Background: Despite the spread of laparoscopic wedge resection for gastric submucosal tumor, there remains a problem on removal of the excess mucosa in resecting a tumor with intraluminal growth, which sometimes leads to postoperative deformity of the stomach. In addition, distal or proximal gastrectomy may replace in cases located around the pyloric ring or esophago-gastric junction. Then we have developed a new technique, Laparoscopy and Endoscopy Cooperative Surgery (LECS) which is an effective approach for submucosal tumor regardless of characteristics. Methods: A total of 12 patients underwent LECS between July 2006 and July 2007 in our hospital. In LECS, resection line is determined from within the abdominal cavity using endoscopic submucosal dissection (ESD). A seromuscular incision is made laparoscopically and lesion is then removed. Operation time, intraoperative blood loss, number of staplers, conversion to open surgery, postoperative gastric dilatation, time to oral intake, hospital stay were compared with 17 cases with conventional laparoscopic approach. Results: LECS was completed successfully in all patients including cases adjacent to the esophago-gastric junction or pyloric ring; neither conversion to open surgery nor complications were occurred. Surgical outcomes were comparable to those of conventional procedure. Mean operation time was about 30 minutes-longer and postoperative blood loss was 12ml more than conventional approach. The number of staplers used for excision in LECS (2.1±0.8 pieces) was significantly less than conventional group (3.2± 0.5 pieces). Conclusions: LECS is an effective procedure for resecting a submucosal gastric tumor with minimum removal of the stomach wall. In addition, this approach can be applied for lesions located at the vicinity of the esophago-gastric junction or pyloric ring.

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Purpose: Gender differences are assumed to exist in the biological response to medical insult and clinical outcome.We clarified gender differences in prognostic factors of severe acute pancreatitis (SAP). Methods: We compared backgrounds between men and women with SAP, then divided 146 patients with SAP into survivor (80 men and 24 women) and nonsurvivor (28 men and 14 women) groups and surveyed significantly different prognostic factors in laboratory data on admission. Results: The mean onset age in women was significantly higher than that in men. The most frequent etiology of SAP was alcohol in men, and gall stones in women. BE, BUN, Cr, Ca, BS, LDH, AST, PT, T-Bil, and PaO₂ showed significant differences in men. We found significant differences in lymphocyte counts, BUN and Cr in women. BE on admission was significantly lower in nonsurviving men (-7.1±1.2mEq/L) than in surviving men (-0.8±0.8mEq/L). Lymphocyte count on admission was significantly lower in nonsurviving women (539±74/mm³) than in surviving women (1, 101±211/mm³). Conclusions: Prognostic factors on admission appear to differ by gender in patients with SAP, i.e., BUN and Cr show no gender difference, BE differs in men, and lymphocyte counts differ in women.

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We describe a case of primary upper thoracic esophageal adenocarcinoma with gastric adenocarcinoma. A 59year-old man admitted for nasal bleeding was found in gastroesophageal endoscopy to have two pedunculated polyps in a slightly depressed lesion (0-Ip+0-IIc) in the upper thoracic esophagus and a broad tumor in a slightly depressed lesion (0-IIa+IIc) in the middle gastric body on the major curvature. Biopsies showed moderately differentiated adenocarcinoma of the esophagus and poorly differentiated adenocarcinoma of the stomach. Computed tomography showed an enlarged lymph node (106 rec L) diagnosed as metastasis. Tumors were resected by a transthoracic esophagectomy and total gastrectomy with D2 lymph nodes dissection. There were no barrett.s mucosa nor ectopic gastric mucosa in the resected specimen. The peripheral epithelium in the esophageal tumor was consistent with carcinoma in situ differentiating into adenocarcinoma. Such a case of primary esophageal adenocarcinoma is rare.

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We present two cases of gastric adenocarcinoma following complete remission of malignant gastric lymphoma after chemoradiotherapy. The patients were two men, one 75 years old and 65 years old. Endoscopy showed malignant gastric lymphoma (diffuse large B cell lymphoma, stage II₁) in both, who underwent CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) chemotherapy and radiotherapy. After complete malignant lymphoma remission (CR), upper endoscopic studies in follow-up showed gastric carcinoma, necessitating pylorus-preserving gastrectomy in one with pathological stage T1 (SM2) N0 M0 Stage IA, and total gastrectomy in the other with pathological stage T3 (SS) N2 M0 CY1 Stage IV. Both suffered distant metastasis soon after surgery. Close gastric follow-up is thus important following chemoradiation therapy, witch is reported to involve the risk of a second gastric malignancy.

