We report multiple GISTs of the jejunum in a patient with R.s disease in whom no functional mutations were found in c-kit or PDGFR α.

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We repossrt a case of appendiceal metastasis from lung cancer with acute appendicitis. A 65-year-old man underwent left pneumonectomy and mediastinum lymphnode dissection for left lobe lung cancer at the age of 64. Nine months later, suffered recurrent lymph node metastasis undergoing radiation therapy. He suffered right lower abdominal pain during radiation therapy, found to be due to acute appendicitis with a tumor. He received antibiotic therapy with fasting, temporarily improving, but an appendicitis requiring surgery. The surgical specimen showed a 6cm mass on the back of the cecum. This tumor was diagnosed as appendiceal metastasis because the histology of carcinoma resembled the previous specimen from left lung cancer. Pathological findings showed poorly differentiated adenocarcinoma with abscess formation. Carcinoma mainly involves proper muscles and invades the mucosa and subserosa. He died of pneumonia 12 months after his last surgery. We discuss therapy for metastatic appendiceal tumor with appendicitis in cancer patients and review the literature.

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We report a case of collision tumor with cecal adenocarcinoma and appendiceal mucinous cystadenocarcinoma associated with ulcerative colitis. A 62-year-old man treated with prednine and salazopyrin since suffering ulcerative colitis at 27 years of age stopped taking his medicine after entering remission in 1998. He then suffered anemia in November 2004. Colonoscopy showed findings compatible with mild ulcerative colitis, and detected a type-2 tumor in the cecum that proved in a biopsy to be well differentiated adenocarcinoma. He underwent right hemicolectomy in February 2005. The postoperative macroscopic specimen showed another appendiceal tumor filled with mucin inside next to the cecal tumor, i. e., two different types of carcinoma, welldifferentiated adenocarcinoma and mucinous cystadenocarcinoma, colliding at a clear boundary without intermingling. These findings satisfy rigorous criteria for collision tumor. Primary colorectal collision tumor is rare, and this case may be the first reported with both of these components.

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A Japanese woman in her 50s admitted for abdominal pain, anorexia and dysgeusia from December 2002 gradually showed finger chromatosis, nail plate atrophy, glossitis, and a 10kg weight loss in two months. We diagnosed the case as Cronkhite-Canada syndrome. Symptoms were ameliorated by conservative treatment. Readmission was required in November 2004.Though we performed conservative treatment, bowel obstruction occurred. Colonography showed multiple granular tubercles in the ascending colon and ileal obstruction. We conducted laparoscopic ileocecal resection. Pathological diagnosis showed an inflammatory polyp of about 25cm at terminal ileum and advanced edema. The postoperative course was good and blood albumin improved to 4.4g/dl, body weight increased and diarrhea, chromatosis, depilation, and nail plate atrophy were resolved in 2POM. We concluded that surgery is a choice of the treatment in patients who do not respond to conservative therapy.

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We report a case of rectal cancer in a rectal diverticulum with the periproctal abscess. The patient was a 58year-old man with anal pain and high fever. He was diagnosed with cancer in the lower rectum and a periproctal abscess and fistula from at the lower margin of the tumor. After controlling the inflammation, we performed an abdominoperineal excision of the rectum for a preoperative diagnosis of rectal cancer with penetration. Examination of the surgical specimen revealed a cancer in diverticulum at 1.5cm distal to the type I tumor. The cancer in diverticulum made the fistula to the abscess cavity. Histopathological examination revealed that the cancer in diverticulum was moderately differentiated adenocarcinoma but the proximal lesion was well to moderately differentiated adenocarcinoma that had invaded to the sub-adventitia (a₁). We failed to detect the cancer in diverticulum before surgery. Cancer in the rectal diverticulum is very rare, but it has possibility of penetration in early stage and small lesion. We must be considered the possibility of malignant diseaseon patients with a periproctal abscess.

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A 68-year-old man admitted for abdominal fullness was found in Computed tomography (CT) and magnetic resonance imaging (MRI) to have a homogeneously enhanced right retroperitoneal tumor with focal calcification adjacent to right kidney and right psoas muscle. Abdominal ultrasound showed a tumor with calcification dominant in the center of highly echoic parts. Angiograpy of the right renal artery and right lumbar artery showed tumor staining. We resected the tumor. The 24.5×20.5×11.5cm tumor adhered to the inferior pole of the right kidney and weighed 1, 600g. Histological examination showed mature adipose tissue with collagen fiber, including trabecular bone tissue. The definitive diagnosis was primary well-differentiated liposarcoma with metaplastic bone formation. The postoperative course was uneventful and the patient has survived 15 months since surgery with no evidence of recurrence.

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