The efficacy, safety and feasibility of the titration using fentanyl injection for managing cancer pain were investigated. Sixteen patients with gastrointestinal cancer and cancer pain not controlled with nonsteroidal anti-inflammatory drugs were treated with continuous intravenous administration of fentanyl 6 μg/mL for titration. The starting dose of fentanyl was 1 ml/h, which was increased until pain relief was achieved. The pain score improved significantly from 3.8±2.1 to 1.1±1.1 (p<0.05), and titration succeeded in 14 (88%) of 16 patients. The time required for pain relief was 5.7±4.5 days. The fentanyl patch was then easily adopted in 10 of the 14 patients, and pain relief was maintained thereafter. Adverse events of more than grade 2, including nausea, vomiting, constipation, and respiratory suppression, were not observed even with no prophylactic medications. These results suggest that titration using continuous intravenous administration of fentanyl is effective, safe, and feasible for induction treatment of cancer pain, and that fentanyl is suitable for managing pain in gastrointestinal cancer patients who may have malignant bowel obstruction.

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Background: In Japanese Classification of Gastric Carcinoma (The 13th Edition), Stage IB is defined as T1N1M0 and T2N0M0. We attempted to create a system for predicting recurrence of Stage IB gastric cancer after curative resection. Methods: Between April 1989 and March 2008, 1,110 patients with gastric cancer underwent surgical resection at our hospital. And 123 patients with histologically proven stage IB were included in this study. Of them, 14 patients (11.4%) experienced recurrence. Results: Multivariate analysis with all these patients revealed that advanced form at macroscopic pathology (p=0.009), more than two metastatic lymph nodes (p=0.0004), and less than D2 lymph node dissection (p=0.0012) were selected as risk factors for recurrence. Patients who had more than two risk factors among of them showed the recurrence rate 58.3%. And there was significant difference in the cumulative 5-year recurrence-free survival rate between this group and the group which has less than two risk factors. Conclusions: We considered that the risk factors for recurrence were advanced form at macroscopic pathology, more than two metastatic lymph nodes, and less than D2 lymph node dissection, and the patients who have more than two factors were high risk group for recurrence. Adjuvant chemotherapy may be effective for this group, but further examination is necessary.

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A 65-year-old man referred for epigastric discomfort was found in gastric endoscopy to have an open ulcer in the middle gastric posterior. Biopsy showed signet-ring cell carcinoma. Computed tomography (CT) and abdominal ultrasonography showed no metastatic lesion, and laparoscopy-assisted distal gastrectomy (D1+β) and pathological examination indicated mucosal carcinoma and no lymphnode metastasis. Serum CEA concentration was elevated and paravertebral metastasis was found. TS-1, TS-1+cisplatin, irinotecan hydrochroloride, and paclitaxel were sequentially administered. One year and five months after chemotherapy initiation, neurological symptoms such as dizziness appeared. Cerebrospinal fluid examination showed meningeal carcinomatosis, after which the man soon died. Leptomeningeal carcinomatosis is uncommon in those with gastric mucosal cancer, but its possibility should be kept in mind when tumor markers are elevated.

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We report a case of primary gastric choriocarcinoma admixed with an alpha-fetoprotein (AFP)-producing gastric cancer, which showed rapid progress after surgery. A 78-year-old woman was hospitalized for gastric cancer in the upper stomach. Abdominal computed tomography detected the upper gastric tumor and the swelling of adjacent lymph nodes. Initial laboratory data showed high level of serum AFP (166 ng/ml). We performed total gastrectomy with resection of pancreatic tail and spleen. Hislogy confirmed the tumor consisted of two components: primary gastric choroiocarcinoma (PGC) and yolk sac tumor-like AFP-producing gastric cancer. Pathological staging was pT2N2M0 and Stage IIIA. The patient suffered immunocompromised status after surgery, and died because of infectious endocarditis on the 48th postoperative day. Although an autopsy revealed many small tumor thromboses in the intrahepatic portal vein, there is no evidence of metastasis in other organ. Primary gastric choriocarcionma is very rare and extremely malignant. Furthermore there are few reports of the coexistence case with yolk sac tumor-like gastric cancer; this case suggested that a retrodifferentiation of the gastric adenocarcioma caused two types of embryonic cancer-like components. The autopsy revealed small tumor thromboses in the liver which were not detected by enhanced CT. This finding would be helpful to determine the treatment strategy.

