Background: Plication of an esophageal hiatus during surgery for esophageal hiatal hernia is a common practice; however, a mesh may be used if the hiatus is markedly enlarged. Recently, various late complications occurring as a result of mesh-induced esophageal and/or gastric wall injuries have been reported. Case presentation: A 71-year-old woman presented at a neighborhood clinic in November 2010 with chief complaints of respiratory distress on exertion and heartburn. She was diagnosed as having a large esophageal hiatal hernia and was treated at our hospital using a laparoscopic Toupet fundoplication with mesh repair of the esophageal hiatus. Two years and 1 month after the operation, the patient complained of a bowel obstruction. An upper gastrointestinal endoscopy revealed that part of the mesh had extruded into the esophageal lumen, resulting in ulceration and stricture of the esophageal wall. Endoscopic balloon dilatation failed to improve the esophageal stricture. In July 2012, the patient underwent a lower esophagectomy with proximal gastrectomy and was discharged on the 25th hospital day. Conclusions:We experienced a rare case requiring surgical treatment for a mesh-induced esophageal wall injury after surgery for a giant esophageal hiatal hernia. The selection of a soft, durable mash and its firm securement at a position distant from the gastrointestinal wall may be important to avoid late esophageal wall injury.

Metastatic tumors of the small intestinal tract from extra-abdominal sites are rare. We report herein a rare case of small intestinal metastasis from esophageal carcinoma that presented with perforated peritonitis. A 71-year-old man with dysphagia was referred to our hospital for further examination and treatment, and was diagnosed with type 3 advanced esophageal squamous cell carcinoma of the lower thoracic esophagus. Based on a diagnosis of Stage II cancer, a radical esophagectomy with three-field lymph node dissection was performed after neoadjuvant chemotherapy composed of 5-fluorouracil plus cisplatin. Pathological examination of the resected specimen revealed a moderately differentiated squamous cell carcinoma, extending into the adventitia with lymph node metastasis (T3, N2, M0, Stage III). During postoperative adjuvant chemotherapy, the patient complained of abdominal pain and was found to have perforated peritonitis. Emergency laparotomy was performed. A jejunal perforation with a submucosal nodule approximately 80 cm distal from the ligament of Treitz was detected, and completely resected by jejunal partial resection. Histopathology of the specimen showed a perforation of the small intestine due to metastasis of esophageal squamous cell carcinoma with mesenteric lymph node metastasis. The patient died of cancer 9 months after surgery. An extremely rare case of small intestinal metastasis from esophageal carcinoma presenting with perforated peritonitis was described.

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short-term and long-term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L-BMI group characterized by a BMI < 18.5 kg/m(2) and an N-BMI group characterized by a BMI ≥ 18.5 kg/m(2). Clinical and pathological outcome were compared between groups. The study included 40 patients in the L-BMI group and 300 patients in the N-BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L-BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L-BMI group (P = 0.006). The 5-year overall survival rate was higher in the N-BMI group (63.6%) than in the L-BMI group (32.3%) (P < 0.001). The 5-year disease-free survival rate was also higher in the N-BMI group (58.0%) than in the L-BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349-3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease-free survival after an esophagectomy for the resection of ESCC.

We report a case of early esophageal carcinomas associated with achalasia treated by endoscopic submucosal dissection. A 46-year-old man was diagnosed of esophageal achalasia, flask type and Grade II in 2001, and had been treated by pneumatic dilatation for symptomatic achalasia conservatively. The patient was operated by Tokai University method, Heller's long esophagomyectomy, Hill's posterior cardiopexy, fundoplication and selective proximal vagotomy using a laparotomy in August 2009. One year and three months after the operation, two lesions of early carcinomas of type 0-IIb and 0-IIc, each 1cm in size, were detected in the middle thoracic esophagus, and treated by endoscopic submucosal dissection. Pathological examination of the each lesion revealed proliferation of squamous cell carcinoma in situ (T1a-EP). The entire esophageal mucosa around the carcinoma demonstrated hyperplastic changes of stratified squamous epithelium and foci of intraepithelial neoplasia. In the patient of achalasia, food stasis in esophagus is thought to induce chronic hyperplastic esophagitis, converting eventually to malignant transformation. Achalasia is known as a risk factor of esophageal squamous cell carcinoma. Careful long-term follow-up for patients of achalasia by endoscopic screening is recommended, even if after treatment by pneumatic dilatation or operation for achalasia.

