An evaluation of quality of life (QOL) after surgery in ulcerative colitis patients in Japan is not clarified. We studied long-term postoperative case for QOL via questionnaires (SF36v2) mailed to subjects. Methods: Subjects were 138 of 151 cases of ulcerative colitis surgery conducted from 1984 to 2008 and still being followed up. Two surveys had been conducted in 2005 and 2008 on postoperative QOL inquiring about the correlation between the postoperative period and QOL, time-dependent changes in personal QOL, and the correlation between bowel function and QOL. The national average SF36 score is 50. Results: The response was 83.5% (96/115) to the first questionnaire and 76.1% (105/138) to the second. SF36 scores for (the first/second questionnaire) were PF 54.0/52.6, RP 50.9/49.6, BP 52.3/53.7, GH 47.3/47.7, VT 52.2/49.7, SF 50.5/49.8, RE 51.1/49.2 and MH 52.1/49.1. Four subscales showed scores under 50 for within two years after surgery (six subscales for the second questionnaire) but scores were improved after five years. A high score group (higher than 14) of the defecation score (0-18) showed high significantly favorable scores of QOL in five subscales compared with a low score group. The SF36 scores of 78 patients from whom we received a questionnaire two times in a row showed around 50. Conclusions: The QOL for those undergoing postoperative ulcerative colitis was equivalent to the national average, and improved as postoperative time passed. Satisfaction with bowel function influenced postoperative QOL.

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Spontaneous submucosal hematoma of the esophagus (SSHE) is an uncommon condition rarely combined with a Mallory-Weiss tear. A 68-year-old woman diagnosed with cholecystolithiasis and choledocholithiasis underwent endoscopic sphincterotomy and removal of bile duct stones, followed by laparoscopic cholecystectomy aggravated by an atrophic gallbladder. Early on postoperative day (POD) 1, she suffered a coughing spell followed by hematemesis of 50 ml. Upper gastrointestinal endoscopy on the same day showed a submucosal hematoma in the posterior wall of the lower esophagus extending to the cardia, where a mucosal laceration was noted. She was diagnosed with SSHE associated with a Mallory-Weiss tear, and was treated conservatively. The clinical course was uneventful and healing of the hematoma and laceration was confirmed endoscopically.

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We report the case of a 58-year-old man with advanced esophageal cancer successfully treated with a tracheal stent for airway obstruction following chemoradiotherapy. When he presented with an esophago-tracheal fistula, we put a covered esophageal stent in place, but he developed another esophago-tracheal fistula at the oral side of the covered stent 4 months later, so we placed another covered stent into the previous one. After this, the man could eat easily without dysphagia. Fourteen months thereafter, he died of pneumonia. Pathological findings showed no residual tumor. Our report focuses on chemoradiotherapy risk following stent placement and management of complications.

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We report a case of a gastric cancer remnant previously involving an esophagectomy among multiple cancers of more than three organs. A 76-year-old-man who had undergone distal gastrectomy with Billroth-I reconstruction for gastric cancer at age 36, esophagectomy with reconstruction using the colon for multiple early esophageal cancers at 63, and a resection for left lung cancer at 74, was found at the last surgery in computed tomography (CT) to have two tumors in the left lateral hepatic segment. Follow-up CT showed them to be growing, and they were eventually diagnosed as hepatocellular carcinoma based on CT angiography. Endoscopy also detected a gastric cancer remnant of macroscopic type 0IIc, and a pathological type of poorly differentiated adenocarcinoma and signet-ring cell carcinoma. We radically resected the gastric remnant cancer and two hepatocellular carcinomas, preserving the left colic artery feeding the reconstructed colon and removing the gastric remnant together with the left lateral hepatic segment. After resection, we constructed an anastomosis between the reconstructed colon and the jejunum using the Roux-en-Y method.

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Afferent loop obstruction is a dismal disease requiring prompt diagnosis and treatment. A 60-year-old man undergoing total gastrectomy for gastric remnant cancer with Roux-Y reconstruction (antcolic) had been operated on 25 years earlier for a gastric ulcer with wide resection and Billroth II reconstruction (retrocolic). Soon after surgery, bleeding from the elevated jejunum mesentery necessitated relaparotomy. On postoperative day (POD) 12, liver dysfunction and hyperamylasemia were observed and computed tomograph (CT) scan showed a markedly dilated duodenum and afferent loop obstruction. Because the intrahepatic bile duct was mildly dilated, percutaneous transhepatic cholangiodrainage (PTCD) on POD 15 was conducted under ultrasonic (US) guidance and dilation of the duodenum was improved using a PTCD catheter. The obstructive segment was around the Treitz ligament, and continuous drainage of the segment improved passage. On POD 35, the catheter was removed. PTCD appears to be one of a very effective procedures for treating afferent loop obstruction without surgery.

