Introduction: Many reports on sentinel node (SN) navigation surgery in gastric cancer patients have been presented and have evaluated different tracers and injection methods. We studied the combined use of fluorescent beads with a particle diameter closer to that of a cancer cell than other tracers and dye (indocyanine green; ICG) to detect SN. Methods: Subjects were 31 patients with cN0 gastric cancer who gave prior written consent to participate in this study. One day before surgery, we injected fluorescent beads into the submucosal layer around the primary lesion endoscopically. During surgery, ICG was injected into the subserosal space from the serosal side surrounding the primary lesion. After ICG injection, a green SN was detected within 15 minutes. Ultraviolet irradiation was used for extracted lymph nodes and fluoresent nodes were assumed to be SNs. Results: In combined bead/dye injection, SN detection in early gastric cancer was 92% (23/25), in fluorescent beads alone 76% (19/25), and in ICG alone 60% (15/25). The mean number of SNs was 2.3 in all 3 procedures. SNs were detected in 7 cases in which both tracers were used. SNs with fluorescent beads were detected in lymph nodes of both the first and second compartments. Conclusions: SN detection increased in combined bead/dye injection, but it was difficult to detect fluorescent lymph nodes hidden in adipose tissue during surgery due to tissue autofluorescence.

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We report a rare case of gastric perforation due to cytomegalovirus infection that required surgical treatment. A 41-year-old man presented weight loss, low grade fever, and vomiting. Upper gastrointestinal endoscopy showed a large ulcer on the antrum of the stomach. The biopsy specimen of the ulcer showed cytomegalic cells with intranuclear inclusion bodies and blood test was positive for human immunodeficiency virus (HIV) antibody. A diagnosis of cytomegalovirus (CMV) infection of the stomach due to acquired immunodeficiency syndrome (AIDS) was made and he was admitted to our hospital. We conducted conservative medical therapy with a proton pump inhibitor (PPI) and antiviral agent. However, we could not continue antiviral therapy due to pancytopenia. Three weeks later he had abdominal pain, and upper gastrointestinal endoscopy showed a huge perforation of the ulcer on the antrum of the stomach. The abdominal CT showed a large quantity of free air and ascites. Based on the diagnosis of ulcer perforation due to cytomegalovirus infection of the stomach, we conducted emergency laparotomy. Laparotomy revealed a large perforated ulcer (approximately 4 cm in diameter) on the antrum of the stomach, and we performed distal gastrectomy. The resected specimen showed a cytomegalic cell infiltration 11 mm apart from the ulcer margin. Although his condition was improved, AIDS progressed gradually and he died 239 days after the operation.

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We report a case of advanced gastric cancer with para-aortic lymph node metastasis that underwent radical gastrectomy after neoadjuvant chemotherapy, and in this case, thoracoscopy was useful in excluding mediastinal lymph node metastasis. The patient was a 70-year-old man in whom a large type 2 advanced gastric cancer accompanied with para-aortic and mediastinal lymph node metastasis was diagnosed. We attempted combination therapy of Docetaxel, CDDP and TS-1. After 2 courses of treatment, the primary lesion and regional and para-aortic lymph nodes were significantly reduced in size, suggesting that this therapy had induced a partial response (PR). However, the size of mediastinal lymph node did not change. FDG-PET showed accumulation of FDG located in the mediastinal lymph node, in which metastasis was suspected. To judge the possibility of radical excision, we performed thoracoscopic biopsy of the mediastinal lymph node. No metastasis was shown in the mediastinal lymph node biopsy, so we performed curative total gastrectomy with D3 lymph node dissection and cholecystectomy with curative intent. The pathological findings showed that there were very few cancer cells either in the primary lesion and only one lymph node (No.3). There has been no recurrence for two years after the operation.

