Introduction: We review our work in adult intestinal transplantation at a European single center. Patients and Methods: In the last 7 years, we have conducted 29 isolated intestinal transplants in 28 adults whose underlying diseases were short bowel syndrome (17), intestinal failure (9), and intestinal tumors (2). Transplant indications were loss of venous access (15), recurrent sepsis (12) and electrolyte fluid imbalance (5). Immunosuppression was based on monoclonal antibodies using induction therapy. In the early period, daclizumab was used for induction, and tacrolimus and steroids were administered for maintenance. After 2002, we applied alemtuzumab or antithymocyte globulin as an induction agent with low-dose tacrolimus monotherapy maintenance. Results: Median follow-up was 977 days. Actuarial 5-year patient survival was 74% and graft survival 71%. Death was caused by sepsis and graftectomy mainly by rejection unresponsive to anti-rejection therapy. Among the 22 recipients alive, 19 (86%) have normal bowel function with a regular diet without parenteral support. Conclusions: Isolated intestinal transplantation in adults had 5-year patient and graft survival rates similar to those in other solid organ transplantation. Intestinal transplantation thus appears to be an effective alternative in patients with intestinal failure and/or short bowel syndrome; however, further study is needed to establish as standard treatment.

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We report a case of benign esophageal ulcer with an esophagomediastinal fistula treated by esophagectomy. A 49-year-old man with an esophageal ulcer who had undergone conservative therapy with H₂-blocker or PPI at a local hospital since September 1997 was referred in July 2003 due to deterioration of the ulcer and esophageal stenosis developing in response to medication. The cause was not clarified by 24-hour pH monitoring, pathological test, or other examination, indicating surgery that the man declined. He continued to undergone endoscopic balloon dilation and PPI administration, but suffered back pain and severe dysphagia in August 2007 due to mediastinitis after the ulcer perforated, necessitating surgery, which he agreed to. During esophagectomy via right thoracotomy, the ulcerous esophagus was found to tightly adhere to adjacent tissues. The ulcer perforated reached to the aorta. The postoperative course was uneventful, and he was discharged on postoperative day 27.

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Endocrine cell carcinoma (ECC) of the esophagus is a rare form of esophageal carcinoma having a dismal prognosis due to its aggressive malignancy. We report the case of a patient with ECC managed by resection and adjuvant chemotherapy. A 56-year-old man, suffering one month of postprandial epigastralgia, was found in esophagography and esophagoscopy to have an elevated 4cm lesion of the middle and lower thoracic esophagus. Biopsy specimens were histologically diagnosted as undifferentiated carcinoma. We judged the man to be a candidate for curative surgery after preoperative examination found no distant organ metastasis, lymph node metastasis, direct adjacent tissue invasion. We conducted thoracic esophagectomy with three-field lymph node dissection and retrosternal reconstruction by gastric tube. Immunohistochemically, the tumor in the resected specimen stained positive for synaptophysin, chromogranin A, and NSE, yielding a definitive diagnosis of nonsmall-cell ECC, pT2pN2M0 pStage III. Postoperatively, he underwent 4 courses of adjuvant chemotherapy with CDDP and VP-16. He remains alive without evidence of recurrence in the 37 months as of this writing. Operative indications should be carefully determined due to the high risk of invasiveness. Multidisciplinary treatment such as chemotherapy could bring relatively long survival even after radical resection.

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We report a very rare case of esophageal carcinoma composed of basaloid carcinoma and adenosquamous carcinoma components developing from the same area. The patient was a 71-year-old male who presented with a 3-month history of swallowing difficulty. He visited a nearby hospital, and was referred to our hospital with a diagnosis of esophageal carcinoma. On endoscopic examination, a all circumference type-3 lesion was recognized 34cm below the incisors. The lesion was diagnosed as a squamous cell carcinoma on biopsy, and complete excision of the thoracoabdominal esophagus was undertaken. Pathological examination of the excised specimens showed wide-ranging intraepithelial extension of the squamous cell carcinoma and infiltration of the basaloid carcinoma component into the submucosal layer and infiltration of the adenosquamous carcinoma component into the tunica externa. These areas of infiltration were recognized immediately beneath the carcinoma in situ. However, there was no evidence of transition from one area of infiltration to another. The findings were consistent with the diagnosis of a collision tumor. The stage was pT3pN0M0 and pStage II¹⁾ . This case the presence of the two infiltrating lesions of specific histological types immediately beneath the common intraepithelially extended lesion is extremely rare. With regard to the etiopathology, it was estimated that individual infiltrative lesions had developed from the same intraepithelial squamous cell carcinoma, based on the absence of evidence of transition from one area of infiltration to another.

