Introduction : Few prospective studies have evaluated the postoperative quality of life (QOL) in patients with rectal cancer using validated QOL measurements. The aim of this study was to compare postoperative QOL in patients undergoing low anterior resection (LAR) or high anterior resection (HAR) for rectal cancer. Patients and methods : Subjects were 87 patients undergoing LAR (n=52) or HAR (n=22) for rectal cancer who participated in a prospective study in which detailed information was collected through standardized measurements of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38. Repeated measures analysis of variance was used for statistical analysis. Results : Patients undergoing LAR had a significantly higher incidence of defecation problems (CR 38) than those undergoing HAR (P=0.01). No significant results were obtained for the remaining scores between the groups. A significant postoperative improvement in 5 subscales was noted in rectal cancer patients. Discussion : It has been reported that patients undergoing LAR have poorer postoperative defecatory function than those undergoing HAR, and this was confirmed by rectal cancer patients who responded to QOL questionnaires in the present study.

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Intraoperative peritoneal lavage cytology (CY) is considered to be effective for early detection of peritoneal dissemination and a positive case is defined as non-curative in gastric cancer. In bile duct cancers, surgical resection has not been an option for patients positive for CY. However, its significance remains unclear. The purpose of this study was to clarify the significance of positive CY in biliary tract cancer. From January 2001 to December 2008, 66 patients with biliary tract cancer underwent CY. The data we evaluated included gender, age, primary site, CY, peritoneal dissemination, stage and curability. The stage and the curability are based on the General Rules for Surgical and Pathological Studies on Cancer of the Biliary Tract published by the Japanese Society of Biliary Surgery. There were 33 patients with bile duct cancer, 26 with gallbladder cancer, and 7 with cancer of the papilla of Vater. There were 4 patients with stage I cancer, 11 with stage II, 10 with stage III, 15 with stage IVa and 26 with stage IVb. Twenty patients were in the curability A stage, 18 in curability B, and 28 in curability C. Nine patients showed peritoneal dissemination. 7 patients had positive findings on CY. Among the 7 patients, peritoneal dissemination was not found in 2 patients. The median survival time (MST) of patients with peritoneal dissemination was 9.5 months and the survival rate was significantly lower than those without peritoneal dissemination. The MST of patients with positive CY was 9 months and the survival rate was lower than that with negative CY, but the difference was not statistically significant. The 2 patients with positive CY and negative peritoneal dissemination underwent chemotherapy. One patient with hilar cholangiocarcinoma was still alive 41 months after diagnosis. Another with lower bile duct cancer died 23 months later due to hemorrhage from a splenic arterial pseudoaneurysm. These 2 patients had longer life expectancy than patients with positive peritoneal dissemination (P=0.0283). Further studies will be needed to determine the prognostic value of CY.

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Background : The area above the pancreas is a challenging site at which to perform dissection of the lymph nodes during gastrectomy. Therefore, knowledge of the perigastric vessels is important. The objective of this study was to examine the usefulness of computed tomography (CT) for the identification of perigastric vessels. Methods : One hundred fourteen patients with gastric cancer underwent CT. A 5-mm-thin-slice frontal image was reconstructed. These images were examined preoperatively to detect anomalyies of the celiac artery, the existence of the accessory left hepatic artery (ALHA) and the location of the left gastric vein (LGV). During gastrectomy, the distribution of the perigastric vessels was compared with that of those suggested by the CT analysis. Results : Arterial anomalies were recognized in 7 preoperative cases. Defects in the common hepatic artery were found in 6 cases and the left gastric artery was directly divergent from the aorta in 1 case. Moreover, the ALHA was recognized in 7 cases. In all cases, the anomaly of the artery detected on CT was consistent with that identified during gastrectomy. The LGV was identified by CT in 102 of the 114 cases (89.4%). The accuracy rate was 94.7%. Conclusion : CT was useful for identifying the anomaly of the celiac artery and the location of the LGV prior to gastrectomy.