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Carcinosarcoma is rare neoplasm, and true gastric carcinosarcoma which of sarcomatous component is differentiating toward definite mesenchymal elements is extremely rare. We report a case of true gastric carcinosarcoma. A 69-year-old woman admitted for vertigo, palpitation, weight loss and tarry stool. Preoperatively diagnosis is gastric carcinoma by endoscopic biopsy, and Distal gastrectomy with Billroth-II reconstruction was underwent. Microscopically, the gastric tumor and metastatic lymph nodes consisted of intimately mixed adenocarcinoma and sarcomatous elements in which spindle cells growing. The sarcomatous components of the tumor was stained immunohistochemically for αSMA, and confirmed the pathological diagnosis of true carcinosarcoma. Only 12 cases of true gastric carcinosarcoma have been reported in Japan to our knowledge.

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A 68-year-old woman seen for liver dysfunction and intrahepatic dilation of the left lobe found in ERCP to have a filling defect of the left hepatic duct, necessitating hilar cholangiocarcinoma surgery. Intraoperative cholangioscopy showed that the papillary tumor originated from the left hepatic duct, but had not spread to either the common or the right hepatic duct, resulfing in left hepatectomy with caudate lobectomy. Histopathologically, the resected specimen showed papillary proliferation of the bile duct epithelium consisting of columnar epithelial cells arranged in a single layer. No invasive lesion was recognized under submucosa. The tumor was diagnosed as biliary papillomatosis. In regular 6-month computed tomography (CT), a weakly stained mass was found in the lower CBD, confirmed by MRCP and ERC. Lower CBD cancer was suspected, necessitating pancreatoduodenectomy. Histological examination showed recurnent biliary papillomatosis. Biliary papillomatosis is a rare tumor categorized as benign, but should be followed up for asynchronous recurrence.

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Ischemic heart disorders are often treated by coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA), but epigastric manipulation requires care to avoid RGEA injury. We report the case of a 72-year-old man with a history of CABG using RGEA who underwent pylorus-preserving pancreatoduodenectomy (PPPD) for invasive pancreatic cancer while preserving the RGEA. The man had been diagnosed with a pancreatic tumor when seen for anemia. Computed tomography (CT) showed the RGEA to be going to mediastinum at the left side of a hepatic falciform ligament, confirmed during surgery. The gastroduodenal artery (GDA) and the root of the RGEA had not invaded by cancer. After confirming the condition of the GDA, RGEA, and anterior superior pancreatoduodenal artery (ASPD), we dissected only the ASPD root. The histopathological finding was invasive ductal carcinoma and moderately to poorly differentiated adenocarcinoma.

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A 23-years-old man diagnosed in childhood as having chronic idiopathic intestinal pseudoobstruction (CIIP) and admitted for abdominal fullness and weight loss in December 2005. He underwent conservative therapy with total parenteral nutrition (TPN). In August 2006, his high fever and abdominal fullness became aggravated, suggesting acute peritonitis. Abdominal X ray imaging showed on enlarged intestine and subphrenic free air, but not peritonitis irritation. He was eventually diagnosed with pneumatosis cystoides intestinalis (PCI) with CIIP. Abdominal contrast-enhanced computed tomography (CT) showed no ascites, but indicated a double-layered structure at the small intestinal wall. Ten days after long-tube suction, enhanced CT showed that free air had decreased and PCI had disappeared. Emergency surgery was previously recommended for intestinal obstruction accompanied by free air with PCI because of suspected intestinal perforation. Our case suggests that surgical decision-making be done more circumspectly.

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Adenocarcinoma of Meckel's diverticulum is rare, with only 36 cases reported to our knowledge in Japan. A 43-year-old man seen for lower right pain and diagnosed from computed tomography (CT) with a malignant ileal tumor was found in surgery to have a 48 mm tumor at the apex of Meckel's diverticulum 120 cm from the ileocecal valve. The tumor had invaded the abdominal wall adjoining the right side of the bladder, presenting with dissemination, paraaortic lymph node swelling, and liver metastasis. The diverticulum and tumor were resected. Pathologically, the tumor was well-differentiated adenocarcinoma developing from Meckel's diverticulum containing ectopic gastric mucosa that may have given raise to the tumor.

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We report a case of primary squamous cell carcinoma of the ileum. A 36-year-old man was admitted for right lower abdominal pain, and was diagnosed with squamous cell carcinoma of the ileum, suspect of direct invasion to sigmoid colon and right ureter, and liver metastasis detected in small intestinal fiber and abdominal CT. Two months after ileocecal resection, sigmoidectomy, and right ureterectomy, we conducted two-stage hepatectomy. Histopathologically, findings showed pure well -differentiated squamous cell carcinoma of the ileum and liver metastases. As of this writing 22 months after the last surgery, he has remained recurrence-free. Primary squamous cell carcinoma of the small intestine has, in so far as we know, been reported in only 3 cases in the Japanese and Engligh literature.

