Introduction: Gastroduodenal involvement is frequently seen in Crohn's disease, but advanced lesions which require surgery are rare. We report results for surgery in gastroduodenal Crohn's disease. Patients and Methods: We reviewed the medical records of patients with gastroduodenal Crohn's disease operated on between January 1996 and December 2006. Results: Among the 893 laparotomies for Crohn's disease, 17 (1.9%) involved gastroduodenal Crohn's disease. Symptoms were vomiting in 13, abdominal pain in 3, and a combination of the two in 1. Pyloric stenosis was detected in all 15 patients undergoing gastrointestinal barium studies, with stenosis reaching the second portion of the duodenum in 10. Surgery involved 11 selective vagotomies and antrectomies, 3 distal gastrectomies, and 1 each of gastrojejunostomy, duodenal strictureplasty, and omental perforation plug. Mean operating time was 4 hours and 17 minutes and mean blood loss was 331 ml. Postoperative complications developed in 5 patients, i.e. 2 anastomotic stenoses requiring fasting, 2 of ileus, and 1 of gastroduodenal bleeding requiring surgery for hemostasis. There were 12 non-caseous epithelioid granulomas and 10 fistulas out of 14 resected specimens. One developed erosions at the anastomotic site but no stenosis was seen in the mean 43 months of follow-up. Discussion: Selective vagotomy and antrectomy in gastroduodenal Crohn's disease is considered useful because could resect fistulas complicating commonly, preserved large remnant stomachs and had good short-term results.

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Background: We clarified the benefits and diszdvantages of the evaluating of surgical morbidity using common terminology criteria for adverse events, version 3.0 (CTCAEv3.0), for gastric cancer. Patients and methods: Subjects were 154 patients who had undergone surgery for gastric cancer from December 2004 to December 2006. Surgery involved distal gastrectomy in 93, total gastrectomy in 38, gastrojejunostomy in 10, and others in 13. We prospectively evaluated operative morbidity using CTCAEv3.0. Results: Surgical complications occurred in 125 patients (81.2%), and adverse reactions exceeding grade 3 in 27 (17.5%). Intraoperative complications occurred in 1.3%, surgery-related complications during hospitalization in 19.5%, nonsurgery-related complications during hospitalization in 78.6%, and complications after discharge in 11.7%. There was no hospital death. Median duration of postoperative hospital saty was 21 days. Conclusion: While we conclude that surgical morbidity can be evaluated using CTCAEv3.0 for gastric cancer, further assessment will be necessary to use it practically.

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Background: Although laparoscopic appendectomy (LA) is widely done in many countries, it is rarely conducted for complicated appendicitis involving perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. Methods: We retrospectively analyzed the clinical records of 230 patients who had undergone appendectomy for complicated appendicitis during this study period. Of them, 146 had undergone LA, 84 conventional OA, and 5 patients were converted to the open procedure after laparoscopy (CA). We compared these groups for background factors, intraoperative findings, postoperative findings, and hospital discharge. Results: Patient demographics were similar in the LA and OA groups (p>0.05). Intraoperative blood loss was significantly higher in the open group (p<0.001), even though operating time was slightly longer than in the laparoscopic group (p<0.001). Overall postoperative complications were significantly higher in the open group at 32.1% than in the laparoscopic group at 13.7% (p<0.001). Wound infection was significantly more common in the open group at 23.8% than in the laparoscopic group at 7.5% (p<0.001). Intraabdominal infection was equally common in the two groups. Hospitalization was significantly shorter in the laparoscopic group (p<0.001). Hospital discharge was equal in the two groups. Conclusions: Our findings indicate that LA is safe and useful even in treating complicated appendicitis.

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We reported a patient with perforated gastric cancer who underwent palliative gastrectomy after resuscitation for cardiaopulmonary arrest (CPA) and was discharged without any neurological disturbance. The 81-year-old-man who had presented appetite loss, weight loss, right abdominal pain, and nausea 2 months ago, was transferred to our critical care center because of consciousness disturbance. He developed CPA 12 minutes after his arrival at the hospital and was resuscitated within 6 minutes. Some image findings such as contrast-enhanced CT showed intraperitoneal free air and irregularity of the antrum, suggestive of gastrointestinal perforation, peritonitis and the abdominal compartment syndrome. We managed the patient with primary fluid resuscitation for septic shock and performed emergency laparotomy with the object of decompression and control of the infectious focus. Intraoperatively, we found gastric cancer with serosal invasion in the lower anterior portion and peritoneal dissemination, and performed palliative gastrectomy with Roux-en-Y reconstruction (LCirc, type 3, pT3 (SE), sN3, sH0, sP1, fStage IV, ly3, v2, INFβ, tub2>por2). The postoperative course was uneventful. After 8 months, contrast-enhanced CT showed metastatic recurrence in the intraperitoneal lymph nodes, liver and lung. The patient died 14 months (407 days) after the operation.

