Background : Patients undergoing a curative rectal cancer resection have a risk of developing loco-regional recurrence. A curative resection for local recurrence is the option of improvement in prognosis. However, a curative resection is sometimes too invasive and should be considered in selected patients. Methods : A total of 43 patients with locally recurrent rectal cancer cancer who had been treated by operation between 1989 and 2007 were retrospectively reviewed, and the factors including CEA-dt (doubling time of carcinoembryonic antigen) were analyzed. Results : The 5-year overall survival rate after the operation for local recurrence was 50.8%. Gender, presence of distant metastasis, tumor size, CEA-dt and curability were found to be significant prognostic factors. A multivariate analysis demonstrated the presence of distant metastasis, CEA-dt and tumor size to be significant prognostic factors for overall survival. The 5-year overall survival rates of patients with the CEA-dt ≥150 days and a tumor size <5cm were 76.9%. Conclusions : The tumor size and CEA-dt were useful prognostic factors that were recognizable before surgery. Patients with locally recurrent rectal cancer with a CEA-dt ≥150 days and a recurrent tumor size <5cm are considered to be good candidates for surgery.

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A 76-year-old woman seen for abdominal pain on February 2005 and found in Endoscopy to have an irregular protruding lesion in the upper thoracic esophagus underwent endoscopic mucosal resection elsewhere of part of the lesion and was followed up endoscopically despite a pathological diagnosis of verrucous tumor. Two years later, the tumor grew and biopsy showed it to be malignant. Endoscopic and histological examination yielded a diagnosis of esophageal squamous cell carcinoma, for which we conducted thoracoscopic esophagectomy with lymph node dissection, reconstructing the alimentary tract with a gastric tube through the posterior mediastinal route. Macroscopic findings of the resected specimen showed a white protruding lesion surrounded by a small protruding area measuring 70 x 40mm. Histologically, the well-differentiated squamous cell carcinoma had papillary proliferation to the epithelium. These findings led to a diagnosis of esophageal verrucous carcinoma. Histological findings of pT1b, pN0, and M0, identified p-stage I. No sign of recurrence has been observed in the two years since surgery. Esophageal verrucous carcinoma is extremely rare with only 24 cases reported as of this writing in the English and Japanese literature.

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A 12-year-old boy referred elsewhere for pancreatitis and pseudopancreatic cysts had gone for seven years without the cause being clarified. At age 12, his recurring abdominal pain was found in abdominal ultrasound and computed tomography (CT) to be due to gastric duplication and gallstones. Following cholecystecomy, pyloric gastric duplication was found to have adhered to an aberrant pancreatic lobe at the transverse mesocolon. After the adhesion was removed, the cyst, which was separate from the stomach, was found to communicate with the main pancreatic duct, necessitating duplication cystectomy and pancreatic lobectomy of the aberrant lobe. Gastric duplication is comparatively rare, with only 14 cases involving communication with the pancreatic duct-all difficult to diagnose and treat--reported in the last 50 years according to PubMed. In our case, aberrant pancreatitis and the ensuing pseudo pancreatic cyst were apparently due to insufficient duplication-cyst drainage.

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We report a case of spontaneous jejunum rupture following total gastrectomy. An 83-year-old woman with dementia undergoing total gastrectomy for gastric cancer and esophagojejunostomy through the retrocolic root was discharged on postoperative day 19. Two months later, she was seen in an emergency for acute abdominal pain. Physical examination showed muscular abdominal defense. Computed tomography showed abdominal free air necessitating emergency surgery for panperitonitis due to a perforated digestive tract. Surgical findings showed the left upper abdominal cavity to be filled with a food mass and 5cm of the anal side of the jejunum from the esophagojejunostomy torn in a half circle. Neither ulceration nor inflammation was seen, and a diagnosis of spontaneous jejunum rupture enabled the lesion to be sutured in two layers followed by abdominal lavage and draining. No stenosis was seen at the distal jejunum, so we concluded that excessive oral intake expanding the jejunum had triggered a spontaneous jejunum rupture.

