Purpose: ESD has been the standard treatment for selected cases of early gastric cancer. Additional gastrectomy is often performed on patients, who do not satisfy the inclusion criteria for ESD based on pathological examination of ESD specimens; however, the majority of patients who undergo additional gastrectomy may not have lymph node metastasis (LNM). This study aimed to investigate the optimal indications for additional gastrectomy for patients, who do not satisfy the inclusion criteria for ESD. Patients and Methods: Between 2004 and 2011, 51 patients who underwent additional gastrectomy for lesions that did not meet the inclusion criteria after ESD, were enrolled in this study. The clinicopathological characteristics, incidence and risk factors of LNM, and outcomes were retrospectively evaluated. Results: LNM was observed in 6 cases (11.8%). The median follow-up time was 56 months (range, 10–107 months). There were 2 recurrences during the follow-up period. One patient developed distant lymph node metastasis, and the other developed liver metastasis. The 5-year disease-specific survival was 97.9%. Multivariate analysis revealed that the presence of venous involvement was significantly associated with LNM (OR 14.68; 95% CI 1.97–109.25, P=0.009). Sixteen cases of the differentiated type without lymphovascular involvement had no LNM. Conclusion: Additional gastrectomy is strongly recommended for patients with venous involvement in ESD specimens because of the risk of LNM. Although more evaluations are needed, additional gastrectomy may be avoided in differentiated type cases without lymphovascular involvement, because of the low probability of LNM.

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We report a case of a 68-year-old woman, who underwent extended right hepatectomy with extrahepatic bile duct resection for intrahepatic cholangiocarcinoma (ICC). Histopathological examination showed a mass-forming type of ICC and no lymph node metastasis. Adjuvant chemotherapy with gemcitabine and cisplatin was performed for 6 months after operation, and S-1 was administered intermittently from 11 months after operation, because the serum CA19-9 level was elevated without imaging evidence of recurrence. She presented with nausea and vomiting 32 months after operation. Upper gastrointestinal endoscopy showed pyloric stenosis. Enhanced CT showed a circumferential submucosal thickening of the pyloric wall. Distal gastrectomy was performed, and we considered a diagnosis of gastric cancer or metastatic gastric cancer from ICC. Histological findings of the gastric lesion were compatible with metastasis of ICC. Immunohistochemical staining of CK19 and CA19-9 were positive in both the primary and metastatic lesions. To the best of our knowledge, this is the first case of metachronous gastric metastasis from ICC.

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We report a rare case of enteropathy-associated T-cell lymphoma occurring in the ascending portion of the duodenum. Most gastrointestinal primary malignant lymphomas are B-cell type, and the T-cell type is rare. Moreover primary malignant lymphomas are rarely found in the duodenum. An 82-year-old man presented with abdominal pain and nausea. CT examination revealed stenosis in the ascending portion of the duodenum. Upper gastrointestinal endoscopy revealed a polypoid lesion with redness and irregular ulceration on the entire circumference of the ascending portion of the duodenum. Preoperative endoscopic biopsy was inconclusive. We performed operation for diagnosis and treatment of the intestinal obstruction of the tumor. The tumor was located from the ascending part of the duodenum to the transition of the jejunum. Intraoperative pathological findings suggested a malignant lymphoma. We performed partial duodenal resection. Postoperative histopathology confirmed enteropathy-associated T-cell lymphoma. The man subsequently received 6 courses of CHOP therapy. At 9 months after surgery, follow-up examination showed mesenteric lymph node recurrence, small bowel perforation, and intra-abdominal abscess. The man died at one year after surgery.

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A 68-year-old man was referred to our hospital with a 5 cm tumor in S8 of the liver with elevated levels of serum PIVKA-II for further investigation. CT showed a nodular tumor consisting of two different components. The large component which showed little enhancement by contrast enhanced CT, demonstrated a massive fat-containing area by magnetic resonance imaging. The other component which was smaller and next to the large component was well-enhanced in the arterial phase and washed out in the venous phase of contrast enhanced CT, was considered to be typical hepatocellular carcinoma. Based on radiological findings, two differential diagnoses were considered: one large hepatocellular carcinoma (HCC) with 2 components; and a large angiomyolipoma (AML) accompanying with small HCC. Partial hepatic resection was performed. Histopathologically, the tumor was diagnosed as a moderately differentiated HCC of simple nodular type with extra nodular growth as the whole tumor, consisting of the large HCC component with massive fatty change and a small HCC component with little fatty change. Massive fatty change is usually seen in small, well-differentiated HCC, and rarely observed in larger, moderately differentiated HCC. Here, we report a case of a 5-cm moderately differentiated HCC with massive fatty change mimicking AML.

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A 78-year-old woman with dementia was transferred to our hospital with hypoglycemia. Insulinoma in the uncinate process of the pancreas was diagnosed based on the findings of enhanced abdominal CT, angiography and the clinical symptoms. We managed the hypoglycemia with an intravenous drip of glucose for preoperative management. This was difficult, because the patient repeatedly removed the intravenous drip herself. We therefore administered subcutaneous injections of octreotide as an alternative method, which was effective in managing her hypoglycemia. We performed enucleation of the tumor, the location of which was confirmed by intraoperative ultrasonography. A rapid insulin immunoassay was used to intraoperatively monitor the patient to confirm the absence of any remnant tumor. After surgery, the hypoglycemia disappeared and the patient has remained symptom-free. This case of insulinoma with preoperative hypoglycemia was successfully managed by subcutaneous injections of octreotide. This appears to be an effective treatment in cases difficult to manage by intravenous drip.

