Purpose: We aimed to conduct an objective and comprehensive evaluation of the venous system, which is regarded as important in gastrectomy, by using multi-detector row computed tomography (MDCT). Materials and Methods: We enrolled 100 Japanese patients (64 men and 36 women, mean age: 67.8 years) who underwent gastrectomy for gastric cancer without a branching anomaly of the common hepatic (CHA), splenic (SpA), and superior mesenteric arteries (SMA). We objectively evaluated the preoperative MDCT images regarding the left gastric (LGV), splenic (SpV), and inferior mesenteric veins (IMV). Results: We identified the LGV in 78 cases (78%). The identification rate was significantly improved by three-dimensional reconstruction of the MDCT images (P=0.01). The LGV was drained into the portal vein (PV) via the dorsal side of the CHA in 31 cases (39.7%), the SpV via the ventral side of the SpA in 21 cases (26.9%), and the PV via the dorsal side of the CHA in 15 cases (19.2%). At the 11p locus, the SpV was located in the caudal and middle third of the pancreas in 50 cases (50%). At the 11d locus, the SpV was located on the caudal side of the SpV in 40 cases (40%). We identified the IMV in 90 cases (90%), flowing into the SpV in 48 cases (53.3%). Conclusion: By using high-definition MDCT imaging, we could evaluate venous systems related to gastrectomy noninvasively, objectively, and comprehensively. The anatomical information objectively and comprehensively assessed in this study may contribute to improving gastrectomy procedure.

Purpose: The aim of the study was to investigate the efficacy of measuring non-contrast CT attenuation (Hounsfield Unit; HU) of incarcerated intestines with obturator hernias for determination of resection. Materials and Methods: Twenty-three patients (24 lesions), with a diagnosis of intestinal obstruction with obturator hernia at our hospital were enrolled in this study. The CT attenuations were measured at the following three points, 1) luminal contents of the incarcerated intestinal tract, 2) incarcerated intestinal wall of the fundus, and 3) incarcerated intestinal wall of the neck. The lesions were classified into 11 types in the intestinal resection group and 13 types in the non-resection group. The average CT attenuations between the two groups were compared by statistical methods. The criterion of intestinal resection was macroscopic necrosis or perforation of the incarcerated intestines. Results: The average CT attenuation of the incarcerated intestinal wall at the fundus was 17.61±10.57 HU in the resection group and 27.41±12.98 HU in the non-resection group. Significant differences were observed between the two groups by univariate (P<0.05) and multivariate analyzes (P<0.05). The cut-off value prediction value of intestinal resection was 27 HU according to the examination of the receiver operator characteristic (ROC) curve. There were no significant differences between the two groups in the average CT attenuation of the other sites. Conclusion: Measuring non-contrast CT attenuation of the incarcerated intestinal wall at the fundus was necessary in determining whether resection of the incarcerated intestine with obturator hernia was required.

A 50-year-old woman complained of right cervical swelling and dysphagia. She was referred to our hospital due to suspicion of thyroid tumor by neck US. CT showed a cystic tumor involving a minute amount of air on the back of the right thyroid lobe, and the tumor was suspected to be continuous to the mucous membrane of the esophagus. Esophagography suggested a barium-filled sac protruding from the right lateral wall of the cervical esophagus. It was diagnosed as a Killian-Jamieson diverticulum. Because she had symptoms, we performed a resection of the diverticulum. Intraoperative air supply by the nasogastric tube led to expansion of the diverticulum, and was an effective method in identifying it.

A 75-year-old man was admitted to a local hospital with a chief complaint of tarry stool. Upper gastrointestinal endoscopy revealed a type 3 tumor occupying the second to third portion of the duodenum with blood coagula. Transcatheter arterial embolization was selected for the patient to control the hemorrhage from the tumor, because he was found impossible to undergo general anesthesia and operation for severe chronic obstructive pulmonary disease. He was referred to us for further examination and surgical intervention after controlling the hemorrhaging temporarily. He was in a state of shock with a large quantity of tarry stool and progression of anemia five days after transfer. We judged that hemostasis by artery embolization would be difficult and performed emergency subtotal stomach-preserving pancreaticoduodenectomy. The prominent tumor was centered on the second to third portion of the duodenum with macroscopic invasion of the pancreas. Histopathological examination showed tumor cells showing solid proliferation with clear nucleolus but without keratinization or ductal structures. Immunohistologically, the tumor was diagnosed as duodenal undifferentiated carcinoma. Despite the patient being discharged on postoperative day 36, he died three months after the surgery due to multiple liver metastases. We report a rare case of duodenal undifferentiated carcinoma that caused intestinal bleeding and fatal outcome.

A 63-year-old man who felt abdominal distension was found to have a 60×48×45 mm mass in the left lower quadrant on abdominal US. From the enhanced CT and MRI images of his abdomen and high levels of the tumor markers CEA (6.4 ng/ml) and CA19-9 (65.3 U/ml), he was suspected of having mesenteric cystic lesions with malignant potential. Therefore, he underwent surgery for diagnosis and curative treatment. The tumor lesion was identified to be in the iliac mesentery, and enterectomy including removal of the tumor, was performed under laparoscopy. Histological analyses demonstrated that the tumor was mucinous cystadenoma arising in a partially duplicated ileum. At the time of surgery, the tumor was already perforated and tumor cells were found to be floating in the mucus. Therefore, careful follow-up was necessary owing to the possibility of the recurrence of pseudomyxoma peritonei. To the best of our knowledge, only 3 cases in Japan and 3 cases abroad of pseudomyxoma peritonei arising in an alimentary tract duplication have been reported to date, and hence the future progress of our case is of great interest.

A 79-year-old man presented with transient aphasia. We diagnosed multiple cerebral infarctions and he eventually recovered without permanent dysfunction. After 4 weeks, he came back to our hospital with fever and back pain. A spine MRI suggested spongylitis and transesophageal echocardiography revealed vegetation on the mitral valve causing valvular insufficiency. The result of blood culture was positive for Streptococcus bovis (S. bovis). Taking account of the association between S. bovis and colorectal cancer, we performed screening colonoscopy and found an invasive rectal cancer. Under a diagnosis of infective endocarditis (IE), spinal osteomyelitis and rectal cancer, we started him on vancomycine (VCM) and gentamycine, which were eventually changed to ampicilline (ABPC) according to the results of the sensitivity test. After 46 days of treatment, the white-cell count and CRP level became near normal and laparoscopy-assisted low anterior resection of the rectum and lymph node dissection were performed. The postoperative course was uneventful and he was discharged from the hospital on the 18th postoperative-day. It is advisable to examine the colon when S. bovis is positive in blood culture. When planning surgical resection, one should also take care to rule out infectious lesions caused by blood-stream infection and emboli. We think appropriate selection of preoperative antibiotics for sufficient duration is a key to achieve good perioperative course without morbidity.