Background/Aims: In esophageal cancer patients, postoperative pneumonia frequently occurs. In the oral cavity, dental plaque is the major reservoir of bacteria, and it is possible that oral bacteria are aspirated into the upper respiratory tract after an esophagectomy. We evaluated the interaction between preoperative dental plaque and postoperative pneumonia in patients undergoing esophagectomy. Patients and methods: Thirty-nine patients of thoracic esophageal cancer who underwent an esophagectomy were investigated. Preoperatively, dental plaque was collected and the bacterial flora investigated. If postoperative pneumonia occurred, the sputum was harvested and the pathogens were evaluated. Result: Postoperative pneumonia was observed in 14 patients (35.9%): 5 (71.4%) of the 7 patients in the pathogen positive group developed postoperative pneumonia, and 9 (28.1%) of the 32 patients in pathogen negative group developed. In 2 (40.0%) of 5 patients who had pathogenic bacteria in the preoperative dental plaque, the same pathogenic bacteria were also identified in the postoperative sputum. Conclusion: Pathogens in preoperative dental plaque are risk factors for postoperative pneumonia following thoracotomy in patients with thoracic esophageal cancer.

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Introduction: We conducted a study to determine the computed tomography (CT) findings useful in alimentary tract perforation diagnosis and management. Methods: We reviewed abdominal CT from 180 patients treated for gastroduodenal (n=99), jejunoileal (n=25), and colorectal (n=56) perforation from January 2000 to January 2008. We focused on extraluminal free air (FA) and intraperitoneal fluid collection (FC). We classified FA into upper and lower FA based on the level of the third duodenal portion, and superficial FA and deep FA based on whether FA was adjacent to the anterior peritoneal surface. FC was evaluated by extent and location. Results: FA was detected in 97% of gastroduodenal, 56% of jejunoileal, and 78.6% of colorectal perforations. In upper FA, 97% involved gastroduodenal, 52% jejunoileal, and 66.1% colorectal perforations, and in lower FA 18.2%, 24%, and 58.9%; in lower-deep FA 1%, 16%, and 51.8%. Sensitivity of lower-deep FA findings in diagnosing colorectal perforation was 51.8% and specificity 96.0%. Lower-deep FA was noted only in one case of gastroduodenal perforation, although upper FA was seen in all but three cases. FC extent and site showed no correlation with bowel perforation site. In all cases of gastroduodenal perforation treated successfully conservatively, FC width around the liver was 5 mm or less, with or without some FC in the pelvic cavity. FC in these cases did not increase in 24 hours. Conclusions: We found a correlation between FA and alimentary tract perforation sites. In gastroduodenal perforation, a small amount of FC with no increase in 24 hours was reliable for CT findings in indicating conservative therapy. CT findings were useful in handling alimentary tract perforation. Appropriately interpreting CT findings thus leads to prompt diagnosis and appropriate treatment.

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Purpose: We clarified the feasibility of inguinal hernia surgery by junior residents. Materials & Methods: We analyzed 139 retrospective cases of radical inguinal hernia surgery between April 2005 and December 2007. Of these, 134 involved mesh-plug repair and 5 Prolene hernia repair. We retrospectively compared the recurrence rate, the rate of complications, blood loss volume, operating time, and the length of postoperative hospital stay between patients treated surgically by junior residents (group R, n=72) and those treated by surgical staff (group S, n=67). Results: Total rates of recurrence and complication were 5.8% in group R and 8.6% in group S, respectively. Significant statistical differences were seen between groups in recurrence rate (group R, 9.7%; group S, 1.5%: p<0.05) and operating time (group R, 88 min; group S, 64 min: p<0.001). No statistically significant difference was seen in blood loss volume, rate of complications, or the length of postoperative hospital stay. Conclusions: The incidence of short-term complications in inguinal hernia surgery conducted by junior residents was identical to that of surgical staff. The high recurrence rate seen in inguinal hernia surgery by junior residents evoked, however, the need to implement surgical treatment guidelines for junior residents.

