Purpose: We examined that the manipulations of liver retractors in laparoscopy-assisted gastrectomy (LAG), and the influence of postoperative liver function on liver retraction in LAG. Patients and Methods: We investigated one hundred and fourteen patients undergoing LAG in our institution: P method group (the technique using a Penrose drain to suspend the liver; n=13), S method group (snake retractor connected to the Octopus retractor holder; n=19), and N method group (Nathanson liver retractor connected to the Octopus retractor holder; n=82). To investigate the difference for three liver retrarctions, we measured the time required the liver retraction, and the alanine aminotransferase (ALT) levels preoperatively, on postoperative day (POD) 1 and on POD 7. Results: The time required the liver retraction was 14.1 min (P method group), 3.8 min (S method group), and 2 min (N method group). On N method group we needed the shortest time to retract liver with significant (p<0.0001). On all groups ALT level on POD1 increased than preoperative ALT level significantly, and ALT level on POD7 decreased than ALT level on POD1 significantly. Examining the proportion of ALT level on POD1 to preoperative ALT level, the proportion of N method group was significantly lower than P method groups (p=0.0071). Abnormal elevation of ALT (>200 IU/l) was observed in 4 patients of S method group (21.1%), and 7 patients of S method group (8.5%). On the other hand, no patient in P method group showed an abnormal elevation of ALT. Conclusions: It is possible for the Nathanson liver retractor to retract liver quickly, but we give special attention to liver dysfunction postoperatively.

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We report a rare case of glomus tumor of the stomach coexisting with gastric cancer. A 63-year-old man visited our hospital because of a sensation of abdominal fullness and was admitted with a diagnosis of pyloric stenosis for evaluation. Abdominal CT showed a mass at the pylorus which caused stenosis of the gastric lumen and induced gastric dilatation. There was a submucosal tumor observed at the oral side of the pylorus mass. The submucosal oval mass was strongly and heterogeneously enhanced. Cholelithiasis was diagnosed by abdominal sonograph. The pyloric tumor was diagnosed as gastric carcinoma by biopsy. The submucosal tumor without ulceration was also observed at the oral side of the cancer by endoscopy. Gastric cancer with pyloric stenosis, submucosal tumor and cholelithiasis were diagnosed preoperatively. Distal gastrectomy and cholecystectomy were performed. On the longitudinal cut surface of the type 3 tumor, the distal portion was white firm and the oral portion was brown soft. Pathologically the white portion was diagnosed as carcinoma and the brown one was glomus tumor.

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We report here a surgical case of metastatic liver tumor in a 64-year-old man who was admitted to our hospital due to shock from a hemorrhagic gastric submucosal tumor, in whom an emergency partial gastrectomy was performed. Pre- and post-operative examinations revealed a metastatic liver tumor deriving from a gastrointestinal tumor (GIST) with a tumor thrombus extending into the right atrium. Extended left hepatic resection and tumor thrombectomy under assisted circulation was performed in order to prevent imminent death. c-Kit and CD34 immunostaining of the tumor were positive, and a final diagnosis of metastatic GIST of the high risk group was made. We propose that the best treatment for metastatic liver tumor from GIST is a combination of imatinib and surgery. In such cases, it is necessary to provide surgical treatment first for the metastatic liver tumor, taking great care with the thrombus/infarction of the pulmonary veins.

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A 47-year-old man had frequent episodes of Inose-type hepatic encephalopathy due to large porto-systemic shunt from the splenic vein to the right common iliac vein via the inferior mesenteric vein. Coiling occlusion by interventional radiology (IVR) technique was attempted at another hospital, but was unsuccessful because the diameter of the shunt vessel was too large. He admitted to our hospital for surgical closure of shunt vessel. Intraoperative direct portography of the branch of the jejunal vein revealed that all mesenteric blood flew out into the large shunt vessel. Intrahepatic portal flow was absent. Before manipulation, portal venous pressure was 8 mmHg. When the shunt was clamped, recovery of hepatopetal portal blood flow was observed on portography and Doppler US. The portal venous pressure increased to 12 mmHg. Complete closure of the shunt vessel was then performed. The blood ammonia level was normalized on the day after surgery and recovery was uneventful. He has had no episodes of encephalopathy for 8 months after surgery. Surgical closure is an option that is effective for large porto-systemic shunts which cannot be closed by IVR.

