Introduction: We analyzed clinicopathological features and prognosis between patients with P0CY1 and P1. Methods: Intraoperative peritoneal lavage cytology was conducted in 339 patients undergoing gastric cancer surgery from 1996 to 2005. We found that ClassV cells in Papanicolaou's classification were positive for malignant cells (CY1). Results: There were 281 patients in P0, including 33 patients with CY1, and the incidence of CY1 was 11.7%. All with P0CY1 showed T3 or T4 invasion and lymph node metastasis, which were more advanced factors than that of those with P0CY0. The P0CY0 survivial was better than in P0CY1, and P0CY1 survival better than in P1. In dividing P1 into P1, P2 and P3 based on general rules for gastric cancer study, P0CY1 and P1 survival were better than in P3. We divided P0CY1 into two groups based on the number of free cancer cells in peritoneal lavage cytology. Survival in patients with a few cancer cells was better than that of those with many. In cases of P0CY1 undergoing gastrectomy and lymphadenectomy, the MST of group D2 was 497 days and that of group D0, D1 was 264 days, although this was not statistically significant. Conclusions: CY1 appeared to be a worse prognostic factor, but P0CY1 survival was better than in P1. Peritoneal lavage cytology for evaluating the number of free cancer cells may thus be a useful prognostic factor.

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Pancreatic cancer has a dismal prognosis, although this may improved by curative surgery and adjuvant chemotherapy, we undertook an observational study to clarify whether adjuvant chemotherapy with gemcitabine provides an overall survival advantage in patients undergoing curative resection for pancreatic cancer. Patients and Methods: Subject were 213 patients undergoing curative resection for histologically verified pancreatic cancer (resection rate: 55%) from August 1981 to March 2007. Of these, 133 without adjuvant chemotherapy were assigned to a control group and 80 underwent adjuvant chemotherapy with gemcitabine in a gemcitabine group (intension-to-treat). Survival was analyzed, and the two groups compared. Results: Median survival was 21.1 months in the gemcitabine group and 12.2 months in the control group. Overall survival differed significantly between groups (p=0.029, log-rank) (hazard ratio: 0.785, 95%cCI: 0.642-0.949), and the survival curve was significantly better in the gemcitabine group than in the control group in a subgroup of patients who showed unfavorable factors, i.e., microscopic residual tumor (R1), lymph node metastasis, portal vein invasion, extrapancreatic nerve plexus invasion, and tumor of the pancreatic head. The survival curve for patients undergoing adjuvant chemotherapy for longer than 3 months (n=47) was significantly better than for those undergoing less than 3 months (n=20). Conclusions: Adjuvant chemotherapy with gemcitabine significantly prolonged overall survival in patients undergoing curative resection for pancreatic cancer.

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We report a long-term survival case of alpha-fetoprotein (AFP) producing esophageal carcinoma after radical resection. A 49-year-old man admitted with dysphagia was found to have advanced carcinoma of the esophagogastric junction. Barrett's epithelium was found around tumor. Preoperative serum AFP was 89.8 ng/ml, necessitating lower esophagectomy and total gastrectomy. Histopathological studies showed moderately differentiated adenocarcinoma with lymph node metastasis. Tumor cells had clear cytoplasm and immunohistochemical staining for AFP was positive. Serum AFP concentration decreased and the man is alive without recurrence eight years after surgery. Since the operative curability is a factor associated with the survival of patients with AFP producing carcinoma, it is necessary to carry out an adequate operation.

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A 58-year-old woman with a sore throat since December 2005 and gradually developing dysphagia was no longer able to ingest solid food in March 2006. She was found to have a giant polyp 5 cm in length with polypoid features on a narrow stalk arising in the cervical esophagus covered by normal esophageal epithelium. CT and MRI showed no invasion of surrounding tissues and pathological examination indicated no evidence of malignancy. The mass judged to be a benign esophageal polyp, was resected endoscopically. Pathological evaluation yielded a definitive diagnosis of small cell carcinoma. Local recurrence in the esophagus was diagnosed 6 months after the initial resection. Irradiation alone at a dose of 30 Gy induced complete remission. She is presently living with no evidence of recurrence. Nearly all giant polyps arising in the cervical esophagus have been reported to be benign. The differential diagnosis of esophageal tumors should therefore include malignant tumors of uncommon histological type rarely associated with polypoid features.

