Purpose: The lymphatic distribution of remnant gastric cancer differs depending on the procedure of primary gastrectomy. We retrospectively evaluated the clinicopathological characteristics and the outcomes in node positive remnant gastric cancer patients, and analyzed the localization and rate of lymph node metastases by the difference in primary procedure. Methods: Forty-nine patients with remnant gastric cancer who underwent completion gastrectomy in our hospital between January 2001 to August 2012 were analyzed retrospectively. Results: The node-positive group was 12 cases, and the node-negative group was 37 cases. The rate of depth of invasion, lymphatic and venous invasion and the undifferentiated type carcinoma in the node positive group were high comparing with the node negative group. Nine patients (75%) in the node positive group had recurrence, and the median time for relapse-free interval was 8.5 months (range, 2–30 months). The cumulative 5-year survival proportion was significantly different between the node positive group (0%) and the node negative group (82%) (P<0.001). In the gastrojejunostomy primary procedure group (Billroth II reconstruction or Roux-en-Y reconstruction), the tendency of metastases to be located at the mesojejunal lymph node station was observed. Conclusion: The node-positive remnant gastric cancer patients showed poor prognosis. To improve the outcome, dissection of the mesojejunum should be meticulously performed in the gastrojejunostomy group, and intensive adjuvant chemotherapy is required to prevent recurrence.

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We demonstrate the merits and demerits of using exploratory laparoscopy for detecting multiple organ injuries in a patient with impalement injury. A 40-year-old man fell from a ladder and was impaled by a garden stake. The stake penetrated through the perineal region and was accidentally removed. On admission, he had diffuse abdominal tenderness with guarding and rigidity, and a laceration of the perineal region. CT scan images showed free air around the rectum below the peritoneal reflection and a fracture of the left third rib with subcutaneous emphysema on the left chest wall. Transanal rectal repair, laparoscopic sigmoid colostomy, and exploratory laparoscopy were planned. Exploratory laparoscopy following rectal repair and laparoscopic sigmoid colostomy revealed diaphragmatic injury. Therefore, open repair of the diaphragm was performed. The postoperative course was satisfactory, except for pulmonary atelectasis requiring reintubation. Exploratory laparoscopy may be useful for detecting intraabdominal organ injuries in patients with abdominal impalement injury; however, we should keep in mind that pneumo­peritoneal pressure can result in pulmonary complications through the diaphragmatic injury.

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A case of gastric gastrointestinal stromal tumor (GIST) with Castleman’s disease has not previously been reported. Here we report a case of a 49-year-old man who had presented with an abnormality detected on upper gastrointestinal series. A CT scan demonstrated the tumor, measuring 12×8 cm, connected to the antrum-greater curvature of the stomach. Lymph nodes near the tumor were swollen. We performed surgical resection with a diagnosis of a gastric GIST. The tumor was located at the greater curvature of the stomach with extramural invasion. Many lymph nodes (No-6 & No-14v) around the tumor were swollen. Intraoperative frozen section of the lymph node showed the histology of Castleman’s disease. Four months after the operation, the recurrence of GIST was not detected and the swollen lymph nodes had disappeared.

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A 50-year-old woman was found to have a tumor of the papilla of Vater. An endoscopic biopsy showed suspicion of neuroendocrine tumor. Abdominal enhanced CT showed a tumor at the papilla of Vater and an extramural mass at the third portion of the duodenum. The tumor at the papilla of Vater was diagnosed as duodenal neuroendocrine tumor, and the extramural mass was suspected to be duodenal GIST. She underwent pancreaticoduodenectomy. Intraoperative findings revealed that the tumor located at third portion of the duodenum was suspected to be a regional metastatic lymph node. Histopathologically, the tumor at the papilla of Vater consisted of neuroendocrine tumor component and ganglioneuroma component. Thus, the tumor was diagnosed as gangliocytic paraganglioma. Another tumor in the mesentery was diagnosed as a regional lymph node metastasis from the gangliocytic paraganglioma. Cases of gangliocytic paraganglioma with lymph node metastasis are very rare.

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A 54-year-old man whose continuous diarrhea improved by a proton pump inhibitor, was referred to our hospital for examination of a gastrinoma. As a result of examinations, we suspected that he had 4 gastrinomas in the duodenum and 1 gastrinoma in the pancreas. He also had hyperparathyroidism, and we diagnosed multiple endocrine neoplasia type 1 (MEN1). We performed subtotal stomach-preserving pancreatoduodenectomy (SSPPD) for duodenal and pancreatic gastrinomas. Histopathological findings revealed 19 duodenal gastrinomas and 1 pancreatic mucinous cystadenoma. He has survived without any recurrence since the operation. Duodenal gastrinoma with MEN1 is usually multiple and small-sized, and therefore we could not detect all tumors preoperatively.

