Background: Recently, the transabdomino-hiatal approach (TAH) for advanced gastric cancer with esophageal invasion (AGCE) has been increasingly adopted after the results of a randomized control trial comparing between the transthoracic approach (TT) and TAH for AGCE was published. This study aimed to compare the treatment results between TAH and TT, and to examine the optimal approach for AGCE and the comparative efficacy of dissection of mediastinal lymph nodes. Methods: Eighty-one patients with AGCE, comprising 51 cases treated by the TT approach and 30 by the THA approach, were reviewed clinicopathologically. Results: There were more patients with advanced clinical stage in the TAH group than in TT group (P=0.028). The operation time was significantly longer and intraoperative bleeding significantly greater in the TT group (P<0.001 and P=0.054, respectively). There were no significant differences in the clinicopathological findings, including the macroscopic type, depth of invasion, extent of lymph node metastasis, length of esophageal invasion, extent of mediastinal lymph node metastasis, pathological stage or morbidity between the two groups. Mediastinal lymph node metastases were found in 9 cases (18%) in the TT group and 6 cases (20%) in the TAH group. There was also no significant difference in the survival between the two groups. Two of the 6 patients with mediastinal lymph node metastases in the TAH group showed survival of more than 4 years. Conclusion: The present study demonstrated that TAH might be a useful approach for AGCE, as the therapeutic results and morbidity in the TAH group were comparable to those in the TT group despite the larger number of advanced cases. Also, dissection of mediastinal lymph node appears to be an essential technique, even in patients treated by the TAH approach, since some cases of AGCE with mediastinal lymph node metastases showed longer survival.

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Introduction: We retrospectively reviewed cases of proximal gastrectomy without splenectomy conducted in patients with upper gastric cancer to determine the optimal indication of proximal gastrectomy for gastric cancer. Patients and Methods: Between July 1992 and September 2007, 206 patients underwent proximal gastrectomy. We reviewed patient and tumor features, prognosis, and recurrence. Results: Histological depth of 206 patients was pM in 49, pSM in 121, pMP in 28, pSS in 7, and pSE in 1. Lymph node metastasis was pN1 in 22, pN2 in 3. Cumulative 5-year survival rate was 92.5% for pStage IA, 86.0% for pStage IB, and 61.5% for pStage II. Postoperative recurrence occurred in 5 patients, mediastinal lymph node metastasis in 3, lung metastasis in 1, splenic hilum lymph node metastasis in 2. Depths of invasion in all recurrent cases were equal to or deeper than MP. Discussion: Our results suggest that the "optimal" indication for proximal gastrectomy without splenectomy should be restricted for early gastric cancer.

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A 75-year-old man undergoing gastrointestinal endoscopy for examination of a gastric ulcer and found to have a reddish region at the esophagogastric junction (EGJ). This biopsy was found to have adenocarcinoma of the abdominal esophagus necessitating lower esophagectomy through a left thoracoabdominal approach and proximal gastrectomy. Histological examination showed specimens to be revealed well differentiated tubular adenocarcinoma, involving the submucosal layer, but no metastasis to lymph nodes. In this case, No Barrett esophagus or ectopic gastric mucosa were seen around the tumor and most tumor cells were located in the esophageal lamina propia, rather than in the submucosal layer, suggesting that the tumor originated from the cardiac glands of the esophagus.

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A 46-year-old man esophageal cancer admitted as an emergency due to sever chest pain and high fever, was diagnosed with perforated esophageal cancer based on chest computed tomography (CT) findings. Right thoracotomy showed perforation of the lower thoracic esophagus with empyema. Esophagectomy with lymph node dissection was done with subsequent reconstruction using a gastric tube via a presternal route. After the intrathoracic cavity was washed with normal saline, drains were inserted. Macroscopic findings showed type 2 esophageal cancer with perforation in the center of the ulceration. Histological findings showed moderately differentiated squamous cell carcinoma with twelve metastases in perigastric nodes and marked lymphatic and venous invasion. The postoperative course was uneventful and the man was treated with adjuvant chemoradiation 2 months after surgery. He underwent chemotherapy for recurrence 10 months after surgery, dying 22 months after surgery. If a patient's general condition can tolerate surgery, esophagectomy with lymphadenectomy plus simultaneous reconstruction may be an option in the surgical management of esophageal cancer perforation, and adjuvant therapy may provide long-term survival.