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A 69-year-old man who had undergone pylorus preserving pancreatoduodenectomy for duodenal carcinoma 2 years earlier experienced abdominal distension, then ileus 2 months later. Colonoscopy showed circumferential strictures of the hepatic flexure, transverse colon, and sigmoid colon but no malignancy in mucosal or submucosal biopsy. Abdominal CT showed thickening of the intestinal wall of the ascending colon, sigmoid colon, and cecum. FDG-PET showed accumulation in the transverse colon. Intestinal metastasis from duodenul carcinoma was suspected, but benign strictures could not be denied. Right hemicolectomy and sigmoidectomy yielded a pathological diagnosis of well differentiated adenocarcinoma of the submucosa and muscularis externa compatible with hematogenous metastasis to the intestine from duodenal carcinoma. Cases of intestinal metastasis hematogenously from duodenal carcinoma are very rare.

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We report to our knowledge the first case of resected hepatosplenic malignant lymphoma. A 55-year-old Jehovah's Witness woman underwent abdominal CT showing solid masses in the liver and spleen. Superficial lymph nodes were not palpated. Laboratory data showed LDH of 711 IU/l, positive HBsAg, and IL-2R of 748 U/ml. A liver biopsy showed diffuse multiplication of large B cell type lymphocytes. A diagnosis of malignant lymphoma localized in the liver and spleen was made by bone marrow tap, head MRI, and FDG-PET. Because of impending tumor rupture, we conducted lateral segmentectomy of the liver followed by splenectomy. THP-COP therapy was conducted postoperatively in 3 courses. She has had no recurrence in 3 years.

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A 76-year-old man admitted for hyperbilirubinemia was found in computed tomography (CT) to have a common bile duct (CBD) mass, and a dilated intrahepatic and CBD. Endoscopic retrograde cholangio-pancreatography showed stenosis of the CBD. Cytological examination of bile showed no malignancy. Pyrolus-preserving pancreaticoduodenectomy was conducted bases on a diagnosis of CBD tumor. Histologically, inflammatory cells but no malignancies were found, yielding a definitive diagnosis of inflammatory pseudotumor (IPT). Only 14 such cases originating in the extrahepatic bile duct have been reported previously. IPT is now recognized as IMT, a true neoplasm, necessitating new diagnostic measures.

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A 37-year-old man seen for left abdominal and back pain diagnosed with acute pancreatitis with arteriovenous malformation of the pancreatic body and tail initially underwent conservative therapy, but continued to experience severe abdominal pain. We conducted distal pancreatectomy with splenectomy and partially resected the stomach and transverse colon because of tight adhesion to surrounding tissues and the formation of new blood vessels. The postoperative course was uneventful except for abdominal abscess.

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A 68-year-old woman with dysphasia and found to have a multilocular cystic mass in the pancreatic body and tail was found in abdominal ultrasonography and computed tomography to have an 8 cm diameter mass in the pancreatic tail. ERCP showed the main pancreatic duct to be obstructed at the tail and no continuity to be found between the tumor and the pancreatic duct. Distal pancreatectomy, proximal gastrectomy, and splenectomy were done. The mucous-containing cystic tumor found in the pancreas body and tail consisted histopathologically of atypical columnar cells and a fibrous capsule, and had invaded the stomach. No ovarian-type stroma were detected by HE staining or immunohistological examination using estrogen receptor and progesterone receptor antibodies. Adenomatous papillary growth was found in the main tumor and branch pancreatic ducts in the pancreatic margin. Due to the absence of communication between the tumor and the pancreatic duct, we diagnosed this case as an indeterminate mucin-producing cystic neoplasm.

