Background : Even now, It have not a take on the definition of the esophagogastric junction, it is difficult to make a preference of treatment for carcinoma of esophagogastric junction. This study aimed to compare the treatment results between an abdominal-transhiatal approach (TH) and a left thoracoabdominal approach (LTA) for carcinoma of esophagogastric junction on the basis of the definition of the Japanese Classification of Esophageal Carcinoma, and to examine the optimal approach for carcinoma of the esophagogastric junction and the comparative efficacy of dissection of mediastinal lymph nodes. Methods : We resected 23 cases of carcinoma of the esophagogastric junction, comprising 8 cases treated by the LTA and 15 cases treated by the TH, and reviewed the results clinicopathologically. Results : There were no significant differences in the clinicopathological findings, including the tumor size, the length of resected esophagus, and the number of lymph nodes dissected between the two groups. The operation time was significantly longer in the LTA group (P<0.001) and the intraoperative bleeding was also significantly greater in the LTA group (P<0.001). Mediastinal lymph node metastases were found in 7 cases (30.4%). After a follow-up period of 3.5 years, recurrence after surgical resection had been found in 7 cases (30.4%). There were no cases of regional recurrence, only distant recurrence. All patients except one case died from primary disease. Conclusion : The present study demonstrated that TH might be a useful approach for carcinoma of esophagogastric junction. Dissection of mediastinal lymph nodes appears essential to perform a radical procedure.

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Introduction : The aim of this study was to assess the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) in elderly patients with gastric cancer compared with the short-term outcome in the nonelderly. Method : We reviewed 197 patients who underwent LADG between January 2001 and September 2009. Of these, 63 patients (aged 70 years or more) were compared with 134 younger patients. Preoperative co-morbidity and surgical results were analyzed. Multivariate analysis was performed to detect predictive factors for postoperative morbidity. Results : Co-morbidity was more common in elderly patients than in the nonelderly (60.3% versus 34.3%; p<0.001). The operating time was significantly shorter (p=0.008) and there were fewer retrieved lymph nodes in elderly patients (p=0.001). The incidence of postoperative morbidity did not differ between both groups (6.3% versus 5.2%), and there were no significant differences in the time to first flatus or postoperative hospital stay. Logistic regression analysis was performed to detect predictive factors for postoperative morbidity using the following 8 clinicopathological determinants; age, gender, comorbid disease, operating time, blood loss, degree of lymph node dissection, and Stage. No factor was significantly associated with postoperative morbidity. Conclusion : LADG is a safe and less invasive treatment for gastric cancer in elderly patients who have greater co-morbidity.

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Aims : Para-aortic lymph node (LN216) metastasis of colorectal cancer is considered as distant metastasis and is usually an indication for chemotherapy. However, long-term survival may sometimes be obtained by resection. We examined patients that had undergone dissection of metastatic LN216 para-aortic lesions in our department, based on which we evaluated the operative indication for LN216 metastasis. Patients : We examined 9 cases that had no other distant metastases and had undergone systemic dissection of LN216 in our department between December, 2003 and March, 2010. There were 4 men and 5 women, with an average age of 63., The primary tumors were 2 transverse colon cancers, 3 sigmoid colon cancers and 4 rectal cancers. Results : Six patients had been given diagnoses of LN216 metastases as recurrence after resection of their primary cancer (the stages of their primary cancers were Stage II in 1 case, Stage III ain 1 case and IIIb in 4 cases), while 3 cases had been diagnosed simultaneously with their primary cancer (Stage IV). One of the Stage IV cases underwent LN216 dissection one year after resection of the primary tumor, following chemotherapy, while the other 2 Stage IV patients received LN216 dissection on the occasion of the resection of the primary tumor. The 2-year survival rate after LN216 dissection was 64%; (metachronous dissection cases: 85%, simultaneous dissection cases: 0%) and the longest survival time was 6 years and 9 months. No recurrence was seen in 6 cases. There was no significant difference of in age, gender, site of the primary tumor, or, histological type of the primary tumor. On the other hand, the outcomes of the casse that underwent metachronous LN216 dissection were significantly better than those who underwent simultaneous 216LN dissection and primary tumor resection (p=0.035). Conclusions : Localized LN216 metastasis of colorectal cancer can achieve good long term survival after dissection of para-aortic LN dissection and surgical treatment can be indicated in selected cases.

