Anal Side Research Articles

Congenital esophageal stenosis because of tracheobronchial remnant and treated by circular myectomy: a case report

Congenital esophageal stenosis (CES) is a rare anomaly, and appropriate management is not well established. We performed myectomy of the esophageal wall in a child with critical esophageal stenosis caused by tracheobronchial remnant (TBR). An 18-month-old boy was admitted to our hospital having frequent vomiting and failure to thrive. Esophagography and esophagoscopy showed abrupt stenosis at the lower esophageal wall. Balloon dilatation was performed but was ineffective. Surgery was performed under a diagnosis of CES because of TBR. Cartilage was palpable in the stenotic esophageal wall, and extirpation of the muscular layer of the stenotic portion was performed, leaving the mucosal layer intact. The muscular layer was closed loosely using interrupted 5-0 absorbable sutures to match the oral and anal sides together. Postoperatively, the esophageal passage was improved to the point that the patient was able to take solid foods without vomiting. This successful outcome suggests that circular myectomy of the TBR is worth recommending as a surgical procedure for short segment and stenosis of patients with CES because of TBR.

Effect of Itopride Hydrochloride on the Ileal and Colonic Motility in Guinea Pig In Vitro

PurposeItopride hydrochloride (itopride) inhibits acetylcholinesterase (AChE) and antagonizes dopamine D2 receptor, and has been used as a gastroprokinetic agent. However, its prokinetic effect on the small bowel or colon has not yet been thoroughly investigated. The aim of this study was to investigate the effects of itopride on motor functions of the ileum and colon in guinea pigs.Materials and MethodsThe distal ileum was excised and the activity of peristaltic contraction was determined by measuring the amplitude and propagation velocity of peristaltic contraction. The distal colon was removed and connected to the chamber containing Krebs-Henseleit solution (K-H solution). Artificial fecal matter was inserted into the oral side of the lumen, and moved toward the anal side by intraluminal perfusion via peristaltic pump. Colonic transit times were measured by the time required for the artificial feces to move a total length of 10 cm with 2-cm intervals.ResultsIn the ileum, itopride accelerated peristaltic velocity at higher dosage (10-10-10-6 M) whereas neostigmine accelerated it only with a lower dosage (10-10-10-9 M). Dopamine (10-8 M) decelerated the velocity that was recovered by itopride infusion. Itopride and neostigmine significantly shortened colonic transit at a higher dosage (10-10-10-6 M). Dopamine (10-8 M) delayed colonic transit time that was also recovered after infusion of itopride.ConclusionItopride has prokinetic effects on both the ileum and colon, which are regulated through inhibitory effects on AChE and antagonistic effects on dopamine D2 receptor.

The effect of mosapride citrate on proximal and distal colonic motor function in the guinea‐pig in vitro

Mosapride citrate (mosapride), a substituted benzamide, is a selective 5-HT(4) receptor agonist, and is known to have prokinetic properties on the stomach. However, it is unclear whether mosapride also has a prokinetic effect on the colon. We previously found that mosapride significantly shortened colonic transit time in the guinea-pig, an animal with a distribution of colonic 5-HT(4) receptors similar to that of a human. So, we aimed to separately evaluate the effect of mosapride on proximal and distal colonic motor function in the guinea-pig. Proximal (approximately 8 cm from the ileocolic junction) and distal colon (approximately 8 cm from the anus) were removed. Both ends of the colon were connected to a chamber containing a Krebs-Henseleit solution. To measure colonic transit time, artificial faeces were inserted into the oral side of the lumen and moved towards the anal side by intraluminal perfusion via a peristaltic pump. A total of 6 cm of transit was observed and time was measured in 2 cm increments. A tissue bath study, using electrical stimulation, was performed to estimate the contractile activity of the circular musculature of the colon. Immunohistochemical staining for 5-HT(4) receptors was performed in the myenteric plexus and circular muscle in both proximal and distal colon, and the stained area was measured using a microscope and computer software. Mosapride enhanced contraction at 10(-9) to 10(-7) mol L(-1), coinciding with rapid transit both in proximal and distal colon. This pattern was more prominent in proximal colon. At the high dose (10(-6) mol L(-1)) mosapride had little or no effect on colonic contraction. This stimulatory effect was attenuated by GR113808, atropine and tetrodotoxin. In the myenteric plexus, the density of 5-HT(4) receptors was significantly greater in the proximal colon than in the distal colon, but in circular muscle the density was greater in the distal colon. Thus, mosapride accelerates transit through increased contraction in the proximal colon more than distal colon. The different distribution of neuronal and muscular 5-HT(4) receptors may support these findings. Therefore, mosapride may be a useful alternative to tegaserod and cisapride for constipation.