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We report a case of descending mediastinitis due to perforation of the esophagus associated with dermatomyositis. In July 2008, the patient, a 55-year-old woman, complained of the rash on her face. Dermatomyositis was diagnosed and steroids were prescribed. In September, she suffered neck pain and fever. We diagnosed mediastinitis due to perforation of the cervical esophagus, based on esophagograms and cervicothorasic computed tomography (CT). We operated the cervical and mediastinal drainage through anterior neck. Seven days later, CT revealed an effusion in the right thoracic cavity and posterior mediastinum. Therefore we performed additional thoracic and mediastinal drainage through a right thoracotomy. The mediastinitis improved after that operation. However, it also took time to heal the cutaneo- esophageal fistula. She was released from hospital with tube feeding 162 days after her first surgery, and we reoperated after her closed fistula was found on the 205th day. There are some reports that dermatomyositis has caused the complication of a digestive tract ulcer, but they rarely cause perforation. In this case, the patient was saved by cervicothorasic drainage for the mediastinitis caused by the fistula during the treatment of her dermatomyositis.

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We report a case of a 47-year-old woman who had lymph node metastasis 10 years after endoscopic resection for minute gastric carcinoid. A small submucosal tumor had been diagnosed in the gastric body. The tumor was curatively removed by endoscopic resection in another hospital. The pathological examination showed the tumor was gastric carcinoid, measuring 3 mm in diameter, invading the submucosa. Eight years after, screening abdominal ultrasonography revealed lymph node swelling (12 mm) beside the gastric lesser curvature, and a further two years later she was introduced to our department. Gastroscopy showed only scar, but no residual tumor nor new lesions in the stomach with no chronic atrophic gastritis. Serum gastrin was within normal levels. The lymph node swelling was diagnosed as metastasis of carcinod tumor by laparosopic biopsy. We evaluated recurrence of gastric carcinoid and conducted total gastrectomy with lymph node dissection. Pathologically, six metastatic lymph nodes were revealed in the gastric regional area, but no other new lesions in the whole gastric wall. Minute gastric carcinoid tumors rarely have high malignancy potential.

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The patient was a 65-year-old man who had received laparoscopy-assisted high anterior resection for advanced rectal cancer and distal gastrectomy without splenectomy for early gastric cancer at the same time. We could not point out any findings of ischemic change or anastomosis leakage in the early postoperative period. However, on POD 15, gastroscopic examination showed extensive mucosal necrosis mainly around the anastomotic region in the gastric remnant. Based on these findings, we performed total gastrectomy on POD 21. Ischemic necrosis of the gastric remnant is a rare and serious complication of distal gastrectomy. It is hoped that early diagnosis by a gastroscopy in the early postoperative period will help to save patients in which this complication is suspected.

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A 53-year-old woman presented with back pain. She was admitted to hospital because a mass was detected in the right upper abdomen. Upper gastrointestinal endoscopy and hypotonic duodenography showed type 2 advanced cancer in the second portion of the duodenum. Computed tomography (CT) revealed a primary duodenal cancer with invasion to both the head of the pancreas and superior mesenteric vein. The patient was treated with combined chemotherapy using TS-1 and CDDP. TS-1 (80 mg/m²) was orally administered for 3 weeks (day 1-21), and CDDP (60 mg/m²) was simultaneously administered on day 8 every 5 weeks. The chemotherapeutic regimen was repeated for 3 cycles. CT after chemotherapy revealed the tumor to have decreased in size, while also showing an improvement of the pancreas and superior mesenteric vein invasion. The patient thereafter underwent a curative pancreaticoduodenectomy. The pathological grade was determined to be Grade 1b. The resection margins were negative (R0). The patient was doing well and showed no signs of any recurrence of the cancer at 12 months after the initiation of therapy. TS-1/CDDP combination chemotherapy was effective for locally advanced duodenal cancer.