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A 78-year-old man underwent proximal gastrectomy for gastrointestinal stromal tumor (GIST) of the stomach in November 2004.The pathological diagnose was GIST, and it was positive for KIT and CD34 immunohistochemically, indicating it was in a high risk group. Administration of imatinib mesylate at a dose of 400 mg/day was given for 21 months after surgery as adjuvant chemotherapy. In November 2000, abdominal computed tomography (CT) revealed local recurrence of GIST invading the liver and diaphragm making curative resection difficult, so administration of imatinib mesylate was restarted. Three months after reinitiating imatinib mesylate treatment,abdominal CT showed reduction in tumor size. Therefore,we judged this lesion to be resectable and performed local resection. Histopathologically, the tumor was replaced by angiomatoid change,and no viable tumor cells were detected. Pathological complete response (pCR) was obtained. This was a rare case, in which local recurrence of GIST invading the liver and diaphragm was resected after neoadjuvant chemotherapy by imatinib mesylate, and pathological complete response was obtained.

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We report a case of mucinous adenocarcinoma of the duodenum in a 79-year-old woman. The patient was admitted to our hospital because of anemia. Upper gastrointestinal endoscopy and a barium meal showed an irregular ulcerative lesion in the anterior wall of the duodenal bulb. Biopsy yielded a diagnosis of well differentiated adenocarcinoma. After the preoperative examination, we performed pancreatoduodenectomy. Pathological findings revealed mucinous adenocarcinoma. Mucin stain for MUC5AC and MUC6 were both positive, but MUC2 was negative. We therefore diagnosed gastric-type adenocarcinoma. We reviewed 10 Japanese cases of mucinous adenocarcinoma of the duodenum and analyzed the clinicopathologic features.

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A 56-year-old man was admitted to our hospital due to contusion on the right lateral chest wall. Blood pressure was 84/47 mmHg on admission. Blood examination revealed no anemia but he was positive for the HCV-antibody regardless of having had no history of liver diseases. Abdominal CT revealed high density ascites and the multinodular main tumor of the liver S6, with a proximal diameter of 10 cm, grew extrahepatically, with small nodules in S5 and S8 of the liver in the background of liver cirrhosis pattern. A diagnosis of traumatic rupture of hepatocellular carcinoma was established, emergency angiography and TAE was performed. About 1 month later, we carried out subsegmentectomy of the liver S6 and radiofrequency ablation of hepatic S5 and S8. Since traumatic rupture of hepatocellular carcinoma is extremely rare, and the pathology of this disease is different from that of spontaneous rupture, liver reserve might be relatively well preserved. Consequently, curative operation might be possible after TAE in many cases of traumatic rupture of hepatocellular carcinoma.

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Xanthogranulomatous cholecystitis (XGC) is comparatively rare and difficult to distinguish from advanced gallbladder cancer (GBC) by imaging studies. It is important to accurately diagnose XGC preoperatively, because patients undergo unnecessarily extensive surgery, such as liver resection, if GBC is diagnosed. We selected 3 cases of XGC diagnosed by post-operative pathological examination, between April 2007 and March 2009. Multi Detector-row CT (MD-CT) was useful for preoperative diagnosis of XGC, because it could detect an enhanced continuous mucosal line and intramural hypoattenuated nodule that are distinctive of XGC. Furthermore, measurement of gallbladder wall blood flow (GWBF) and both resistance index (RI) and pulsatility index (PI), indicating vascular resistance by color Doppler US, were also useful for making a differential diagnosis between XGC and GBC. However, it is still difficult to precisely diagnose XGC preoperatively despite progress in imaging studies, and because a higher percentage of XGC coexists with GBC. Therefore intraoperative pathological examination plays an important role in selecting the most suitable surgical procedure.