118 Background: Emerging evidence suggests that sarcopenia might have an adverse impact on the survival of patients with cancer. We herein investigated the impact of sarcopenia on the long-term outcome of patients with esophageal cancer after curative surgery by analyzing the muscle cross-sectional area using computed tomography (CT). Methods: Sarcopenia was assessed in 204 patients undergoing a macroscopic curative esophagectomy for the resection of esophageal cancer between January 2005, and December 2008 at Tokai University Hospital by measuring the cross-sectional area of the psoas muscle at the level of the third lumbar vertebra on CT images obtained before surgery. The measured total psoas area (TPA) was normalized according to the patient’s height. Sarcopenia was defined as a TPA of ≤525 mm/m2 for men, and ≤375 mm/m2 for women. The impact of sarcopenia was assessed after controlling for clinical factors using multivariate modeling. Results: The median follow-up period was 60 months. The median patient age was 64 years; 184 (90%) patients were male and 20 (10%) were female. The median TPA was 580 mm/m2 for the men and 386 mm/m2 for the women. Sixty-nine (34%) patients had sarcopenia (TPA ≤525 mm/m2 for men, 375 mm/m2 for women ). The overall five-year survival rates were 33% for the patients with sarcopenia, and 66% for those without sarcopenia. In a multivariate analysis, a low body mass index (BMI ≤ 18.5 kg/m2; hazard ratio [HR], 1.87 [P = 0.028]), pathological stage of disease (HR for stage I, 1.587 in stage II [P = 0.219], 4.146 in stage III [P < 0.001], and 6.712 in stage IV [P < 0.001]), tumor location (HR of upper thoracic for middle and lower thoracic, 2.350 [P = 0.002]), and sarcopenia (HR, 1.858 [P= 0.006]) were independently associated with the overall mortality. Conclusions: Sarcopenia is associated with an increased risk of overall mortality in esophageal cancer after curative surgery independent of tumor-specific factors and the BMI. The development of effective interventions for sarcopenia warrants further study to improve the prognosis of patients with esophageal cancer.

Prognostic factors for superficial esophageal cancer cannot be limited to such factors as lymph node metastasis (N factor), depth of tumor invasion (T factor), and genetic alterations. The purpose of this study was to examine whether invasive growth patterns of tumors, such as infiltrative growth pattern c (INFc) and budding, represent new useful prognostic factors for superficial esophageal cancer.

The glycoprotein laminin 5γ2 chain (LN-5γ2) has recently become a focus of increased interest and investigation as a marker of invasion in gastrointestinal malignancies. We investigated the significance of LN-5γ2 expression as a prognostic factor in superficial esophageal cancer. The study population consisted of 87 patients who had undergone a transthoracic esophagectomy and three-field lymphadenectomy for the treatment of superficial esophageal cancer at Tokai University Hospital. Formalin-fixed, paraffin-embedded sections of the resected specimens were examined using immunohistochemical staining and hematoxylin and eosin staining to assess the correlations between the LN-5γ2 expression pattern and the clinicopathological factors (age, sex, T-factor, N-factor, ly-factor, v-factor, degree of differentiation, infiltrative growth pattern, tumor node metastasis classification of malignant tumors [TNM] stage, etc.) and the patient outcome. The expression pattern of LN-5γ2 was classified into an extracellular type (E type), characterized by the staining of extracellular matrix such as the basement membrane and the stroma (31 cases, 35.6%), and a cytoplasmic type (C type), characterized by the staining of the cytoplasm in the cancer cells (56 cases, 64.6%). The expression pattern was not correlated with any of the clinicopathological factors that were assessed. However, univariate analyses of the survival analysis data showed that the N-factor (P = 0.011), TNM stage (P = 0.011), and LN-5γ2 C type (P = 0.017) were prognostic factors. A multivariate analysis revealed that the N-factor (P = 0.049) and LN-5γ2 C type (P = 0.048) were prognostic factors. In the survival analysis, a univariate analysis of the 75 T1b cases also showed that the N-factor (P = 0.048), TNM stage (P = 0.048), and LN-5γ2 C type (P = 0.029) were prognostic factors, while a multivariate analysis showed that the LN-5γ2 C type (P = 0.035) was a prognostic factor. The C type expression of LN-5γ2, i.e. confined to the cytoplasm, was correlated with an unfavorable outcome among the patients with superficial esophageal cancer in the present series. Observation of the LN-5γ2 expression pattern may be useful for the diagnosis of highly malignant tumors.

BACKGROUND:In 2009, the rate of thoracoscopic esophagectomy for esophageal cancer was about 20% in Japan. This low rate may be due to the difficulty in maintaining a good surgical field and the meticulous procedures that are required. The purpose of this study was to establish and evaluate a new procedure for performing a thoracoscopic esophagectomy while the patient is in a prone position using a preceding anterior approach to make the esophagectomy easier to perform.METHODS:We have performed thoracoscopic esophagectomy using our new procedure in 60 patients with esophageal cancer. Each patient was placed in a prone position and five trocars were inserted; only the left lung was ventilated and a pneumothorax was maintained. The esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. The lymph nodes around the esophagus were also dissected anteriorly and posteriorly. The patients were sequentially divided into two groups and their clinical outcomes were evaluated.RESULTS:The mean operative time for the thoracoscopic procedure for the latter 30 cases (203 min) was shorter than that for the former 30 cases (260 min) (P = 0.001). Among the 52 cases without pleural adhesion, the mean blood loss in the latter 26 cases (18 mL) was also less than that in the former 26 cases (40 mL) (P = 0.027). There were no conversions to a thoracotomy and no operative deaths in this series. Postoperative complications related to the thoracoscopic procedure occurred in 8 cases (27%) in the former group and in 4 cases (13%) in the latter group.CONCLUSIONS:Thoracoscopic esophagectomy with the patient in the prone position using a preceding anterior approach is a safe and feasible procedure. As experience performing the procedure increases, the performance of the procedure stabilizes. This method seems to make the esophagectomy easier to perform.

