Introduction: Salvage esophagectomy is the sole curative intent treatment for patients with persistent or recurrent locoregional disease after definitive chemoradiotherapy (CRT) for esophageal carcinoma. However, salvage esophagectomy is a very high-risk operation, and airway necrosis is a fatal complication. Methods: Between 1997 and 2007, 49 patients with thoracic esophageal cancer underwent salvage esophagectomy after definitive CRT. We retrospectively compared patients with and without airway necrosis, and investigated operative procedures related to airway necrosis. Result: Airway necrosis occurred in five patients (10.2%), of four patients (80%) died during their hospitalization. Airway necrosis seemed to be closely related to operative procedures, such as resection of bronchial artery and cervical and subcarinal lymph node dissection. Bronchogastric fistula following necrosis of gastric conduit occured in 2 patients reconstructed through posterior mediastinal route. Conclusions: Airway necrosis is a highly lethal complication after salvage esophagectomy. It is important in salvage esophagectomy to take airway blood supply into consideration sufficiently and to reconstruct through retrosternal route to prevent bronchogastric fistula.

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Introduction: Drug-eluting coronary stents (DES) are widely used to treat coronary heart disease, although long-term dual antiplatelet therapy with aspirin and thienopyridine are needed to prevent stent thrombosis. No evidence exists, to the best of our knowledge, of the safety of drug substitution in patients undergoing major noncardiac surgery after DES implantation. Methods: We reviewed the cases of the most recent fifteen consecutive patients undergoing surgery for gastrointestinal tract cancer following DES implantation, assessing data on preoperative status, perioperative management, and patient outcome, including postoperative bleeding and thrombotic complications. Results: Surgical indications included nine cases of gastric cancer, three of colon cancer, and three of rectal cancer. Surgery involved six partial distal gastrectomies, three total gastrectomies, three colon resections including one laparoscopic surgery, and three low anterior resections including one laparoscopic surgery. Median duration to surgery after DES implantation was 17 months. In four of the ten most recent cases, surgery was done within 12 months after DES implantation. Perioperative antithrombotic management generally consisted of continuing aspirin therapy until one day before surgery and thienopyridine therapy interruption with substitute heparin administration one week before surgery. Surgery was safe and free of perioperative stent thrombosis and severe bleeding complications. Conclusion: Under rigorous perioperative antithrombotic management, patients with gastrointestinal tract cancer were successfully treated without severe complications after DES implantation. With the number of such patients expected to increase, perioperative antithrombotic management protocols and cancer screening before DES implantation must be established.

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We report a case of hemophilia acquired due to the inhibitor against coagulation factor VIII following esophagectomy. A 55-years-old man, undergoing esophagectomy via a left thoracoabdominal approach. The right hip swelling reported on post operative days (POD) 53, Hb of 7.5 g/dl necessitated emergency admission. Computed tomography (CT) showed the bleeding around the right hip joint. The patient had slightly prolonged prothrombin time (PT) and severely prolonged activated partial prothrombin time (APTT). We observed the man using the red cell mannitol adenine phosphate (RC-MAP) and fresh fresh-frozen plasma (FFP), but bleeding continued. And the activity of the Coagulation factor VIII was < 1%, and the inhibitor against coagulation factor VIII was > 5 BU/ml, yielding a diagnose is acquired hemophilia. However rare acquired hemophilia may be, care must be taken against it after cancer surgery.

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A 70-year-old man seen for a tight sensation during swallowing was found to have a Type-1 tumor of the lower thoracic esophagus and hospitalized for a continuous fever of 38°C or higher. His white blood cell count (WBC) was 18,100 /mm³ and CRP 22.64 mg/dl. His fever persisted as did his high WBC of 20,500 /mm³ and CRP of 25.09 mg/dl. Serum G-CSF high at 64 pg/ml (normal: 18 pg/ml or lower), he was diagnosed with a G-CSF-producing tumor, necessitating resection of the middle and lower esophagus, dissection of 2 regions, resection of the subtotal gastric tube, and intrathoracic anastomosis. Pathological evaluation indicated epithelial and non epithelial tumor components, indicating esophageal carcinosarcoma. GCSF immunostaining was positive for syncytium in tumor cells. Progression based on TNM classification was pT2, pN0, M0, and pStage IIA. The postoperative course was good, his condition returned to normal, and he was discharged on postoperative day 38. No recurrence has been seen in the five years since surgery.