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We herein report a case of long-term survival after hepatectomy for liver metastasis from cancer of the papilla of Vater and review the literature. A 55-year-old man underwent pylorus-preserving pancreaticoduodenectomy (PPPD) in August 1998. The histopathological diagnosis was well differentiated tubular adenocarcinoma without lymph-node metastasis. Six years later, a liver metastasis (segment 8, single nodule, 7 cm in size) was detected on a follow up CT scan in 2004, and the patient was treated by segment 8 liver resection. He is alive without recurrence for 12 years after initial operation and for 6 years after hepatectomy. The review of the reported literature suggests that in selected patients with liver metastasis from carcinoma of the papilla of Vater, i.e. solitary, papillary or well differentiated tubular adenocarcinoma, and the duration of liver metastasis greater than 3 years after initial surgical treatment, hepatectomy is an option for long-term survival.

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The patient was a 52-year-old man who visited our hospital with the chief complaints of fever, abdominal pain and vomiting. Blood examinations revealed a marked increase in acute-phase reactants and increase in the biliary enzyme levels, and abdominal ultrasonography revealed gallbladder enlargement and gallbladder wall thickening. Plain abdominal computed tomography revealed a cystic lesion with an isodensity contour and low-density center, measuring approximately 2.0 cm in diameter, in the neck of the gallbladder. Based on these findings, acute cholecystitis due to a cystic lesion in the neck of the gallbladder was diagnosed. Because the inflammation was severe, emergency percutaneous transhepatic gallbladder drainage (PTGBD) was performed. The lesion was found to be a pedunculated tumor with a smooth surface by PTGBD imaging, and to be multilocular with a uniformly thickened wall by magnetic resonance imaging. Thus, we suspected a multilocular cystic benign tumor, and performed laparoscopic cholecystectomy. Examination of the resected specimen revealed that the tumor was pale red in color and pedunculated, with a smooth surface, and the histopathological findings were consistent with the diagnosis of a hyperplastic polyp of the metaplastic epithelial type. Acute cholecystitis due to incarceration of a hyperplastic polyp is rare. Therefore, we report our case as the first such case reported from Japan.

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On admission, a 78-year-old man with lower abdominal pain, was found to have a cystic tumor 30 mm in diameter with an intracystic elevated mass in the left medial section of the liver by US and CT. MRI and enhanced US revealed a multilocular cystic tumor with an enhanced elevated lesion. DIC-CT showed mild stenosis of the left hepatic duct, but mucin was not recognized in the bile duct. These findings suggested a cystic neoplasm of the liver, and the patient underwent left hepatic lobectomy. Histopatological examination revealed a multilocular tumor composed of papillary, mucin-producing neoplastic epithelium with various degrees of atypia and the tumor communicated to the bile ducts. Immunohistochemically, the neoplastic epithelium was partly positive for MUC1, MUC5AC and MUC6, but negative for MUC2. The tumor was a mucin-producing bile duct tumor which resembled branch duct type intraductal papillary mucinous neoplasm (IPMN) of the pancreas.

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A 59-year-old man was examined by a computed tomography (CT) because of increased level of fasting blood sugar. During the CT examination, his blood pressure had suddenly gone up extremely high. The CT revealed bilateral suspicious pheochromocytomas and multiple pancreatic endocrine tumors. Resection of the adrenal tumors and pancreatectomy were performed separately. Histological examination resulted in diagnoses of adrenal pheochromocytomas and pancreatic non-functioning endocrine tumor. Because the von Hippel-Lindau disease (VHL disease) was suspected by the combination of the multiple endocrine tumors, genetic testing was done, which confirmed a missense mutation in VHL gene. We should consider the possibility of VHL disease when a special combination of multiple tumors was found.

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A 57-year-old man visited a local hospital with abdominal pain and was found to have elevated liver and biliary tract enzymes. Endoscopic sphincterotomy was done under suspicion of choledocholithiasis. Then he presented progressive anemia due to hemobilia, and he was referred to our hospital after emergency embolization of the posterior superior pancreaticoduodenal artery. Arteriovenous malformation (AVM) in both the head and tail of the pancreas was diagnosed and we performed pancreatectomy preserving the middle portion of the pancreas as a function preserving procedure. Subtotal stomach-preserving pancreatoduodenectomy and distal pancreatectomy with splenectomy were performed. A modified Child method and distal end-to-side pancreatojejunostomy was selected for reconstruction. Though he had a Grade B postoperative pancreatic fistula that required percutaneous drainage, he recovered without occurrence of diabetes or any recurrence 2 years after surgery. AVM of the pancreas is regarded as congenital anomaly and frequently has multiple feeding arteries, thus resection can be radical and effective treatment. Though technically demanding, resection preserving the middle portion of the pancreas can be an alternative to total pancreatectomy for patients with multifocal lesion in order to preserving pancreatic endocrine and exocrine functions.