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A 71-year-old woman was admitted to our hospital because of sudden onset of upper abdominal pain and vomiting. On admission, she had marked tenderness in the right upper abdomen. Abdominal CT revealed the presence of a defect of the gallbladder wall and ascites around the gallbladder. Abdominal ultrasonography and computed tomography showed no gallbladder stone. We diagnosed idiopathic perforation of the gallbladder and an emergency operation was performed. After laparotomy, we identified about 200 ml biliary ascites in the peritoneal cavity. Culture of biliary ascites yielded no bacterial growth. Perforation of the wall was found at the body of the gallbladder. We conducted cholecystectomy and abdominal drainage. Postoperative course was good and postoperative MRCP revealed no anomaly of the biliary system. Histological examination revealed necrosis of the gallbladder, infiltration of neutrophils and thrombus formation were found at the perforated site. Idiopathic perforation of the gallbladder diagnosed preoperatively is a rare case. We present this case, together with a review of the literature.

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Lymph node metastasis is one of the most serious prognostic factors in patients with intrahepatic cholangiocarcinoma. Furthermore, treatment of recurrent intrahepatic cholangiocarcinoma is difficult. We report a rare case of long-term survival in a patient who had metachronous para-aortic lymph node metastasis from intrahepatic cholangiocarcinoma. A 70-year-old man was followed up after endoscopic mucosal resection for esophageal cancer and referred to our section with space-occupying lesion of the liver. Computed tomography (CT) demonstrated a 3.0-cm-diameter tumor located in S6, which was hyperattenuated in the early phase. Tumor cells were heptitis B antigen positive. He underwent partial hepatectomy under a preoperative diagnosis of hepatocellular carcinoma. The histopathological diagnosis was intrahepatic cholangiocarcinoma. At 16 months after the first operation, CT showed a swollen lymph node behind the inferior vena cava. After the second operation, we diagnosed metachronous para-aortic lymph node metastasis of intrahepatic cholangiocarcinoma. At 26 months after the first operation, a swollen lymph node around the celiac artery was found. He underwent a third operation at another institution. The histopathological findings were moderately differentiated adenocarcinoma, which was the same as the previously resected tumors. The patient is still alive without recurrence 3 years after the third resection and over 5 years after the first operation.

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A 60-year-old man presented with icterus and stomachache. Enhanced CT showed dilatation of both the main pancreatic duct and bile duct, enhanced wall thickening in the lower bile duct, and minute linear calcification along the pancreatic duct in the pancreatic head. ERCP showed redness of the main papilla and bile duct-duodenum fistula. Biopsy of papilla and fistula did not reveal malignancy. FDG-PET showed strong accumulation in the pancreatic head. Because malignant disease of the lower bile duct or pancreatic head could not be denied, we performed pylorus-preserving pancreatoduodenectomy though the tumor markers were not elevated. A pathologic diagnosis of pancreatic abscess caused by actinomycosis was estalished. Actinomycosis in the pancreas is extremely rare. The fistulous opening of the bile duct to the duodenum may be one cause.

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A 63-year-old man presented with upper abdominal pain, caused by acute pancreatitis. Further examination revealed that there was a small neoplastic lesion in the main pancreatic duct. We diagnosed pancreatic intraductal tumor or small pancreatic cancer and performed distal pancreatectomy with lymph node dissection. A soft and white nodular mass, 10 mm in diameter, filled the lumen of the main pancreatic duct. Mucus was not observed in the main pancreatic duct. Microscopic findings showed that the tumor cells proliferated to form tubular glands with a papillary lesion in the surrounding pancreatic ducts. We diagnosed this tumor as intraductal tubular carcinoma (ITC) finally. Intraductal tubular neoplasms (ITNs) are classified as IPMNs according to the Sixth edition of the General Rules for the Study of Pancreatic Cancer in Japan, but this classification is unclear. Only 13 cases were reported in Japanese literature. The pathogenesis of ITNs including ITC is unclear, therefore it is necessary that we accumulate more cases of ITNs and evaluate its clinicopathological features.