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We report successfully treating a bronchial fistula due to a reconstructed gastric-tube after resection of esophageal cancer. A 62-year-old man diagnosed with esophageal cancer, and underwent subtotal esophagectomy followed by reconstruction using an intrathoracic gastric tube. Histological study of the specimen showed moderately differentiated squamous cell carcinoma with pStage I (pT1b and pN0). Discharged on postoperative day (POD) 18 without complication, he was readmitted 14 days after discharge with fever and coughing. Computed tomography (CT) scan, an upper gastrointestinal series, and endoscopy showed pneumonia due to gastric tube-bronchial fistula caused by a peptic gastric ulcer. Fistula persistence despite conservative pneumonia therapy, including respiratory support, necessitated further surgical intervention. In reoperation, the fistula between the gastric tube and the lung was separated off and closed with simple sutures. To prevent fistula reopening, a pedunculated diaphragm flap was patched over the closed gastric tube site. The man is doing well without recurrence 30 months after reoperation.

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After undergoing laparoscopy-assisted distal gastrectomy with antecolic Roux-en-Y reconstruction for early gastric cancer, a 49-year-old woman was seen for dull abdominal pain and epigastric discomfort. Her abdomen was not distended and no gross peritoneal signs were seen beyond midabdominal tenderness upon palpation. Plain abdominal radiography showed no bowel obstruction, but abdominal computer tomography showed bowel and mesenteric vessel twisting (whirl sign). When conservative treatment based on a diagnosis of internal hernia was unsuccessful, we conducted laparoscopic surgery the next day, finding that the entire small intestine from the jejunojejunostomy to the end of the ileum had herniated through the Petersen's defect and was misplaced on the left side of the abdomen. With drawing the small intestine from the Petersen's defect and repositioning it laparoscopically obviated intestinal resection since the herniated intestine had no ischemic change. Internal hernia following distal gastrectomy is rare, but the incidence of Petersen's hernia is expected to increase with the increasing incidcence of Roux-en-Y reconstruction. Prompt diagnosis remains the most important factor in reducing internal hernia morbidity.

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A 32-year-old woman seen for epigastralgia and diagnosed with early gastric cancer of the upper stomach was found histologically to have signet-ring cell carcinoma. Her grandfather, mother, brother, and uncle had died of diffuse gastric cancer between the ages of 26 and 32. Following total gastrectomy with Roux-en-Y esophagojejunostomy, pathological examination showed 38 signet-ring cell carcinoma lesions restricted to the mucosa of the stomach. This case was considered juvenile familial gastric cancer, with a clinical character very similar to hereditary diffuse gastric cancer due to E-cadherin (CDH-1) gene mutation.

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We report a very rare case of solitary fibrous tumor (SFT) of the liver. A 52-year-old woman admitted for consciousness disturbance had a tumor palpated in the low abdomen. Blood glucose was 22 mg/dl. Hypoglycemia was improved by glucose DIV. Tumor markers were normal. Blood insulin and C-peptide were low, but IGF-I and IGF-II were normal in endocrinological examination. Abdominal computed tomography showed an idiopathic tumor 20 cm in diameter in the abdominal cavity drooping over the pelvis from the left lateral liver, and necessitating partial hepatectomy with tumorectomy. The resected tumor 25.0×22.5×6.4 cm, 3 kg weighted. Histological examination showed SFT of the liver with tumor cells positive for vimentin and CD34. Immunohistologically, C-kit was negative. The postoperative course was uneventful and hypoglycemic symptoms immediately disappeared. The woman remains well and without recurrence 3 years after surgery. Most hepatic SFT is benign but may have malignant histological features and recur locally or metastasize-a fact that diagnosticians should be aware of.