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A 65-year-old man underwent a partial duodenectomy for a 35 mm gastrointestinal stromal tumor (GIST) located in the third portion of the duodenum in August, 2000 and was followed up with no adjuvant therapy. A liver mass was detected by abdominal CT in June, 2009 and he was referred to our hospital for examination and treatment. Though disease-free survival was as long as 9 years, a biopsy of the liver mass strongly suggested liver metastasis from the GIST of the duodenum. The specimen was composed of spindle cells positive for c-kit immunohistologically, and GIST was diagnosed. Because the mass was solitary and the liver function was good, we judged that there was an indication for operation, and performed a right hepatectomy. In this case, asymptomatic liver metastasis was detected by the imaging diagnosis, so it is suggested that long-term follow-up including diagnostic imaging is needed for patients with GIST of the duodenum even 5 years or more after the operation.

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A 20-year-old woman had a traffic accident, while driving a car with her seat belt fastened. An air bag was deployed during the accident. She sustained a right femoral fracture and CT showed ascites collection, injuries of the liver, spleen and pancreas. Emergency interventional radiology did not show any extravasation from these organs. Non-operative management was performed for 8 days, when peritonitis with severe abdominal pain developed. CT detected circumscribed fluid collection in the omental bursa. Biliary peritonitis with common bile duct injury was diagnosed, and emergency surgery was performed. The common bile duct was completely transected, and choledochojejunostomy was performed. The postoperative course was good. Extrahepatic biliary tract injury due to blunt trauma is rare and it was initially difficult to diagnose this injury. It often occurs in complete transection.

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We report a case of prolonged survival after treatment for recurrence of hilar cholangiocarcinoma found in the abdominal wall, with peritoneal dissemination, almost 2 years after primary excision. A 65-year-old woman presented with epigastric discomfort and investigations revealed hilar cholangiocarcinoma invading the left branch of the portal vein. She underwent extended left hepatic lobectomy with excision of the caudate lobe and extrahepatic bile duct, and was discharged after an uneventful recovery, on postoperative day (POD) 25. A follow-up computed tomography (CT) scan 22 months later, identified a recurrent lesion 3 cm in size in the median abdominal wall. As there were no signs of other organs being involved, excision was performed. A solitary peritoneal dissemination 2 cm in size was identified in the greater omentum and excised at the same time. The patient was discharged on POD 11, and was prescribed 100 mg TS-1 per day orally, 4 weeks on, 2 weeks off. At the time of writing, 57 months after the first operation, the patient is well with no signs of further recurrent lesions. Recurrence of hilar cholangiocarcinoma is generally associated with a poor prognosis; however, this case shows that excision followed by chemotherapy for a solitary abdominal wall recurrence, even with peritoneal dissemination, can achieve long-term survival.

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We report a case of operated ileus in a 67-year-old woman who underwent an operation for a right ovarian cyst, after taking polycarbophil calcium drugs. She was admitted for abdominal fullness and vomiting. Twelve days before admission, she took polycarbophil calcium drugs prescribed by a primary care physician for 7 days due to diarrhea. Abdominal computed tomography (CT) showed expansion of the small intestine with feces. At first she was managed with an intestinal decompression long tube. However, 4 days later, the abdominal pain became worse, ascites was found by CT examination and laparotomy was performed. After lysis of adhesions, filling feces in the expanded small intestine were hard to pass through to the anal side, therefore feces were removed by cutting the intestinal wall. The intraperitoneal adhesions delayed intestinal transit. The calcium polycarbophil caused more swelling and hardening in the small intestine. We believe this operated ileus was caused by the adhesions and this drug. We discuss our case in light of a review of the literature.