患者は77歳の女性で，数日前より腹痛を自覚し救急外来を受診した．腹部は板状硬であり，腹部CTにて肝表面に腹水と少量の遊離ガスを認めた．右側結腸には憩室が多発していたが明らかな石灰化や膿瘍形成の所見は認めなかった．右側結腸憩室穿孔に伴う汎発性腹膜炎と診断し同日緊急手術を施行した．右側結腸を授動し詳細に観察すると，盲腸後部に存在する虫垂の先端部で壊死穿孔をきたしていた．虫垂根部の炎症は認めず，虫垂切除術を施行した．虫垂穿孔で腹腔内遊離ガスを認めることはまれである．術後の病理組織学的検査所見にて虫垂原発の印環細胞癌と診断され，断端も陽性であったため2期的に結腸右半切除術を施行した．今回，穿孔性腹膜炎で発症した虫垂原発印環細胞癌の1例を経験し，術中には虫垂癌と診断することは成しえなかったが，あらためて本症を念頭においた術式選択と，切除虫垂における病理組織学的検討の重要性を再認識した．

Background The case of adenocarcinoma with human chorionic gonadtropin (HCG), primary in the male gallbladder, is extremely rare. A Medline search has shown only a few similar cases reported. Methods We herein describe a case of primary gallbladder adenocarcinoma associated by ectopic HCG positive tumor cells in a 79-year-old male. Results Pathological examination showed a mixture of moderately and poorly differentiated adenocarcinoma with ectopic HCG and placental alkaline phosphatase (PlAP) in tumor cells, though the increase of serum or urinary HCG secretion was not confirmed. The literatures were also reviewed. Conclusions A case of gallbladder cancer with ectopic HCG production is quite rare in the literature, though many similar cases in other site, especially in GI tract, are reported. Embryological consideration suggests the increased frequency of similar cases more than being thought now.

The designated area of the columnar-lined esophagus (CLE) is anatomically defined by the distal limit of the lower esophageal palisade vessels (LEPV) and the term 'Barrett's esophagus' is equally used along with the name CLE in Japan. The aim of this study was to investigate the actual prevalence of CLE based on the Japanese criteria and to evaluate the criteria per se. A total of 42 esophagi consecutively resected at this institute were included. All subjects underwent a surgical resection for squamous cell carcinoma of the esophagus. The position of the LEPV, squamocolumnar junction, the prevalence of CLE and intestinal metaplasia were investigated both pre- and postoperatively. Preoperative endoscopy revealed CLE based on the Japanese criteria in half of all patients. In the resected specimens the distal limit of LEPV was lower than the squamocolumnar junction in 95.2%. In other words, almost all cases had CLE (equivalent to Barrett's mucosa in Japanese criteria). However, most of the CLE areas were very short and their average maximum length was only about 5 mm. In addition, no intestinal metaplasia was observed in any of the CLE cases. Almost all individuals might therefore be diagnosed to have CLE or Barrett's mucosa based on precise endoscopic observations in Japan. The CLE located in a small area, e.g. less than 5 mm, defined according to the LEPV criteria without any other factor concerning typical Barrett's esophagus such as signs of gastroesophageal reflux should therefore be excluded from consideration as a high-risk mucosa.

本邦では稀とされてきた Barrett食道癌報告例が，近年急速に増加している.そのBarrett食道癌を早期に内視鏡で発見するには，好発部位を知っておくことが重要である。当科で扱ったBarrett食道癌と，本邦報告例を臨床的に検討し，Barrett食道癌の好発部位につき検討した。 当科で扱ったBarrett食道癌33例と，本邦におけるBarrett食道癌報告590例を対象とし，癌の発生部位に関して，1．Barrett食道内の位置（口側・中央・肛門側） 2．局在（前壁・後壁・左壁・右壁）を検討した。Barrett食道内における癌は，口側・中央・肛門側ではほぼ同等に発生していた。その理由として，口側粘膜は細胞増殖活性の指標となるKi-67 LIが肛門側に比べ高値である一方で，肛門側は，口側に比べ，発生からの時間的経過が長く，炎症による粘膜の脱落再生が惹起される可能性が高いので発癌しやすい，と推察した，これらの理由より，Barrett食道の口側・肛門側のどちらにも発癌のみられる原因のひとつではないかと推察した。 腫瘍の局在では，前後壁では差がなかったが右側壁は左側壁の2倍以上の頻度で発生していた。この理由は明らかにできず，今後の検討課題としたい。