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A 25-year-old woman admitted for severe upper abdominal pain was found in ultrasonography to have a low echoic area in the lateral hepatic segment and free fluid was confirmed in the Morrison pouch, Douglas pouch and left subphrenic space. These findings and her shock status on presentation suggested intraabdominal hemorrhage due to hapatic tumor rupture. Enhanced computed tomography (CT) revealed extravasation from the liver tumor in segment 3. She underwent therapeutic arterial embolization (TAE) achieving successful hemostasis. Serum AFP and protein induced vitamin K absence (PIVKA) II were very high, yielding a definitive diagnosis of hapatocellular carcinoma. After initial recovery, she was considered suitable for curative hepatic resection and underwent left lateral segmentectomy. Peritoneal dissemination was not confirmed in laparotomy. Histological examination of the resected specimen showed moderately differentiated hepatocellular carcinoma. She has been regularly followed up and has shown no sign of tumor recurrence in the 21 months since surgery.

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An 81-year-old man was admitted to our hospital for calculus cholecystitis; he showed improvement after conservative treatment. However, after 1 month, he presented with sudden episodes of vomiting with loss of appetite. Abdominal computed tomography revealed a gallstone that was 8 cm in diameter; the calculus had displaced from the gallbladder to the duodenal bulb through a fistula. Upper gastrointestinal series revealed a cholecystoduodenal fistula. Bouveret's syndrome was diagnosed. The symptoms improved after the gallstone had displaced to the stomach. We attempted to crush the gallstone endoscopically, but the attempt was unsuccessful. Therefore, operation was performed. We closed the cholecystoduodenal fistula, extracted the gallstone present in the stomach, and performed cholecystectomy and gastrojejunostomy because of duodenal stenosis. This is the first report of a patient with Bouveret's syndrome who showed improvement in symptoms after an impacted gallstone had displaced from the duodenal bulb to the stomach.

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A 63-year-old woman seen for right back pain was found in enhanced computed tomography (CT) to have a multilocular cystic lesion 3 cm in diameter in the pancreatic head and body border. Endoscopic retrograde cholangiopancreatography showed communication between the cyst and the pancreatic duct, which was not dilated. Pancreatic juice cytology indicated no malignancy. Endoscopic ultrasonography (EUS) showed an intramural nodule in the cystic lesion. Based on a tentative diagnosis of intraductal papillary mucinous neoplasm branch subtype (adenoma or adenocarcinoma) of the pancreas, we recommended surgery, but the woman desired follow-up. Ten months later, EUS showed that intramural nodules in the cystic lesion had grown, so we conducted pylorus preserving pancreaticoduodenectomy. The cut tumor surface was multilocular and 26×15 mm. Histological examination showed multiple cysts lined with single-layered cuboidal cells. Immunohistochemically, tumor cells were positive for PAS. Macroscopically, a brown structure was seen inside of the cyst, but cells were not seen histologically. The definitive pathological diagnosis was serous cystic tumor macrocystic type.

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A 32-year-old woman diagnosed with a pancreatic tumor 20 years earlier, treated by resection elsewhere and found histopathologically to be a solid-pseudopapillary neoplasm (SPN) of the pancreas, was seen for abdominal pain at the age of 29. Examination showed her to have a pseudo-cyst of the pancreatic head with intraluminal bleeding. At the age of 31, the solid part of the tumor was suspected to have grown and no pancreatic body or tail was detected. Fine-needle aspiration biopsy yielded a diagnosis of SPN, necessitating tumorectomy with duodenal preservation. Histopathology of the resected specimen was compatible with the SPN. The tumor was positive for NSE, vimentin, PgR, and synaptophysin, similar to the tumor removed 2 decades earlier. We diagnosed the case as a local recurrence of the earlier SPN.