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A 34-year-old Myanmarese man was admitted because of tarry stool and severe anemia (Hb 3.6). Gastric varices with red color sign and a small ulcer at the posterior wall of the fornix and upper body of the stomach were revealed by upper gastrointestinal endoscopy which suggested the origin of the bleeding. Abdominal CT scan showed multiple masses in the spleen, a mass at the splenic hilum and multiple swollen lymph nodes at the hepatic hilum. The liver was morphologically normal. Accordingly, it was supposed that the cause of the gastric varices and their rupture was left-sided portal hypertension because of disrupted of splenic venous circulation caused by the masses in the spleen and at the splenic hilum. Surgery was thought necessary to prevent re-bleeding, therefore, laparoscope-assisted resection of the pancreatic tail and spleen and devascularization of the lower esophagus and upper stomach was performed. The resected specimen showed that the multiple masses in the spleen and the mass at the splenic hilum were abscesses by resulting from caseous necrosis of tuberculosis. We present this case, with a review of the literature, because it is rare that solitary gastric varices are formed by left side portal hypertension due to tuberculous splenic abscesses.

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A 89-year-old woman with no history of abdominal surgery consulted a local physician with a chief complaint of epigastric pain and was referred to the emergency department of our hospital. Severe tenderness and the Blumberg sign were observed in the abdomen upon examination. CT scan of the abdomen showed clustering of small bowel loops behind the stomach and in front of the pancreas with decreased contrast enhancement of the intestinal wall. Under a diagnosis of intestinal hernia, emergency laparotomy revealed an oval defect about 5 cm in a diameter in the mesentery of the transverse colon. A 15 cm portion of the small intestine was incarcerated through the defect and caused necrosis. The small intestine was reverted by manipulation and resected followed by anastomosis. The defect was then closed by suturing and the postoperative course was uneventful.

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A 65-year-old woman was admitted to a local clinic after suffering from upper abdominal pain for one month. Computed tomography (CT) showed an intra-abdominal mass. With the suspicion of a mesenteric tumor, she was referred to our hospital for exploration and treatment. On admission, slight abdominal tenderness was accompanied by a fist-sized mass palpated in the right upper quadrant. The patient developed strong abdominal pain on the fifth day after hospital admission. Emergent enhanced abdominal CT showed target sign in the small intestine and a laparotomy was performed with the diagnosis of intussuscepton. Operative findings revealed the intussusception in the jejunum 25 cm distal to the Treitz's ligament and partial resection of the jejunum was performed because of the failure of attempts at manual reduction. The submucosal lesion measuring 4.0×3.5×2.5 cm was recognized in the resected specimen. The mass was located 55 cm from the Treitz's ligament. Histopathological findings revealed a cavernous lymphangioma in the jejunum. Although lymphangioma of the small intestine is rare, it should be considered as a possible cause of the intussusception.

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A 69-year-old man was admitted to the hospital with abdominal pain and vomiting. An abdominal X-ray examination and CT scan showed small intestinal air and dilated small intestine. A long tube was inserted for simple obstruction. Intestinal contrast study through a long tube showed stenosis of the jejunum. Double-balloon endoscopy revealed circular ulcer. Laparoscopic assisted partial small intestine resection was carried out without a definite diagnosis. The resected specimen had a 31×13 mm size circular ulcer. Histopathological examination, it was diagnosed arteriovenous malformation (AVM). The patient was discharged from the hospital on the 7^th postoperative day without complication. There have been no cases of intestinal obstruction by AVM in Japan.

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We encountered a case of malignant lymphoma of the small intestine under medication with tacrolimus after lung transplantation. A 22-year-old man suffered from drug-induced interstitial pneumonia caused by having taken methotrexate for juvenile idiopathic arthritis since age 16. The patient received bilateral lungs transplantation from a brain-dead donor. Tacrolimus had been used for immune suppression. Six months after the lung transplantation, ileal malignant lymphoma (diffuse large B-cell lymphoma), one of the posttransplant lymphoproliferative disorders, occurred. Five days after rituximab administration was initiated, massive intestinal hemorrhage from the tumor occurred. Immediately after colonoscopic hemostasis intra-abdominal free air appeared. Emergency laparotomy was performed under a diagnosis of gastrointestinal perforation. Though the ileum where the hemostasis had been performed was not perforated, a site in the ileum 120 cm from the ligament of Treitz was perforated. We resected both the perforated site and the ileocecum where lymphoma was excised. The patient died from exacerbation of the malignant lymphoma on the 52nd day after the operation.