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A 45-year-old woman undergoing distal esophagectomy through a left thoracoabdominal incision for abdominal esophageal cancer with a postoperative diagnosis of pT3N0M0 Stage II was found in computed tomography (CT) one year after surgery to have mediastinal lymph node swelling anterior to the trachea. For a definitive diagnosis, we conducted mediastinal lymphadenectomy with video-associated thoracic surgery. Histologically, we found epithelioid cell granuloma with strong central caseous necrosis and Langhans' giant cells, indicating lymph node tuberculosis. We could not confirm the tubercle bacillus, so she was diagnosed with tuberculosis lymphadenitis because the tuberculin reaction was very strong and pathology findings were typical of tuberculosis. She was administered antituberculous drugs for six months and her later course was good. Three years since esophageal cancer surgery and the two years since the diagnosis of the tuberculosis. No recurrence has been seen to date in the upper mediastinum lymph node lesions following trachea lymph node recurrence are rare in abdominal esophageal cancer. We should therefore consider diseases other than cancer, particularly tuberculosis lymphadenitis, if findings suggest upper mediastinum lymph node swelling anterior to tracheal lymph nodes.

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A 46-year-old woman reporting 4 weeks of general fatigue was found in blood tests to have severe anemia of 2.9 g/dl, necessitating a blood transfusion. Five years earlier, a traumatic spleen injury had necessitated transcatheter arterial embolization (TAE). Endoscopic examination showed a submucosal tumor with dilated vessels in the fornix of the gastric posterior wall. Abdominal enhanced computed tomography (CT) showed an unclear submucosal tumor and thickened gastric wall with abundant blood flow adhering to the spleen. Because the diagnosis was imprecise, we conducted abdominal angiography, finding marked dilation of the left inferior phrenic artery, for which angiography showed a round hypervascular lesion about 10 cm in size via the gastric fornix, indicating the spleen, with the other part of the spleen fed by the splenic artery. We diagnosed the condition as intragastric bleeding from gastric collaterals and varices caused by the dilated left inferior phrenic artery. Due to the high probability that TAE for the left inferior phrenic artery has caused the intra-abdominal abscess, we ligated the left inferior phrenic artery, leaving the left gastric artery, and conducted a splenectomy. Endoscopic examination 6 months after surgery showed no dilated vessels. Angiography was thus very useful in diagnosis and treatment selection. Intragastric bleeding from gastric collaterals and varices after splenic artery embolization is very rare, to our knowledge.

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We report a case of biliary cystadenocarcinoma. A 59-year-old woman diagnosed with simple hepatic cyst elsewhere 2.5 years ago and admitted with abdominal discomfort was found in CT and MRI to have a cystic tumor 22 cm in diameter in the right hepatic lobe. The inner surface of the cystic tumor was smooth, and no suspected mural nodule was enhanced. Based on suspected biliary cystadenocarcinoma, we conducted right hepatic lobectomy. Macroscopically, the resected tumor was a simple hepatic cyst with no mural nodule or septum. Histopathologically, well-differentiated adenocarcinoma had spread flat to most of the cystic wall. A transitional portion from adenoma to adenocarcinoma suggested that this cystadenocarcinoma resulted from malignant transformation from cystadenoma. Asymptomatic hepatic cystic tumors are often found incidentally in mass screening. Biliary cystadenocarcinoma may, however, be difficult to distinguish from a simple hepatic cyst. The occurrence of hepatic cystic tumor should thus raise the possibility of biliary cystadenocarcinoma.

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The tumor of 5 cm in diameter found in segment 7 of the liver of a 59-year-old man with a history of hepatitis B was determined to be Cholangiocellular carcinoma (CCC) by computed tomography and angiography. Right lobectomy of the liver was performed in August 2003. The whitish firm mass without a capsule was found histopathologically to have both glandular and trabecular structures, as well as cholangiolocellular carcinoma (CoCC), and slight mucin production indicated by alcian blue staining. Immunohistochemistry results were as follows: cytokeratin (CK)-7 (+), -19 (+), -8 (+), Hep-Par1 (-). From the pattern of Epithelial membrane antigen (EMA) expression, the tumor was diagnosed as CoCC with CCC differentiation. Serum CEA and CA19-9 becoming normal postoperatively rose again two years later. The man died of mediastinal lymph node metastasis, multiple lung metastasis, and pleuritis carcinomatosa 3 years and 3 months after initial surgery. Both CoCC and combined hepatocellular and Cholangiocellular carcinoma may originate in hepatic progenitor cells and, indeed, may be the same disease.

