Objective: Anastomotic leakage of the esophagocolostomy is the most serious complication of esophageal surgery using colon interpositioning. We have conducted colon interpositioning for esophageal replacement with a vascular anastomosis since 1989 to overcome this severe complication. Patients: Here we retrospectively review all 86 patients with esophageal disease who underwent colon interpositioning between 1981 and 2007, 77 had esophageal cancer, and 9 benign esophageal disease. We compared the morbidity and mortality between 62 patients who received vascular anastomosis from 1989 to 2007, with the 24 patients who did not receive this from 1981 to 1988. Results: The main postoperative complication was anastomotic leakage. Comparing the incidence rate of anastomotic leakage between patients with vascular anastomosis and patients without it, anastomotic leakage developed less frequently in patients with vascular anastomosis (23%) than in patients without it (63%) (p=0.0003). Anastomotic leakage of esophagocolostomy occurred in 13 (54%) in patients without vascular anastomosis, and 7 of these patients required surgical repair. In patients with vascular anastomosis, leakage of esophagocolostomy occurred in 6 (10%), and all cases healed spontaneously. The postoperative mortality rate was lower in patients with vascular anastomosis (2%) than in patients without vascular anastomosis (17%) (p=0.007). Of 62 patients with vascular anastomosis, 51 underwent supercharge and superdrainage, and 11 underwent superdrainage alone. Anastomotic leakage developed less frequently in patients with the supercharge and superdrainage (6%), than in patients with superdrainage alone (27%) (p=0.03). Conclusions: Our findings suggest vascular anastomosis in colon interpositioning for esophageal surgery gives some advantage, and that the supercharge and superdrainage is more effective than superdrainage alone.

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We report the case of minute superficial esophageal cancer coexisting on a granular cell tumor in the esophagus. A 50-year-old man referred for superficial esophageal cancer of lower esophagus was found in endoscopy to have a round protruding lesion 12 mm in diameter having a slightly rough surface not stained by Lugol solution. Biopsy specimens pathologically indicated well-differentiated squamous cell carcinoma. Endoscopic ultrasonography showed an isoechoic mass in the submucosal layer, diagnosed as esophageal cancer cStage I (T1bN0M0) and necessitating chemoradiotherapy. Although the unstained lesion disappeared after chemoradiotherapy, the submucosal tumor-like lesion remained, and was resected endoscopically. Pathologically, it was diagnosed as a granular cell tumor. The definitive diagnosis was superficial esophageal cancer coexisting on a granular cell tumor.

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We report a case of parahiatal hernia. An 86-year-old woman reporting sudden left-sided chest and upper abdominal pain but having no history of chest trauma was found in chest X-ray to have gastroenteric gas that overlapping the left lower lung field. An upper gastrointestinal series showed organoaxial gastric volvulus, mostly protruding into the left thoracic cavity. Magnetic resonance imaging (MRI) showed that the stomach and part of the transverse colon had migrated into the left thoracic cavity, indicating a paraesophageal hernia with gastric volvulus was preoperatively diagnosed. Laparotomy found a diaphragmatic defect lateral to the left crus of the diaphragm after the stomach and transverse colon were reduced into the abdomen. The 6.0×5.0 cm hernia orifice was separated from the esophageal hilus, and the crus of diaphragm was located between the hilus and the hernia orifice. The definitive diagnosis was a parahiatal hernia, a type of diaphragmatic hernia. The diaphragmatic defect was sutured and closed. She was discharged without complication. Parahiatal hernias, which are so rare that their existence is doubted, they are characterized by the presence of distinct crus of diaphragmatic between an anatomically normal esophageal hiatus and the diaphragm defect.