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A 18-year-old woman not wearing a seatbelt and injured in a traffic accident was found to have a board-like abdomen and sereve tenderness. Abdominal computed tomography showed free air in the abdominal cavity, necessitating emergency laparotomy under a diagnosis of panperitonitis due to gastrointestinal perforation. The stomach had been completely transected at the antrum, necessitating distal gastrectomy and Billroth II reconstruction with a Braun anastomosis. She was discharged on postoperative day 15. Traumatic gastric transection without other injury has not, to our knowledge, been previously reported.

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We report a case of endocrine cell carcinoma and adenocarcinoma of the stomach in synchronous multiple cancer. A 71-year-old man admitted for left-flank pain was found in endoscopy to have an open ulcer and irregular surrounding mucosa in the lesser curvature of the middle stomach. Biopsy showed adenocarcinoma. Upper gastrointestinal contrast radiography showed another lesion similar to a submucosal tumor with a central ulceration in the posterior wall of the middle body, only two months after the first examination. Abdominal CT showed no metastatic lesion in any organ. Laparoscopy-assisted distal gastrectomy with regional lymph node showed two tumors, one IIc+III cancer and the other tumor was suspected to be a submucosal tumor, diagnosed as moderately differentiated adenocarcinoma and endocrine cell carcinoma staining for synaptophysin and neuron-specific enolase (NSE). The two tumors were not related. Although gastric endocrine cell carcinoma prognosis is dismal, the patient remains alive 18 months after surgery.

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Essential thrombocythemia (ET) is rare and characterized by persistant thrombocytosis, necessitating measures to prevent thrombotic complications We report a case of essential ET with gastric cancer. A 77-year-old man with ET was treated with aspirin and hydroxycarbamide for 8 years experienced epigastralgia, found in gastrointestinal fiberscopy to be early gastric cancer in the U region. Upon admission, we changed his therapeutic ET regimen from aspirin to heparin and postponed hydroxycarbamide from 2 days preoperatively before laparoscopy-assisted total gastrectomy. Heparin was resumed on postoperative day (POD) 2 and aspirin on POD 5. Because his platelet count exceeded 70×10⁴/μl, we resumed hydroxycarbamide on POD 12. No ET-related complication occurred. Adequate platelet count control and anticoagulant therapy through the perioperative period are very important for surgical patients with ET. In so far as we know, no gastrointestinal cancer patients with ET have been treated by laparoscopic surgery.

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We report a rare case of hepatic mucinous cystadenoma (MCA) of the caudate lobe. A 74-year-old woman referred for epigastralgia was found in abdominal ultrasonography and computed tomography to have a multicystic tumor of the hepatic caudate lobe with an 7 cm in diameter enhanced septum and partial wall calcification. Based on a preoperative diagnosis of hepatic MCA, we conducted a left hepatectomy and caudate lobectomy in April 2007. The multicystic tumor contained mucus and the hepatic caudate lobe was thinned. Pathologically, the cyst wall was covered with columnar epithelium containing ovarian-like stroma but was free of malignant components. Differentiating cystadenoma and cystadenocarcinoma before surgery is difficult, even histologically. Since hepatic MCA is a rare neoplasm with possible malignant formation, we recommend complete tumor resection.

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A 62-year-old woman seen for a cystic tumor of the pancreas was found in abdominal computed tomography (CT) to have an absence of the dorsal pancreas and the presence of a 9 cm cystic tumor in the head of the pancreas. PET/CT for tumor FDG uptake indicated high malignant potential, although intraoperative cytological diagnosis by fine-needle aspiration was benign. Because malignancy could not be completely ruled out by frozen section diagnosis of solid components, we conducted pancreatic resection with lymph node dissection. Subsequent pathological examination showed a solid-pseudopapillary tumor (SPT) with vascular and lymphatic invasion. Reports of malignant SPT of the pancreas associated with dorsal agenesis are extremely rare, and we discuss the relevant literature.