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We present the case of a 53-year-old man diagnosed with thoracic esophageal cancer with brain and right scapular metastases. We conducted chemoradiotherapy for the primary lesion and scapula, and stereotaxic radiotherapy for brain metastasis. After reevaluation, we conducted subtotal esophagectomy followed by twofield lymphadenectomy and additional chemotherapy with docetaxel. The man remains progression free in the 21 months since the first therapy. It is rare for patients with stage IVb esophageal cancer to remain recurrence-free for such a long time. We discuss our case in light of a review of the literature.

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We report two resected cases of gastric granular cell tumors. Case 1: A 40-year-old man admitted after gastroscopy showed a submucosal tumor 1.5cm in diameter with a molar-like appearance at the greater curvature of the gastric fundus. Biopsy showed a granular cell tumor necessitating laparoscopic partial resection of the stomach. Case 2: A 42-year-old woman admitted for epigastralgia was found in gastroscopy to have a submucosal tumor 1.5cm in diameter on the lesser curvature of the lower stomach. Histological diagnosis was not accurate and a carcinoid tumor could not be ruled out, so we partially resected the stomach. Both resected specimens were microscopically located in the submucosal layer. Tumor cells were arranged in small clusters with long, abundant granular eosinophilic cytoplasm strongly positive for PAS and S-100 protein. Both cases were pathologically diagnosed as granular cell tumors. Such gastric tumors are rare, with only 32 cases reported in Japan.

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A 75-year-old man with acute myeloid leukemia brought to complete remission by systemic chemotherapy was diagnosed by gastrointestinal endoscopy with advanced gastric cancer of the upper stomach during examination for severe anemia. He underwent total gastrectomy with D2 lymphadenectomy. One year and 5 months later, he underwent magnetic resonance imaging (MRI) of the brain due to changes in personality and vomiting. MRI showed three cerebral metastases, but computed tomography (CT) of the chest and abdomen and ultrasound imaging of the abdomen found no other metastasis. Tumor markers were within normal limits. The brain tumor was biopsied because acute myeloid leukemia recurrence could not be ruled out, and histopa thological examination showed moderately differentiated adenocarcinoma consistent with gastric cancer, yielding a definitive diagnosis of brain metastases from gastric cancer. He underwent cyberknife radiosurgery to lessen clinical symptoms and was discharged. Although a second cyberknife radiosurgery was required for two brain metastases 5 months after initial radiosurgery, he is doing well without evidence of metastases to the brain, chest, or abdomen, one year after the diagnosis of brain metastasis.

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We report a rare case of metastatic colon cancer which occurred 13 years after gastric cancer surgery. A 69-year-old woman visited our hospital with complaint of postprandial abdominal discomfort. We suspected colon cancer with primary diffuse invasion to the transverse or metastatic colon cancer from barium enema and colonoscopy. Postoperative histological examination identified poorly differentiated adenocarcinoma identical to the gastric cancer that the woman had 13 years earlier. Finally, the lesion was definitively diagnosed as me-tastatic colon cancer from gastric cancer by immunohistological findings, that showed same pattern in mucin phenotype. We studied 54 cases (73 lesions) in reports in the literature from 2001to 2006. Histologically, metas tatic colon cancer from the gastric cancer often involved signet ring cell carcinoma or poorly differentiated adenocarcinoma. In 46. 3% of cases (25 cases), metastasis was detected 5 years or more after surgery. In fatal cases following reoperation, mean survival was 16. 6 months. Survival time was independent of the time to metastasis detection, and tumor markers were not effective in prediction.

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A 80-year-old woman admitted for vomiting without bile juice after meals, anorexia, and upper abdominal distension. Plain abdominal computed tomography (CT) findings showed a high-density 1×1.5cm foreign body inside the second portion of the duodenum. Upper gastrointestinal endoscopy showed severe duodenal stenosis, necessitating laparotomy. After an unsuccessful attempt to reduce the mass, it was removed via duodenotomy on the opposite side of the ampulla of Vater. The mass was a loquat seed, probably ingested one month earlier. The seed was impacted in the duodenum, and adhered to the duodenal mucosa. No obstruction was seen on the anal end of the duodenum. The stenosis was close to the ampulla of Vater, eliminating the need for structure-plasty. After the duodenotomy was closed, we conducted gastrojejunostomy. The patient's postoperative course was uneventful. The fact that abdominal CT clearly showed the loquat seed contributed to greatly to diagnosis, together with the patient's detailed history.