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We report a case of gastric granular cell tumor that was completely resected en bloc by laparoscopy-assisted partial gastrectomy. A 56-year-old man seen for a stomach tumor found 1 year earlier in a medical checkup was found in upper gastrointestinal endoscopy to have a 25-mm submucosal tumor growing inside the upper lesser gastric curvature. The tumor grew to 30 mm within 10 months, necessitating ultrasonography. The diagnosis was a 36 mm submucosal tumor originating in the fourth layer. Fine-needle aspiration biopsy done under endoscopic ultrasonography yielded a diagnosis of gastrointestinal stromal tumor (GIST). Abdominal ultrasonography and computed tomography did not show metastasis and the patient was scheduled to undergo surgery. The postoperative course following laparoscopy-assisted partial gastrectomy was favorable, and the man was discharged 8 days after surgery. Histopathological analysis showed the neoplasm to be a 4.5×3.5×3.5 cm submucosal tumor. Histological analysis revealed tumor cells with eosinophilic cytoplasm that proliferated by forming large and small lesions, and immunological staining detected S-100 and synaptophysin, but no KIT, CD34, smooth muscle actin, or epithelial markers. The definitive diagnosis was a granular cell tumor.

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Few cases of histologically proven pancreatists in gastric aberrant pancreatic tissue have been reported, A 43-year-old man admitted for epigastric pain was found in blood tests to have slight inflammatory change without elevated serum amylase. Endoscopic examination showed a submucosal tumor with central umbilication on the greater curvature of the middle gastric body. Abdominal computed tomography (CT) showed a mass, 10 cm in diameter, with scattered calcification and a cystic lesion accompanied by swollen perigastric lymph nodes. After failing to determine a pathological diagnosis after two attempts at EUS-guided fine needle aspiration, we conducted segmental gastrectomy to severe resective margins, because tumor sized did not rule out malignant gastrointestinal stromal tumor or advanced gastric cancer. Histologically, the tumor was diagnosed as aberrant pancreas with acute pancreatitis located between the submucosa and muscularis propria.

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A 50-year-old man was admitted for epigastralgia in September 1998, and was found to have free air on the plain abdominal X-ray. Upper gastrointestinal endoscopiy revealed an ulcer in the lower anterior wall of the stomach, with the endoscopic findings strongly suggestive of perforation of the gastric ulcer. Therefore an emergency operation was performed. At laparotomy, a perforation was identified on the greater curvature in the lower anterior wall of stomach. Extended gastrectomy was conducted followed by gastroduodenectomy. Specimens of the resected stomach showed a perforated gastric ulcer lesion measuring 2.5×1.8 cm in size on the greater curvature in the lower anterior wall. The perforation itself measured 0.3 cm in diameter and was present at the center of the gastric ulcer. The histologic findings in the surgical specimen were suggestive of moderately differentiated tubular adenovarcinoma invading the submucosal layer around the ulcer in the gastric wall. Postoperatively, no signs of recurrence were detected by regular imaging and blood tests. When laparoscopic cholecystectomy was performed for the diagnosis of cholelithiasis in September 1998, peritoneal dissemination was detected. Although chemotherapy was started following this surgery, the patient died of peritonitis carcinomatosa five years and eleven months after the gastrectomy. Perforation of early gastric cancer is rare, and a case like ours, who died of peritonitis carcinomatosa after gastrectomy is very rare.

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We report a case of hepatosplenic abscess caused by oral infectious pathogens. A 48-year-old man admitted for fever and abdominal pain and undergoning drainage of a hepatic abscess was referred to us for treatment of a coexisting splenic abscess. Many patients of hepatosplenic abscess are immunocompromised due to conditions such as leukemia or intensive chemotherapy. Reports of hepatosplenic abscesses in the absence of systemic disorders are rare. The patient's medical history was unremarkable. All of his teeth showed black pigmentation and were decayed. Typical oral infectious pathogen Streptococcus anginosus and a pigmented gram-negative anaerobic periodontal pathogen were isolated from abscesses. We conclude that the hepatosplenic abscesses in this case were caused by oral infectious pathogens. The relationship between oral hygiene and systemic diseases such as infectious endocarditis are well known, but no case of hepatosplenic abscess caused by oral infectious pathogens has, to our knowledge, been reported, thus far. Ultrasonography-guided drainage of the splenic abscess was conducted safely.