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We report a rare case of low-grade marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) occurring in the liver. A 71-year-old-man seen for a space-occupying 0.8cm lesion of the liver on ultrasound sonography (US) examination was found in needle biopsy to have low-grade marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type. He was not treated in two years and ten months, and the tumor grew to 7.4cm necessitating hospitalization in February 2006. Laboratory data was within the normal range. Ultrasonography indicated a solitary hypoechoic mass in the posterior segment (S6) of the hepatic right lobe penetrating the portal vein. Computed tomography (CT) revealed a homogenous low-density area not enhanced by dynamic study. The patient underwent partial resection of the liver in March 2006, completely resecting the tumor. The resected specimen showed that atypical small to intermediate lymphoid cells proliferating in the tumor, with lymphoepithelial lesions recognized. The diagnosis was low-grade hepatic marginal zone B-cell MALT lymphoma. The patient has shown no reccurrence in follow-up during the one year since surgical resection.

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Focal nodular hyperplasia (FNH) may be difficult to differentiate from hepatocellular carcinoma (HCC). We report a case of FNH with unusual MRI and Sonazoid US fingings. A 41-year-old woman with hepatitis B virus and suffering from epigastralgia was found to have serum liver function test and tumor marker results within normal limits. Contrast-enhanced computed tomography (CT) showed a 3cm high-density area with a central nonenhanced lesion having a central scar-like center in segment 1. Sonazoid US showed a. spoke wheel sign. in the early vascular phase, but a defect in the postvascular phase. Superparamagnetic iron oxide MRI showed decreasing uptake. Due to the possibility of HCC, we conducted a hepatic caudate lobectomy. The pathological examination indicated FNH. Given that Kupffer cells are not reflected in some image findings, it is important to conduct a microscopic diagnosis, including resection, to definitively rule out FNH.

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Traumatic ruptured hepatocellular carcinoma (HCC) is very rare, and only 16 cases have been reported, to our knowledge, in the English and Japanese literature. We report a new case, summarizing the 16 reported cases. A 69-year-old man was admitted to an emergency hospital due to shock after a traffic accident. Computed tomography (CT) demanstrated the rupture of HCC at segment 8 of the liver and transcatheter arterial embolization (TAE) was subsequently carried out. He recovered from the initial critical condition, and was transferred to our department for further treatment. Although HCC, 6cm in diameter, was detected in segment 8 of the liver, no viable HCC could be observed in CT, so he was discharged and carefully followed up. Seven months later, a few viable nodules were detected around the HCC treated by TAE. Segment 8 of the liver was anatomically excised together with the adhering omentum and diaphragm. Washing cytology in the abdominal cavity showed findings for cancer to be negative. Histologically, viable well-differenciated HCC was evident around the necrotic tumor. He was discharged on postoperative day 14 and remains alive 8 months after surgery with bone metastasis.

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A 60 year-old man admitted for fever and epigastralgia was found in computed tomography to have a swollen gall bladder with a thickened wall located to the left of the umbilical portion and diagnosed as acute cholecystitis of the left-sided gall bladder. Direct cholangiography showed the aberrant right hepatic duct, draining into the cystic duct. After reducing inflammation by perctaneous transhepatic gall bladder drainage (PTGBD), we conducted laparoscopic cholecystectomy. The gall bladder wall was stiff and the gall bladder fundus was located to the left of the ligamentum teres. We dissected the liver bed, endeavoring to avoid umbilical injury. We stapled and closed the neck of the gall bladder, without approaching the cysti duct to avoid damaging the aberrant hepatic duct. The man was discharged on post operative day 6. We found no record of such a case in the Japanese literature.