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A 53-year-old woman admitted for abnormal metabolic activity in the left lateral hepatic segment detected by ¹⁸F-fluorodeoxyglucose positron emission tomography had a history of cholecystolithiasis, choledocolithiasis, and acute pancreatitis. Abdominal enhanced computed tomography showed a ring-like enhanced tumor lesion 3cm in diameter in segment S3 of the liver, necessitating left lateral segmentectomy based on a preoperative diagnosis of cholangiocellular carcinoma. Macroscopically, the tumor, a yellowish white hard mass in the resected specimen, was considered cholangiocellular carcinoma. Postoperative pathological examination showed, however, that the lesion was not tumorous and had only fibrosis and proliferation of inflammatory cells and fibroblasts, leading to a diagnosis of granulomatous abscess. It is thus important to consider granulomatous abscess as a differential diagnosis of cholangiocellular carcinoma in a patient who has a history of biliary tract surgery.

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A 72-year-old male presented to our emergency room complaining of epigastralgia. Physical examination revealed jaundice and mild epigastric tenderness. Laboratory studies revealed a serum total bilirubin level of 4.6 mg/dl, serum GOT of 699IU/l, serum GPT of 477IU/l, and a WBC count of 10, 400/μl. A diagnosis of cholecysto-choledocholithiasis and cholecystitis with situs inversus totalis (SIT) was made, because the chest X-ray revealed dextrocardia and abdomial computed tomography (CT) showed complete transposition of the abdominal viscera. The patient was admitted and started on antibiotics. The day after admission, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and basket extraction of the multiple common bile duct stones was undertaken. Three dimensional (3D) CT revealed a right-left reversal of the biliary and vascular system without other additional anomalies. The following day, laboratory test results remained within normal limits, therefore, laparoscopic cholecystectomy (LC) was performed. The operation could be safely performed with the surgeon standing on the right side of the patient. The insertion sites for the trocars were prepared in reference to the 3D-CT images, and the operation was performed with the right hand using the double-hand technique. This is the first case in Japan, based on a thorough search of the literature search of LC after ERCP with sphincterotomy for cholecysto-choledocholithiasis in a patient with SIT.

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A 69-year-old man admitted for high fever and epigastralgia was found in abdominal ultrasonography (US) to have a cystic tumor at the tail of the pancreas. He recovered in conservative therapy using several antibiotics. Endoscopic retrograde pancreatography (ERP) showed mild deformity of the main pancreatic duct, but no abnormal findings for the papilla of Vater and no evidence of eosinophilic gastroenterocolitis in biopsy specimens of gastric and duodenal mucosa. Tumor marker serum levels were normal and no abnormal findings were seen in angiography examination. His case was diagnosed as inflammatory pancreatic tumor accompanied by chronic pancreatitis, and he was treated using several antibiotics, recovered in three weeks. Six months later, he was readmitted for recurrent pancreatic tumor, and treated again using antibiotics, but the cystic lesion at the pancreas tail remained in abdominal computed tomography. Because the existence of a malignant neoplasm could not be excluded, we conducted distal pancreatectomy with splenectomy. Histological findings for the pancreatic tumor showed marked eosinophilic infiltration of the parenchyma around the pseudocyst formation with fibrosis. The definitive diagnosis was eosinophilic pancreatitis. Twelve months post operatively, abdominal CT showed cystic lesion at the body of the pancreas, so he was treated using oral suplatast tosilate, after which the latest tumor was no longer detected in abdominal CT, and he has done well since.

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We report a rare case of adenosquamous cell carcinoma of the pancreas with colonic obstruction together with a review of the literature. A 77-year-old woman referred for periumbilical pain and diagnosed with colonic obstruction in January 2007 was found in enema studies to have total colonic obstruction of the splenic flexture necessitating emergency loop colostomy of the transverse colon. Microscopic colonoscopic biopsy findings showed adenocarcinoma, positive for cytokeratin (CK) 7 and negative for CK20 in immunohistochemistry-a pattern not typical of colonic cancer. Further examinations led to a diagnosis of pancreatic-tail cancer with invasion of the descending colon, necessitating distal pancreatectomy with splenectomy, left colectomy, left nephrectomy, and partial gastric and diaphragmatic resection in February 2007. 13 months after surgery, she is doing well without sign of recurrence. Histopathological diagnosis was adenosquamous cell carcinoma of the pancreas that had infiltrated the splenic capsule, the hilum of left kidney and the descending colon.