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A 36-year-old man consulted our hospital for abdominal discomfort and nausea. Abdominal US showed multiple hypo echoic lesions which were visualized on enhanced CT as low-density areas in the spleen. Laboratory data, including the serum sIL-2 (324 U/ml), were within normal limits. The SUV on FDG-PET imaging was 4.8, suggestive of malignancy, and we performed open splenectomy under the diagnosis of primary splenic malignant tumor. The removed spleen measured 11×9×4 cm in size, weighted 200 g, and showed multiple yellow-white colored nodules. Histopathologically, a large number of granulomas composed of Langerhans-type multinucleated giant cells and epithelioid cells, and collagen fibers were recognized in the specimen. No nests of caseation necrosis or Hodgkin's cells were recognized, and acid-fast bacterial fluorescent staining and Ziehl-Neelsen staining were negative. Finally, we made the diagnosis of splenic sarcoidosis. The postoperative course of the patient was uneventful, and he was discharged on the 13^th postoperative day. There were no lesions in any other organs, including the lungs, skin or eyes, until the time of writing (1year and 8months after the operation).

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We report a rare case of primary splenic angiosarcoma diagnosed after 3.5-year follow-up as splenic hemangioma. A 77-year-old man with a splenic tumor diagnosed as hemangioma was found in abdominal CT to have morphological change and increased tumor size after 3.5 years. Because we suspected malignant transformation, we conducted splenectomy. The pathological tumor diagnosis was splenic angiosarcoma, and our first case of long-term preoperative observation. This case may aid in understanding the natural history of this disease.

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A 76-year-old man seen in 1999 for epigastralgia, anorexia, and weight loss underwent examination and conservative management with placement of a nasogastric tube under a diagnosis of ileus. Relief was temporary and episodes repeated for four years. Admitted for detailed examinations in 2003, he was found in barium examination of the small intestine to have segmental stenosis and dilation of the oral side of the ileum. Conservative therapy was again ineffective, necessitating surgery was performed. On operation, we found three-wall thickness and stenosis around the terminal ileum, resecting about 90 cm of the ileum, including the stenosis. Macroscopic examination of the resected intestine showed three segmental ulcers and microscopic examination Ul-II ulcers with inflammatory cell infiltration, and fibrosis, mainly in the submucosal layer. An increase in small vessels and reproduction of submucosal epithelium were also seen in the ileum between stenosies. Multiple ulcers and ileum between stenosis apparently formed a continuous region due to the segmental ischemia. No evidence of reoccurrence was seen two years after surgery. Such cases should thus be surgically treated without delay.

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We report our experience in a patient who had ileocecal intussusception due to ileal endometriosis. A 40-year-old female was treated in the emergency department of this hospital (on an outpatient basis) for epigastric pain in October 2004; her symptom resolved with fluid therapy and she was sent home. On the following morning, the patient developed nausea and vomiting with worsening of the abdominal pain, and visited the emergency department of the hospital. Abdominal examination revealed right abdominal tenderness and positive Blumberg's sign. Abdominal ultrasonography revealed bowel hypoperistalsis in the right lower abdomen, intestinal dilatation and multiple concentric signs in the ileocecal region. Furthermore, emergency contrast CT revealed ascites and ileal swelling, Suggestive of strangulation ileus due to intussusception, and emergency surgery was performed. Hemorrhagic ascites was found in the abdominal cavity. A submucosal tumor was detected in the terminal ileum, which had intussuscepted into the Bauhin valve. The intussusception was manually reduced, and then ileocecal resection+D2 as conducted because of the possibility of malignancy. The excised specimen proved to be a submucosal tumor measuring 3 cm in size, and postoperative histopathological examination indicated the diagnosis of intestinal endometriosis.

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The patient was a 33-year-old woman diagnosed to have colon cancer with multiple liver metastases. In June 2007, she underwent laparoscopic-assisted colectomy with functional-end-to-end anastomosis using 4 linear staplers. On postoperative day 21, she was initiated on chemotherapy with FOLFOX6 (5-fluorouracil, leucovorin, and oxaliplatin). She also received bevacizumab on postoperative day 60 and day 74. On postoperative day 78, she developed acute abdominal pain, and CT showed the presence of free air in the abdomen. Under the diagnosis of peritonitis due to gastrointestinal perforation, an emergency operation was conducted. Surgical exploration showed a perforation at the anastomotic site of the stapler, therefore, the portion of the colon containing this anastomotic site was resected and transverse colostomy was performed. Thereafter the patient developed wound and abdominal infection with suspected gastrointestinal reperforation, and increase in the size of the liver metastases was noted. On postoperative day 107, she died. Attention should be paid to the major complication of gastrointestinal perforation associated with the use of bevacizumab; this is the first case report of its resulting in death in Japan.