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A 51-year-old woman admitted for intestinal obstruction had her symptoms ameliorated in conservative therapy but they recurred after eating. Based on a diagnosis of idiopathic intestinal obstruction, we conducted laparotomy, finding a jejunal obstruction 170 cm distal from Treitz's ligament. We resected the part of the jejunum containing the 2.6×2.2 cm tumor. Histopathological findings showed well-differentiated tubular adenocarcinoma originating from a Heinrich type III aberrant pancreas. Gemcitabine hydrochloride administered for peritoneal recurrence delayed her demise until 28 months after initial surgery, suggesting that gemcitabine hydrochloride may be promising in treating aberrant pancreatic cancer as well as primary pancreatic cancer. Aberrant pancreatic cancer in the jejunum is rarely encountered, and we review cases reported in the literature.

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We report an extremely rare case of extraluminal GIST resembling diverticulitis due to tumor necrosis. A 74-year-old-woman seen for 1 month of lower left abdominal pain was found in blood tests to have an elevated inflammatory response. Abdominal ultrasonography showed a tumor-like low echoic mass in the sigmoid colon. Computed tomography (CT) showed sigmoid colon enlargement and wall thickening, with surrounding fatty tissue density elevation. Colonoscopy detected easily bleeding hole like as diverticulum of the sigmoid colon, suggesting diverticulitis with an intraabdominal abscess. Based on this diagnosis, we conducted hand-assisted laparoscopic surgery (HALS). Operative findings showed a hard smooth-surfaced mass protruding from the sigmoid colon wall and adhering to the retroperitoneum, necessitating sigmoidectomy with partial retroperitoneal excision. The histopathological diagnosis was gastrointestinal stromal tumor (GIST). The postoperative course was uneventful and the woman is doing well without recurrence 12 months after surgery.

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We report a case of mesenteric inflammatory myofibroblastic tumor (IMT). A 78-year-old man was found in computed tomography to have a mesenteric mass. The tumor was identified by fluorine-18-fluorodeoxyglucose and positron emission tomography (FDG-PET) as potentially malignant, necessitating jejunostomy. The solid surgical tumor specimen was determined histopathologically to be an IMT. FDG-PET is thus useful for diagnosing IMT. We review the Japanese literature on mesenteric IMT and FDG-PET findings in such cases.

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A 64-year-old man brought by ambulance to the hospital due to vomiting, consciousness disturbance and dysbasia was found in laboratory findings to have diabetic ketoacidosis, and dehydration, suggesting pancreatitis. During conservative 24-hour treatment, abdominal tenderness developed, creatine kinase rapidly elevated and computed tomography disclosed a thickened segmental intestinal wall with an indistinct border, ascites, and pleural effusion. Thus, these clinical findings necessitated emergency surgery. Laparotomy showed multiple spotted necroses of the distal ileum. The superior mesenteric artery and its main branches pulsated, yielding a diagnosis of nonocclusive mesenteric ischemia (NOMI), necessitating partial resection of the ileum. The postoperative course was uneventful. NOMI is intestinal tract ischemia caused by contraction of the mesenteric artery in patients with systemic low perfusion. Given normal serum HbA1c and decreased urinal C-peptide, we definitively diagnosed this case as fulminant type 1 diabetes, which should be considered in cases of diabetic ketoacidosis without a history of diabetes. The importance of following up closely on physical abdominal findings and imaging in diagnosing cases of acute abdomen in subjects with consciousness disturbance cannot be overemphasized.