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We report a rare case of bleeding gastointestional stromal tumor in Meckel's diverticulum. A 50-year-old man was admitted with melena. CT scan demonstrated an abdominal mass of 15 cm in diameter. Operation was carried out because the mass was thought to represent either a submucosal tumor of the small intestine or a mesenteric tumor. The tumor with the omphalomesenteric vessels arose from the anti-mesenteric side of the ileum, approximately 80 cm apart from the ileocecal valve. Partial resection of the ileum including the tumor was performed. On the resected material, the tumor cells had strong immunopositive reactions for CD34 and KIT, and the diverticulum had ileal mucosa, and the tumor communicated with the diverticulum. This diverticulum was Meckel's because of its position and histological composition, and the presence of the omphalomesenteric vessels. Therefore, the tumor was diagnosed as GIST arising from Meckel's diverculum.

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A 60-year-old woman complained of abdominal distension. Ultrasonography, computed tomography and magnetic resonance imaging revealed a huge tumor with solid and cystic regions, accompanied with pleural effusion and ascites. The serum level of CA125 was elevated. These findings suggested a primary ovarian cancer. At laparotomy, ovary and uterus were intact, and a tumor 20 cm in size was found to originate from the jejunum and invade the urinary bladder. The extramural tumor of the jejunum was resected, and pleural effusion and ascites disappeared after the operation. The fascicular spindle-shaped tumor cells were found to be histopathologically positive for c-kit immunohistochemical staining, yielding a diagnosis of a cystic gastrointestinal stromal tumor of the small intestine. Preoperative differential diagnosis from ovarian tumor was difficult in this case. This is considered to be the first case of pseudo-Meigs syndrome caused by a small intestinal GIST in Japan.

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A 67-year-old woman who had undergone total gastrectomy with Roux-en-Y reconstruction for advanced gastric cancer 4 years previously was admitted to our hospital for treatment of severe anemia. Upper and lower gastrointestinal endoscope examinations revealed no remarkable findings. Abdominal enhanced computed tomography revealed a hypervascular tumor and wall thickening in the second and third portion of the duodenum. Magnetic resonance imaging revealed a high intensity tumor of 10 mm distal to the duodenal papilla. With a diagnosis of duodenal tumor, the patient underwent laparotomy in March 2008. Intraoperative duodenoscopy revealed type 2 duodenal tumor in the second portion, which was diagnosed as adenocarcinoma by frozen section examination. The patient therefore underwent pancreatoduodenectomy. After Roux-en-Y reconstruction, careful follow-up of the duodenum is necessary, because that portion cannot be evaluated by routine gastrointestinal studies.

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The patient was a 66-year-old woman who had undergone low anterior resection for rectal cancer in March 1995 and resection of hepatic metastasis (S2, S3-4, S8) in May of the same year. She noticed tenderness in her right anterior chest in February 1999, and a chest CT scan revealed a tumor accompanied by calcification in her right anterior chest wall. Adenocarcinoma was diagnosed with needle cytology, and resection was performed in March 1999 since it was determined possible. Because of metastasis to the left lung (S10), surgery was performed in May 2000. Now, it is 15 years since resection of the primary lesion and 11 years since resection of the chest wall metastasis. Since then, no manifestations of recurrence have been observed, and the patient has been in a favorable condition. Although few cases concerning metastasis to the chest wall from colon cancer have been reported, radical resectioncan result in long-term survivalin certain cases.