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We report a rare case of calcifying fibrous tumor of the gastric wall. A 44-year old woman was seen by a health checkup barium study for an abnormal observation indicating a round defect impinging on the lumen suggesting submucosal gastric tumor at the distal anterior wall. Gastroscopy revealed a 3×3 cm distal anterior bulge with normal overlying mucosa. Computed tomography (CT) indicated a gastric tumor with calcification projecting from the gastric wall excised in laparoscopic gastric wedge resection. On gross examination, the surgical specimen was a firm gray-white mass 30×26×24 mm well-demarcated but unencapsulated. Microscopically it consisted of dense collagenous tissue containing sparse spindle cells, psammomatous calcification, and multifocal lymphoplasmocytic infiltrates. Immunohistochemically, cells were positive for vimentin and negative for CD34, c-kit, α-smooth muscle actin, desmin, S-100, and NSE. The histology was characteristic of a rare calcifying fibrous tumor-only the second, to our knowledge, reported in Japan.

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We report a case of colonic metastasis initially suspected of being primary colon cancer following surgery for Stage IA gastric cancer. A 69-year-old man with gastric cancer who underwent distal pyloric gastrectomy in March 2007 was found pathologically to have highly atypical cancer cells diagnosed as Stage IA cancer (por1 with sig, pT1 (SM2), pN0, sH0, sP0, and sM0). CEA gradually increased postoperatively to 9.4 ng/ml eight months later, at which point positron-emission tomography indicated a mass in the ascending colon. Colonoscopy showed an ulcerous lesion suggested by biopsy to be poorly differentiated adenocarcinoma subsequently diagnosed as primary ascending-colon cancer necessitating right colectomy in January 2008. This was rediagnosed as gastric cancer metastasis based on pathological findings and cytokeratin-immunostaining. Colonic metastasis of Stage IA gastric cancer, which is early-stage, is extremely rare and no other such cases have, to our knowledge, been reported in Japan. Even early-stage gastric cancer can be highly malignant and metastatic when cancer cells are highly atypical, as this case suggests.

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A 64-year-old man with a 9 cm gastric gastrointestinal stromal tumor (GIST) and plateletderived growth factor receptor alpha (PDGFR-alpha) mutation-positive was found in a medical checkup to have a submucosal tumor (SMT). Endoscopy showed the 9 cm SMT to be located in the lesser curvature of the posterior pyloric wall. Immunohistochemical staining of biopsy specimens were all negative for c-kit, CD34, alpha-SMA and S100. Suspecting the SMT to be gastric GIST, we conducted distal gastrectomy. Abdominal computed tomography and diffusion-weighted magnetic resonance imaging indicated that the tumor grew both inward and outward, but no liver or peritoneal metastasis was seen. Pathologically, spindle and epithelial-like cells had formed irregularly. Only CD34 immunohistochemical stein was positive, while c-kit, alpha-SMA and S100 were negative. No KIT gene mutation was detected, but PDGFR-alpha mutation D842V was identified in exon 18. The size was 85 mm and the mitotic index was two cells per 50 high-power fields. This classified the GIST into an immediate risk group. Surgery was curative, and the PDGFR-alpha exon 18 D842V mutation was imatinib-resistant, so the man was followed up without adjuvant therapy. For the postoperative treatment strategy, gene search of GIST was useful.

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Micropapillary carcinoma is reported to be an aggressive variant of carcinoma afflicting organs including the breast, lung, urinary bladder, and major salivary glands. It is associated with frequent lymph vascular invasion and dismal clinical outcome. A 56-year-old man seen for an abnormality in fluoroscopy and having undergone proximal gastric resection for early gastric carcinoma 5 years earlier was found in endoscopy to have an 0-IIa+IIc lesion at the greater curve of the antrum. Biopsy results indicated moderately differentiated adenocarcinoma. Computed tomography (CT) showed lymph node swelling around the duodenum. We resected the remnant stomach in D2 lymphadenectomy. The carcinoma consisted mainly of well to moderately differentiated adenocarcinoma. The tumor invaded deepest to the slightly submucosal layer (sm1) and showed micropapillary carcinoma in pathology. Metastatic lymph nodes consisted mostly of micropapillary carcinoma. Micropapillary carcinoma may also have higher malignancy potential in gastric cancer.