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A 71-year-old man who had been given a diagnosis of C-ANCA associated artiritis at a nearby hospital was admitted to our hospital. Based on pathological findings of kidney and skin biopsies, a diagnosis of Wegener's granulomatosis (WG) was given. He was successfully treated with steroid pulse therapy and cyclophosphamide pulse therapy. On the 32nd day, he suddenly began to suffer from severe abdominal pain. We conducted abdominal CT, which showed free air in the abdominal cavity, necessitating emergency surgery. The descending colon had been perforated, so we resected the perforated region with a stoma of oral colon. During the postoperative course, there was recurrence of WG which was difficult to control, however, we were able to save the patient's life. Although the prognosis of WG has improved, cases of intestinal perforation with WG are still rare and have bad prognosis. We must be aware of gastrointestinal lesions of WG, and in case of perforation, an emergency operation with postoperative intensive care are essential.

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A 62-year-old woman presented with a chief complaint of bloody stool while being treated for hepatitis C at the Department of Internal Medicine at our hospital and sigmoid colon cancer was diagnosed after a detailed stool examination. The patient had a history of pulmonary infarction after delivery at the age of 31. Her blood test was positive for anticardiolipin-β2GP-I complex antibody, and antiphospholipid antibody syndrome was diagnosed in 2004. Therefore, anticoagulant therapy was started. She was treated with oral warfarin potassium after mitral valve replacement (prosthetic valve); however, this drug was discontinued and unfractionated heparin was started. The administration of unfractionated heparin was preoperatively discontinued, and resection of the sigmoid colon cancer was performed. Anticoagulant therapy was restarted immediately after the operation; however, postoperative bleeding from the resection site was observed, leading to hematoma formation in the abdominal cavity. In addition, there was bleeding from the anastomotic site during adjustment of the anticoagulant dose, for which blood transfusion was needed. Thereafter, the hematoma was suspected of being infected, and 63 days after the operation the hematoma was removed. The postoperative course was good without fatal thrombosis, and the patient was discharged from the hospital. Here, we report a case of antiphospholipid antibody syndrome with difficulty in perioperative anticoagulant therapy, with some bibliographic considerations.

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A 52-year-old man was previously given a diagnosis of rectal cancer and underwent low anterior resection at another hospital. Sixteen months after primary surgery, serum levels of carcino-embryonic antigen (CEA) showed a slight increase. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed multiple cystic lesions surrounding an anastomosis site. Colonoscopy showed a smooth elevated lesion like a sub-mucosal tumor near the anastomosis. Since 18F-fluoro-deoxy-glucose positron emission tomography (FDG-PET) showed a slight accumulation of FDG at the site of cystic lesions, local recurrence was diagnosed and he was referred to our hospital. We performed Hartmann's procedure, however, histopathological examination showed no malignant findings. We therefore diagnosed the cystic lesions as implantation cyst. Implantation cyst is one of comparatively rare complications seen after gastrointestinal anastomosis that is not widely recognized. The incidence of this disorder is increasing due to the prevalence of stapled anastomosis and is also difficult to distinguish from recurrence. No previous cases which showed increased serum CEA levels and FDG accumulation by FDG-PET have been reported. We herein present this rare case of implantation cyst with a review of the literature.

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It is almost unknown that there are some reports about bowel necrosis as one of the lethal complications related to postoperative early enteral nutrition. We report our experience about two cases of bowel necrosis associated with postoperative enteral nutrition. Patient 1, a 77-year-old woman with cancer of the duodenal papilla received pancreatoduodenectomy. On postoperative day (POD) 14 she underwent surgery for emergency massive bleeding from the portal vein. Then, 8 days from the emergency operation, enteral nutrition of semi-elemental formula was started via a trans-nasal jejunal feeding tube. At 14 days after the onset of enteral nutrition, she was given a diagnosis of bowel necrosis, and massive enterectomy was performed. Patient 2 was a 79-year-old woman who had undergone resection for gastric cancer. We then performed total gastrectomy. Enteral nutrition via a transnasal jejunal feeding tube was started on POD 4. On POD 6, bowel necrosis was diagnosed, and massive enterectomy was performed. Both cases survived their critical states and were discharged. Bowel necrosis associated with enteral nutrition after abdominal surgery has been reported in Western countries. We report our experience and the results of our literature search of past related papers.

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