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An 81-year-old woman was admitted to our hospital for lower abdominal pain. There was localized resistance with tenderness in the mid-lower abdomen. Blood examination showed an increased inflammation reaction. Abdominal multidetector-row computed tomography (MDCT) showed that superior mesenteric artery was running along the right dorsal side of the superior mesenteric vein. In cranial view, the ascending colon and transverse colon were located at the left side of the vertebra with the small intestine shifting to the right. Intestinal malrotation was diagnosed based on these MDCT findings. Swelling appendicitis adjacent to the displaced cecum was detected in the mid-lower abdomen. Upon diagnosis of acute appendicitis with intestinal malformation, emergency laparotomy was performed with a small incision over the lower to mid abdomen. Intraoperative findings were consistent with the pre-operative MDCT findings. Purulent fluid collection was noticed around the swelling appendix. Ileocecal resection was carried out due to perforation at the orifice of the appendix with severely inflamed cecum. Her postoperative course was good without any complications. We were successful at making a preoperative diagnosis of acute appendicitis associated with intestinal malrotation with MDCT, resulting in appropriate surgical management. MDCT may enable us to treat patients with this type of appendicitis more effectively by selecting minimally invasive surgery.

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A 40-year-old woman in the 35th week of pregnancy underwent Caesarean section and an adhesiotomy for intestinal obstruction. An intestinal tube was inserted during the operation. The tube was removed on the 4th postoperative day, and the patient was discharged on the 29th postoperative day. The patient was admitted again due to vomiting 16 days after the discharge. Abdominal CT revealed intussusceptions of jejunum. Conservative treatment was unsuccessful and surgery was performed. Jejunojejunal intussusception was found at 25 cm from the Treitz ligament, and was repaired manually. It was supposed that the intestinal tube inserted in the previous operation caused the intussusception. We examined reported cases of intussusception induced by an intestinal tube and classified the causes into 3 types. Type 1: peristaltic activity without organic cause. Type 2: leading end of the intestinal tube. A; a balloon. B; side-holes. Type 3: withdrawing the tube. In the reported cases, the most common cause was Type 1 of the classification we proposed.

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A 79-year-old man was admitted to our hospital for abdominal pain and distention. Ten years ago, he had been treated for ileus due to an enterolith at another hospital, where endoscopic lithotripsy ended in failure. He had occasionally suffered from abdominal pain during the past 10 years. After admission to our hospital, computed tomography revealed a stone in the terminal ileum. Small bowel enteroscopy showed an enterolith, however, endoscopic lithotripsy was unsuccessful. Although he was very old and had chronic obstructive pulmonary disease, operation with a mini-laparotomy 4 cm in length was performed. Bowel swelling by an enterolith and stenosis were observed 10 cm and 30 cm oral from the iliocecal valve, respectively. The enterolith was extirpated by an enterotomy of the stenotic portion. The stone was 40 mm in diameter, and had four layers. Chemical analysis of the stone revealed calcium oxalate, indicating a true enterolith. The postoperative course was uneventful and he left hospital on the 16th postoperative day. Ileus due to a true enterolith is rarely cured by conservative therapy, and has a risk of intestinal perforation, therefore, it should be treated as soon as it is diagnosed. Our case was safely treated by mini-laparotomy and stricture-plasty.

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We report a case of follicular lymphoma of the ileum in which complete response to chemotherapy was confirmed by surgical resection of the remaining cicatrical stenosis. A 55-year-old man with abdominal pain and distention and given a diagnosis of ileus was admitted to our hospital. CT revealed circumferential wall thickening of the ileum in the right pelvis. Double balloon enteroscopy (DBE) revealed an irregular-shaped, ulcerated mass lesion in the terminal ileum. Based on microscopic findings of the biopsy, follicular lymphoma was diagnosed. Immunohistochemical analysis was positive for CD10+and BCL2+. After alleviation of ileus symptoms, 6 courses of chemotherapy (R-CHOP) were started. At the end of the 4th course of chemotherapy, the patient was readmitted to our hospital because of ileus symptoms. On CT, the severity of the circumferential wall thickening of the ileum in the right pelvis had reduced compared with before chemotherapy. Double balloon enteroscopic examination revealed a cicatricial appearance of the stenotic lesion in the ileum. Because the ileum obstruction did not improve with medical management, a partial resection of the ileum was performed. Histological examination of the resected specimen showed no presence of lymphoma cell infiltration. Thus, the patient was judged to have attained pathological complete response to chemotherapy.