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A 63-year-old man with abdominal pain was found to have a tumor that thickened the wall of the sigmoid colon, dilation of colon on the oral side and a diaphragmatic tumor that was irregularly enhanced irreguraly, and exclusive liver anterior segments. After decompression by a transanally inserted metallic stent, we performed surgery. The diaphragmatic tumor adhered to anterior liver segments, but there was no direct invasion into the liver, so we were able to ablate it, and perform sigmoidectomy and partial resection of the right diaphragm. The diaphragmatic tumor was 65 x 60 x 45 mm in size, and solid with a smooth surface and contained internal necrotic tissue. The resected specimen of the diaphragm revealed the same histological findings as the sigmoid colon specimen. Metastasis to the diaphragm is very rare in colorectal cancer especially a solitary metastasis as in this case. All reported cases were located on the right side, as in the present case. Etiologically, the tumor cells might have been absorbed or have infiltrated into the peritoneal stomata of the diaphragm.

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We report a case of anal metastasis from rectal cancer. A 68-year-old man was admitted for anal pain. A huge tumor, 15 cm in diameter, was present at the right side of the perianal region. The biopsy specimen from the anal tumor revealed adenocarcinoma. Abdominal CT revealed wall thickening of the upper rectum besides the perianal large mass. Preoperative colonofiberscopy could not be performed due to the huge tumor of the anus. Double cancers of the rectum and anus were highly suspected. Abdominoperineal resection with extended perineal resection was performed. Pelvic floor reconstruction was done using vertical rectus abdominis musclocutaneous flaps. Macroscopic findings showed, type 2 rectal cancer and compressed anal mucosa from the perianal mass. Microscopic examination revealed moderately differentiated adenocarcinoma of the rectum, similar histological findings of the perianal tumor, no anal fistula, and intact anorectal epithelium. This is a rare case of anal metastasis from rectal cancer having no past history of anal disease such as fistula in ano.

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A 78-year-old woman was admitted to our hospital with high fever and obvious melena. The serum level of soluble IL-2 receptor was markedly high (1,910 U/ml), and an irregular mass was found 4 cm from the anal margin on digital examination. Abdominal computed tomography demonstrated the circumferential wall thickening of the lower rectum with peritumoral inframmatory changes. Colorectal endoscopy showed an easily-bleeding tumor with ulcer formation at 4 cm from the anal margin. We made a diagnosis of malignant tumor, possibly malignant lymphoma, originating from the lower rectum. We performed abdominoperineal resection with D2 lymph node dissection. The final diagnosis was extranodal NK/T-cell lymphoma originating from the rectum, with positive CD8, EBER and TIA-1 antibody reaction. The patient received postoperative chemotherapy with DeVIC (carboplatin, etoposide, ifostamide and dexamethasone), but died due to disseminated intravascular coagulation syndrome following disease recurrence.

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Background/Purpose : Because incarcerated obturator hernia might be perforated during reduction, it is important to reduce carefully. We compared the classical pulling method, water pressure method and manual femoral pressure method. Patient and method : In this study, we reviewed 32 patients (2 men, 30 women) given diagnoses of incarcerated obturator hernia by computed tomography or magnetic resonance imaging who underwent reduction. Ages ranged from 73 to 106 years old. Five patients who had recovered naturally at the time of laparotomy were excluded. The pulling method was used in 13 patients; The water pressure method in 5; and the manual femoral pressure method in 9. Results : Out of all patients, only 1 treated by manual finger pressure had already been perforated before surgery, and was therefore excluded. The perforation ratio during reduction was 5/13 in the pulling method group, 1/5 in the water pressure method group and 0/8 in the manual femoral pressure method group, respectively. One patient eachwho had perforation died in the pulling method and water pressure method groups, respectively. Conclusion : The majority of patients with incarcerated obturator hernia are super-high aged. When treating this disease, it is necessary to consider the reduction method which prevents surgical site infection to reduce complications.

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