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A 53-year-old man undergoing Miles operation and systemic chemotherapy (FOLFIRI) for advanced rectal cancer with simultaneous liver metastasis then underwent 6 courses of bevacizumab combined with FOLFOX chemotherapy. The second day after the final administration of bevacizumab, he presented right lower abdominal pain with fever. CT showed inflammatory change in the ileocecal region with cecal diverticula and presence of free air. Ileocecal resection with simultaneous anastomosis were immediately performed under a diagnosis of diverticular perforation during bevacizumab treatment. The postoperative course was uneventful except for delayed incisional healing. Bevacizumab, a recombinant humanized monoclonal IgG1 antibody that binds to and inhibits the biological activity of human vascular endothelial growth factor, when combined with intravenous 5-fluorouracil-based chemotherapy, is indicated for first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum. Since diverticulitis is a risk factor for intestinal perforation during bevacizumab treatment, caution must be exercised when bevacizumab is given to patients with intestinal diverticuli.

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A 58-year-old man discharging pus through a colostomy closure was found to have a fistula formed on the operation scar and draining liquid stool. The colostomy had constructed for ileum myelitis and closed 40 years ago. Fistulography and barium enema showed colon cancer forming a colocutaneous fistula. Colonoscopy showed type 2 sigmoid colon cancer and the pathological diagnosis of biopsy specimens was adenocarcinoma. Enhanced CT detected sigmoid colon cancer invading to the abdominal wall but no metastatic lesions. We conducted sigmoid colon resection with radical excision of the abdominal wall and lymph node dissection. Microscopic findings showed that cancer had invaded to subcutaneous tissue and formed a colocutaneous fistula through abscess formation. The pathological diagnosis was moderately differentiated adenocarcinoma. Surgery was considered curative. Cancer had easily invaded subcutaneous tissue because the abdominal fascia was partially defective and the scar may have contributed to the colocutaneous fistula.

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We report a rare case of gastrointestinal stromal tumor (GIST) arising from cecal intussusception. A 61-year-old man admitted for abdominal pain and a jelly-like stool was found in ultrasonography and computed tomography to have intussusception caused by a protruding tumor of the right colon. Colonoscopy showed a hard spherical mass with erosion in the cecum. Benign tissue found in a tumor biopsy necessitated laparoscopy-assisted iliocecal resection. Histopathologically, H&E staining showed fascicular proliferation of spindle cells that, together with positive immunological staining for c-kit and CD34, yielded a diagnosis of uncommitted GIST.

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We report a case of a 92-year-old woman successfully treated with elective colon resection after successful reduction of intussusception caused by sigmoid colon carcinoma using a colorectal tube. We reviewed 81 cases of intussusception secondary to sigmoid colon cancer from the Japanese literature. According to the intussusceptum location, S-R type located in the rectum accounted for 42 cases and S-P type located in the perineum for 30 cases. The remaining 9 cases were located in the oral side to sigmoid colon. In the S-P type, 80% of the patients were woman, but the S-R type showed no gender significance. The rate of abdominal ileus was only 10% in the S-P type, significantly lower than the 38% in the S-R type. The rate of resection following intussusception reduction was significant higher in the S-R type at 83% than in the S-P type at 53% while reduction was not possible in 12% of the S-R type or 23% of the S-P type. Around 30% in both groups required colostomy. If possible, elective resection of colon carcinoma with intussusception is recommended. Our case series is, to our knowledge, the first report of primary elective resection of the colon after reduction of intussusception using a colorectal tube.