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We report a rare case of choledochocele associated with an adenoma of the duodenal papilla. A 81-year-old man admitted for epigastralgia was found in abdominal computed tomography (CT) and magnetic resonance cholangiopancreaticography (MRCP) to have a cystic lower end of the distal common bile duct. Upper gastrointestinal endoscopy showed a soft spherical mass proximal to the ampullary orifice. The papilla was covered by granular duodenal mucosa and histopathological examination showed a tubular adenoma. We conducted a transduodenal sphincterotomy and sphincteroplasty under a diagnosis of suspected choledochocele associated with adenoma of the duodenal papilla. In many cases, a choledochocele should be readily treated endoscopically. Our choledochocele associated with ampullary adenoma, however, was difficult to distinguish preoperatively from choledochocele associated with carcinoma. Physicians should thus be aware that carcinoma may develop in a choledochocele. Due to the possibility of malignant changes already induced, the ampullary mucosa should be observed for several years even after endoscopic treatment or surgery.

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We report a case of bile duct carcinoma with situs inversus totalis. A 75-year-old woman referred for obstructive icterus was found in abdominal computed tomography (CT) to have situs inversus totalis and bile duct obstruction due to a tumor. Percutaneous transhepatic cholangiography (PTC) showed an elevated tumor from the upper to the middle of the common bile duct. In surgery based on a diagnosis of bile duct carcinoma, we found a soft tumor of the common bile duct, resecting the bile duct with lymphadenectomy and reconstruction with an extrahepatic bile duct jejunostomy. The definitive diagnosis was early bile duct cancer, papillary with superficial spreading, and moderately differentiated adenocarcinoma. This is only the seventh case of bile duct carcinoma with situs inversus, to our knowledge, reported in the Japanese literature.

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We report a case of rare hepatic malignant primary cholangiolocellular carcinoma (CoCC). A 87-year-old man followed up after transurethral resection of a bladder tumor, was found to have a solitary hepatic tumor measuring 30 mm in diameter in an abdominal computed tomography (CT) checkup. It showed peripheral enhancement in the arterial phase and enhancement retention in the delayed phase. Preoperative echo-guided biopsy indicated moderately differentiated cholangiocarcinoma (CCC). Histological findings for the resected tumor showed small ductules similar to cholangioles proliferating in an anastomosing pattern with abundant fibrous stroma having neither HCC-like areas, nor CCC-like areas. Immunohistochemically, the tumor presented cells diffusely positive for CK7 and CK19, and negative for HepPar1. PAS and Alcian blue staining showed an absence of mucin in tumor cells. C-kit staining showed focally positive cancer cells. These findings are compatible with CoCC.

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Left-sided portal hypertension (LSPH) is a rare disease caused by impaired splenic venous return, associated with gastric varices and splenoma in patients free of chronic liver disease. Gastric varices accompanying LSPH can be cured radically by splenectomy, but requires care when selecting the treatment mode. We report a case of malignant pancreatic lymphoma associated with this condition. A 57-year-old woman seen in May 2006 for hematemesis was found in endoscopy to have a solitary gastric varix and advised to be hospitalized for detailed examination. Preoperative diagnostic imaging showed a dilated short gastric vein and splenoma without liver cirrhosis. A tumorous lesion detected at the splenic hilus led to adiagnosis of LSPH and underwent splenectomy and tumor resection, after which the gastric varix disappeared. The resected tumor was histopathologically rated as malignant pancreatic lymphoma. The possibility of LSPH must thus be borne in mind when diagnosing and treating patients with gastric varices or splenoma but no liver cirrhosis.