New Laparoscopic Double-Stapling Technique

Laparoscopic surgery for colon cancer has been shown by several randomized, controlled trials to be an acceptable alternative to open surgery; however, laparoscopic rectal surgery has not been evaluated in a randomized trial. One of the most serious problems associated with laparoscopic rectal surgery are bowel clamping, irrigation, and transection of the rectum, and laparoscopic rectal surgery has not been as reliable as open rectal surgery. We present our new technique, the laparoscopic double-stapling technique, which eliminates these problems. This technique uses curved Doyen forceps introduced through the wound just above pubis symphysis for clamping the rectal wall at the anal side of the tumor. An endolinear stapler (length 60 mm) is inserted through the same wound, applied at the rectal wall parallel and caudal to the Doyen forceps, and transects the rectum under pneumoperitoneum. We used this technique for eight cases of rectal surgery. The laparoscopic double-stapling technique provided secure bowel clamping and rectal irrigation. The number of cartridges used in laparoscopic double-stapling technique cases was not more than 2, with an average of 1.6 per patient. None of the laparoscopic double-stapling technique cases experienced major complications. We consider that many cases of rectal cancer that are suitable for laparoscopic low anterior resection can undergo laparoscopic surgery by using this technique, which will improve the quality of rectal surgery.

Serial changes in swallowing function in a case of dysphagia after jejunal reconstruction of the cervical esophagus: a case report

The patient was a 56-year-old woman. Cervical esophagectomy for cervical esophageal cancer with preservation of the larynx, bilateral neck dissection, and free jejunum reconstruction were performed in our hospital. The oral and anal sides of the free jejunum were reconstructed by end-to-side anastomosis. The oral-side blind pouch of the free jejunum was long, and the jejunum was atonic. We performed serial swallowing video fluorographic imaging 1 month and 6 months after surgery to quantitatively analyze (1) oral transit and pharyngeal transit time, (2) emptying times of the test diet in the free jejunum, (3) regurgitation of test diet, and (4) the minimal diameter of the free jejunum. At 1 month and 6 months after surgery, oral and pharyngeal transit time were evaluated as normal. Six months after surgery, emptying time of the test diet in the free jejunum was reduced compared with that 1 month after surgery. Six months after surgery, regurgitation of test diet from the blind pouch had decreased by approximately 36% compared with that at 1 month after surgery. Furthermore, 6 months after surgery, motility of the transferred jejunum had improved compared with that 1 month after surgery. These findings suggested that the food-transporting activity of the free jejunum recovered over time; however, the blind pouch length should be made as short as possible, and the jejunum should be anastomosed in a stretched position from the perspective of swallowing function.