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A 72-year-old woman complaining of melena was admitted to a local hospital. Upper gastrointestinal endoscopy demonstrated a type 0-IIc tumor of the greater curvature in the middle third of the stomach that was determined to be a poorly-differentiated adenocarcinoma. She was referred to our hospital, and laparoscopy-assisted distal gastrectomy with D1+lymph node dissection was performed for the T1aN0M0 Stage IA gastric cancer. Eventually, however, a laparoscopy-assisted total gastrectomy with D2 lymph node dissection including splenectomy was performed because metastases of the left greater curvature lymph nodes along the left gastroepiploic artery were found during intraoperative pathological examination. Histopathological examination demonstrated a non-solid type poorly-differentiated adenocarcinoma confined to the mucosa with metastases to nineteen regional lymph nodes. However, a more detailed pathological examination confirmed a few gastric cancer cells in the submucosa. Meticulous care should be taken when clinically diagnosing intramucosal gastric cancers such as these, in which extensive lymph node metastases are not diagnosed clinically but pathologically. Interestingly, in our case, the tumor invasion into the submucosa was demonstrated only after a more detailed pathological examination.

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Undifferentiated sarcoma of the liver (USL) is usually observed in children. USL in adults is extremely rare and considered an aggressive neoplasm with an unfavorable prognosis. We report a case of USL in a 73-year-oldwoman. She was admitted to our hospital for a huge mass in the right lobe of the liver. On admission, laboratory data showed slight liver dysfunction, but hepatitis and tumor markers were negative. US, CT and MRI showed a large mass involving the right lobe of the liver. The tumor was enhanced slightly but mainly hypovascular. Right hepatectomy was performed. The resected specimen weighed almost 1500 g, and the tumor was 15×15 cm in size, lacked a capsulate and showed hemorrhage, necrosis and gelatinous material. Microscopically, the tumor consisted of atypical interlacting spindle cells and numerous cells with eosinophilic hyalin globules, positive to PAS, were noted. The tumor was stained for vimentin, desmin, alpha SMA and CD56 by immunohistochemistry. The definitive diagnosis was USL. Adjuvant chemotherapy was not performed. She had recurrent peritoneal disseminations in the right kidney after the first operation and was treated by radiotherapy and surgery. She remains alive 50 months after the first surgery. USL is a very aggressive tumor and prognosis is generally poor, but combined surgical treatment and radiotherapy for the recurrence of peritoneal dissemination may promote longer survival.

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A 74-year-old man was admitted to our hospital due to icterus and elevation of serum transaminase. His CT and MRI images showed a tumor with a smooth surface in the dilated upper and middle extrahepatic bile duct. Since biopsy of the tumor at ERC examination revealed a spindle cell malignancy, we planned an operation. A polypoid tumor was found in the extrahepatic bile duct and intraoperative pathological examination of the tumor showed sarcomatous tumor. Extrahepatic bile duct resection and Roux-en-Y biliary reconstruction was performed. Histological examination of the specimen showed sarcomatous atypical cells in the polyoid tumor, adenocarcinoma cells around its stalk, and a few mixed area of blended sarcomatous/adenocarcinoma cells. Immunohistological staining showed that the sarcomatous cells were positive for epithelial markers and the final pathological diagnosis was carcinosarcoma. Although liver metastasis appeared at 16 months after operation, he is alive and well 27 months after operation with gemcitabine chemotherapy.

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A 66-year-old man, who had undergone pancreatoduodenectomy for a cancer of the duodenal papilla, was admitted to our hospital because of pancreatitis, 58 months postoperatively. Radiological examination showed the dilated remnant pancreatic duct with a protein plug. Although conservative therapy using a protease inhibitor was symptomatically effective, pancreatitis attacks reccurred frequently. Endoscopic balloon dilation for the pancreato-jejunal anastomosis resulted in remission of the attacks, but pancreatitis relapsed 6 months after the procedure with a protein plug and dilation of the pancreatic duct. Bromhexine hydrochloride was orally administered anticipating increasing in the secretion of pancreatic juice of low viscosity. Three months after starting this medicine, the protein plug in the pancreatic duct disappeared and the diameter of the duct decreased. In the 42 months since then, no pancreatic attacks nor protein plugs have occurred. Bromhexine hydrochloride therapy is a possible alternative for to treat residual pancreatitis after pancreatoduodenectomy, before attempting surgical or endoscopic therapy, which are invasive and complicated.