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The most common complication associated with insertion of a plastic biliary stent due to postoperative bile duct stricture is occlusion. It has been speculated that deodenobiliary reflux through the main duodenal papilla leads to occlusion. Percutaneous transhepatic cholangiodrainage (PTCD) is a viable treatment option for postoperative bile duct stricture, but necessitates long-term external biliary drainage. We report a percutaneous transhepatic procedure for biliary endoprostheses and distal tube implantation in the subcutaneous space. Excellent long-term results and improvement in quality of life were reported in four cases. We attempted percutaneous transhepatic biliary endoprostheses using a biliary decompression tube, devised during or after surgery, and then replaced with CLINY PTCD tube (CREATE MEDIC, Yokohama, Japan). Using the guidewire technique, 7 Fr catheter was introduced initially, and during the process of fistula formation, was gradually replaced up to 12 Fr catheter preserving the papilla of Vater dilation. The tip of the catheter was placed in the common bile duct and the distal end was implanted in the subcutaneous space. Excellent long-term results were obtained, with up to 5 years and 1 month patency. In one case, the tube was occluded with sludge after 15 months, but the tube could be replaced easily and improved the external biliary drainage. Thus, this procedure is useful in cases of occlusion resulting from postoperative bile duct stricture.

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Prognosis of gallbladder carcinoma patients with positive para-aortic lymph nodes is poor. We report a case of long-term survival in a patient with the above mentioned condition who underwent pancreaticoduodenectomy for residual metastatic lymph nodes. The patient was a 51-year-old man with gallbladder carcinoma who underwent cholecystectomy with wedge resection of the gallbladder bed. We found suspicious lymph nodes in the retro-pancreaticoduodenal area, which appeared to require pancreaticoduodenectomy for complete dissection. However, we abandoned pancreaticoduodenectomy and opted for observation after radiotherapy because para-aortic lymph node metastasis was observed. Although retro-pancreaticoduodenal lymph nodes progressively enlarged thereafter, no new metastatic lesions appeared. Therefore, we performed pancreaticoduodenectomy with residual metastatic lymph node dissection 4 years after the first surgery. Five years after the second surgery, the patient is in good health without any sign of recurrence. Immunohistochemical analysis revealed significant intratumoral infiltration of immune cells, suggesting that the antitumor immune response may be one of the factors influencing long-term survival in the patient.

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We report a case of solid-pseudopapillary neoplasm (SPN) of the pancreas with duodenal invasion in a 73-year-old man who was admitted for the evaluation and treatment of a gastric tumor and a pancreatic tumor. Upper gastrointestinal endoscopy revealed early gastric cancer at the gastric angle. Enhanced abdominal computed tomography and magnetic resonance imaging showed a tumor in the head of pancreas, which was 4.5 cm in diameter, consisting of cystic components and solid components. Based on a diagnosis of early gastric cancer and SPN of the pancreas head, we conducted pancreatoduodenectomy. Histopathologically, we diagnosed early gastric cancer and SPN of the pancreas with duodenal invasion. The patient is doing well, and shows no signs of recurrence 1.5 years after operation.

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We report a case of intraductal papillary mucinous carcinoma (IPMC) with high fluorodeoxyglucose uptake in the thickened cystic wall. We diagnosed branched intraductal papillary mucinous neoplasm (IPMN) in a 60-year-old man by CT examination. A half year later, significant thickening wall of the IPMN cyst was recognized on CT. According to the FDG-PET finding high fluorodeoxyglucose uptake agreed with the thickened cystic wall. Since the tumor was diagnosed as IPMC, pancreatoduodenectomy was performed. The pathological diagnosis was IPMC with minimal invasion, because of lining by the atypical epithelium cell of the cyst wall. Malignant tumor cells were found in parts of the thickened wall, and inflammatory cell infiltration with mainly lymphocytes in the other most parts. High FDG-PET fluorodeoxyglucose uptake was suspected at the thickened wall with inflammation.

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A 90-year-old man was admitted for fever and abdominal pain. Lower gastrointestinal endoscopy and barium enema study showed a type 2 tumor at the ileocecum. Abdominal computed tomography releaved lymph node swelling around the tumor in addition to para-aortic lymph node swelling. We performed right colectomy and found that the tumor was in the ileum close to the ileocecal valve. Histologically, the tumor was diagnosed as moderately to poorly differentiated squamous cell carcinoma without components of adenocarcinoma. Therefore, we diagnosed primary squamous cell carcinoma of the ileum. To the best of our knowledge, only 7 other cases of primary squamous cell carcinoma of the small intestine have been reported to date.

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A 71-year-old woman complained of lower abdominal pain. Abdominal CT demonstrated a tumor in the pelvis, and the histological diagnosis by needle biopsy was diffuse large B cell lymphoma. The patient underwent R-CHOP chemotherapy. After 6 courses of chemotherapy, the tumor of ileum and mesenteric lymphadenopathy disappeared; however, the patient developed repeated small bowel obstruction. Thus, a partial resection of ileum and lymph node biopsy was performed. Macroscopic findings of the resected ileum showed severe stenosis with ulcer. Microscopically, viable lymphoma cells were not found in the resected intestine and lymph nodes. This case suggests that malignant lymphoma of the gastrointestinal tract with a complete response to chemotherapy sometimes requires surgical resection due to an obstruction.