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A 45-year-old Japanese man sought confirmation of his condition after the discovery of bloody stool. He had a history of acute pancreatitis 8 years earlier, of heavy alcohol consumption and of smoking one pack of cigarettes a day. Before the first examination, he had had a few days of epigastric discomfort. He showed no signs of shock, and laboratory data showed neither anemia nor an abnormal serum amylase level. Upper gastrointestinal endoscopy showed stomach wall swelling suggesting a submucosal tumor, but no ulcer or erosion was seen. Sigmoidoscopy showed fresh blood in the lumen but no bleeding point could be detected. Computed tomography (CT) showed a 3 cm lesion at the pancreas tail with the same enhancement as the splenic artery and attached to the transverse colon. The main pancreatic duct was calcified and dilated. The diagnosis was a ruptured splenic pseudoaneurysm into the transverse colon, necessitating aneurysmectomy with distal pancreatectomy and splenectomy, together with simultaneously resection of the colon segment adhering to the aneurysm. The postoperative period was uneventful. Colonic rupture of a splenic pseudoaneurysm is very rare disease. But tendency to rupture of pseudoaneurysm needs a definitive therapy for it at a proper time.

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A 77-year-old man developing ileus several times and treated elsewhere since November 2006 was admitted in February 2007. Abdominal computed tomography showed intussusception of the small intestine and endoscopic examination showed a tumor in jejunum. Based on a diagnosis of a tumor of the small intestine, we conducted laparoscopy-assisted partial jejunal resection. Histopathological findings showed poorly differentiated leiomyosarcoma. Six months after the first operation, the man was admitted because for abdominal pain and found in computed tomography to have a tumor 10 cm in diameter in the abdomen, which we diagnosed as mesenteric hematoma. Because we found that the tumor grew in computed tomography taken 4 days after, we conducted partial jejunal resection. Histopathological findings showed recurrence of leiomyosarcoma at the mesenterium.

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Nonsteroidal antiinflammatory drugs (NSAIDs) negatively affects the upper and lower digestive tract. We report two cases of perforation of the lower digestive tract induced by NSAIDs. Case 1: A 75-year-old woman reporting back pain and malaise on day 1 from her first use of lornoxicam for tendovaginitis was found in abdominal computed tomography (CT) to have thickening of the descending colon and free air in the retroperitoneal space, necessitating surgery that showed one perforation of the transverse colon and two of the descending colon. We conducted left hemicolectomy and setting of the ascending colostomy. Case 2: A 72-year-old woman reporting abdominal pain on day 7 after her first use of sulpyrine for fever was found in abdominal CT to have thickening of the ileocecal region and free air around the liver, necessitating emergency surgery that showed two perforations - one in the terminal ileum and another in the transverse colon - with serositis of the sigmoid colon. We conducted ileocecal resection and partial resection of the transverse and sigmoid colon, and setting of the ileostomy and mucous fistula. In colon perforation induced by NSAIDs, several perforations and ulcers may occur separately, requiring extensive colon resection.

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A 51-year-old man admitted for sudden anal bleeding, was found in colonoscopy to have a large ulcer in the descending colon, although biopsy disclosed only nonspecific inflammation. After a short remission, the man suddenly developed massive anal bleeding and hemorrhagic shock. Emergency laparotomy showed bleeding from a penetrating colon ulcer into the spleen and pancreas, necessitating partial colectomy including the penetration site, splenectomy, and distal pancreatectomy. Histopathology revealed massive necrosis of the entire colonic wall with resultant penetration, but prominent degenerative changes significantly limited further etiological evaluation of the lesion. Despite intensive treatment, the man died of fulminant hepatitis on day 77 after surgery. Autopsy showed enteropathic NK/T-cell lymphoma involving the intestines, kidneys, lungs, and liver. Although rare, enteropathic lymphoma should be considered as a differential diagnosis when an idiopathic colonic ulcer is found.

