Background: We discuss reasonable surgery for upper gastric cancer based on invasion depth and lymphatic spread. Methods: Subjects were 401 patients with gastric cancer in the upper third of the stomach between 1973 and 2005, treated by surgical resection first and showing H0P0M0. We analyzed the lymphatic spread of splenic hilar lymph nodes (No.10), superior pancreatic lymph nodes (No.11), right gastro omental lymph nodes (No.4d), suprapyloric lymph nodes (No.5) and subpyloric lymph nodes (No.6) and their clinicopathological features. Results: In 126 cases with splenic hilar lymph node (No.10) dissection whose depth of invasion was within SS, 5 cases (4.0%) had positive nodes. All 5 had tumors either on the left side or the margin between the left and right areas. Of these, 4 had tumors over 40mm in diameter and lymph node metastasis at Level 1. In 126 cases with superior pancreatic lymph node (No.11) dissection, 8 cases (6.3%) had positive nodes. Of these, only 3 had distal superior pancreatic lymph node (No.11d) metastasis. All 3 had tumors either on the left side or the margin between the left and right areas and lymph node metastasis at Level 1.Of these, 2 had diameters exceeding 40mm. In 189 cases with right gastro omental lymph node (No.4d) dissection, 3 cases (1.6%) had positive nodes, all tumors being either on the left side or the margin between the left and right areas and with diameters exceeding 40mm. We saw no metastasis of suprapyloric (No.5) or subpyloric lymph nodes (No.6). Lymph node metastasis ratios were higher in cases whose depth of invasion was SE or SI. Conclusions: We rarely encountered No.4d, 5, 6, 10 or 11d lymph node metastasis if the depth of invasion was within SS and the tumor was in the lesser curvature, or the tumor diameter was within 40mm or no lymph node metastasis occurred at Level 1. In such cases, we propose that proximal gastrectomy with lymph node dissection of D1 with No.7, 8a, 9 and 11p be made reasonable surgery for upper gastric cancer.

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We report a case of laparoscopic surgery for reflux esophagitis with severe esophageal stenosis. A 64-year old man admitted for heartburn, dysphasia, and vomiting was found in upper gastrointestinal endoscopy to have reflux esophagitis with Los Angeles Classification Grade D and pin-hole stenosis of the lower esophagus. Initially administered proton pump inhibitor did not ameliorate, symptoms, so we conducted seven sessions of endoscopic balloon dilation, without favorable effect and with early return of the stenosis. Fraction time pH<4 was 6.8% in 24-hour pH monitoring, and the manometry showed a low esophageal body amplitude. Based on a diagnosis of reflux esophagitis with severe esophageal stenosis, we conducted laparoscopic Toupet fundopliction. Dysphasia disappeared postoperatively, as did the mucosal break and esophageal stenosis as evidenced in gastrointestinal endoscopy. In 24-hour pH monitoring, fraction time pH<4 was normalized to 0.3%.

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A 55-year-old man who had undergone total gastrectomy, splenectomy, and cholecystectomy for Borrmann 4 type gastric cancer in October 1994 reported appetite loss, leg edema, and coughing. He became aware of these symptoms in February 2002 and underwent examination in March 2002. Ultrasonographic echocardiography showed massive pericardial effusion with right ventricular collapse with cardiac tamponade diagnosed due to carcinomatous pericarditis. Cytologyical examination of the pericardial and plural effusion showed class V signet ring cell carcinoma whole-body bone scintigraphy showed multiple bone metastases. TS-1 was orally administered for four weeks per os, with a two-week rest interval. Cytological evaluation of pericardial and plural effusion was negative after only one course of chemotherapy. Bone metastases were also dramatically reduced. The man died of rapid respiratory failure with pulmonary lymphangitis 229 days after the start of the three chemotherapeutic courses. TS-1 is considered useful in managing malignant pericardial effusion. I thought that I should have considered TS-1 as alternatives of a treatment because TS-1 was effective for carcinomatous pericarditis.

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A collision tumor involving malignant lymphoma and adenocarcinoma in the remnant stomach is extremely rare. A 79-year-old man had undergone distal gastrectomy for malignant lymphoma of the duodenum (non-Hodgkin lymphoma, diffuse, small B cell type) 12 years earlier. An ulcerating tumor was found at the gastrojejunal anastomosis and endoscopic tumor biopsy indicated poorly differentiated adenocarcinoma, necessitating total remnant stomach resection. Pathological examination showed a collision tumor of malignant lymphoma (non-Hodgkin lymphoma, diffuse small B cell type, fSM) and adenocarcinoma (por1, fMP) with no nodal metastasis. Clinically, no evidence of recurrence was seen during follow-up. The man died of severe pneumonia two years after the second operation.