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We report a very rare case of splenic hamartoma. A 35-year-old woman with a 38°C fever, myalgia, and arthralgia since September 2007 was seen in October 2007, at which time she underwent computed tomography (CT) to clarify slight liver-function abnormalities. She was found to have a 3 cm splenic tumor, but detailed systemic postadmission examinations indicated no malignancy of other organs. We conducted laparoscopic splenectomy in November for a suspected primary splenic tumor. The operation took 80 minutes and blood loss was 20 mL. To minimize the spleen removal incision, we placed the spleen in an Endo CatchII^TM, where it was divided into three segments prior to extraction. The excised specimen showed relatively well-demarcated, uncovered 3×2.5 cm nodular lesions that were found in histopathological examination to be proliferated splenic cord capillaries in the red pulp. Immunostaining was positive for CD34 and negative for CD8 and factor VIII. Morphology and immunophenotypic studies yielded a diagnosis of splenic cord capillary hemangioma classified as splenic hamartoma.

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We report a case of undifferentiated cancer of the jejunum. An 88-year-old man with high fever and abdominal pain and found in blood tests to have an inflammation was further found in enhanced abdominal computed tomography (CT) to have a small intestinal tumor with a thickened wall and containing peritoneal fluid. Peritonitis necessitated emergency surgery, showing an intestinal tumor 20 cm from the Treitz ligament on the anal side and adhering to the small intestine 10 cm from the oral side of the Bauhin valve. Turbid peritoneal fluid was found, but no intestinal perforation. The small intestine was resected extensively. Histologically, the tumor was anaplastic carcinoma. Immunohistochemical examination showed the lesion to be positive for CAM5.2 and p63. The patient recovered enough to be discharged, but he died of multiple brain metastases 3 months postoperatively. Anaplastic carcinoma of the jejunum is rare, with only 14 cases of anaplastic carcinoma of the small intestine reported in the Japanese literature.

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We report a case of inoperable extra and intrahepatic metastasis from colon cancer successfully treated with spacer placement surgery and subsequent proton beam radiotherapy. A 74-year-old man undergoing sigmoidectomy and extended left hepatectomy for sigmoid colon cancer with synchronous multiple liver metastases, experienced recurrent hepatic metastasis 14 months later, together with a tumor thrombus extending into the inferior vena cava (IVC) and peritoneal seeding. FOLFOX was ineffective and abandoned with pulmonary fibrosis. The man was referred for particle radiotherapy. Because the liver tumor adjacent to the stomach precluded direct particle radiotherapy, we recommended two-stage treatment with spacer placement and subsequent proton beam radiotherapy. Our rationale was to displace the digestive tract from the irradiation field by spacer placement, thereby enabling proton beam radiotherapy. In the first stage, he underwent laparotomy to place Goretex sheets and the greater omentum to maintain distance between the tumor and stomach. A month later, in the second stage, he underwent proton beam radiotherapy of 64 GyE in 8 fractions. After two-stage treatment was completed, the two metastatic lesions had disappeared together with the IVC tumor thrombus.

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A 56-year-old man admitted for upper abdominal pain and acute myocardia infarction in June 2006 underwent left kidney partial resection for renal cell carcinoma (RCC) in 1999 and partial lung resection for a tumor metastatic from RCC in 2005. Laboratory tests on admission showed serum amylase elevated to 1,883 IU/L. Abdominal contrast-enhanced CT showed a diffusely enlarged, heterogeneously enhanced pancreas with fluid collecting in the omental bursa and left pararenal space. Based on a diagnosis of severe acute pancreatitis, we undertook percutaneous coronary intervention, followed by continuous nafamostat mesilate and imipenem infusion from the celiac artery. After severe acute pancreatitis had been treated, the man was found in abdominal contrast-enhanced CT to have a well-enhanced, 3 cm pancreatic head tumor. Based on the above findings, we suspected pancreatic metastasis from RCC and conducted pancreatoduodenectomy and necrosectomy in August 2006. Pathological examination of the resected specimen showed clear cell carcinoma resembling previously resected RCC. The man remains in good health without recurrence 2 years after surgery. Severe acute pancreatitis caused by pancreatic metastasis from RCC is rare.

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