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We report a rare case of rectovaginal fistula (RVF) after sex reassignment surgery (SRS) in a 33-year-old male-to-female transsexual. Having undergone SRS 7 years earlier, she had been treated elsewhere 3 years earlier for fecal discharge and bleeding from the neovagina. Contrast enema and endoscopy showed an ultra-high RVF of the rectosigmoid portion, necessitating sigmoid colostomy immediately after admission. Repair of the RVF by a transsacral approach from outside of the rectum was conducted 2 months later. The RVF was successfully closed but with difficulty due to severe intrapelvic adhesion. The colostomy was closed 2 months later. The patient has been problem-free in the 1 year and 3 months since repair. The cause of the RVF was thought to be obturator decubitus due to long-term continuous intravaginal stenting. Vaginal function has not been restored because the patient fears recurrence. We know of no reports of treatment by local repair with a transsacral approach for extremely high RVF of the rectosigmoid portion.

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A 53-year-old man underwent low anterior resection for rectal cancer in June 2002, followed by adjuvant chemotherapy and lung resection for two lung metastases in July 2004. When he became jaundiced in March 2007, total serum bilirubin and carcinoembryonic antigen were elevated. Abdominal computed tomography (CT) showed a tumor at the pancreatic head with calcification and intrabiliary growth, and dilated pancreatic and bile ducts, necessitating pancreaticoduodenectomy based on a diagnosis of solitary metastatic pancreatic cancer from rectal carcinoma -a rare condition difficult to diagnose preoperatively. Due to the mass with calcification and intrabiliary growth, we suspected this lesion to be metastatic pancreatic cancer. We summarized 25 reported cases of resected metastatic pancreatic cancer in Japan. Twelve patients among 23 survived more than one year after pancreatic resection and five patients died within a year, suggesting that pancreatic resection for metastatic pancreatic cancer can be surgically treated to prolong survival.

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A 74-year-old woman with gastric cancer underwent total gastrectomy with hepatic lateral segmentectomy. On postoperative day 1, she reported chest compression with sudden-onset tachycardia and respiratory distress without chest pain. Chest X-ray showed cardiomegaly, and electrocardiography showed ST-segment elevation in precordial leads. Troponin T and BNP increased, although no elevation occurred in other cardiac enzymes. We diagnosed the case as Takotsubo cardiomyopathy based on typical findings of echocardiography in which the base of the left ventricle was hyperkinetic and the remainder of the left ventricle akinetic. On POD6, the woman suddenly developed severe hypoxia and cardiogenic shock, necessitating mechanical ventilation. Chest X-ray showed congestion and a pneumonia shadow suggestive of exacerbated heart failure due to pneumonia. A sputum culture obtained yielded MRSA. With amelioration in pneumonia, however, her condition improved and abnormal left ventricular movement disappeared during postoperative week 3. It is thus important to recognize this disease when it happens because it occurs unexpectedly with common surgical treatment such as surgery, anesthesia, endoscopic examination, and other procedures requiring.

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A 79-year-old man undergoing leiomyosarcoma resection of the antebrachium 6 years earlier and referred for a liver tumor found in computed tomography (CT) was diagnosed with liver tumors with multiple metastases from antebrachial leiomyosarcoma by biopsy, necessitating extended S4 segmentectomy and S8 partial hepatic resection of liver. He remains alive for 4 year with no recurrence. Superficial leiomyosarcoma is very rare, and its subcutaneous form involves a high rate of recurrence and metastasis. We report this case due to the patient's long survival after complete metastatic lesion resection.

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We evaluated the relationship between body mass index (BMI), CT-estimated fat volume, operation time, and blood loss in laparoscopy-assisted distal gastrectomy (LADG) for carcinoma. Subjects were 16 patients undergoing LADG for early gastric cancer (cT1N0M0) in the lower or middle-third stomach, between March 2007 and February 2008, in our hospital. No major complications occurred. Correlations were seen between BMI and operation time, and BMI and blood loss. We measured intra-abdominal fat volume at the umbilicus level using abdominal CT. Correlations between fat volume and operation time, and fat volume and blood loss, were greater than those of BMI. The operation part times during surgical procedures were measured in all cases. Among them, greater variance was observed in lymph node No. 4d, 6 dissection and lymph node No. 7, 8a, 9 dissection procedure. Correlations between these operation part times and fat volume were also observed. Obesity lengthened operation time and increased blood loss in LADG. Fat volume measured by CT indicated the effect of obesity on operation more clearly than BMI.

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