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A 60-year-old man undergoing pancreaticoduodenectomy for advanced pancreas head carcinoma suffered recurrence at the dorsal site of the remnant pancreas despite adjuvant chemotherapy. When he was hospitalized for hemorrhagic shock with hematemesis, abdominal computed tomography showed that the recurrent tumor had encased the splenic artery and a splenic artery pseudoaneurysm had perforated the stomach. The pseudoaneurysm was considered due splenic artery invasion by recurrent carcinoma and obstructive pancreatitis. The pseudoaneurysm was successfully treated by transcatheter arterial embolization and the man was discharged after one month. To our knowledge, splenic pseudoaneurysm perforating the stomach in carcinoma recurrence is extremely rare, with only 17 such cases reported in the Japanese literature.

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Intussusceptions caused by anisakiasis of the small intestine are very rare. We report such a case. A 35-year-old man who had eaten raw squid for dinner that evening reported epigastric pain and vomiting, and was treated for acute gastroenteritis, but was diagnosed with intussusception of the small intestine when abdominal Computed tomography showed multiple concentric rings the next morning. In emergency surgery, we invaginated the jejunum from 20 cm at the portion to about 15 cm away from the Treitz ligament. After reducing the intussusception manually, we resected about 30 cm of the jejunum due to severe edema. Macroscopically, the resected mucosa was reddish and edematous, but histopathological findings showed the body of anisakis in the submucosal layer to have eosinophilic leukocyte infiltration. Anisakis stuck in the jejunum region forms eosinophilic granuloma, which causes intussusception.

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A 24-year-old woman with upper right quadrant pain and diarrhea, found to have a palpable mass in the lower abdomen, and a tumor of the right ovary suspected from computed tomography (CT) findings and referred to a gynecology department, was found in blood tests to have high CA125 of 348.9 U/ml. Magnetic resonance imaging (MRI) showed pelvic lesions extending to the supraumbilical region; both ovaries were identified separately. A tumor originating from the mesentery rather than ovarian tumor was suspected and surgery conducted. Both ovaries were found to be normal. A pelvic mass originating from the mesentery had invaded the small intestine. Tumor nodules occurring in the greater omentum were diagnosed by rapid pathological diagnosis as undifferentiated malignancies, necessitating partial small intestine resection together with the tumor originating from the mesentery. The woman's postoperative course was satisfactory and she was discharged on day 15 of hospitalization. Based on pathology, the patient was diagnosed as having a peripheral primitive neuroectodermal tumor (pPNET). Nodes in the greater omentum had a similar histology, so the woman underwent adjuvant chemotherapy. pPNETs of the mesentery are rare, so we report this one together with a review of the literature.

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A 27-year-old woman seen for irregular menstruation, and found to have a right ovarian cyst became pregnant and underwent laparotomy during the 18th week of pregnancy. Instead of an ovarian cyst, she was found to have a 13 cm spindle-shaped tumor of the appendix, necessitating appendectomy and partial ceacal resection to avoid possible perforation during pregnancy. The surgical specimen proved histologically to be an appendiceal mucinous cystoadenoma. The patient and fetus had an uneventful postoperative course followed by a natural childbirth. We review the literature on appendiceal mucocele in pregnant women and its features.

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60-year-old male began to experience mucoid bloody stools in June 2001. Colonoscopy revealed multiple reddish protruding lesions mainly in the rectum and scattered from the sigmoid to the transverse colon, covered by mucous exudates. The pathological diagnosis following an endoscopic mucosal resection was cap polyposis. Although he was followed by medical treatment, the symptoms worsened. In May 2004, a laparoscopy assisted low anterior resection of the cap polyposis of the rectum was performed. After the operation, his symptoms improved and his quality of life is progressing satisfactorily. The etiology of cap polyposis is still unknown and no specific treatment has been established. Surgical treatment is one of the choices for the treatment of refractory cap polyposis that does not respond to conservative medical treatment. However, the efficacy of a surgical resection is less than 55%, so the indications for the procedure should be considered very carefully. Laparoscopic surgery is minimally invasive and is often useful in the treatment of refractory cap polyposis that does not respond medical treatment.