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Perioperative surgical management in patients with polycythemia vera (PV) is important. We report a case of duodenal ulcer perforation requiring emergency surgery. A 56-year-old man diagnosed with PV at age 25 and undergoing medication but who intermissioned himself at age 36 and later admitted for postprandial ab-dominal pain was found in abdominal computed tomography and gastrointestinal endoscopy to have peritoni-tis caused by duodenal ulcer perforation, necessitating emergency omental patch surgery. He suffered postop-erative complication of acute respiratory distress syndrome (ARDS) but no bleeding or thrombosis. His condi-tion improved after intensive care involving endotracheal intubation and respiratory control and continuous infusion of sivelestat sodium, and he discharged on postoperative day 24. Perioperative management for PV patients must take into account the possibility of pulmonary complication, bleeding, and thrombosis because of the constant activation of neutrophils and increased elastase release, that make pre-ARDS status.

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We report a case of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) successfully treated with multimodel therapy. A 82-year-old man with HCC who had undergone transcatheter arterial chemoembolization (TACE) 4 times and admitted for rapidly elevated AFP was found in abdominal computed tomography (CT) to have HCC (S5) 6cm in diameter with PVTT (Vp3) and two satellites (S4). When the high resection rate and poor liver function ruled out right hepatectomy, we conducted intraoperative ligation of the right portal vein and radiofrequency ablation (RFA) and three-dimensional postoperative comformal radiotherapy (total: 45Gy). HCC recurred in the right liver alone at 6, 15, and 20 months after surgery. Percutaneous RFA was achieved for all of these lesions. Two years postoperatively, AFP remains within a normal range and the patient is doing very well without reccurrences. Operative portal ligation combined with RFA and three-dimensional postoperative comformal radiotherapy is thus quite useful in treating unresectable HCC with PVTT (Vp3).

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We report a case of synchronous quadruple cancer gastric cancer, hepatocellular carcinoma, renal cell carcinoma, and rectal cancer in a 78-year-old Japanese man. Early gastric cancer was incidentally found on gastroscopyduring a regular physical examination. Liver tumor and a left renal tumor were detected by further examination using US and CT. Upon surgical referral, rectal cancer was detected on colonoscopy. After endoscopic submucosal dissection of the stomach for early gastric cancer, left lobectomy of the liver, abdominoperineal resection and left nephrectomy in a three-stage operation, histological examination showed quadruple cancer well-differentiated gastric adenocarcinoma, hepatocelluler carcinoma, well-differentiated rectal adenocarcinoma, and left renal cell carcinoma. Since synchronous quadruple cancers including hepatocellular carcinoma is extremely rare, we report this case and review the literature.

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A-69-year-old woman was referred to our hospital with the chief complaint of right hypochondrial pain. Detailed examination revealed a tumor in the duodenal lumen arising from the lower part the bile duct, however, a definitive diagnosis could not be made preoperatively. We considered carcinoma of the duodenum or of the ampulla of vater or bile duct and GIST in the differential diagnosis. Pancreaticoduodenectomy was performed. The tumor was of stet nodular type, measuring 80×75×34mm in size. Histopathological examination showed the presence of adenocarcinoma, squamous cell carcinoma and sarcoma components in the same tumor. Immunohistochemical study showed strongly positive staining of the sarcoma component for c-kit. The tumor was diagnosed as true carcinosarcoma, probably arising from the lower part of the bile duct. The sarcoma component was confirmed to be GIST. Although curative resection was performed, the patient died on the 184^th postoperative day because of multiple liver metastases, lung metastases and lymph node metastases. Because true carcinosarcoma of the bile duct is rare, we have reported this case here.

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A 59-year-old man undergoing pancreatic resection twice in 7 months for primary IPMC and remnant pancreatic ductal carcinoma was found in abdominal computed tomography to have a pancreatic head tumor during admission diabetus mellitus treatment. We conducted pancreatoduodenectomy for the branched IPMC. A histopathological study revealed minimally invasive IPMC and the negative margin of the pancreatic duct. Tumor markers gradually rose from 4 month after initial surgery, and a tumor in the remnant pancreas was identified by CT 6 months after that. We conducted total remnant pancreatecomy for recurrent IPMC. The recurrent tumor consisted of moderately differentiated adenocarcinoma with highly invasive growth, without intraductal adenoma on papillary proliferation. Primary IPMC showed both MUC1 and MUC2 to be positive but K-ras was mutation-negative, where as the secondary carcinoma showed MUC1 positive but MUC2 negative and K-ras mutation positive. We concluded that the two cancers were different origin.

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We report a case of the rupture of a huge CA19-9 producing splenic cyst. A 39-year-old woman admitted for left side abdominal pain, was found in computed tomography to have a 15×9cm-splenic cyst, occupying almost of the spleen surrounded by ascites. She also had high serum CA19-9 of 7, 490U/ml. We suspected peritonitis due to splenic cyst rupture, and conducted splenectomy. The inner surface of the splenic cyst was white, irregular, and mesh-liked, covered with stratified squamous epithelium. The cystic fluid and ascites were brown. CA19-9 in cystic fluid was high at 711, 000U/ml. The cyst was found histologically to be epithelial and immunohistochemical staining was positive for CA19-9 in cystic fluid. After surgery, serum CA19-9 returned to the normal range. Upper and lower gastrointestinal endoscopy showed no further abnormality.