Concurrent colorectal cancer existing at the anal side of obstructive sigmoid colon cancer treated preoperatively with a transanal decompression tube : A Case Report

Concurrent colorectal cancer existing at the anal side of obstructive sigmoid colon cancer treated preoperatively with a transanal decompression tube : A Case Report

中下部進行直腸癌における肛門側直腸間膜内のリンパ節転移頻度と郭清効果における検討

中下部進行直腸癌における直腸間膜内のリンパ節転移状況を明らかにし, 特に肛門側mesorectum内のリンパ節転移状況とその郭清効果, さらに壁外進展様式 (Distal cancer spread : DCS) について検討した. 検討1 : 根治度A, Bの中下部直腸癌189例のうち腫瘍直下のmesorectum内リンパ節を251-1-T, 腫瘍から5cm口側を1-O, 5～10cmを2-O, 腫瘍から2cm肛門側を1-A, 2～4cm肛門側を2-Aとし, 各リンパ節の転移頻度と5年生存率を乗じて郭清効果Indexを求めた. 検討2 : 42例の肛門側標本を4mm幅に全割しDCSについて検討した. 結果 : 検討1 郭清効果は1-TはIndexがRa18.1, Rab24.3, Rb28.3と高値だが, 1-AはRa1.0, Rab2.7, Rb0であり, 2-Oや252に近い郭清効果を示した. 検討2 DCSの頻度は4.8% (2/42例) でlyであった. 吻合部近傍に再発した6例中4例は肛門側進展例であった. 考察 : 現在1群とされている肛門側2cm以内のリンパ節は中枢側2群リンパ節に近い郭清効果であった. 分化型で限局型腫瘍はmesorectumを2cm切除することで十分であり, 上記以外では壁外進展を考慮し2cm以上切除する必要があると思われた.

Anterior Resection of Rectal Cancer Through a One Hand-Size Incision with or without Laparoscopy: Proposal of One Hand-Size Incision Surgery (OHaSIS)

One hand-size incision surgery (OHaSIS) is a surgery that is carried out through one hand-size incision with or without laparoscopy. Safety, feasibility and recovery advantage of the anterior resection of rectal cancer by the OHaSIS were studied. Nineteen consecutive patients with rectal cancer, consisting of seven rectosigmoid, six upper rectal, and six lower rectal cancers, were treated with anterior resection, including seven high, six low, three super-low, and three partial intersphincteric resections, through a suprapubic longitudinal one hand-size incision. The initial 11 patients were treated in combination with laparoscopy and the following eight patients were treated without laparoscopy. All anterior resections with mesorectal excision were completed in a safe manner with acceptable operative time (average 245 min), blood loss (average 280 g), and postoperative complications without any elongation of the initial incision. When compared with 12 previous high and low anterior resections by conventional open surgery (OS), the 13 high and low anterior resections by the OHaSIS showed equivalent operative time, blood loss, anastomotic procedures of single stapling, lymph node numbers dissected, surgical margin of the anal side of the tumor, and complications. Moreover, analysis of perioperative parameters for surgical invasiveness, including a body temperature >37 degrees C, days of bed rest, and days of use of parenteral narcotics, revealed a recovery advantage in the OHaSIS group compared with that in the OS group. These results suggest that anterior resection for patients with rectal cancer by the OHaSIS is safe, feasible, and less invasive than conventional OS, and has sufficient operative performance. Although the survival benefit and recurrence rate by this approach must be ensured in a future trial, we would like to propose the new concept of OHaSIS for treating rectal cancer.

Novel Procedure of Endoscopic Submucosal Dissection Using Double Graspers for Early Stage Gastric Cancer