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A 74-year-old man who had undergone pancreatoduodenectomy for carcinoma of the papilla of Vater in August 2010 was admitted to the emergency room due to consciousness disorder in December 2010. Hepatic encephalopathy was ascertained, which resulted from hepatic failure resulting from the extrahepatic portal vein obstruction owing to postoperative pancreatic fistula. Because of lack of response to conservative management, portal venous stenting was tried two months later. At first, transileocolic portal venous stenting was chosen because the intrahepatic portal venous flow could not be comfirmed. When the first stenting failed, stringlike stenotic intrahepatic and extrahepatic portal veins with slow blood flow was observed, which suggested the probability of cannulization of the portal vein. Finally, stenting under portography and dilation of the portal vein obstruction were achieved via a percutaneous transhepatic route. Portal blood flow was improved, and subsequently, liver failure disappeared. In this article, we report effective transhepatic portal venous stent placement as one treatment option for benign extrahepatic portal venous obstruction after pancreatoduodenectomy.

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In October 2003, a 78-year-old man underwent a distal pancreatectomy for invasive ductal carcinoma in the tail of the pancreas. After the operation, he received systemic chemotherapy based on gemcitabine (1,000 mg/m²/week for 3 months) and oral tegafur-uracil (300 mg/day for 57 months). He had no recurrence for 6 years after the initial operation. In November 2009, dynamic abdominal computed tomography (CT) scan revealed a 13 mm tumor with weak enhancement in the remnant pancreas. Adenocarcinoma was diagnosed by brushing cytology of the pancreatic duct and biopsy of the tumor under endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Since there were no findings of other metastatic tumors, a total remnant pancreatectomy with portal vein resection and direct reconstruction was performed in December 2009. The histological findings yielded a diagnosis of metachronous pancreatic carcinoma, and not local recurrence because the disease-free span was much longer than the typical course of recurrence. The margin of the two surgical specimens were negative for carcinoma. Curatively resected metachronous invasive ductal carcinoma of the pancreatic head and the remnant pancreas is extremely rare. It is important to suspect metachronous cancer as well as recurrence in patients with secondary pancreatic tumor.

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We report a rare case of resected remnant pancreatic cancer. A 69-year-old man underwent subtotal stomach preserving pancreatoduodenectomy for cancer of the papilla of vater. The tumor was histologically diagnosed as moderately differentiated tubular adenocarcinoma without regional lymph node invasion (Stage III). Abdominal CT performed 6 years later revealed a 2 cm tumor in the remnant pancreatic body with a dilatation of the distal main pancreatic duct. A remnant distal pancreatectomy, in addition to splenectomy and left adrenectomy, was performed. Histological diagnosis was moderately differentiated tubular adenocarcinoma of the pancreas that was similar in morphology to, but was different in immunohistochemical profiles from the previous tumor. Moreover, histological examination of the non-cancerous region distal to the tumor revealed the findings of obstructive pancreatitis. Thus, it appears clinically and histologically that the pancreatic tumor is a metachronous pancreatic cancer, but not metastasis from cancer of the papilla of vater. Five of six patients with remnant pancreatic cancer after pancreatoduodenectomy for cancer of the papilla of vater reported in Japan developed the pancreatic cancer 5 years or later after the first operation. Therefore, a long-term follow-up of patients who underwent pancreatoduodenectomy is essential.

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We report a case of chronic intestinal pseudo-obstruction (CIP) complicated with pneumatosis cystoides intestinalis (PCI), in whom partial resection of the jejunum was effective. A 69-year-old woman under treatment for scleroderma had abdominal distension. We diagnosed CIP with PCI secondary to scleroderma. Her symptoms improved with conservative therapy, however, they deteriorated again as oral intake always caused fever. Therefore, we performed resection of the jejunal segment affected by PCI. After the operation, she was able to ingest orally sufficiently to maintain good nutritional condition. The surgical indications of CIP with PCI secondary to systemic disease such as scleroderma are controversial. If the lesion affected by PCI is localized and oral intake is difficult because of PCI, resection of the affected segment should be considered.