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A 40-year-old man undergoing right hemicolectomy for repeated ascending colonic diverticulitis and discharged on postoperative day 21 reported slight wound pain, but no abnormality in physical examination and on laboratory data was seen, so he was prescribed painkillers. On day 18 after discharge, he was admitted for severe upper abdominal pain. Contrast-enhanced CT showed dilation of the superior mesenteric vein (SMV) and radiolucency in SMV under confluence of splenic vein, suggesting SMV thrombosis. Conservative therapy with continuous intravenous heparin administration was initiated because of no signs of intestinal necrosis. Abdominal findings indicated slight improvement and the thrombus contracted within 13 days of treat-ment as seen in CT. Intravenous heparin administration was replaced by warfarin potassium. Three months after therapy, CT showed further contraction of the thrombus and reflow in the SMV. Because the blood coagulation studies showed no abnormalities and portal hypertention was not observed, SMV thrombosis in this case was thought to have been induced by right hemicolectomy.

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Mesenteric fibromatosis is a rare clinical entity. We report a 41-year-old woman with the disease who presented with lower abdominal pain. Preoperative examination including ultrasonography, computed tomography, and colonoscopy indicated a submucosal tumor in the transverse colon. After laparotomy, the lesion was diagnosed pathologically as a gastrointestinal stromal tumor, 4.2cm in diameter, originating in the muscle layer of the colon. One year and eight months postoperatively, computed tomography showed an intraabdominal mass, 5cm in size, adjacent to the transverse colon. Upon laparotomy, we found a tumor involving the anastomosis site from the previous operation. Postoperative pathological examination confirmed the diagnosis of mesenteric fibromatosis. The specimen resected in the previous operation was reexamined and diagnosed as the same disease. Mesenteric fibromatosis does not metastasize but often invades surrounding tissues and tends to recur locally. The diagnosis may be difficult, especially when it involves the intestinal muscle layer.

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We reported two cases of refractory enterocutaneous fistula treated with somatostatin analogue (SMS) and proton-pump inhibitor (PPI). Case1: An 87-year-old woman reporting upper abdominal pain diagnosed with diffuse peritonitis due to a perforated duodenal ulcer underwent omental patch repair. On postoperative day (POD) 2, intestinal fluid was discharged from the omental patch drain, resulting in a refractory duodenocutaneous fistula. SMS was injected with PPI and the discharge rapidly decreased. On day 19 after SMS injection, the fistula had closed. Case 2: A 65-year-old man undrgoing hemicolectomy for ascending colon cancer was found on POD 10 to have changed drain content and anastomotic leakage. Intestinal fluid discharged from the median surgical incision resulted in a refractory ileocolonic anastomocutaneous fistula. SMS was injected with PPI and the discharge rapidly decreased. On day 11 after SMS injection, the fistula had closed.

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A 68-year-old woman with diarrhea and melena was found in irrigoscopy to have haustra disappearing along the cecum through the descending colon in the narrowed lumen with partial thumb-printing. Lower gastrointestinal endoscopy indicated mucosal edema and erosion at the same site, suggesting ischemic enteritis. She was followed up in conservative treatment with a drug for controlling intestinal function. Lower gastrointestinal endoscopy conducted about 5 months later due to sustained diarrhea showed no change in observations. Abdominal plain radiography and abdominal computed tomography indicated linear emergence of reticulate calcification along the cecum through the mesentery of the descending colon occurring since the first visit. Because these findings suggested phlebosclerotic colitis, we biopsied the lesion. The deposition of amorphous substances (HE staining) and collagen fibers (Azan staining) in the mucosa found in biopsy confirmed the diagnosis of phlebosclerotic colitis. We conducted laparoscope-assisted subtotal colectomy to relieve symp-toms.The woman.s postoperative course was favorable, with symptoms relieved. She is now being followed up in an ambulatory setting.

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We report the case of a 72-year-old man in whom an inferior mesenteric artery aneurysm occurred 2 years after colon cancer surgery. He was admitted for melena in October 2006, and had a history of sigmoidectomy for sigmoid colon cancer in October 2004 without recurrence of the cancer. Abdominal CT showed a mass 28mm in diameter on the left side of the left common iliac artery, continuing to the inferior mesenteric artery. Colonoscopy showed a blood lump near the anastomosis of previous surgery, but the bleeding point could not be detected. We diagnosed the case as inferior mesenteric artery aneurysm penetrating the intestinal tract.After hospitalization, the patient went into shock due to melena, necessitating emergency surgery. An aneu-rysm was palpated at the mesentery in the proximity of the colonic anastomosis and we found that the small intestine had adhered to the aneurysm. We conducted aneurysmectomy with resection of colonic anastomosis and the adhering part of the small intestine. Inferior mesenteric artery aneurysm is rare, and we report this case with a review of the literatures.