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A 63-year-old man seen for upper abdominal pain was found in abdominal ultrasonography (US) to have confirmed in a huge hepatic tumor. Computed tomography (CT) and abdominal angiography to be a hypervascular solid tumor, necessitating right trisegmentectomy of the liver, based upon a diagnosis of liver metastasis from an omental tumor resected and diagnosed 15 years earlier as leiomyosarcoma. Histological examination showed spindle cells forming a fascicular pattern. Immunohistochemical analysis showed the tumor to be positive for KIT but negative for myogenic or neurogenic makers. The omental tumor resected previously had shown exactly the same staining patterns in all markers tested, indicating that the liver tumor had metastasized from the extragastrointestinal stromal tumor (EGIST) arising from the omentum. A tumor recurred at the base of the skull 6.5 years after the hepatectomy, after which the patient was administered sunitinib after tumorectomy. No evidence exists on EGIST treatment or prognosis, and the biological difference between EGIST and ordinary GIST remains unclear. The clinicopathological features must therefore be determined to clarify a strategy for metastatic EGIST.

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Primary retroperitoneal cystadenocarcinoma is a very rare tumor. A 56-year-old woman who was diagnosed as having a retroperitoneal tumor presented to our hospital with lower abdominal pain and bloody stool. Radical surgery was carried out and the macroscopic findings showed that the tumor was 11×13 cm in diameter and oval in shape with smooth surface, and the lumen with multiple elevated portion was occupied with mucous fluid and a muddy brown substance. Pathological studies showed some atypical papillary cells and a vestigial of Mullerian system. Also both ovaries were normal-sized. Thus, the definitive diagnosis was primary retroperitoneal cystadenocarcinoma with direct invasion to the rectum and vagina, and multiple lymph nodes metastases. After undergoing adjuvant chemotherapy with low dose CDDP/TS-1, the woman is still alive without recurrence 1 year 2 months after the operation.

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Tachyarrhythmia is a major complication after radical esophageal cancer surgery. We report five such cases in which short-acting β₁ selective blocker (landiolol hydrochloride) successfully improved the abnormal heart rate. Preoperative electrocardiography and echocardiography were normal in all subjects. Tachyarrhythmia occurred on postoperative day (POD) 2 or 3. In the first two cases, landiolol hydrochloride was administered after other antiarrhythmic agents such as digitalis and verapamil failed. It was administered as the initial drug in the last three cases. The landiolol hydrochloride dose was 20 μg/kg/min in the first case as a recommendation, and 2 μg/kg/min in the others. The heart rate markedly decreased within a few minutes and systolic blood pressure was unchanged during landiolol hydrochloride administration in all cases. The half-life of landiolol hydrochloride is about 3-4 minutes, which makes it superior in drug administration, and may be useful for managing tachyarrhythmia caused by surgery for esophageal cancer.

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To evaluate the clinical significance of the serum p53 antibody in colorectal cancers, we preoperatively measured tumor markers, including the serum p53 antibody in 251 cases of colorectal cancer and compared them to patient profiles. Tumor markers were 31.2% positive for CEA, 15.8% positive for CA 19-9, and 31.6% positive for p53. The percentage of more than one of these markers being positive was 60.0%. In patients with fecal occult blood, p53 antibodies were significantly more positive than CEA (p=0.0215). In stage I subjects, p53 antibodies were significantly higher than CEA (p=0.0003). In 28 cases of synchronous multiple cancer, p53 antibodies were positive in 53.6% significantly higher than in those with single cancer. In 8 cases of synchronous double cancer, positive p53 antibodies were 50%. These results indicate the need to carefully check for synchronous multiple and double cancer in subjects in whom p53 antibodies are positive.

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The aim of this paper is to share our first experience of a novel procedure with da Vinci surgical system^® for colorectal cancer here in Japan and provide the current status of robot surgery. A 77-year-old male was transferred to our department for curative surgery of sigmoid colon cancer (T1N0M0). The patient was placed in Trendelenburg position and 5 ports were inserted into the abdominal cavity. After that, patient cart with 4 arms was docked on the left caudal side. Superior rectal artery and vein were divided, sigmoid colon was mobilized and rectum was dissected in robotic surgery. The outcomes of this case were comparable to those in the literature in terms of blood loss, morbidity and length of hospital stay, apart from operative duration due to being unfamiliar with robot. Robotic surgery might be feasible and safe procedure for colorectal cancer.

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