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The intrabiliary tumor growth (IBTG) of liver metastasis is well recognized, however, multiple liver metastases with simultaneous IBTGs are rare. A 71-year-old man who underwent a rectal amputation for rectal cancer in 2004, was admitted due to a chief complaint of abdominal pain. CT revealed two tumors at segment 5 and segment 7 of the liver, respectively, and also showed both tumors had ITBGs. ERCP showed a filling defect in the right hepatic duct. Therefore, he was given a diagnosis of liver metastases from rectal cancer with IBTGs. A right hemihepatectomy with a resection of the extrahepatic bile duct was performed after percutaneous transhepatic portal vein embolization. In the resected specimen, the tumors were 4.0 cm and 4.4 cm in diameter respectively, and macroscopic ITBGs extending from each metastasis collided with each other at the right hepatic duct. Histopathologically, the tumors were diagnosed as well-differentiated adenocarcinoma, which were compatible with liver metastases from the rectal cancer. He has had no signs of recurrence 38 months after the second surgery. A solitary colorectal liver metastasis with IBTG is common, accounting for 10% of all liver metastases from colorectal cancer; however, multiple liver metastases with simultaneous macroscopic IBTGs are rare. The macroscopic IBTG is reported to be a favorable factor. Our patient also had a long, disease-free interval. In order to perform complete resection of the tumor, it is important to evaluate preoperative examinations adequately, and obtain a surgical margin.

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An abdominal CT indicated a cystic lesion on the pancreatic tail in an 83-year-old woman in November 2010. In May 2012, she was introduced to our department because the cystic lesion had enlarged. Abdominal CT at that time showed that the cyst wall of the pancreatic tail had thickened with a solid nodule appearing in the cyst. Abdominal MRI and MRCP also detected the cyst in the pancreatic tail, although no communication between the cystic lesion and main pancreatic duct could be found. Endoscopic ultrasound (EUS) indicated that a part of the nodule invaded the pancreatic parenchyma. Furthermore, FDG-PET/CT revealed a high fluorine-18-deoxyglucose (FDG) accumulation in the pancreatic tail. The cystic lesion with a solid mass was diagnosed as intraductal papillary mucinous neoplasm-derived invasive pancreatic cancer, and we conducted distal pancreatectomy. Based on histopathological findings of the resected pancreas, the tumor was diagnosed to be intraductal papillary mucinous adenoma without any malignancy. When the cyst enlarged rapidly and the solid component appeared, it was necessary to consider the possibility of pancreatitis, even if the tumor exhibited a high up-take of FDG.

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A 43-year-old man was admitted to our department because of epigastric abdominal pain. CT showed intraperitoneal hemorrhage, and possible active intestinal hemorrhage. Emergency surgery was performed, and the patient was given a diagnosis of Meckel diverticulum with serosal bleeding. Partial resection of the ileum, including the lesion, was performed. Although no ectopic mucosa or tumor was detected in the pathological specimen, diverticulum within Meckel diverticulum was noted. We believe that damage to the subserosal vessels, resulting from increased pressure inside the diverticulum, caused the intraperitoneal hemorrhage. This is a rare case presenting an intraperitoneal hemorrhage in the absence of tumor or perforation. In addition to this case, we review similar cases previously reported in the literature.

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Postoperative anastomotic leakage is one of the major complications which can result in serious morbidity in colorectal surgery. In our institution, we routinely perform intraoperative colonoscopy (IOCS) for the direct inspection of the double-stapling-technique (DST) anastomosis to check its patency. Here, we report 2 cases of anastomotic leakage found by IOCS and well managed by endoscopic clipping simultaneously. The sites of anastomotic leakage were clearly recognized by IOCS and were successfully closed by endoscopic clipping. After the endoscopic clipping, the leak-test result of IOCS was negative, therefore we did not construct ileostomy or colostomy. Both cases showed no postoperative anastomotic leakage. Direct suturing closure or re-anastomosis is usually performed for anastomotic leakage found during the operation. However sometimes it may be difficult depending on the location of the anastomosis site. It seems that endoscopic closure by clipping may be useful for preventing anastomotic leakage in rectal surgery.

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We report a case with anorectal malignant melanoma diagnosed due to multiple liver tumors detected by follow-up MRI scan after rectal cancer resection. A 62-year-old man underwent low anterior resection for advanced rectal carcinoma. The pathological diagnosis was Stage III. Abdominal MRI scan performed 30 months after the operation showed multiple liver tumors. Liver biopsy revealed malignant melanocytes. Repeated colonoscopy demonstrated anorectal malignant melanoma. The survival was short due to aggravation of the disease without any intensive treatment. He died of liver failure 4 months after detection of the tumor. Coincidence of anorectal malignant melanoma and rectal cancer is rare. Malignant melanoma is a disease with poor prognosis, therefore, early diagnosis and intensive chemotherapy is mandatory. Pitfalls of early diagnosis of anorectal malignant melanoma were discussed.

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