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We report a rare case of the sigmoid colon cancer with solitary sacral metastasis 4 years after a curative resection. A 75-year-old man with a history of sigmoid colon resection for Stage I cancer in 2001 visited in 2006 with severe perianal pain. Radiologic findings showed a solitary sacral tumor and aspiration biopsy cytology pathologically revealed the sigmoid colon cancer metastasis. Systemic chemotherapy and local irradiation showed no response. Transcatheter arterial injection chemotherapy (TAIC) of the tumor-feeding artery was performed 13 times. There were no obviously clinical change of tumor size and decrasing the tumor markers, and he died of multiple lung metastasis for 6 years 8 months after operation. The combination treatment of surgery, systemic chemotherapy and TAIC was needed to bone metastasis of the colon cancer. This rare case is reported and discussed.

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A 58-year-old man with a submucosal tumor in the rectum Rb area found in a medical examination underwent endoscopic submucosal dissection (ESD) due to the tumor being clinically suspected of being a rectal carcinoid. Histologically, the 4 mm tumor had negative vertical and horizontal margins but accompanied minimal vascular invasion. The man underwent additional surgery after providing informed consent. Histological examination of the surgical specimen showed lymph node metastasis at station 251 (Japanese Classification of Colorectal Carcinoma, 7th Edition). If a patient with a rectal carcinoid presents findings such as a tumor exceeding 10 mm in size, invasion deeper than the muscularis propria, a central depression, a contour surface, and vascular invasion, additional surgery and careful follow-up are necessary. For tumors less than 5 mm in size, the indication for additional surgery is controversial because almost all cases in this subgroup has no lymph node metastasis and quality of life (QOL) may be impaired by additional intervention. As seen in this case, for a rectal carcinoid with vascular invasion, additional surgery and careful follow-up are necessary, regardless of lesion size.

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A 24-year-old man admitted for left abdominal pain, and previously found elsewhere to have intraabdominal tumors and liver metastasis was found in contrast-enhancement computed tomography (CT) to have a 90 mm tumor in the left abdomen and pelvis with multiple liver metastasis. No tumor causing peritoneal dissemination or liver metastasis was found, however, in endoscopic examination or PET. CA125 at 100 U/ml and Neuron-specific eolase (NSE) at 83.4 ng/ml were elevated. Unable to obtain a histological diagnosis with fine-needle aspiration cytology, we conducted open incisional biopsy and totally resected the omental tumor. The definitive diagnosis was desmoplastic small round cell tumor (DSRCT). The man was treated to 5 courses of high-dose chemotherapy based on the P6 regimen. Two courses of chemotherapy reduced tumors of abdomen and liver metastasis and decreased serum CA125 and NSE levels, but the man died 7 months after diagnosis due to tumor regrowth. In cases of abdominal tumor in young patients, DSRCT should be considered as a differential diagnosis.

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Many surgeons consider the colon a secondary option for the esophagus following esophagectomy in patients with a history of gastrectomy or gastric cancer. Preoperative angiography is used to evaluate arterial variations or abnormalities potentially influencing the choice of the colon or a vascular pedicle for the graft. So we studied whether three-dimension (3D) angiography based on multidetector-row computed tomography (CT) (3D-CT angiography) enable us to evaluate arterial abnormalities. Subjects were 3 patients -two men and one woman (average age: 61 years)- undergoing elective esophageal reconstruction using the colon. 3D-CT angiography sufficiently evaluated the anatomy of colonic arteries and communication between colonic marginal arteries. This information is useful in preoperative planning for vascular dissection and additional microvascular anastomosis. 3D-CT angiography also satisfactorily evaluated the postoperative vascular patency of colon conduits. So 3D-CT angiography is an easy, less invasive alternative to conventional angiography in determining esophageal reconstruction using the colon.

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[in Japanese]

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