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A 23-year-old woman presented with a history of repeated abdominal pain and vomiting since the 12th gestational week. Radiological studies revealed dilatation of the entire small intestine without mechanical obstruction, and dysmotility of the ileocecal region was suspected. Her symptoms continued after delivery, despite conservative treatment, and ileocecal resection was performed at age 24 years. The resected specimen showed a remarkable decrease in the density of enteric ganglion cells, therefore chronic idiopathic intestinal pseudo-obstruction (CIIP) was diagnosed. Subtotal colectomy was subsequently performed at 25 years of age, but her symptoms persisted. Long-term parenteral nutrition became difficult because of catheter-related complications and her nutritional status worsened. Therefore, at age 29 she underwent jejunostomy, and her symptoms improved. She is now able to eat and her nutritional status continues to improve. Autoimmune abnormality has recently been reported to be one of the causes of CIIP, and some relation between pregnancy and autoimmune disease has been recognized. Our case suggests that immunological changes during pregnancy may cause CIIP.

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A 77-year-old woman visited our emergency outpatient department after experiencing abdominal pain for several days. Upon examination, she exhibited a board-like abdomen, and an abdominal computed tomography examination showed ascites and a small amount of free air on the surface of the liver. Although numerous diverticula were observed in the right colon, no apparent calcification or abscess formation was seen. We performed emergency surgery based on a diagnosis of panperitonitis associated with a perforation in a right colon diverticulum. The right colon was mobilized and carefully observed, and necrosis and perforation were seen at the tip of the appendix, located posterior to the cecum. Because no inflammation was observed at the base of the appendix, we performed an appendectomy. The presence of intra-abdominal free air arising from a perforation of the vermiform appendix is rare. Because postoperative histopathological examination revealed primary signet-ring cell carcinoma of the vermiform appendix and the resection margin was positive, we subsequently performed a right hemicolectomy using a two-stage procedure. Here, we report a case of primary signet-ring cell carcinoma of the vermiform appendix with perforation peritonitis. Although we were unable to diagnose the appendiceal cancer intraoperatively, this case illustrates the importance of considering the possibility of such cancer when choosing an operative method and of histopathologically examining resected appendices.

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We report a case of ileo-ovarian fistula in Crohn's disease. A 22-year-old woman was given a diagnosis of ileocolic type Crohn's disease at age 20. She was admitted with right lower abdominal pain. Intestinal fluorography did not show an entero-ovarian fistula, but CT revealed air and fluid level in the right ovarian cyst. We performed laparotomy under diagnosis of ileo-ovarian fistula, and performed resection of the terminal ileum and the right adnexa. Fistula formation is one of the major complications of Crohn's disease although ileo-ovarian fistula due to Crohn's disease is rare.

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Morgagni foramen hernia is a rare form of diaphragmatic hernia. Since it is located on the anterior edge of the diaphragm and does not have an anterior rim, it is difficult to achieve a secure closure and maintain the tension of closure after suturing the hernia orifice. The extra-abdominal suture method for Morgagni foramen hernia was first reported by Kuster in 1992. This technique is one which can maintain a tight closure by using rectus abdominis fascia. In recent years, several cases of laparoscopic repair with the extra-abdominal suture method for Morgagni foramen hernia have been reported. We recently performed this method in an 85-year-old woman complaining of epigastralgia and vomiting who visited our emergency department. Computed Tomography revealed a diaphragmatic hernia in which the transverse colon and greater omentum were incarcerated. We diagnosed Morgagni foramen hernia and attempted to perform laparoscopic repair. Laparoscopy showed the diaphragm hernia in which the transverse colon and greater omentum were impacted. Hernia contents were reduced smoothly into the abdominal cavity by grasping forceps. The size of the hernia orifice was 6×3 cm in diameter. The defect of diaphragm was closed by the extra-abdominal suture method. She has had no recurrence of hernia for four years after surgery. The extra-abdominal suture method can provide secure closure of the hernia orifice for Morgagni foramen hernia in which the anterior rim is absent.

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