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A case in which the natural course of extranodal marginal zone b-cell lymphoma is observed is rare, but previous reports support response to treatment, especially in slow tumor progression, as we report here. A 78-year-old man diagnosed with reactive lymphadenopathy in cervical lymph node biopsy was referred for surgery for gastric cancer found in gastric polyp biopsy. Preoperative examination showed enlarged neck, mediastinum, and paraaortic lymph nodes treated by total gastrectomy when cervical lymph node biopsy showed no gastric cancer metastasis. The resected specimen showed atypical lymphocyte invasion under tumors subsequently diagnosed immunohistochemically as marginal zone B-cell lymphoma. Similar cervical and paraaortic lymph node observation led to a diagnosis of gastric extranodal marginal zone b-cell lymphoma with metastatic lymph node involvement. Four outpatient courses of rituximab for lymphoma reduced enlarged mediastinal lymph nodes in one year. No recurrence has been seen in the 2 years since.

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A 66-year-old man undergoing hepatic intraarterial chemotherapy and radiofrequency ablation for hepatocellular carcinoma (HCC) in 2005 and heavy particle radiotherapy in July 2008 had had his lesions disappear. He was rehospitalized after follow-up abdominal computed tomography (CT) detected a polypoid gallbladder-lumen mass. Dynamic CT showed a well-demarcated, enhanced tumor in the gallbladder, suspected of being gallbladder carcinoma and necessitating cholecystectomy in August 2009. Pathological examination showed moderate differentiated hepatocellular carcinoma in the lamina propria and gallbladder muscle layer invading submucosal vessels, diagnosed as gallbladder metastasis from hepatocellular carcinoma. Few such gallbladder metastases have been reported to date, so we have documented this extremely rare case.

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We report an extremely rare case of solitary liver metastasis from papillary thyroid carcinoma. A 56-year-old woman referred for a lung-cancer screening-detected liver tumor. Her medical history included right thyroid lobectomy for papillary carcinoma 18 years earlier and total thyroidectomy for adenomatous goiter 2 years thereafter. Blood tests showed markedly-elevated preoperative serum thyroglobulin. Computed tomography (CT) showed a lateral hepatic tumor with a central scar and capsule-like structure. Contrast medium enhanced the lesion in the early phase, with washout in the late phase. Magnetic resonance imaging (MRI) showed lesions in the left seventh rib and first lumbar vertebra in the same phase as the liver tumor. Whole-body bone scintigraphy showed increased tracer uptake in the sixth thoracic vertebra and seventh rib, yielding a diagnosis of solitary liver tumor with multiple bone metastases. The liver tumor was suspected of being hepatocellular carcinoma and liver metastases from thyroid cancer. The liver tumor was resected concomitant to lateral segmentectomy with rib biopsy. Histopathologically, both lesions were papillary thyroid carcinoma metastases.

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We report a case of pancreatic macrocystic serous cyst adenoma associated with acute pancreatitis. A 47-year-old woman seen for upper abdominal pain and hospitalized elsewhere showed increased serum CRP and amylase and an increased white blood cell count in laboratory data. Computed tomography (CT) showed severe pancreatic body and tail edema with abdominal and left thoracic and abdominal effusion, diagnosed as acute pancreatitis and treated conservatively. CT on admission also showed a cystic pancreas-head lesion. After acute pancreatitis subsided, she was hospitalized for us to diagnose and treat the cystic lesion. The main pancreatic and common bile ducts showed no dilation, and endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) were negative for the cystic lesion. MRCP showed the same findings. The cystic lesion was recognized as a multilocular tumor similar to intraductal papillary mucinous neoplasm (IPMN) or mucinous systic neoplasm (MCN). The preoperative clinical diagnosis was pancreatic cystic neoplasm (IPMN>MCN>SCN), necessitating pancreaticoduodenectomy. The resected specimen was pathologically diagnosed as pancreatic macrocystic serous cyst adenoma, a rare neoplasm leaving us unable to discriminate it from IPMN or MCN.

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We report a case of rare intestinal perforation due to dialysis-related amyloidosis. A 79-year-old woman undergoing hemodialysis for 17 years, undergoing two operations for right carpal tunnel syndrome, sigmoid colon resection due to diverticulosis bleeding, and medical therapy for angina pectoris, acute heart failure, and pulmonary tuberculosis was admitted and underwent surgery for nontraumatic right femoral neck fracture. Following postoperative abdominal pain and diarrhea, she suffered severe abdominal pain 2 days after surgery. Abdominal computed tomography (CT) showed free air and ascites. Emergency laparotomy confirmed two small-intestine perforation sites necessitating partial resection and anastomosis. Histopathologically, amyloid deposits were found perivascularly in the submucosal layer around perforations. Postoperative wound infection, deep-seated mycosis, severe diarrhea, and acute heart failure developed at the time all healed in conservative treatment, and the woman was discharged 78 days after emergency surgery.