Background and Aim: Endoscopic submucosal dissection (ESD) for early stage gastric cancer (EGC) has improved the success rate for en bloc resection. It has been also reported that several techniques of traction of lesions are useful for ESD; however, these are complicated and invasive. The aim of this study is to assess the usefulness of ESD using double graspers for EGC. Subjects and Methods: Subjects were 23 lesions of EGC, which were histopathologically differentiated adenocarcinomas within the mucosa and without ulcers. Mean size of the lesions was 16.3 mm, range from 10-35 mm. Sixteen of 23 lesions were at the gastric body, 5 at the antrum and 2 at the angulus. A short hood was attached to the distal tip of an endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After circumferential cutting around the lesions using a needle knife at a Endo-Cut mode, the endoscope was pulled out once. Next, a grasper (inside grasper) inserted through an accessory channel of the endoscope grasped the tip of the other grasper (outside grasper), which was outside the endoscope. Both graspers and endoscope were inserted into the stomach, and the anal side of the lesions was grasped by the outside grasper controlled by the endoscope and the inside grasper. Thereafter, the inside grasper was released and pulled out. Finally, with traction of the lesions towards the oral side by the outside grasper, the submucosal layer of lesions was dissected using the needle knife at a forced coagulation mode. Hemostasis for bleeding was carried out using the needle knife at a spray coagulation mode or clips. Results: (1) All lesions were able to be grasped with the outside grasper. (2) Traction of the lesion towards the oral side by the outside grasper was able to make the submucosal layer wider and more visible. Therefore, dissection could be more easily carried out under direct vision, with both safety and certainty. (3) Both the endoscope and the outside grasper was able to be moved easily and independently. (4) All lesions were able to be resected en block. (5) No bleeding requiring blood transfusion or a perforation occurred. Conclusion: ESD using double graspers is very useful for easily dissecting EGC with safety and certainty not only at the body but also the angulus and the antrum.

Structural development of PGP9.5-immunopositive myenteric plexus in embryonic rats

To investigate relationships between changes in the 3-dimensional structure of the myenteric plexus and the time at which functional movement of intestine begins in mammalian embryos, whole mounts of embryonic rat intestine were examined under confocal laser scanning microscopy on spacer-equipped glass slides after immunostaining with antiprotein gene product 9.5 antibody. At embryonic day 12.5, very few nerve cells were scattered throughout the small intestine, but no immunostained structures were apparent on the anal side of the large intestine. At embryonic day 13.5, immunostained fibers appeared on the oral side of the large intestine. Nerve cells and associated fiber bundles formed neuronal networks with large meshes in both intestines. Marked increases in number of nerve fibers and decreases in mesh size were seen in the small intestine between embryonic days 13.5 and 15.5. Similar changes were found in the large intestine between embryonic days 13.5 and 16.5. After embryonic day 16.5, nerve cells were arranged parallel to circular muscle fibers, and networks formed by cell fibers elongated until the neonatal period in both intestines. Meconium passed through the large intestine from embryonic day 17.5. Thin fiber bundles extended from the ganglion to the inner side of the myenteric layer, parallel (and occasionally extending) to the circular muscle fibers. Formation of nerve fiber networks and arrangement of nerve cells parallel to circular muscle fibers probably relate to movement coordination for inner circular muscle fibers in the intestinal wall, and development of this neural network may be important for acquiring intestinal movements before birth.

Diagnosis of the depth of invasion of esophageal carcinoma using digital radiography

Objective: The purpose of our investigation was to determine the usefulness of digital radiography (DR) for diagnosing the depth of invasion of esophageal carcinoma. Methods: We evaluated 59 patients with esophageal carcinomas who underwent DR. During continuous DR in tangential views, the most distended image of the esophagus was chosen. Percent esophageal stenosis (PES) was based on the diameter across the lesion of maximal narrowing and the average of the normal oral and anal side diameters. The maximal thickness of the tumor was measured on sequentially prepared specimens. We evaluated whether the percent of esophageal stenosis correlated with the maximal thickness of the tumor on histologic findings. Receiver-operating characteristic (ROC) curves were constructed to establish the cut-off level for PES in diagnosing the depth of tumor invasion. Accuracies for the depth of the invasion were calculated based on PES using DR. For the accuracy rate, DR was compared with endoscopy and endoscopic ultrasonography (EUS). Results: There was a close correlation between PES and pathological thickness of the tumor. PES values (mean ± S.D.) were 2.45 ± 0.75% in Tis and T1a tumors, 13.3 ± 10.9% in T1b tumors, 35.2 ± 11.1% in T2 tumors, 55.2 ± 18.1% in T3 tumors, and 86.1 ± 7.5% in T4 tumors. Using the ROC analysis, 12.5, 37.5, and 44.4% were the highest cut-off values of PES for differentiating ≤T1a, ≤T1b, and ≤T2 tumors. Regarding T staging, 45 (76%) of 59 lesions were staged correctly with EUS, whereas 47 (80%) were staged correctly with DR. Conclusion: DR is useful for diagnosing the depth of the invasion because esophageal stenosis calculated using DR is an objective index of tumor infiltration. The accuracy rate of the depth of invasion with DR was as good as that of EUS.