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A 73-year-old woman admitted for melena was found in colonoscopy to have a type 2 tumor in the rectosigmoid area, necessitating high anterior resection under a diagnosis of rectal cancer. Histologically, the tumor consisted of moderately differentiated adenocarcinoma, with small papillary neoplastic cell clusters floating in clear spaces resembling lymphatic channels. The tumor penetrated the serosa, with lymphatic invasion and metastasis in 6 regional lymph nodes. Immunohistochemically, MUC1 was expressed at the stroma-facing surface of cells. Morphological and immunohistochemical findings yielded a definitive diagnosis of rectal cancer with micropapillary carcinoma components. Micropapillary carcinoma has a dismal diagnosis with a high incidence of lymphatic invasion and lymph node metastasis. Although micropapillary carcinoma has rarely been reported in the colorectum, the presence of micropapillary carcinoma in colorectal cancer mandates the need for aggressive therapy.

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Anorectal malignant melanoma, while rare, involves a dismal prognosis and lacks an established therapeutic regimen. We report a case treated with local excision and immunochemotherapy and showing no sign of recurrence in the 3.5 years since surgery. A 56-year-old woman with an anal tumor was found on physical ex-amination to have a pedunculated polyp 20mm in diameter on the anorectal wall and diagnosed histologically after biopsy as malignant melanoma. She underwent local excision. Pathological findings were malignant melanoma sm2, ly0, v0, ow (-), aw (-), ew (-). Following adjuvant immunochemotherapy, she has remained well without recurrence in the 3.5 years since surgery. We review cases of local excision in Japan, and propose local excision as a curative alternative in cases of pedunculated polyps 10mm or less in diameter and penetrating to the submucosal layer but without ulcers.

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A 59-year-old woman with discomfort in sexual intercourse, elevated serum CA125, and ascites, underwent neoadjuvant chemotherapy with 3 courses of CBDCA/TXL followed by bilateral salpingo-oophorectomy, omentectomy, and lymphadenectomy of intrapelvic and paraaortic lymph nodes based on a diagnosis of serous surface papillary carcinoma of the peritoneum (SSPC). Adjuvant chemotherapy with the same regimen was added. Repeatedly increased intraabdominal masses and serum CA125 continued. In January 2007, she reported epigastric fullness and serum CA125 rose again. Abdominal CT showed a mass 2cm in diameter at the gastric antrum, and upper gastrointestinal endoscopy showed a submucosal tumor-like lesion at the posterior wall of the pyloric antrum, necessitating partial gastrectomy in May 2007 based on a diagnosis of gastric submucosal tumor or metastatic lesion from SSPC. Macroscopic findings showed the mucosal layer of the stomach to be intact, suggesting a primary gastric submucosal tumor. However, pathological examinations showed the tumor to be a metastatic SSPC lesion. No recurrent lesion has been detected in the 6 months since removal of the metastatic gastric lesion.

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We assessed the safety of laparoscopic subtotal cholecystectomy (LSC) in patients with complicated severe cholecystitis or fibrosis. Laparoscopic cholecystectomy was conducted in 750 patients during 3 years and 8months. Of these 25 required LSC, because dissection of Calot. s triangle would be dangerous. The gallbladder was divided from the liver bed fundus first, followed by subtotal gallbladder removal and closure of the remnant, using an endoscopic linear stapler (ELS) or using laparoscopic suture and ligation. The gallbladder was incised, at the level of Hartmann. s pouch to confirm its location, to remove contents, or to conduct intraoperative cholangiography through the cystic duct orifice, when necessary. The gallbladder mucosa left on the liver bed was ablated. No cases required conversion to laparotomy. The gallbladder neck was closed by ELS in 19 and by laparoscopic suturing in 6. Mean operating time was 143 minutes, and mean postoperative hospitalization 5.2 days. We found a case of delayed bile leakage and another of choledocholithiasis due to residual gall-stones. In one case, we found incidental gallbladder cancer. LSC for severe cholecystitis appears to be safe in avoiding serious complications, such as bile duct injury.

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