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A 66-year old man undergoing partial ileal resection for gastrointestinal stromal tumor (GIST) was diagnosed with multiple liver metastases seven months later. Imatinib mesylate administration was initiated, stabilizing tumors 1.5 years. After he reported abdominal pain, computed tomography (CT) showed an intestinally obstructive tumor. Laparotomy for suspected GIST recurrence radiologically showed an 8cm tumor in the ileal mesentery 210cm distal to the ligament of Treitz and 15cm proximal to the ileal anastomosis. After surgical resection, tumor cells were microscopically diagnosed as differentiated spindle fibroblasts with abundant collagen fibers but without karyomitosis. Immunohistochemically, cells were negative for c-kit, CD34, and S-100 but positive for β-catenin with nuclear translocalization, yielding a pathological diagnosis of mesenteric desmoid tumor. No desmoid tumors have been reported to develop during imatinib mesylate chemotherapy, and it was difficult to differentially diagnose these tumors preoperatively.

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We report two cases of hepatic portal venous gas without bowel necrosis. Case 1: A 79-year-old woman hospitalized for cerebral infarction developed enterocolitis symptoms of the intestine luxus. Case 2: A 48-year-old woman developed paralytic ileus symptoms due to neuroleptic internal use. In a review of 106 cases of portal venous gas without bowel necrosis reported from 1986 to 2008 in Japan, overall mortality was 4.7% and underlying diseases were inflammatory bowel disease (45.3%), gastrointestinal trace (GIT) obstruction and dilation (29.2%), sepsis (9.4%), iatrogenic injury and trauma (4.7%), cancer (3.8%), and miscellaneous (7.5%). Surgery was done in 51.4%. Positive PCI was 26.6%. Given the many causes of portal-vein gas without bowel necrosis, determining a treatment policy requires careful physical examination and accurate diagnostic imaging.

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A 19-old man admitted to our hospital due to nausea, vomiting, and dehydration. Abdominal CT demonstrated target-shaped thickening of the small intestine suggesting intussusceptotion. Contrast radiography of the small intestine showed the clubbed finger sign suggesting intussusception in third portion of the duodenum. Based on these findings, we conducted laparoscopic surgery. A retrograde intussusception of jejunum with a preceding tumor was present around the Treitz ligament. Manual repositioning was performed under laparoscopic surgery. A tumor about 3cm in diameter was identified. Partial jejunum resection including the tumor and functional anastmosis were also performed under laparoscopic surgery. The polyp was histologically diagnosed as a Peutz-Jeghers polyp. Solitary Peutz-Jeghers polyp was rare. This patient did not have typical mucocutaneous pigmentation or hereditary factors, so that we concluded that this patient had incomplete Peutz-Jeghers syndrome. We report this rare case of the retrograde small intestinal intussusception with Peutz-Jeghers polyp treated by pure-laparoscopic surgery.

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A 75-year-old man admitted for intestinal obstruction was found in abdominal computed tomography (CT) to show a target sign on the ascending colon, and gastrografin enema showed a cup-like filling or ring-like colon defect at the same place. Colonoscopy showed a type 2 cecal tumor from which biopsied specimens demonstrated malignant lymphoma, necessitating ileocecal resection. Histologically, the B cell tumor was found to be malignant lymphoma of the non-Hodgkin diffuse medium cell type. After undergoing adjuvant R-CHOP chemotherapy, he has shown no recurrence in 8 months. We report this case with a review of the Japanese literature because intussusception in adults due to malignant colon lymphoma is extremely rare.

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A 32-year-old man admitted for abdominal pain and lumbago and diagnosed with sigmoid colon cancer with brain and multiple bone marrow metastases Reported anal bleeding, and laboratory data indicated acute disseminated intravascular coagulation (DIC). During anti-DIC therapy and blood transfusion, he suddenly developed peritonitis symptoms. An emergency Hartmann's procedure detected a perforated lesion and his condition became life-threatening as DIC deteriorated. Within 2 weeks of initiating an oxaliplatin/5-fluorouracil/leucovorin regimen (modified FOLFOX-6) on postoperative day6, clinical and laboratory evidence of acute DIC was resolved and his condition gradually improved after several cycles of this regimen. A partial response was also seen in brain and bone marrow metastases. Acute DIC due to such metastasis is extremely rare and generally considered fatal even with chemotherapy. Our case is unique in that modified FOLFOX-6 was effective in colon cancer accompanied by acute DIC.