Particular cutaneous side effects with etoposide-containing courses: is VP16 or etoposide phosphate responsible?

Etoposide is commercially available in France in two different pharmaceutical forms: VP16 and its phosphate ester (etoposide phosphate, EP). EP shows better chemical and physical properties, is said to be less toxic but is five times more expensive than VP16. Some criteria were defined for the use of each form in the Paediatric Oncohaematology Department in Hopital Sud in Rennes. As some particular cutaneous side effects were observed during treatment with etoposide-based course in this department, a retrospective study was initiated. The aims of this work were to determine the side effects (especially cutaneous toxicity), whether the pharmaceutical formulation of etoposide had any influence on the toxicity of the drug, and whether the observed side effects resulted from etoposide alone or from particular antineoplastic drug associations. Five types of etoposide-containing protocols were chosen: NB 97 and NB 99 (neuroblastoma), FRALLE 93 (acute lymphoid leukaemia), LAME 91 (acute myeloid leukaemia), OS 94 (osteosarcoma), Ewing 97 and Euro-Ewing 99 (Ewing sarcoma). The medical files of 36 children (88 EP courses, 25 VP16 courses) included in these protocols were analysed on the basis that if a child showed a side effect during a course, the child had to have recovered from that side effect before the beginning of the next course. Apart from classical side effects (haematological and digestive toxicities etc.), two particular cutaneous side effects were observed: (1) palmar-plantar eruptions and nail inflammations, and (2) irritation of the anal area and anal fissures. Those side effects were observed with three of the studied protocols: NB 97, OS 94 and Ewing sarcoma treatments. No striking differences in toxicity appeared between the two etoposide formulations, but this retrospective study seemed to confirm the appearance of particular cutaneous and anal side effects especially with two associations: (1) etoposide-ifosfamide (OS 94 and Ewing 97), and (2) etoposide-ifosfamide-Adriamycin-vincristine (VIDE course of the Euro-Ewing 99 protocol).

P0026 PP EFFECT OF GHRELIN ON THE GASTROINTESTINAL MOTILITY IN CONSCIOUS RATS

Introduction: Ghrelin, a novel growth-hormone-releasing peptide isolated from rat and human stomachs, has been reported to increase appetite in rats and humans. The clinical usefulness of this novel substance is currently under investigation. However, little is known about its direct effects on the alimentary. In the present study, we examined its effects on intestinal motility in conscious rats. Methods: Male Wistar rats weighing 300–400 g were fasted for more than 24 hours before experiments. After being anesthetized with pentobarbital, the abdominal wall was opened by mid-line laparotomy, and a miniature strain-gauge force transducer was sutured on the serosal site of intestinal wall 5 cm from the anal side of Treizüfs ligament. Five to 10 days after operation, and confirming the stability of the basal intestinal motility, various concentrations (1, 5, 10, 25, 50, and 100 ƒÊ g/kg, intravenous (IV) injection) of rat ghrelin or saline were given through the caudal vein after 4 minutes of phase 3 contractions. Intestinal motility was quantified by frequency and the mean amplitude of clusters, drug-cluster intervals, duration of clusters, and counting the number of phase 3 contractions. Results: When IV injections of ghrelin (over than 5ƒÊ g/kg) were given to animals, clusters appeared immediately and these patterns consisted of phase 3-like contractions. IV administration of ghrelin increased the frequency of clusters in a dose-dependent manner (Table 1). The mean amplitude of clusters was approximately 50% compared with that of previous natural phase 3 contractions. Drug-cluster intervals were shortened in a dose-dependent manner (Regression analysis: p=0.045). Each duration of clusters was about 2 min, and was shorter than that of natural phase 3 contractions 291 plus-minus 34 min. The number of phase 3contractions for one hour did not change before or after IV injections of ghrelin.Table 1: Induction of intestinal clusters by ghrelinConclusion: Exogenous ghrelin modulated small intestinal motility in conscious rats.