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We report a case of a splenic inflammatory myofibroblastic tumor (IMT). A 40-year-old man presented with left back pain and was found to have a 4 cm splenic mass by ultrasonography. Abdominal enhanced CT and MRI revealed no definitive diagnosis. Since fluorine-18-FDG-PET showed high FDG accumulation in the spleen, we performed laparoscopic splenectomy for suspected malignant tumor. It was histopathologically diagnosed as primary splenic IMT. The postoperative course was uneventful, without recurrence. We suggest that laparoscopic splenectomy is useful in treating splenic tumor, when determining a specific pathological diagnosis.

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A routine annual abdominal CT scan in a 73-year-old woman, who was undergoing outpatient treatment for hepatitis C in our hospital, revealed calcification of veins near the ascending colon, which led to a diagnosis of idiopathic mesenteric phlebosclerosis (IMP). Because no gastrointestinal symptoms were reported, a wait-and-see approach was adopted and the patient was monitored, but serial CT showed slow progression of the condition. During the 6th year of follow-up, she visited our hospital with a chief complaint of lower right abdominal pain and was given a diagnosis of bowel congestion due to an exacerbation of IMP and admitted to the emergency department. After conservative medical treatment failed to alleviate the symptoms, right hemicolectomy was performed. IMP is believed to result from chronic disruption of blood circulation due to phlebosclerosis. It is a relatively rare disease that affects only Asians, especially Japanese individuals. The number of cases of IMP in Japan has recently increased, but the clinical course is monitored over a long period in only rare cases, as it was in this case. We report our case and include a discussion based on the relevant literature.

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A tumor hemorrhage is reported to be a rare adverse reaction of imatinib mesylate in gastrointestinal stromal tumors (GIST). We encountered two patients with tumor hemorrhage under imatinib treatment. Case 1: An 18-year-old woman underwent partial gastrectomy for gastric GIST at 14 years old. She complained of abdominal pain, and intraperitoneal relapse of GIST was diagnosed. She received imatinib mesylate treatment and twice developed an abdominal hemorrhage, which on both occasions was cured by conservative therapy. We resected the GIST as best as we could and restarted imatinib mesylate. There were no hemorrhages or relapses for twenty-nine months and five months, respectively. Case 2: A 35-year-old woman had an abnormality on the upper gastrointestinal series at a medical check-up and was given a diagnosis of gastric GIST, abdominal dissemination and multiple liver metastases. She was treated with imatinib mesylate, however she suffered an intra-abdominal hemorrhage which required surgery. We resected the tumors as best as we could and restarted imatinib mesylate. We obtained a clinical complete response for forty months. We have been successful at continuing treatment with imatinib mesylate with no recurrence, suggesting the efficacy for hemorrhage from GIST caused by imatinib mesylate.

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Open appendectomy remains the most common procedure for appendicitis in pregnant patients. However, recently we have been using laparoscopic appendectomy (LA) for such patients because of progress in laparoscopic techniques based on experience. Five pregnant patients underwent LA between July 2011 to March 2013. The patient’s position and trocar insertion site were confirmed to be appropriate during the operation to establish a good operating field. Close observation of patients and fetuses was performed by both anesthesiologists and obstetricians during the perioperative period. No postoperative complications occurred, and all patients had a normal delivery. Based on these results, we conclude that LA can be an effective method for treating acute appendicitis during all trimesters of pregnancy.

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A 45-year-old man presented with a chief complaint of right lower quadrant pain and underwent detailed examinations. As CT revealed an intraperitoneal abscess 100 mm in size, perforated acute appendicitis was diagnosed and he underwent surgery. During surgery, only appendectomy was performed after confirming the tip of the appendix. A funicular object that was observed from the appendix body to the pelvic floor was diagnosed as being due to inflammation and was resected. A perforation in the appendix body that continued from the funicular object was observed in the resected specimen. The structure initially thought to be an intraperitoneal abscess on preoperative CT was then diagnosed as appendiceal diverticulitis and a second surgical operation was performed. A giant cystoid diverticulum in the appendix was extracted. Furthermore, a true enterolith was found within the diverticulum. Histopathological findings indicated true appendiceal diverticulitis with a muscular layer. We describe a case of giant true appendiceal diverticulitis accompanied by true enterolith.

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A 62-year-old man was admitted suffering from constipation. Colonoscopy suggested a tumor in the ascending colon. Immunohistochemical examination of the biopsy specimens yielded a diagnosis of plasmacytoma, which showed CD79a and CD138 staining. Urine was negative for Bence-Jones protein. Serum immunoglobulin levels were within normal limits. There was no organ dysfunction or bone disorder. The FDG-PET image showed a giant tumor, which showed markedly accumulated FDG in the ascending colon. Thus, we performed right hemi-colectomy on a preoperative diagnosis of extramedullary plasmacytoma (EMP) in the colon. Pathological examination proved that it was plasmacytoma of IgG κ chain origin. We believe that surgery is the first choice for EMP in the colon. Furthermore, we should perform complete resection of the tumor as much as possible.

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Here we report a case of internal hernia in the paracolic gutter of ascending colon. A 73-year-old woman was admitted to the hospital with sudden right lower abdominal pain. A 3×4×6-cm mass and marked of tenderness were noted in the right lower abdominal region. Enhanced multi-detector CT showed dilation of the small intestine, forming a loop in the right lower region of the abdomen. On the suspicion of an internal hernia causing a bowel obstruction of the small intestine, we performed an emergency operation. On laparotomy, we found an approximately 30-cm segment of the ileum incarcerated within the para-ascending colic fossa. We diagnosed the case as an internal hernia in the paracolic gutter of the ascending colon. Here we discuss this very rare type of internal hernia and review the relevant literature.

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