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A 28-year-old woman seen for lower abdominal pain and a large, hard abdominal mass was found in computed tomography (CT) to have excessive right-chest effusion, ascites, a large ovarian tumor, and rectosigmoid (RS) wall thickening. Colonoscopy showed a circular strictured RS tumor for which the diagnosis of rectal cancer and an ovarian tumor necessitated high anterior rectal resection and bilateral salpingo-oophorectomy. Peritoneal dissemination indicated clinical stage IV. The pathological diagnosis was rectosigmoid signet-ring-cell carcinoma and metastatic bilateral ovarian tumors from rectosigmoid cancer. Despite systemic chemotherapy, she developed peritoneal carcinomatosis 12 months postoperatively and died 1 month thereafter.

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Endoscopic retrograde cholangiopancreatography (ERCP) conducted in 4,606 cases since April 2000 included seven of perforation managed by surgery and reviewed here. Four cases involve perforation of the descending duodenum and 1 each of the duodenal bulb, the papilla, and the lower common bile duct. The one with bile duct injury was diagnosed by exploratory laparotomy on post-ERCP day 4 due to peritonitis. Where perforation was confirmed by endoscopy, perforated sites were closed in two and with T tube drainage in two. In two cases of perforation identified by computed tomography (CT), perforation sites could not be found during surgery and drainage irrigation was done. T tube drainage alone was done in the bile duct perforation. The person undergoing laparotomy on post-ERCP day 4 died, but the other six enjoyed an uneventful postoperative course. Our study shows that early surgical closure is required in perforation by the endoscopic instrument itself because the perforation tends to be large. The possibility of conservative therapy should be considered where free air alone is involved.

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We conduct pancreaticoduodenectomy following a retromesenteric approach to reduce blood loss from the congestive resected specimen, facilitating early inferior pancreaticoduodenal artery ligation. Having a direct clear view, we dissect the paraaortic lymph nodes and nerve plexus around the root of the superior mesenteric artery. We have handled 8 pancreaticoduodenctomy cases this way since 2008—six of pancreatic ductal cell carcinoma and one each of intraductal papillary mucinous carcinoma and choledochal cancer—. Three involved portal vein resection and reconstruction. Mean resection time was 385 minutes, mean operating time 651 minutes, and mean total blood loss 392ml. None required transfusion. We have found this procedure useful in early arterial blood flow ligation for pancreatic head lesions and maintaining a clear operative view in lymph node dissection around the superior mesenteric artery root.

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We report two cases postoperative pancreatic fistula treated using endoscopic transgastric drainage, one involving a 30-year-old woman and the other a 58-year-old man. The woman had undergone distal pancreatectomy for mucinous cystic pancreatic-tail adenoma one month earlier was hospitalized due to abdominal distension from pancreatic fluid collecting in the residual pancreas behind the stomach. The man's pancreatic fluid collection was limited following distal pancreatectomy for pancreatic cancer. Both were diagnosed with postoperative pancreatic fistulas and underwent endoscopic transgastric drainage, following which fluid collection decreased and drainage tubes were removed endoscopically. No fluid collection recurred. Endoscopic transgastric drainage, frequently reported for treating pancreatic pseudocysts, is thus effective in treating pancreatic fluid collection due to postoperative pancreatic fistulas close to the stomach.

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We report a series of presacral deep-tissue injuries due to surgical positioning. From January 2001 to December 2004, 4 (4.9%) of 82 subjects undergoing curative rectal cancer resection--all males with extraperitoneal rectal cancer--suffered localized presacral gluteal muscle injury in laparoscopy-assisted surgery individually taking 9 hours 25 minutes, 9.5 hours, 11 hours, and 10 hours and 10 minutes. Blood pressure was well maintained throughout surgery and the lowest diastolic kept within 45 to 50mmHg. On postoperative day 1, all reported gluteal pain, and blood tests showed elevated serum creatine kinase--6,927IU/l, not known, 1,913IU/l, and 3,133IU/l. The first two cases underwent pelvic magnetic resonance imaging (MRI) two weeks postoperatively, with bilateral gluteal muscle injury adjacent to the sacral bone later identified. Muscle injury in the second two cases was found incidentally in abdominal computed tomography (CT) two or three months postoperatively. The presacral skin disorder was relatively mild, and these cases were diagnosed as deep-tissue injury. Efforts are thus needed to minimize sacral pressure and prevent deep-tissue injury, especially in prolonged lithotomy surgery.

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