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We report a case of left hepatectomy for hepaticojejunostomy stricture 5 years after surgery for congenital bile duct dilatation. A 16-year-old woman underwent left and right hepaticojejunostomy at the age of 11 years, because the left hepatic duct communicated directly with the choledocal cyst. About 4 years after the operation, she suffered repeated cholangitis due to hepaticojejunostomy stricture. Preoperative ultrasonography, computed tomography (CT) and MRCP showed dilatation of the intrahepatic bile duct but no intrahepatic stone. In intraoperative findings, the left hepaticojejunal anastomosis was almost completely obstructed. Histologically, the left intrahepatic bile duct was dilated and constricted irregularly. The bile duct wall was thickened with significant fibrosis. The postoperative course was uneventful and the patient is doing well.

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Hepatic resection in nonalcoholic steatohepatitis (NASH) requires a cautious preoperative evaluation and appropriate resection due to possibly decreased hepatic function reserve caused by NASH. Our case involved a 71-year-old woman with elevated hepatobiliary enzyme and diagnosed with hepatic hilar duct cancer extending from the confluence of the right and left hepatic ducts to the right hepatic duct. Her history of diabetes, hyperlipidemia, and fatty liver led us to suspect NASH. Hepatic function reserve was considered sufficient because ICGR15 and HH15 and LHL15 of ^99mTc-GSA scintigraphy were normal. An increased estimated hepatic function reserve of 39.1% was obtained by ^99mTc-GSA scintigraphy following portal vein embolization, and extended right lobectomy was done. No signs of postoperative hepatic failure were seen and the patient has progressed well. Histopathological findings confirmed a diagnosis of NASH, suggesting that surgical methods and evaluating hepatic function reserve as in cases of liver cirrhosis which center around ICGR15 and ^99mTc-GCA scintigraphy are useful in cases of NASH.

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A seventysomething woman with general fatigue and liver dysfunction was found in computed tomography (CT) to have hilar cholangiocarcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) indicated that a tumor occupied the left hepatic duct and spread to the bifurcation of the posterior and anterior branch of the right hepatic duct, necessitating hepatic trisegmentectomy was necessary to achieve margin negative resection and save margins for suturing. Because impaired liver function made the tumor unresectable as is, we conducted external-beam radiation of 30 Gy in 15 fractions, which was shown in CT and ERCP to reduce the tumor to a size, where we could conduct left hepatectomy with a negative surgical margin. Histological examination showed some carcinoma residue scattering at the confluence of the left and right hepatic duct. She was discharged in good health 16 days after surgery and has remained well for 7 the months since without sign of recurrence. We concluded that preoperative radiation therapy for cholangiocarcinoma is useful because it may convert an unresetable tumor to a resectable status.

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Serous cystic neoplasms of the pancreas are regarded as benign, with only rare cases showing signs of malignancy (serous cystadenocarcinoma). We report a rare case of serous cystadenocarcinoma of the pancreas in a 76-year-old man, found incidental to routine physical examination. The pancreatic tumor's maximum diameter was 4.0 cm. Magnetic resonance imaging showed a well-circumscribed multilocular cyst, having a honeycomb appearance containing fine, multilocular cysts, lined by a single layer of cuboidal epithelial cells having round nuclei. Mild nuclear atypia was noted, but nucleoli were not distinct and no mitotic figures were noted. Cytoplasm was clear and the periodic-acid-Schiff (PAS) reaction showed large amounts of glycogen. Although these findings and slight atypia are consistent serous cystadenoma of the pancreas, metastatic foci in peripancreatic lymph nodes and adipose tissue. Indicated that the present tumor was a rare serous cystadenocarcinoma of the pancreas accompanying mild cell atypia and lymph node metastasis.

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We report a case of bowel obstruction due to superior mesenteric artery (SMA) thrombosis caused by Protein C deficiency. A 49-year-old man admitted to emergency room for severe abdominal pain in March 2002 after stopping warfarin treatment (8 mg/day) on his own. He had been diagnosed with Protein C deficiency in 1990 and had continued under outpatient follow-up. Computed tomography (CT) indicated possible superior mesenteric artery thrombosis. Contrast-medium bowel wall enhancement indicated no sign of bowel necrosis, so we undertook thrombolytic and anticoagulant therapy, with the thrombus disappearing, three weeks later. During the next two months, with oral ingestion, he had a fever and abdominal pain repeatedly. Colonoscopy and gastrografin contrast study through a long tube, which indicated extensive stricture from the distant ileum to the transverse colon. Diagnosing the ischemic stricture as irreversible, we conducted right hemicolectomy, partial distant ileal resection, and loop ileostomy. The postoperative course was uneventful and the man was discharged once the loop ileostomy was closed. We review three cases of SMA thrombosis coused by protein C deficiency reported in the literature, and report our case to broaden knowledge on this subject.