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Five months after radical sigmoid colon cancer (pStage IIIb) surgery in September 2007, an 84-year-old man reporting upper abdominal distension was found in abdominal computed tomography (CT) to have multiple liver metastases and widespread left-lobe hepatic congestion. One week after being hospitalized, he died of hepatic and renal failure. A pathological autopsy indicated that he died of multiple liver metastases from poorly differentiated adenocarcinoma and left-lobe hepatic congestion and necrosis due to a tumor embolus forming in the branch inward toward the middle and left hepatic veins, and the left branch of the portal vein. Tumor embolus formation in the hepatic veins and the portal vein caused by large intestinal carcinoma and subsequent hepatic congestion and necrosis are believed to be pathologically extremely uncommon.

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We report a rare case of rectal cancer with small-bowel metastasis. A 73-year-old man who had undergone low anterior resection combined with partial liver resection in June 2003 was found 3.5 years later to have elevated CA19-9. Abdominal computed tomography showed a small-bowel lesion in the pelvis. Positron-emission-tomography-CT showed an abdominal concentration in the small bowel in the pelvis, necessitating laparotomy in January 2007 based on a diagnosis of tumor metastasis from rectal cancer. A tumor infiltrating to the ileal serosal surface necessitated partial ileal resection. Pathological findings for the resected specimen showed a histological similarity to primary rectal cancer. Now, over 6 years after rectal cancer surgery, the patient lives with multiple lung metastases and residual liver metastases and visits the outpatient clinic for chemotherapy, maintaining a good quality of life (QOL). Surgical resection thus occasionally bring a good prognosis and QOL to a patient with isolated small-bowel metastasis from colorectal cancer, despite other metastasis.

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We report an extremely rare case of interdigitating dendritic cell sarcoma of the rectum. A 76-year-old man with dyschezia was found in digital examination to have an elastic hard tumor palpated about 2 cm proximal to the anal verge. Colonoscopy showed a semicircular tumor with a central ulcer similar to a submucosal tumor in the lower rectum. Biopsy, yielded no definite diagnosis, necessitating abdominoperineal resection of the rectum based on the suspicion of gastrointestinal stromal tumor with malignancy. Histological examination showed a diffuse proliferation of atypical cells with irregularly shaped nuclei. These cells had poor bondability and frequent atypical mitoses. Immunohistochemically, tumor cells expressed CD68, CD99, S-100, and vimentin, but were negative for CD1a, CD3, CD79a, CD117, fascin, smooth muscle actin, HLA-DR, and EBER-ISH. Electron microscopy showed no evidence of Birbeck granules. The definitive diagnosis was interdigitating dendritic cell sarcoma (IDCS). The patient received chemotherapy for the remnant lymph nodes swollen along with para-aortic region. As of 8months after the operation, decreasing tendency in the remnant lymph nodes has been observed. As for this disease, about 50cases are reported in the world in the past. Only one case of IDCS occurred to digestive organs has been reported, and this case is the first report that occurred to large intestine in Japan.

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We report four cases of isolated spontaneous dissectin of the superior mesenteric artery (SMA) in four persons seen for abdominal pain and diagnosed using abdominal computed tomography (CT). Case 3 and 4 levealed aneurysmal formation. Case 1: A 62-year-old man diagnosed with suspected intestinal ischemia. We performed emergency surgery, thrombectomy and venous patch repair. Poor postoperative SMA blood flow necessitated emergency reoperation and broad bowel resection, but he died of disseminated intravascular coagulation (DIC) and hepatic and renal failure. Case 2-4: Men aged 51, 50, and 65 years with partial thrombosis of the false lumen were treated conservatively with vasodilators and antiplatelet and anticoagulant agents, and recovered well. Peripheral blood flow was maintained without intestinal ischemia. The 65 year-old man later developed ileus of colon transversum, and stenosis due to diteriorating blood flow of the middle colic artery requiring surgery. Isolated spontaneous dissection of the SMA requires emergency surgery for bowel necrosis and rupture, but otherwise is best met with conservative treatment and comprehensive follow-up. These, in turn, require careful evaluation of surgical indications and procedures.

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We report a case of obturator hernia with hepatic portal venous gas (HPVG). A 91-year-old woman with left lower limb pain, abdominal distention, and vomiting was found in plain abdominal computed tomography (CT) to have a small low-density spot in the peripheral liver and enhanced CT 1 hour after plain CT showed dendritic gas indicative of HPVG and an incarcerated obturator hernia. Emergency surgery using a peritoneal approach determined that the jejunum 230 cm proximal to the ileocecal valve was incarcerated in the left obturator foramen, so the necrosed jejunum was resected. Obturator hernia with HPVG is rare, and requires detailed physical examination and CT to ensure a correct diagnosis.

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