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A 51-year-old man was referred to our hospital because of hematochezia. Emergency colonoscopic examination revealed oozing from the appendiceal orifice, and then hemostasis was temporally achieved by the injection in the appendix lumen of thrombin. Since the patient occasionally presented hematochezia three days later, laparoscopic appendectomy was performed. Laparoscopic findings revealed the appendix to be normal and no signs of inflammation or tumor were seen. Appendectomy, including the appendix orifice, was performed using an automatic stapling device. The serosa of the specimen was grossly unremarkable. A bleeding focus was noted at the proximal portion of the opened appendix. Histopathological findings of the appendix showed bleeding in the lamina propria and dilated smaller veins with the fibrin thrombosis. Histopathological examination indicated the cause of appendiceal bleeding to be angiodysplasia. The postoperative course was uneventful, and the patient was discharged on the 4th postoperative day. There was no postoperative recurrence of hematochezia. To the best of our knowledge, this is the second case of angiodysplasa that caused appendiceal bleeding reported in Japan.

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During outpatient treatment for postsurgery of gastric cancer, a ring-enhanced tumor was detected in the cecum on abdominal CT of a 76-year-old man. Colonoscopy showed the protruding adenomatous lesion in the cecum and the center of lesion was concave. Endoscopic biopsy demonstrated tubular adenoma with severe atypia, and we diagnosed appendiceal intussusception caused by appendiceal tumor (adenoma or carcinoma). At laparotomy, the base of the appendix was partially inverted into the cecum, and ileocecal resection with lymph node dissection was performed. Histopathological examination revealed well differentiated adenocarcinoma in tubulovillous adenoma, which was limited to the mucosa. In Japan, reports (including the present case) of intussusception induced by appendiceal carcinoma and adenoma total 26 patients. Carcinoma was identified 17 cases, and 10 (58.8%) of which confined to mucosal or submucosal layer. These histopathological findings suggested the appropriateness of minimally invasive surgery. However the indications should be evaluated carefully, because some cases were advanced cases, with peritoneal dissemination or lymph node metastasis.

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We report a case of a 53-year-old man with a pagetoid spread of colon cancer at the site of a previous colostomy. The patient was given a diagnosis of Hirschsprung disease at 8 years of age, and underwent surgery 4 times. He has end colostomy with descending colon. Forty-two years after surgery, he noticed a mass at the colostomy site. Biopsy revealed well-differentiated adenocarcinoma. Descending colon including the tumor and colostomy was resected with abdominal wall. Colostomy was made with a transverse colon, and the abdominal wall was reconstructed using lateral femoral arterial musculocutaneous flap. Histopathological findings showed tub2>muc, si (skin), ly0, v0, n0 with pagetoid spread to the skin. He is alive and well without recurrence for 5 years. Although cases of pagetoid spread are rare, there have been some reported in anal canal cancer and rectal cancer. We found no previous reports of cancer with pagetoid spread at the colostomy site, therefore, we present this case with references to the literature.

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An 84-year-old man was observed for postoperative transverse colon cancer at a nearby hospital. CEA and CA19-9 levels increased, so he was referred to our hospital. A type 2 tumor was found in the ascending colon by colonoscopy and the biopsy indicated adenocarcinoma. Abdominal CT did not show liver metastasis and lymph node swelling. Laparoscopic right hemicolectomy with D3 dissection was performed. Pathological examination indicated pSE, pN0, ly1 (D2-40) and v0 (EL), and partial invasive micropapillary carcinoma (IMPC) with moderately differentiated adenocarcinoma and mucinous carcinoma for a background. The patient is alive after 11 months after the operation with no recurrence. IMPC was reported as a variant of invasive breast carcinoma the first time. This has been reported in various organs including the urinary bladder, ureter, lung and parotid gland and the prognosis is known to be bad. Report of IMPC in the colon is very rare, so we report this case of ascending colon cancer with partial IMPC.

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A 65-year-old woman, with a history of systemic lupus erythematosus (SLE) and treatment with prednisolone for 5 years, was admitted to our hospital for acute abdomen. As lupus enteritis was suspected, high doses of corticosteroid therapy were given. This treatment resulted in transient improvement, but fecaluria and intestinal fistula developed. Endoscopic and radiological examination showed vesico-sigmoid colonojejunalcutaneous fistula. As physical examination and laboratory findings did not reveal increased activity of SLE, fistulectomy, rectosigmoidectomy and colostomy (Hartmann’s operation) were performed after steroid tapering. Histopathological findings of the resected specimen showed inflammation of intramural vessels and were compatible with lupus enteritis. After operation, she had an uneventful clinical course. Since intestinal perforation in SLE is rare and has a grim prognosis, careful management of steroid and timing of operation are important.

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