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We report a rare case of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and diabetes insipidus due to intracranial metastasis from colorectal cancer. A 51-year-old woman was admitted for cecal cancer and poorly differentiated adenocarcinoma of the cecum was diagnosed pathologically. Serum sodium level gradually fell to 118 mEq/L 20 days postoperatively. Osmolality was 239 mOsm/kg in plasma and 750 mOsm/kg in urine. Urinary sodium was 132 mEq/L, extracellular fluid volume was normovolemic, and ADH secretion had a serum level of 2.3 pg/ml. The definitive diagnosis was SIADH. Fluid restriction and sodium supplementation raised serum sodium to 138 mEq/L in 6 days. Brain magnetic resonance imaging showed meningeal carcinomatosis, which was thought to have caused the SIADH. Two months postoperatively, she reported polydipsia, polyuria, and thirst. Urine osmolality was 183 mOsm/kg and ADH was below 0.3 pg/ml. Laboratory findings led to a definitive diagnosis of central diabetes insipidus. Her urine volume decreased markedly after intranasal desmopressin administration. Metastasis spreading to pituitary gland, supraoptic nucleus and paraventricular nucleus was suspected to have caused diabetes insipidus.

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An 82-year-old man was admitted to our hospital because of abdominal distention and vomiting. He did not have a history of anticoagulant medication or trauma. We diagnosed large bowel obstruction on X-ray film. Abdominal US, CT, and MRI showed a mass of 6 cm inside of the wall of descending colon. Gastrografin enema showed the stenotic colonic lumen occupied by the mass. Its surface was covered with normal colonic mucosa on colonoscopy, colored dark red. We diagnosed it as a colonic intramural hematoma. We thought of the possibility of avoiding laparotomy. For about 4 weeks, we performed conservative management with a transanal ileus tube. After removing the tube, he left hospital. The colonic intramural hematoma had disappeared on MRI and colonoscopy three months later. We present a rare case of large bowel obstruction by idiopathic colonic intramural hematoma. There is no report of such a case resolved with conservative management by a transanal ileus tube, within the visualization range.

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Background : We report on our initial experience of single port access hernia repair by trans-abdominal pre-peritoneal hernia repair (TAPP) for inguinal hernias. Methods : We investigated the operative outcomes in 9 patients (13 hernias) who had undergone single port access TAPP, compared with 247 patients (354 hernias) who had undergone conventional 3-port TAPP. Results : The operative scars were almost invisible postoperatively and the procedure was completed without any additional ports in the single port access TAPP group. There was little blood loss during the operations in both groups although the mean operative time was significantly longer in the single port access TAPP group than in the conventional 3 port TAPP group (172.9±66.6 min vs. 98.8±39.2 min, respectively). All patients were discharged within 5 post-operative days according to our clinical path without perioperative complications except for one case of seroma which required a single puncture in the single port access TAPP group. The morbidity rate was comparable between single port access and conventional 3-port TAPP groups (11.1% vs. 17.8%, respectively). No recurrences were found in the single port access TAPP group. Conclusion : Single port access TAPP was performed safely with cosmetic advantages compared with traditional 3-port TAPP. Single port access TAPP could be an attractive alternative for patients with inguinal hernias.

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We assessed 11 cases of mesh repair for obturator hernia using a midline extra-peritoneal approach. The Howship-Romberg sign and intestinal obstruction symptoms were recognized in 7 cases in each. The period from onset to operation was 12 hours to 7 days. To cover the obturator foramen, we used mesh sheets in 10 cases and a Kugel patch in 1 case. We repaired both sides of the obturator foramen in all cases. There were 7 cases of incarcerated small intestine, and 5 cases of resection of the intestine. We were able to prevent synthetic mesh infection by adequate washing and drainage of the preperitoneal cavity. The complications were 1 case of ileus, aspiration pneumonia and wound disruption, respectively, with no recurrences. The midline extra-peritoneal approach is useful to observe the bilateral obturator foramen and the operative field, with a minimum incision of the peritoneum at laparotomy, and peeling away a layer to lay down mesh to cover the obturator canal.

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