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A 96-year-old woman with 3 days of abdominal pain and constipation and admitted for further examination. She had no history of peptic ulcer disease or nonsteroidal antiinflammatory drug use. Physical examination showed abdominal tenderness, muscular rigidity, and rebound tenderness in the upper abdomen. Abdominal computed tomography showed ascites and free air, suggesting acute peritonitis caused by upper gastrointestinal (GI) tract perforation. Laboratory data showed a white blood cell count of 10,500 and CRP of 20.4 mg/dl. Exploratory laparotomy showed mesenteric perforation of the jejunal diverticulum 30 cm distal to the ligament of Treitz, necessitating segmental resection of the jejunum, performed. Pathologically, the result was pseudo-diverticulum perforation. Although the patient suffered acute myocardial infarction on postoperative day (POD) 4, she was discharged on POD18. In cases of the upper GI tract, perforation of a jejunal diverticulum should be suspected and emergency laparotomy considered.

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We report rare advanced colon cancer involving a tumor thrombus in the superior mesenteric vein and perforation. We completely resected the transverse colon cancer and obtained a good prognosis, although the superior mesenteric vein tumor thrombus had already perforated the colon. A 68-year-old man reporting abdominal distension from late September 2006 and admitted for continuous vomiting at the beginning of October was found in colonoscopy to have invasive colon cancer obstructing the transverse colon. After his colon was perforated on hospital day 6, we changed to emergency surgery. Preoperative enhanced CT showed a tumor thrombus in the superior mesenteric vein that had grown from the mesenteric vein around the tumor, with no liver metastasis. Intraoperative findings showed no stool contamination in the abdominal cavity, although the cecum was perforated and adhered to and was covered by the wall of the urinary bladder. The perforation had been caused by obstructive colitis on the oral side of the tumor. The main tumor was near the hepatic flexure without liver metastasis or peritoneal carcinomatosis. We conducted right hemicolectomy, opened the superior mesenteric vein, and completely removed the tumor thrombus. We then started and have continued with chemotherapy with no evidence of recurrence.

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Tuberculosis (TB) has rerisen as a major infectious disease, with the proportion of difficult-to-diagnose extrapulmonary tuberculosis (EPTB) cases among all TB now accounting for approximately 20% of those affected in Japan. QuantiFERON^® TB-2 G (QFT) has been used to diagnose TB. We report two abdominal TB cases in which QFT appeared to be useful in diagnosis. Case 1: A 75-year-old woman with an abdominal mass was found in CT to have multicystic masses in the lower abdomen and liver, an adrenal mass, and lymphadenopathy in the hilum of the lung. Despite suspected malignancy, laparotomy and incisional biopsy could not provide a definitive diagnosis. QFT, however, showed positive results, leading to a diagnosis of TB. Case 2: A 73-year-old woman with acute peritonitis who had previously undergone two intestinal resections for inflammatory tumors was found in CT to have an abdominal mass. TB was diagnosed based on overall clinical presentation, including QFT. Abdominal TB often requires differential diagnosis for surgical treatment, and QFT appears very useful diagnosing for these cases.

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While opioids play an important role in cancer pain treatment, adverse drug actions nary and may be difficult to recognize for healthcare professionals not specializing in palliative care. To relieve cancer pain, we developed a clinical pathway (CP) involving oral controlled-released oxycodon to observe World Health Organization (WHO) guidelines. The primary CP endpoint was good sleep and the secondary endpoint absence of pain while resting position. Using the CP improved the observance of the WHO guideline of setting up a rescue dose, combined with NSAIDs, antiemetic, and laxative treatment. Good sleep and absence of pain while resting were archived in 75% of patients within five days by using CP. A specialist in digestive surgery is used to CP using and by using CP, we could accomplish treatment of cancer pain, that we are not used to very much, without a stress.

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