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Spontaneous superior mesenteric artery (SMA) dissections are rare events. We report successful jejunal artery reconstruction using the right gastroepiploic artery in a patient with spontaneous SMA dissection and severe postprandial mesenteric angina. A 42-year-old man seen for severe postprandial abdominal pain and diagnosed with mesenteric angina due to spontaneous SMA dissection was found in computed tomography to have dissected SMA 3cm distal from its origin, necessitating emergency surgery to avoid necrotic change in the small intestine if at all possible due to its high mortality. Laparotomy showed the small intestine to not be necrotic but had a dark color due to poor blood flow. The dissection extended into the origin of the small branches to the jejunum, ileum, ascending colon, and transverse colon, suggesting potential necrosis, if dissection progressed. Although restoration of blood flow to the small intestine was recommended, it was not possible to reconstruct all small SMA branches, so the fourth jejunal artery was reconstructed using the right gastroepiploic artery to avoid total necrosis of the small intestine. The whole intestinal blood flow was restored via the marginal artery as a result of this reconstruction. The man was treated for postoperative anticoagulation using heparin followed by warfarin. The postoperative course was uneventful and postprandial abdominal pain completely disappeared.

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A 44-year-old autistic man undergoing psychiatric therapy at a mental health center was admitted 1 week after ingesting magnets due to abdominal pain with pyrexia. Laboratory data showed severe inflammation and abdominal X-ray, and computed tomography showed 9 intestinal metallic foreign bodies necessitating emergency surgery to remove 9 magnets used in psychiatric treatment. Duodeno-jejunal and jejunojejunal fistula were found at points of magnet contact with the duodenum and jejunum. Magnets were removed and the necrotic duodenum and jejunum partially resected together with the fistula. Duodenojejunostomy, jejunojejunostomy, and duodenostomy with an 8 Fr Atom catheter were successful and the postoperative course was uneventful. Although 26 cases of magnet ingestion have been reported in children in the world, to our knowledge, this is a first such report involving intestinal perforation and fistula after magnet ingestion in an adult.

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We conducted laparoscopic low anterior resection on a 72-year-old man with rectal cancer in October 2007, diagnosed postoperatively as tub2, pSE, pN2 (6/12), cH0, cP0, cM0, fStage IIIb. We administered UFT of 300 mg/day and uzel75 of mg/day in adjuvant chemotherapy on postoperative day 24, but discontinued chemotherapy six days later due to grade 3 nausea. He then suffered grade 4 leukocytopenia, grade 3 thrombocytopenia and grade 3 mucositis dying of multiple organ failure 28 days after chemotherapy administration. Urine uracil was 593.0μmol/g·cre, urine dihydrouracil was 2.1μmol/g·cre, and the dihydrouracil/uracil ratio was 0.004 compared to the standard 0.23-0.67. We could not measure dihydropyrimidine dehydrogenase (DPD) activity in peripheral mononuclear blood cells. The definitive diagnosis was DPD deficiency, only six cases of which, to our knowledge, have been reported in Japan. When chemotherapy side effect are chemotherapy is very severe, it must be stopped immediately and replaced by other treatment.

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A 78-year-old woman followed up since May 1990 after rectal amputation for rectal well-differentiated adenocarcinoma was found in October 2006 to have mildly elevated CA19-9. Abdominal computed tomography (CT) indicated 43×39mm oval tumor between the left internal and external iliac arteries. She was admitted for surgery November 2006 after a diagnosis of primary extraintestinal or mesenchymal tumor or lymph node metastasis from rectal cancer based on CT findings. Operative findings showed a tumor between the left internal and external iliac arteries, and the tumor was excised. In excised specimens, the white, solid 5×4.5×4 cm tumor had bleeding and necrosis. The histological diagnosis was malignant melanoma. Systemic postop erative examination found no primary focus. After she provided written informed consent, we conducted DAC-Tam therapy. At 7 months after surgery, the woman remains recurrence-free.

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Few reports of surgery in children under 14 years of age have been made in ulcerative colitis (UC). Pediatric patients present special problems, such as, adverse influence on school life, indications from surgical treatment, and growth retardation. We studied how many pediatric patients with UC who underwent total proctocolectomy and hand-sewn ileo-anal anastomosis (IAA) at our hospital from 1987 to 2004. Indications for surgery were severe colitis in four, intractability in three, and massive bleeding in one. Emergency surgery was done in 5 patients. The mean preoperative dose of total corticosteroids was about 9, 855mg as a dose equivalent to prednisolone. The only early postoperative complication was wound infection in 3 patients, while late postoperative complications, involved small bowel obstruction in two patients, and severe pouchitis, stenosis of the ileostomy, and anastomotic stenosis in one each. No severe complications were encountered. In longterm results, bowel function was satisfactory, no growth retardation was seen, and school life and employment were not interrupted. In conclusion, surgical treatment for pediatric UC patients provided good results.

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