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We report a patient with an inflammatory pseudotumor (IPT) of the spleen with Epstein-Barr virus (EBV) infection complicated by immune thrombocytopenic purpura. A 67-year-old man found in several ultrasound examinations, computed tomography (CT), and magnetic resonance image (MRI) during treatment for immune thrombocytopenic purpura to have a splenic tumor. He had been observed for six months under the diagnosis of a possibly benign neoplasm such as hemangioma, but the tumor grew and was identified by fluorine-18-fluorodeoxyglucose and positron emission tomography to be potentially malignant, necessitating laparoscopic splenectomy. Histopathologic examination showed an inflammatory pseudotumor with spindle cells positive for EBV by in situ hybridization. No recurrence of thrombocytopenia or other IPT was noted after splenectomy. This suggests that EBV infection may play a role in IPT of the spleen and the development of thrombocytopenic purpura.

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A 63-years-old man admitted for epigastralgia, nausea, and diarrhea was found in abdominal X-ray imaging to have considerable dilated small-intestine gas. CT showed a target sign with a fat component in the lower right quadrant and gastric wall thickening. Upper gastrointestinal endoscopy showed a rough gastric mucosal surface and giant fold. Forceps biopsy specimens from all lesions suggested malignant lymphoma, necessitating laparotomy to diagnose and reposition a suspected intussusception. No intussusception was seen, but was found numerous submucosal tumors in ileocecal lesion. Histopathological examination following biopsy yielded a diagnosis of mantle cell lymphoma. The man had multiple gastric and ileal polyposis and intussusception was caused by polyposis of the terminal ileum. Intussusception in adults due to mantle cell lymphoma is rare, with only 7 cases, including ours, in the literature.

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We report the rare case of a 59-year-old man suffering a perforated colon ulcer induced by nonsteroidal antiinflammatory drugs (NSAIDs). Diclofenac sodium tablets admitted at 75mg/day were administrated for lumbago due to spinal canal stenosis. After six days, the man experienced anorexia, abdominal fullness, and upper right abdominal pain. Physical examination showed signs of peritoneal irritation. Based on a diagnosis of diffuse suppurative peritonitis, we conducted emergency transverse colectomy, finding two perforated ulcer sites and one non-perforated ulcer at the resected transverse colon. Histological examination showed nonatypical cells in the mucosal tissue around the ulcers. It is thus important to bear colon disease mind when NSAIDs are administered as a painkiller.

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A 46-year-old man reporting abdominal pain underwent right hemicolectomy under a diagnosis of ascending colon carcinoma with acute appendicitis. Histopathologically, he had gastrointestinal stromal tumor (GIST) with metastasis to the iliocolic lymph node. The 9cm in diameter tumor involved the right kidney, and a small part of the tumor remained on the capsule of the kidney. Although we administered postoperative imatinib therapy, he died 10 months postoperatively due to the local recurrence. GIST in the large intestine is rare, accounting for fewer than 10% of all GISTs. Those with small/large intestinal GIST reportedly have shorter median survival (29 months) than those with gastric GIST (46 months). Our case of ascending colon GIST with lymph node metastasis showed aggressive growth, cutting survival to only 10 months despite an imatinib treatment because of the possible acquisition of imatinib-resistance during this therapy. Lymph node dissection in our case had little significance because complete resection of the tumor was impossible.

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Metastatic brain tumors are generally treated with radiotherapy because many anticancer drugs cannotcross the blood-brain barrier. We report a case of postoperative brain and spinal metastases from rectal can cer treated with oxaliplatin/fluorouracil/leucovorin (modified FOLFOX-6). A 49-year-old-man underwent Miles. operation with D2 lymphadenectomy for type 2 rectal cancer and segmental resection for liver metastasis. Nine months later, the patient underwent a surgery for cerebellar metastasis during treating with oral uracil and tegafur (UFT) following 5-fluorouracil/leucovorin. He then underwent gamma knife therapy for brain metastases and surgical resection for spinal metastasis 20 months after the first operation and 11 months after cerebellar metastasis surgery. Modified FOLFOX-6 was started thereafter due to recurring brain metastases and residual spinal metastasis. One year later, target lesions were evaluated as making a partial response based on response evaluation criteria in solid tumors (RECIST) and no more new metastases had developed as of this wrinting.

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A 52-year-old man with lower abdominal pain and melena was found in colonofiberscopy to have type 2 rectal cancer mainly located in the anterior rectal wall. Computed tomography and magnetic resonance imaging showed the tumor contacting the prostate and seminal vesicle, indicating tumor invasion to the anterior organsand necessicating abdominoperineal resection associated with prostate and seminal vesicle resection. The man's quality of life (QOL) remained comfortable as simple abominoperineal resection except for urinary incontinence only for 6 months. A solitary metastatic liver tumor occurring at S7 of the liver necessitated partialhepatectomy 4 years and 2 months after initial surgery, but the man remains well 5 years and 2 months since the first operation. We recommend this operation for rectal cancer invading only the prostate and the seminal vesicle due to its high curability and maintenance of postoperative QOL.

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