Novel Procedure of Grasper-associated Endoscopic Mucosal Resection Against Early Gastric Cancer

BACKGROUND and AIM: Endoscopic mucosal resection (EMR) by submucosal dissection against early gastric cancer has improved the rate of en bloc-resection, however more skillful technique should be necessary in comparison with strip biopsy technique, and it has been claimed that there are more complications. Recently many kinds of devices of instruments in EMR have been reported, however it is still difficult to dissect the submucosa of lesions especially located in gastric body. The aim of this study is to assess the usefulness of grasper-associated endoscopic mucosal resection which we have designed against early gastric cancer. SUBJECTS and METHODS: Subjects were 11 lesions of early gastric cancer which has been thought to be remained within the mucosa of gastric body. The average size of those lesions was 16.5mm (range 10-25mm). A short hood (4-mm in length) was attached to the distal tip of an endoscope, and a flexible overtube was inserted with the endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After the circumferential mucosa around the lesion was cut by a needle knife, then the endoscope was pulled out once. Next, a grasper (inside grasper) was inserted through a working channel, and a distal portion of another grasper outside the endoscope (outside grasper) was grasped by inside grasper, thereafter the endoscope was inserted again with the outside grasper. After the lesion was grasped by the outside grasper under control of the inside grasper and the endoscope, the inside grasper was pulled out. Finally, while pulling up the lesion from anal towards oral side by the outside grasper, the submucosal dissection was performed from the anal side lesion. RESULTS: (1) Traction of those lesions towards the oral side by the outside grasper achieved more open and wide range of the vision of the submucosa. (2) All 11 lesions were able to be resected en block by this procedure. (3) Operating time was approximately 60 minutes and shorter than conventional procedure. (4) During procedure, small amount of hemorrhage was the only complication, and there happened no perforation. Furthermore, combined this procedure with squirting water, detection of bleeding spot and instant hemostasis was able to be performed. CONCLUSION: This novel procedure of grasper-associated EMR could make submucosal dissection certainly, more easier and safer against early gastric cancer located in gastric body.

A case of colonic carcinoma type IIc＋Is with sm massive invasion

A 55-year-old male complaining occult blood in stool underwent colonoscopy, colonic carcinoma was detected in the sigmoid colon. Endoscopic examination revealed an elevated lesion with a depression on the anal side. On magnifying endoscopic observation, type VN pit pattern was observed in the depressed area. A massively submucosal invasive carcinoma was highly suspected, and sigmoid colectomy was performed. The resected specimen showed a IIc＋Is lesion, measurihg 12×10mm in diameter includings showed well differentiated adenocarcinoma in the elevated area, and moderately differentiated adenocarcinoma in the depressed area, The depth of invasion was m in the elevated area, and sm2 in the depressed area. Neoplastic cells positive for p53 and Ki-67 were observed in depressed area, but these cells were sparsely seen in elevated area. We surmise that depression may be arised from a part of elevated lesion because these lesions had remarkable differences in their forms and biological characters.

