[A case of Barrett's esophageal carcinoma treated with combined therapy].

During a routine health examination, a 50-year-old man was found to have an elevated lesion at the esophagogastric junction. Poorly differentiated adenocarcinoma was diagnosed from the biopsy findings. Computed tomography showed metastases in the mediastinal, intra-abdominal, and paraaortic lymph nodes. The clinical stage diagnosis was cT2, cN4, cM0, cStage IVa. Combination chemotherapy with docetaxel, CDDP, and 5-FU (DCF) was started initially. After 2 courses of DCF, the primary lesion and mediastinal lymph nodes had decreased in size, but the intra-abdominal lymph node had grown. A curative operation with paraaortic lymph node dissection was considered possible; thus, video-assisted thoracoscopic surgery of the esophagus with 3-field lymph node dissection was performed. The final findings revealed Barrett's esophageal carcinoma, EG, 0-III,23×18 mm, mod-por, CT-pT1b (sm3) pN4, sM0, fStage IV. Histologically, the mediastinal lymph node metastases disappeared with chemotherapy, but no reduction was observed in the abdominal lymph nodes. After surgery, 2 courses of combination adjuvant chemotherapy with CDDP and 5-FU were administered along with 50 Gy of radiotherapy. Subsequently, the treatment was changed to tegafur-gimeracil-oteracil potassium alone on an outpatient basis. The patient remains recurrence free 22 months postsurgery.

Large cell neuroendocrine carcinoma of the ampulla of vater with adenocarcinoma and squamous cell carcinoma components.

A 73-year-old woman visited our hospital complaining of general fatigue and jaundice. Laboratory tests revealed an elevated total bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and γ-glutamyltransferase. Computed tomography and magnetic resonance imaging demonstrated a mass lesion at the ampulla of Vater with dilatation of the common bile duct and main pancreatic duct. Percutaneous transhepatic cholangiography revealed dilatation of the bile duct and a negative filling defect due to the tumor. Pancreatoduodenectomy was performed. The specimen included an ulcerated firm tumor of the papilla Vater. The surface of the ampulla consisted of well-differentiated papillary adenocarcinoma, whereas the deep layer, such as submucosal or muscular layer, contained large cell neuroendocrine carcinoma and squamous cell carcinoma. Immunohistochemistry revealed that the large cell neuroendocrine carcinoma component was positive for chromogranin A, synaptophysin and CD56. The patient died from multiple liver and bone metastases 13 months after surgery. This is a very rare case of a large cell neuroendocrine carcinoma accompanied by adenocarcinoma and squamous cell carcinoma components.

Transvaginal Hybrid NOTES Procedure for Treatment of Gallstone Ileus.

Gallstone ileus is a rare mechanical bowel obstruction, and previously reported cases have been treated laparoscopically with good results. Although transvaginal hybrid NOTES without a minilaparotomy has been reported to decrease the incidence of surgical wound complications, to our knowledge, this procedure has not been used previously to treat gallstone ileus. We present a case of a 63-year-old woman who underwent transvaginal hybrid NOTES procedure for treatment of gallstone ileus. This case was admitted to our hospital following acute-onset abdominal pain and vomiting. We diagnosed gallstone ileus with cholecystoduodenal fistula by computed tomography and performed totally laparoscopic surgery using only three 5 mm abdominal ports with transvaginal specimen extraction and enterectomy. The patient's postoperative course was uneventful, and laparoscopic cholecystectomy and fistula repair were performed 8 months after the initial surgery. The patient experienced additional pain relief and good cosmetic outcomes. In conclusion, using transvaginal hybrid NOTES may become a future option to minimize the invasiveness of other laparoscopic procedures.