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A 52-year-old woman undergoing right mastectomy followed by adjuvant radiotherapy and hormone therapy soon reported upper abdominal discomfort. Enhanced computed tomography showed a portal vein embolism, and CEA and CA19-9 were elevated. The gastrointestinal tract was examined, and an ascending colon cancer was found in colonoscopy. She was admitted and, based on a diagnosis of ascending colon cancer with portal vein tumor thrombosis, she was treated with FOLFIRI, which reduced the tumor thrombosis and CEA. A year later, however, the primary tumor had grown, necessitating laparoscopic right hemicolectomy, followed by FOLFOX, S-1+irinotecan, and S-1 alone. She remains well with no apparent sign of tumor regrowth or recurrence 30 months after surgery.

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We report a rare case of strangulated intrapericardial herniation of the small bowel following establishment of a pericardial-peritoneal window. A 96-year-old woman, in whom a pericardial-peritoneal window was established 5 months before for persistent pericardial effusion, developed sudden intense abdominal pain and was admitted to the hospital. Abdominal computed tomography revealed a segment of the small bowel in the pericardium. As strangulated intrapericardial hernia of the small bowel was suspected, emergent laparotomy was performed. A 30 cm segment of the small bowel was strangulated by the pericardial window, and was necrotic. Partial resection of the small bowel was performed and the window was covered by the round ligament of liver and closed. The postoperative course was good and the patient was discharged on the 24th postoperative day.

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We report a case of peristomal pyoderma gangrenosum treated by topical application of an immunosuppressive drug. The patient was a 25-year-old man in whom sigmoid colostomy had been undertaken for intractable anal fistula. He remained in a good condition with medical therapy, but suddenly presented with rapidly growing skin ulcerations, which were severely painful, appearing acutely at the periphery of the stoma. We diagnosed the condition as pyoderma gangrenosum, and initiated treatment with systemic steroids and topical tacrolimus ointment, and the skin ulcerations healed immediately. Pyoderma gangrenosum, especially in the peristomal region is difficult to treat. Topical tacrolimus ointment is often used for the treatment of pyoderma gangrenosum in the United States and Europe, but its use has been few reported from Japan. We report the present case in detail and discuss it with a review of the literature.

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We report a case of localized peritoneal malignant mesothelioma with lymph node metastases and recurrence in the abdominal cavity. A 63-year-old woman exposed to asbestos in the workplace and seen for anorexia and weight loss was found in abdominal CT to have a well-defined tumor adhering to the gastric wall. The prospective diagnosis was gastrointestinal stromal tumor of the stomach, necessitating open-laparotomy resection. An elastic soft 10 cm tumor with central necrosis was resected with part of the stomach and satellite lymph nodes. Histopathological and immunohistochemical examination showed the localized tumor to be peritoneal malignant mesothelioma with lymph node metastases. The postoperative course was uneventful, but the tumor recurrenced diffusely in the abdominal cavity 6 months after surgery. Despite chemotherapy with paclitaxel, the woman died 13 months after surgery. Resectable localized peritoneal malignant mesotheliomas are often reported to have a good prognosis, but recurrence may have a dismal outcome.

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We report two cases of refractory pancreaticocutaneous fistula, a critical complication that may occur after pancreaticoduodenectomy (PD), successfully treated by interventional internal drainage. Case 1: A 68-year-old man who underwent pylorus-preserving pancreaticoduodenectomy (PpPD) for bile-duct carcinoma began discharging pancreatic juice from the drain on postoperative day (POD) 5, but this halted and the fistula healed spontaneously. The patient was discharged on POD55. However, 3 days later, the fistula showed bleeding and he was readmitted. Abdominal CT and angiography showed bleeding from a pseudo aneurysm at the stump of the gastroduodenal artery, necessitating embolotherapy. Pancreatic juice then began to leak from the fistula. Drainage was continued, but leakage was not cured. On POD142, a T-tube was inserted into the elevated jejunum and the pancreatic duct for internal drainage. About 3 months later, the T-tube was removed. Case 2: A 74-year old woman underwent PpPD for bile duct carcinoma. Pancreatic juice started discharging from the drain, but halted and the fistula healed spontaneously. She was discharged on POD46. However, soon after that, the pancreaticocutaneous fistula wound showed exudation and she was readmitted. A drainage tube was inserted into the pancreatic duct from the fistula. On POD333, a lost-stent short tube was inserted into the elevated jejunum and pancreatic duct for internal drainage. The leakage of pancreatic juice stopped 6 days after this insertion. Percutaneous treatment using a T-tube or an internal drainage tube is useful for pancreaticocutaneous fistula following PD.

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[in Japanese]

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