Role of the Interstitial Cells Distributed in the Myenteric Plexus in Neural Reflexes in the Mouse Ileum

We examined the role of interstitial cells of Cajal (ICC) in the ascending and descending neural reflexes in the ileal segments prepared from wild type mice and c-kit mutant W/WV mice. Localized distension of the ileal segments from wild type mice with a small balloon caused contraction or relaxation of the circular muscle on the oral or anal side of the distended region, respectively. However, these intestinal reflexes were not induced in the ileal segments from the mutant mice. In the small strips that include the step of the pathways from efferent motor neurons to smooth muscle cells, nerve stimulation induced contraction of circular muscle in the absence of atropine and relaxation in the presence of atropine. The extent of nerve stimulation-induced contractions and relaxations of the ileal circular muscle were similar in wild type and W/WV mice. The responsiveness of ileal circular muscle to exogenously added acetylcholine and Nor-1, a nitric oxide donor, was also unaffected in the mutant ileum. Since previous immunohistochemical study had revealed selective loss of ICC within the myenteric plexus (ICC-MY) in the mutant ileum, it was concluded that ICC-MY have an essential role in ascending and descending neural pathways in the mouse ileum.

A Case of Simple Ulcer With Heal Perforation at the Anal Side of Meckel's Diverticulum

A Case of Simple Ulcer With Heal Perforation at the Anal Side of Meckel's Diverticulum

A case of Barrett's esophagus with a sever stenosis

We report a patient of Barrett's esophagus with sever stenosis. A 89 years old male was admitted to our department because of dysphagia on June 19th, 2003. Esophagoscopy revealed a sever middle esophagus stenosis at the level of 27cm from incisors. Esophagogram showed membranate esophageal stricture and sliding hiatal hernia. On June 28th, First balloon dilation was performed. Squamocolumnar junction was observed at the anal side of the stenosis and lower esophagus was lined by columnar epithelium almost 7cm length. Biopsy specimen revealed columnar epithelium with intestinal metaplasia. Therefore we diagnosed as Barrett's esophagus. After two times of balloon dilation he could ingest and discharged. Almost one week after his discharge, dysphagia was exacerbated again. Esophagoscopy revealed restenosis of esophagus, so further two times of esophageal dilation were added. After four times of balloon dilation, esophagogram showed good passege of the esophagus and esophagoscopy revealed improvement of stenosis and remaining of ulcer scar. Double stained by Methylene blue and iodine showed squamocolumnar junction cleary at the stricture point. We reported the case of Barrett's esophagus with a sever stenosis. Repeated endoscopic balloon dilation was seemed effective in benign esophagus stenosis.

Prostaglandin E1‐effective, transient‐type ischemic colitis developed after surgical resection of sigmoid colon cancer. A case report

A 55‐year‐old‐man had a laparoscopic resection of the sigmoid colon due to colon cancer with submucosal invasion. After the surgery he suffered ileus and had a laparotomy. Six months later he complained of frequent defecation. Colonoscopy confirmed a circular ulcer extending from the anal side of the anastomosis in the sigmoid colon to the mid rectum. Endoscopic ultrasound demonstrated thickening of all layers of the diseased colon and rectum. We diagnosed ischemic colitis. After intravenous drip infusion of prostaglandin, symptoms and colonic stricture gradually improved. Although abdominal angiography revealed a narrowing of the peripheral sigmoid branch of the inferior mesenteric artery, blood flow was unrestricted. Colonoscopy performed 84 days after discharge revealed an ulcer scar.

A case of peculiar shaped gastric lipoma

A 64-year-old man came to our hospital with a chief complaint of epigastralgia and palpitation. Upper gastrointestinal bleeding was presumed to be the cause of severe anemia and tarry stools. By emergent endscopic examination, a large submucosal tumor was revealed at the lesser curvature on the anterior wall of the stomach with a protruding lesion seen on the top, and gastric ulcer was also seen at anal side of submucosal tumor. From CT, US and MRI examination, it was suspected to be a gastric lipoma. But there was not detected such a lesion in endscopic examination at two years ago in our hospital, we could not deny the possibility of malignancy for its rapid growth. It was subsequently resected in open surgery. In operation the protruding lesion had changed to a delle. Histological findings showed that the tumor was a gastric lipoma composed of mature adipose tissue. Sometime, delle is formed on submucosal tumor. But we experienced a rare case of gastric lipoma that formed a protruding lesion on the surface.